# Trauma assessment critique



## Jn1232th (Feb 3, 2016)

Can you guys let me know if I miss anything in running a trauma assessment?

Call is a ped vs car. 30 y.o male. Found 20 ft from incident lying supine.

Arrive on scene. Bsi scene safety, scene size up. Call in additional resources if needed and have als go en route. Delegate partner to grab c-spine. General impression. Get AvPU and ABC's. And check skin signs and establish a cheif complaint. 

Pt is Verbal. airway is open. Breathing and has a weak and rapid pulse. Skin is cool and clammy. 

Due to signs, place pt on 15lpm non rebreather. Delegate someone for vitals. Check head for dcapbtls. Check neck for Jvd and back For deformities or step offs. Place a c collar. 
 Barrel hoop chest, palpate abdomen. Opposite palpate upper extremities. Csm present
Barrel hoop pelvis to find deformity.
Opposite palpate lower extremities. Find deformity on left thigh. Possible femur fx but due to possible pelvic fx, traction splint in contraindicated. 
Check csm. Csm present. 

Log roll pt onto backboard. Strap chest, head legs.  Reassess avpu, abc's,and csm's.
 In ambulance raise lower portion 12 inches. Stabilize pelvis with blankets. Get a opqrst and a sample history. Reassess pt every 5 min. And address any secondary injuries. 


Anything I missed or should of done differently???


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## DesertMedic66 (Feb 3, 2016)

Check lung sounds when you are assessing the chest. 

We palpate to feel for crepitus not really to check for deformity, although you can for joints. 

That's pretty much standard for a NREMT trauma assessment. 

Trendelenburg position has not been shown to help so it is not used in a lot of places. If you want to do a pelvic wrap do it before you move the patient to the backboard.


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## Gurby (Feb 3, 2016)

FWIW, at one of the level 1 trauma centers we go to, lung sounds are one of the very first things they check when doing a trauma assessment.  Tension pneumothorax can kill you very quickly.  You can't do anything about it as an EMT-B, but it will be helpful if you let ALS or the hospital know about it asap so they can address it.

You didn't say what the blood pressure was, but if he has rapid/weak heartbeat and cool pale diaphoretic skin, I wouldn't consider traction splint even if the pelvis was intact.  Patient is in shock right now and needs a massive transfusion, a trauma surgeon and an OR - don't waste time ****ing around on scene with a traction splint.  If this is for the NREMT skills station, I would still verbalize that you would consider it but not apply it because of reasons X Y Z.


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## ERDoc (Feb 3, 2016)

Trauma is cookbook medicine.  ABC.  Assess the airway.  The pt is talking so A is done.  Breathing, listen to lung sounds and assess for adequate breathing.  Circulation, distal pulses and external hemorrhaging.  If at any point in the ABCs you find something is not working properly fix it before moving on to the next letter.  I'm not sure what a lot of the other stuff means but your ABCs should take less than 20 secs if there is nothing wrong.  Finish with D and E and then start your head to toe secondary survey.  Touch everything and check for tenderness and deformities.  Don't let impressive injuries distract you.  An open femur fracture is no big deal, it is the occluded airway that is going to kill first.


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## SpecialK (Feb 4, 2016)

I don't understand all of your abbreviations. 

There is no mention of determining the history of mechanism of injury.  Did the patient get hit at 1 km/h or 100 km/h? Did he hit the car? If so, with what part of the body? Did he go flying and land 30 ft away or did he simply get tapped gently then walk 30 feet and fall down? These are the sorts of questions I would be asking  of the patient (if possible), of those present and also thinking when I inspect the scene, particularly the vehicle for damage. 

Awake patients do not need their head held.  The pair of hands holding his head, or the person attached to them, is more useful doing something else.

If he was awake with no signs of inadequate breathing or oxygenation (including significant haemorrhage - lost RBCs and plasma cannot carry oxygen after all!) then I wouldn't bother with supplemental oxygen

What made you think there was a pelvic fracture? Did you wrap the pelvis? This can be done with either a lifting belt, one of the straps off a traction splint (or scoop stretcher) or a commercial device (e.g. the SAM splint) if you have one.  I suppose you could use a sheet but I am told it is not possible to tie these tightly enough and truth be told it's probably accurate.  

I've not seen femoral traction contraindicated with a pelvic fracture.  This seems odd to me, considering traction will pull the femur anteriorly so a pelvic fracture shouldn't be affected, or affect, this at all.

Secondary survey should, like all secondary surveys, focus on finding things which are going to be a problem for which you can do something, or which are going to be clinically significant for the patient.  Spending a great amount of time examining the patient when the information you gain is not going to change what happens to him is time that could be better spent doing something else more worthwhile.  For example, performing a very detailed respiratory or abdominal exam when that information isn't going to change what you do or needs to happen to the patient upon arrival at hospital is pointless.  

I would particularly look for a tension pneumothorax, flail chest, long bone fractures, traumatic brain injury and obvious signs or symptoms of spinal cord injury. These are conditions which are going to either change my management on-scene, or potentially change which hospital the patient is transported to.


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## Mya (Feb 4, 2016)

Some things I would add, if not already assumed were: 
Consent to treat. Usually it's performed in the AVPU section. Not so if it's considered implied in this scenario but just in case.

I thought that clammy skin also meant diaphoretic, so I would say he's in shock and would put a blanket on him with the O2.

Ask if he has any disabilities. Look for deformities (like a broken limb)

I would not jump into DCAPBTLS just yet. I would finish the primary assessment and expose and palpate the chief complaint. Then state that I would formulate a field response, along with code2/3 delegation. Then move on to the rapid trauma. Still no real DCAPBTLS which is done in the ambulance. Right now we're looking for life threats.

You mentioned a leg injury? Splint it with a conforming splint if traction is contraindicated. 

For the rapid trauma I'll palpate the head, look for raccoon eyes, battle signs, csf drainage, anything broken/singed nose hairs. Also look under the neck before you palpate. Anything could be hanging out and you don't want to kill someone. Look for JVD, emphesyma, tracheal deviation, medical alert tags, and stoma in the neck. Check clavicle, rib stability and look for a flail chest, sucking pneumothorax. Palpate the 4 abdominal quads while checking for open wounds, pulsating masses and such. Then pelvic pressure. Then offsetting pressure on all limbs while checking pulses bilaterally. Check CMS!!!

Check CMS before and after splinting!!

After cms is done, apply the C collar. Get the backboard. Turn patient on least injured side and listen to lung sounds while searching for step offs, looking for incontinence. Then place on backboard. Strap/tape. CMS.

Then I do a more detailed physical and look for DCAPBTLS. Get history and such if it wasn't already given.


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## Mya (Feb 4, 2016)

SpecialK said:


> I don't understand all of your abbreviations.
> 
> 
> Awake patients do not need their head held.  The pair of hands holding his head, or the person attached to them, is more useful doing something else.



Even if they're awake, they could have a spinal injury so I was told to always assume a spinal injury if someone is on the ground or has been in a crash. Or that fell and is up walking about even!


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## Joshlaroe (Feb 4, 2016)

SpecialK said:


> I don't understand all of your abbreviations.
> 
> 
> If he was awake with no signs of inadequate breathing or oxygenation (including significant haemorrhage - lost RBCs and plasma cannot carry oxygen after all!) then I wouldn't bother with supplemental oxygen
> .



O2 never hurts! Unless they're in hypoxic drive...


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## Austin carawan (Feb 4, 2016)

I'm assuming csm is comparable to pulse motor sensory? That's the term we were taught


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## Mya (Feb 4, 2016)

Austin carawan said:


> I'm assuming csm is comparable to pulse motor sensory? That's the term we were taught



Yup! I forget about lingo usage...some people aren't too keen on saying PMS hahah so we were drilled to say CMS. Circulation, motor, sensory.


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## Austin carawan (Feb 4, 2016)

Ok, I've just never heard it used, but I want to know any and all mnemonics as we run mutual aid with 2 different counties!


Mya said:


> Yup! I forget about lingo usage...some people aren't too keen on saying PMS hahah so we were drilled to say CMS. Circulation, motor, sensory.


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## Austin carawan (Feb 4, 2016)

Joshlaroe said:


> O2 never hurts! Unless they're in hypoxic drive...


I was always told that you should never with hold oxygen for fear of depressing hypoxia drive unless you are doing a distance transport, because your interaction with the patient will not be long enough to depress hypoxia drive


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## Joshlaroe (Feb 4, 2016)

Austin carawan said:


> I was always told that you should never with hold oxygen for fear of depressing hypoxia drive unless you are doing a distance transport, because your interaction with the patient will not be long enough to depress hypoxia drive



True. I never really knew how long it took to send a patient into hypoxic drive, so that's good to know! I still put O2 on everyone, regardless. Good lookin out.


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## Jim37F (Feb 4, 2016)

Mya said:


> Even if they're awake, they could have a spinal injury so I was told to always assume a spinal injury if someone is on the ground or has been in a crash. Or that fell and is up walking about even!


That's an old, outdated classroom only answer, really only useful to pass the NREMT and now no longer entirely applicable to the real world. New research is showing backboards are generally being used way too much, and that a flat piece of plastic doesn't actually do anything to immobilize the naturally curved human spine (gasp). There's agencies that are doing away with backboards for the use of immobilization entirely, only using them as extrication devices (ease of carrying the patient out of where they're at to the gurney, then removing the board once the patient is on the gurney as there is growing evidence that leaving patients on backboards for any length of time actually causes more harm then good. My county's protocol even says if they are ambulatory and up and walking aound, to generally avoid backboarding them in the first place. Neck pain only buys only a C-collar and position of comfort. Your local protocols will of course take precedence so be sure you know what the latest ones say.



Joshlaroe said:


> True. I never really knew how long it took to send a patient into hypoxic drive, so that's good to know! I still put O2 on everyone, regardless. Good lookin out.


So you are administering a medication to everyone regardless of the lack of indications for that medication? That's exactly what oxygen is, a medicine. You don't give oral glucose or activated charcoal to everyone regardless do you? No, you only give them if they meet the proper indications. Same for oxygen, and no, trauma in and of itself is not an indication for oxygen.


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## Mya (Feb 4, 2016)

Jim37F said:


> That's an old, outdated classroom only answer, really only useful to pass the NREMT and now no longer entirely applicable to the real world. New research is showing backboards are generally being used way too much, and that a flat piece of plastic doesn't actually do anything to immobilize the naturally curved human spine (gasp). There's agencies that are doing away with backboards for the use of immobilization entirely, only using them as extrication devices (ease of carrying the patient out of where they're at to the gurney, then removing the board once the patient is on the gurney as there is growing evidence that leaving patients on backboards for any length of time actually causes more harm then good. My county's protocol even says if they are ambulatory and up and walking aound, to generally avoid backboarding them in the first place. Neck pain only buys only a C-collar and position of comfort. Your local protocols will of course take precedence so be sure you know what the latest ones say.
> 
> I was thinking this was a classroom scenario so I gave a classroom answer, but I definitely agree with you! Everything you've said is exactly what my instructors have told me and that so many pts are unnecessarily backboarded nowadays. Did not even know about the "if people are walking around then no backboard" situation. Haven't worked in the field just yet so I'm anxious to see the non textbook ems life.


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## SpecialK (Feb 4, 2016)

Joshlaroe said:


> O2 never hurts! Unless they're in hypoxic drive...



This is outdated thinking that needs to stop.

Oxygen is a drug, not a magical cureall and can have harmful effects.  Simply, If it is not specifically indicated, don't give it.


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## Chewy20 (Feb 5, 2016)

Joshlaroe said:


> True. I never really knew how long it took to send a patient into hypoxic drive, so that's good to know! I still put O2 on everyone, regardless. Good lookin out.



Right, and I put a collar on everyone as well. Sigh.


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## gotbeerz001 (Feb 5, 2016)

A lot if outdated thoughts here regarding O2 and Spinal Immobilization...


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## Joshlaroe (Feb 5, 2016)

SpecialK said:


> This is outdated thinking that needs to stop.
> 
> Oxygen is a drug, not a magical cureall and can have harmful effects.  Simply, If it is not specifically indicated, don't give it.




I think it needs to not be taught like that anymore, even if it is just for testing purposes. One of my instructors was pretty stubborn about changing his thoughts on the O2 thing, but I do know out in the field we don't do that. But for testing purposes now, yes just to be safe.


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## gotbeerz001 (Feb 6, 2016)

.....


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## RedAirplane (Feb 6, 2016)

The EMT book now at least acknowledges selective Cspine, O2 titration, and supine vs trendelenberg, but instructors (who are full time 911 paramedics) Can be very rooted in those things. 

Now, NREMT isn't even looking for 15 L except in obvious shock or pt just came out of a smoky building.


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## DesertMedic66 (Feb 6, 2016)

RedAirplane said:


> The EMT book now at least acknowledges selective Cspine, O2 titration, and supine vs trendelenberg, but instructors (who are full time 911 paramedics) Can be very rooted in those things.
> 
> Now, NREMT isn't even looking for 15 L except in obvious shock or pt just came out of a smoky building.


One of the fail points for the NREMT trauma assessment test is still "failure to ultimately voice or provide high flow oxygen".


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## Qulevrius (Feb 6, 2016)

DesertMedic66 said:


> One of the fail points for the NREMT trauma assessment test is still "failure to ultimately voice or provide high flow oxygen".



This, plus anything lower than 15 LPM with NRB is considered a critical failure.


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## RedAirplane (Feb 6, 2016)

DesertMedic66 said:


> One of the fail points for the NREMT trauma assessment test is still "failure to ultimately voice or provide high flow oxygen".



I meant on the written test.

Sure, for the scenario, but in the scenario the patient is always pale, cool, and wet, has just had his arm cut off and is littered with a bunch of injuries plus possibly a major medical condition just for good measure. Such a clearly shocky patient should get 15L anyway?


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## DesertMedic66 (Feb 6, 2016)

RedAirplane said:


> I meant on the written test.
> 
> Sure, for the scenario, but in the scenario the patient is always pale, cool, and wet, has just had his arm cut off and is littered with a bunch of injuries plus possibly a major medical condition just for good measure. Such a clearly shocky patient should get 15L anyway?


The proctors are able to change the patient condition and injuries. So the patient may not always be pale, cool, and profuse for skin signs.


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## RedAirplane (Feb 7, 2016)

DesertMedic66 said:


> The proctors are able to change the patient condition and injuries. So the patient may not always be pale, cool, and profuse for skin signs.



Fair enough. I've never had a practical exam without either cyanosis or pale skin and profuse diaphoresis, but I guess YMMV.


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