The concept of simultaneous assessment (team leader) and delegated intervention (team members) in life-threatening emergencies needs to be stressed. Point out that the Initial Assessment is interrupted only for airway obstruction, when the scene becomes too dangerous, or the need to perform CPR. The step-by-step assessment scheme must be taught. Emphasize the need to get the critically injured patient out of the field and to an appropriate hospital as quickly as possible. The 10-minute rule must be reinforced. Stress that the Ongoing Exam should be repeated any time the patient's condition changes. NOTE: Use flowchart miniature to conceptualize and demonstrate how parts of Assessment fit together. You begin in same place for all patients, decision takes you on different paths, but come back to same for all patients. (Students do not need to be able to read flowchart on screen.) NOTE: (U.S.) ITLS patient assessment (Primary Survey, Secondary Survey, and Ongoing Exam) is consistent with U.S. Department of Transportation guidelines. FLOWCHART: The purpose of the Primary Survey is to determine if immediately life-threatening conditions exist and to identify those patients who should have immediate transport to the hospital. Delegate interventions to your team members while you continue the assessment. This is an important concept that immediately addresses problems encountered and yet does not interrupt the assessment sequence and does not increase scene time. This is what teamwork is all about. Interventions performed based on patient needs, resources available and time it will take to execute. Performed by team members during assessment phases without causing interruptions of the assessment. NOTE: Use miniature to conceptualize and demonstrate how survey is a series of steps to be done in sequence without deviation. (Students do not need to be able to read steps on screen.) NOTE: The next series of slides steps through Scene Size-up. Remember: this skill will be taught in skill stations. Don't over lecture. Scene Size-up is the first step of the Primary Survey. NOTE: Click on the screenshot in presentation mode to play the Video clip “ITLS7e Scene Survey” in a browser window. Close the browser window to return to the presentation. It cannot be stressed too much that failure to perform preliminary actions can jeopardize lives. Perform Scene Size-up as described in Chapter 1. NOTE: Use miniature to conceptualize and demonstrate how survey is a series of steps to be done in sequence without deviation. (Students do not need to be able to read steps on screen.) NOTE: The next series of slides steps through Initial Assessment. Remember: this skill will be taught in skill stations. Initial Assessment prioritizes and determines existence of immediately life-threatening conditions. Once scene is safe to enter, team leader must focus on rapid assessment. Remember, once you begin ITLS Primary Survey, only 4 things should cause you to interrupt completion of assessment: Scene becomes unsafe. Must treat an airway obstruction. Must treat cardiac arrest. Must treat life-threatening bleeding. All other problems (such as respiratory arrest or dyspnea) may be addressed by team members. Stopping during survey causes you to overlook essential items. For critical patients, goal should be to have on-scene times of 5 minutes or less. While interventions may be important, only thing proven to increase survival of trauma patients is decreasing time to definitive care (trauma center). Old and very young are at increased risk. Female patients may be pregnant. Observe position of patient. Body position and position in relation to surroundings. Note activity. (Is patient aware of surroundings, anxious, obviously in distress, etc.?) Any obvious major injuries or major bleeding? Observation of patient in relation to scene and mechanism of injury will help you prioritize. If there are multiple patients, rapidly triage them and begin evaluation of the most seriously injured patient first. Assessment begins immediately, even if patient is being extricated. If there is a mechanism of injury that suggests spinal injury, immediately and gently but firmly stabilize head and neck in a neutral position (this can be delegated to a team member). Stabilize head and neck in position found. If head or neck is held in an angulated position and patient complains of pain on any attempt to straighten it. If patient is unconscious and neck is held to one side and does not move when you gently attempt to straighten it. Speak to patient and ask a question such as, “Can you tell me what happened?” Reply gives immediate information about both airway and level of consciousness. If responds appropriately to questioning, you can assume that airway is open and level of consciousness (LOC) is normal. If response is not appropriate, make a mental note of LOC using AVPU scale. Anything below “A” (alert) should trigger a systematic search for causes during Rapid Trauma Survey. Look, listen, and feel for movement of air. Position airway as needed. Avoid extending neck to open airway if trauma suspected. If airway obstructed (apnea, snoring, gurgling, stridor), use an appropriate method (reposition, sweep, suction) to open it immediately. Failure to quickly provide an open airway is one of three reasons to interrupt patient assessment part of ITLS Primary Survey. If simple positioning and suctioning fail to provide an adequate airway, or if stridor is present, advanced airway techniques may be necessary immediately. Checking pulse in neck is not necessary if awake and alert or has a palpable peripheral pulse. Quickly note whether rate is too slow or too fast, and note quality (thready, bounding, weak, irregular). Remember, pulse rate is checking to determine how well blood is circulating and if sufficient for good perfusion. Is it too fast for good perfusion? (>120 in an adult) Is it too slow for good perfusion? (<60 in an adult) It is not a determination of tachycardia or bradycardia. If pulse absent at neck, immediately start CPR (unless there is massive blunt trauma) and prepare for immediate transport. One of four reasons to interrupt assessment during ITLS Primary Survey. At wrist, note skin color, temperature, and condition (and capillary refill in an infant or small child). Pale, cool, clammy skin; thready radial pulse; and decreased LOC are best early assessments of decreased perfusion (shock). Direct control of bleeding. Perform Initial Assessment and go directly to Rapid Trauma Survey. Perform interventions, transport, Ongoing Exams, and possibly a Secondary Survey en route. If dangerous focused mechanism of injury suggesting an isolated injury: Perform Initial Assessment and Focused Exam limited to area of injury. Full Rapid Trauma Survey is not required. Perform interventions, transport, Ongoing Exams, and possibly a Secondary Survey. If no significant life threat in mechanism of injury: Perform Initial Assessment and, if normal: Directly to a Focused Exam based on chief complaint. Secondary Survey would not be necessary. NOTE: Use miniature to conceptualize and demonstrate how survey is a series of steps to be done in sequence without deviation. (Students do not need to be able to read steps on screen.) NOTE: The next series of slides steps through Rapid Trauma Survey. Remember: this skill will be taught in skill stations. Rapid Trauma Survey is a brief exam done to find all life-threats. NOTE: Remember: this skill will be taught in detail in skill stations. Inspect head and neck (look and feel). Measured pulse, respirations, blood pressure. Obtain baseline vital signs and rest of SAMPLE history. Vital signs and SAMPLE should be done during transport for critical patients. Pupils: Size? Reactive? Equal? If altered mental status: Brief neurological exam Identify possible increased intracranial pressure (ICP). Includes pupils, Glasgow Coma Scale (GCS) score, and signs of cerebral herniation Always performed during transport Finger-stick glucose performed at beginning of transport Glasgow Coma Scale Score Eyes, voice, motor, orientation, emotional state Look for medical identification devices. Consider nontraumatic causes of altered mental status. NOTE: Also referred to either as Glasgow Coma Scale or Glasgow Coma Score. Very important to do this as a baseline; how it changes is of critical
importance. NOTE: Notice importance of breathing. Difficulty breathing appears in both groups. Load-and-go patients include: A more detailed history may be taken later during ITLS Secondary Survey. Especially important: If information must be gathered from bystanders, since they will not be available to question once transport is initiated. If patient has loss of consciousness during transport. Upon completion of Initial Assessment and Rapid Trauma Survey or Focused Exam, enough information is available to decide if a critical situation is present. Patients with
critical trauma situations are transported immediately. Most treatment interventions will be done during transport. These “Fix Its” are done at scene, and most of them can be delegated to team members to perform while you continue ITLS Primary Survey. These “Fix Its” are done at scene, and most of them can be delegated to team members to perform while you continue ITLS Primary Survey. If BVM ventilation is sufficient to transfer to ambulance and initiate transport, perform endotracheal intubation in transit. At this point, ITLS Primary Survey is over and team leader may help other rescuers with patient care. It is extremely important to contact medical direction as early as possible with critical patients. It takes time to get appropriate surgeon and operating room team in place, and critical patient has no time to wait. Always notify receiving facility of your estimated time of arrival (ETA), condition of patient, and any special needs on arrival. Ongoing assessment and management include critical procedures performed on scene and during transport and communication with medical direction. NOTE: Click on the screenshot in presentation mode to play the Video clip “ITLS7e Ongoing Exam” in a browser window. Close the browser window to return to the presentation. Ask the patient if there
have been any changes in how she feels. Complete the SAMPLE history if not already done. NOTE: Use miniature to conceptualize and demonstrate how survey is a series of steps to be done in sequence without deviation. (Students do not need to be able to read steps on screen.) NOTE: The next series of slides steps through Secondary Survey. Remember: this skill will be taught in skill stations. Secondary Survey is a more comprehensive exam to identify all injuries, not just life-threatening. ITLS Secondary Survey: NOTE: ITLS Secondary Survey is taught in skill station. Although we say Secondary Survey should be done on critical patients during transport, we have to apply a little common sense. More accurately, we should say “do not delay scene time of a critical patient.” If you are unable to transport, e.g., are waiting for an ambulance/helicopter or patient is being extricated, a Secondary Survey may be performed on scene. DETAILED EXAM of
complaints and previously found injuries In the field, it appears to be useful to predict which patients with normal vital signs are having occult internal bleeding and will soon develop hemorrhagic shock. Services have been using prehospital finger-stick serum lactate levels to predict who will develop shock. If further studies confirm its predictive value, it will very useful. Portable ultrasound can be used to assess for intraabdominal hemorrhage and cardiac tamponade among other things. Abdominal trauma sonography is very commonly used in the initial assessment of trauma patients in the emergency department and is called the FAST exam (focused assessment with sonography in trauma). It is noninvasive and only takes from one to three minutes to perform. What is one thing that is assessed in the rapid trauma assessment?Just like any assessment, the Rapid Trauma Assessment begins with an assessment of your patient's mental status. If your patient is responsive, you would ask them questions to determine how alert and oriented they are (A&O 1-4). REMEMBER, the A&O Scale is: Alert and Oriented to Person, Place, Time, and Event.
What are the components of rapid trauma assessment?Rapid patient assessment. SCENE SURVEY.. SIMULTANEOUS ACTIONS.. Assessment of AIRWAY.. Assessment of BREATHING.. Supporting VENTILATIONS.. Assessment of CIRCULATION.. CONTROL BLEEDING.. ASSESS THE HEAD (quickly through) DCAP-BTLS for obvious injury (inspect and palpate). What are the 5 key components of the primary survey in major trauma?What are the 5 key components of the primary survey in major trauma? ATLS (8th edition) emphasizes the ABCDE approach: Airway maintenance with cervical spine protection. Breathing and ventilation.. Tracheal deviation.. Wounds.. External markings.. Laryngeal disruption.. Venous distention.. Emphysema (surgical). What is the priority assessment for a trauma patient?The trauma assessment begins prior to the patient's arrival with information gathering, the formation of the trauma team, and equipment preparation. On patient arrival, the team begins with the primary survey, which includes an assessment of the patient's airway, breathing, circulation, disability, and exposure.
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What are the most important things to notice when doing a rapid trauma assessment?
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