BTLS Trauma

BASIC TRAUMA LIFE SUPPORTBASIC TRAUMA LIFE SUPPORT

Initial Initial Assessment and Assessment and Management of Management of

TraumaTrauma

Purwoko Sugeng Purwoko Sugeng HH

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IntroductionIntroduction• Golden HourGolden Hour

– Time to reach operating roomTime to reach operating room(or other definitive treatment)(or other definitive treatment)

– NOTNOT time for transport to ED time for transport to ED– NOTNOT time in Emergency Department time in Emergency Department

• EMS does EMS does NOTNOT have a Golden have a Golden HourHour

• EMS has a EMS has a Platinum Ten Platinum Ten MinutesMinutes

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IntroductionIntroduction• Patients in their Golden Hour must:Patients in their Golden Hour must:

– Be recognized quicklyBe recognized quickly– Have Have onlyonly immediate life threats managed immediate life threats managed– Be transported to an Be transported to an APPROPRIATEAPPROPRIATE facility facility

• Survival depends on assessment skillsSurvival depends on assessment skills• Good assessment results fromGood assessment results from

– An organized approachAn organized approach– Clearly defined prioritiesClearly defined priorities– Understanding available resourcesUnderstanding available resources

Trauma AssessmentTrauma Assessment

Load and Go Load and Go Situation ?Situation ?

Load and Go Load and Go Situation ?Situation ? HOSPHOSP

Scene Size-UpScene Size-Up• SafetySafety• Body Surface Isolation (BSI)Body Surface Isolation (BSI)• Number of PatientsNumber of Patients• Additional ResourcesAdditional Resources• Mechanism of Injury(MOI)Mechanism of Injury(MOI)

SafetySafety• TrafficTraffic• SmokeSmoke• ElectricityElectricity• Haz-MatHaz-Mat• Hostile Hostile

PersonsPersons• WeaponsWeapons• DrugsDrugs• SilenceSilence

BODY SURFACE ISOLATIONBODY SURFACE ISOLATION

• GlovesGloves for minimal fluids

• Goggles Goggles for eye protection if there’s any chance of splatter

• Mask and Gown Mask and Gown for gross contamination

Number of PatientsNumber of Patients

Call for additional resources ASAP

Additional resourcesAdditional resources

• ExtricationExtrication• Traffic controlTraffic control• UtilitiesUtilities

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Significant Mechanism Significant Mechanism of Injuryof Injury

Ejection from vehicle

Death in same passenger compartment

Fall of greater than 15 feet or 3 times the patient’s height

Rollover of vehicle

High-speed vehicle collision

Vehicle-pedestrian collision

Motorcycle crash

Unresponsive or altered mental status

Penetrating injury of head, chest, or abdomen

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Bent Steering WheelBent Steering Wheel Broken MirrorBroken Mirror

Distorted PedalsDistorted PedalsDeformed Deformed DashboardDashboard

Spider-Webbed Spider-Webbed WindshieldWindshield

Initial AssessmentInitial Assessment• General ImpressionGeneral Impression• Mental StatusMental Status• AirwayAirway• BreathingBreathing• CirculationCirculation

General ImpressionGeneral Impression

• Age, Weight, GenderAge, Weight, Gender• Position (relative to posture Position (relative to posture

and surroundings)and surroundings)• ActivityActivity• Obvious Injuries/BleedingObvious Injuries/Bleeding

Assess Mental StatusAssess Mental Status

• Take C-Spine controlTake C-Spine control• A – Alert and immediately A – Alert and immediately

responsiveresponsive• V – Responsive to verbal V – Responsive to verbal

stimulistimuli• P – Responsive to painful P – Responsive to painful

stimulistimuli• U – UnresponsiveU – Unresponsive

Assess AirwayAssess Airway• Open if necessary using jaw-thrust Open if necessary using jaw-thrust

maneuvermaneuver• Consider oro- or naso-pharyngeal Consider oro- or naso-pharyngeal

airwayairway• Note unusual sounds and correct Note unusual sounds and correct

causecause– Snoring – oro-/naso-pharyngeal airwaySnoring – oro-/naso-pharyngeal airway– Gurgling – suctionGurgling – suction– Stridor – consider intubationStridor – consider intubation– Silence Silence

Correcting silenceCorrecting silence

• Attempt ventilationAttempt ventilation• RepositionReposition• HeimlichHeimlich• Visualize and removeVisualize and remove• IntubateIntubate• Trans-laryngeal jet insuflationTrans-laryngeal jet insuflation

Assess BreathingAssess Breathing

• Look, Listen, FeelLook, Listen, Feel• Rate, Rhythm, Depth (tidal volume)Rate, Rhythm, Depth (tidal volume)• Use of accessory Use of accessory

muscles/retractionsmuscles/retractions• TreatTreat

– Absent – ventilate x2, check pulseAbsent – ventilate x2, check pulse– < 12/min – assist ventilation< 12/min – assist ventilation– Decreased tidal volume – assist ventilationDecreased tidal volume – assist ventilation– Labored – oxygen 10 liters NRBLabored – oxygen 10 liters NRB– Normal or rapid – consider oxygenNormal or rapid – consider oxygen

Assess Circulation - Assess Circulation - Pulses Pulses

• Compare radial Compare radial and corotidand corotid

• RateRate– NormalNormal– FastFast– SlowSlow

• RhythmRhythm– RegularRegular– IrregularIrregular

• QualityQuality– WeakWeak– ThreadyThready– BoundingBounding

Assess Circulation - Assess Circulation - SkinSkin

• ColorColor• TemperatureTemperature• MoistureMoisture

Assess Circulation - Assess Circulation - BleedingBleeding

• Direct pressureDirect pressure• Pressure dressingPressure dressing

Determine priorityDetermine priority

– Poor general impressionPoor general impression– Mental status changesMental status changes– Difficulty breathingDifficulty breathing– ShockShock– Chest painChest pain– Severe bleedingSevere bleeding– Severe painSevere pain

Load and Go Load and Go Situation ?Situation ?

Rapid Trauma SurveyRapid Trauma Survey• Head to toeHead to toe• Rapid sweep to identify major Rapid sweep to identify major

injuries which could prove life injuries which could prove life threateningthreatening

• DCAP-BTLSDCAP-BTLS

Inspect and Palpate forInspect and Palpate forDCAP-BTLSDCAP-BTLS

====

DCAP

DeformitiesContusionsAbrasionsPunctures/

Penetrations

====

BTLS

BurnsTendernessLacerationsSwelling

Rapid Trauma SurveyRapid Trauma Survey

DeformitiesDeformities ContusionsContusions

AbrasionsAbrasions Punctures/PenetrationsPunctures/Penetrations

BurnsBurns TendernessTenderness

LacerationsLacerations SwellingSwelling

Rapid Trauma SurveyRapid Trauma Survey

HeadNeckChestAbdomenPelvisExtremitiesPosterior

Head: DCAP-BTLS + CrepitationHead: DCAP-BTLS + Crepitation

Neck: DCAP-BTLS + Jugular Vein Distention and Neck: DCAP-BTLS + Jugular Vein Distention and CrepitationCrepitation

Chest: DCAP-BTLS + Crepitation and Chest: DCAP-BTLS + Crepitation and Breath Sounds (Presence and Equality)Breath Sounds (Presence and Equality)

Mid-clavicular Mid-clavicular Mid-axillaryMid-axillary

Listen to both sides of the chest. Is air entry present? Listen to both sides of the chest. Is air entry present? Absent? Equal on both sides? Compare left side to Absent? Equal on both sides? Compare left side to

right side.right side.

Abdomen: DCAP-BTLS + Firmness and DistentionAbdomen: DCAP-BTLS + Firmness and Distention

Pelvis: DCAP-BTLS (Pelvis: DCAP-BTLS (Compress gently)

Extremities: DCAP-BTLS + Distal Pulse,Extremities: DCAP-BTLS + Distal Pulse, Sensation, Motor FunctionSensation, Motor Function

Posterior: DCAP-BTLSPosterior: DCAP-BTLS

Package and begin transportPackage and begin transport• ImmediateImmediate – immobilize, load, go – immobilize, load, go• DelayedDelayed – immobilize, treat as – immobilize, treat as

necessary, transportnecessary, transport

If No Significant MechanismIf No Significant Mechanismof Injuryof Injury

Reconsider mechanism of injury

Determine chief complaint

Perform focused physical exam based on:

Chief complaint

Mechanism of injury

Use DCAP-BTLS on focused area of assessment

Assess baseline vital signs

Obtain SAMPLE history

Focused History and Focused History and PhysicalPhysical• Baseline vital signsBaseline vital signs• SAMPLE HistorySAMPLE History• Focus on and treat injuries found Focus on and treat injuries found

during initial assessment and rapid during initial assessment and rapid trauma assessment as appropriate trauma assessment as appropriate considering priorityconsidering priority

SAMPLE HistorySAMPLE HistorySS == Signs and symptomsSigns and symptomsAA == AllergiesAllergiesMM == MedicationsMedicationsPP == Pertinent past historyPertinent past historyLL == Last oral intakeLast oral intakeEE == Events leading to injury Events leading to injury

or illnessor illness

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Vital SignsRespirations

Pulse

Skin color, temperature, condition

Pupils

Blood Pressure

•

Detailed Physical Detailed Physical ExamExam

• As appropriate, considering As appropriate, considering prioritypriority

• History and vital signs, History and vital signs, neurologicalneurological

• Repeat initial assessmentRepeat initial assessment• Complete critical interventionsComplete critical interventions• Careful head to toe survey Careful head to toe survey

(DCAP/BTLS)(DCAP/BTLS)

Detailed Physical ExamDetailed Physical ExamHead to ToeHead to Toe

• HeadHead – – DCAP/BTLS and creptiationDCAP/BTLS and creptiation• EarsEars – – DCAP/BTLS and blood/fluidDCAP/BTLS and blood/fluid• FaceFace – – DCAP/BTLS and blood/fluidDCAP/BTLS and blood/fluid• EyesEyes – – DCAP/BTLS and discoloration, DCAP/BTLS and discoloration,

pupils, foreign bodies, bloodpupils, foreign bodies, blood• NoseNose – – DCAP/BTLS and blood/fluidDCAP/BTLS and blood/fluid• MouthMouth – – DCAP/BTLS and teeth, DCAP/BTLS and teeth,

foreign bodies, swelling, lacerations, foreign bodies, swelling, lacerations, odorodor

Head to ToeHead to Toe

Detailed Physical Detailed Physical ExamExam

Head to ToeHead to Toe• NeckNeck – – DCAP/BTLS and JVD, crepitationDCAP/BTLS and JVD, crepitation• ChestChest – – DCAP/BTLS and palpate for DCAP/BTLS and palpate for

paradoxical motion, symmetry, crepitation, paradoxical motion, symmetry, crepitation, and auscultate breath soundsand auscultate breath sounds

• AbdomenAbdomen – – DCAP/BTLS and tenderness, DCAP/BTLS and tenderness, rigidity, distentionrigidity, distention

• PelvisPelvis – – DCAP/BTLS and pain, tenderness, DCAP/BTLS and pain, tenderness, motion, crepitationmotion, crepitation

• Upper extremities Upper extremities – DCAP/BTLS and PMS– DCAP/BTLS and PMS• Lower extremities Lower extremities – DCAP/BTLS and PMS– DCAP/BTLS and PMS• PosteriorPosterior – DCAP/BTLS – DCAP/BTLS

On-Going Assessment On-Going Assessment • Subjective changesSubjective changes• Reassess vital signs:neurological,ABCReassess vital signs:neurological,ABC• Reassess injuries Reassess injuries • Reassess interventionsReassess interventions

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