Eighty percent of the key information you will obtain to care for your trauma patient comes from a hands-on exam.
Photo credit: Dan Limmer
Figure 2: Assess the chest during the primary assessment
Photo credit: Dan Limmer
Figure 3: Noninvasive blood pressure (NIBP) monitor.
Photo credit: Dan Limmer
Figure 4: Reassessment is done en route to the hospital—every 5 minutes for the unstable patient, every 15 minutes for the stable patient.
Photo credit: Dan Limmer
Brady is pleased to share with you a preview of our forthcoming EMS Transition Series. Our first offering is for the EMT level. Transition Series: Topics for the EMT by Joseph Mistovich and Daniel Limmer provides both an overview of new information contained within the Education Standards at the EMT level and a source of continuing education for practicing EMTs. Intended for a new generation of EMTs, the text integrates new "topics" that were not contained in the U.S. DOT 1994 EMT-Basic National Standard Curriculum and existing "topics" at a much greater depth and breadth than what was contained in the typical EMT-Basic education program. This text covers what new EMTs need such as medical terminology, expanded pathophysiology and critical thinking. Educating and training EMTs using the new Education Standards, this text provides a solid foundation of knowledge to practice prehospital care. During 2011, EMS World Magazine will feature exclusive excerpts from this new textbook. Transition Series: Topics for the EMT will be available in March 2011. Visit www.bradybooks.com for more information and stay tuned for new topic previews throughout the year!
Standard: Patient Assessment
Competency: Applies scene information and patient assessment findings (scene size-up, primary and secondary assessment, patient history, reassessment) to guide emergency management
- Comparison of the 1994 EMT-Basic curriculum and the National EMS Educational Standards regarding terminology used during the assessment of a trauma patient
- Increased importance of patient physiologic status rather than mechanism of injury in determining patient instability or potential instability
- Primary assessment process for the trauma victim
- Comparison of the secondary assessment for a stable versus an unstable trauma patient
- How vital sign trending can help identify types of traumatic conditions
- Importance of performing a reassessment of the injured or traumatized patient
The first two excerpts in this series will discuss patient assessment: Trauma assessment is the focus of this chapter, and the next chapter in the April issue is medical assessment. This split is done because the ways trauma patients and medical patients are assessed are significantly different. These topics will also introduce you to the patient assessment process as outlined in the National EMS Education Standards because it will differ from the way you were taught in your initial EMT course.
Trauma assessment is a hands-on process. A medical axiom states that 80% of the key information you will obtain to care for your trauma patient comes from a hands-on exam, and 20% comes from the history. You will later learn that the opposite is true for medical patients. This is not to say there is no value in the history; it is just that a hands-on exam is likely to produce more finite and applicable results.
The 1994 EMT-B curriculum provided a detailed, scripted approach to patient assessment. You likely learned a scene size-up, initial assessment, and rapid trauma exam or focused assessment, followed by a detailed, then an ongoing, assessment.
The National EMS Education Standards do not provide this scripted approach. The standards do include a scene size-up, which is very similar to the existing size-up, and a primary assessment, which is similar to the existing initial assessment. Missing from the standards is the detailed information on executing the subsequent hands-on assessments. The standards do include a reassessment, which is similar to the existing ongoing assessment.
The 1994 EMT-B curriculum provided a detailed, scripted approach to patient assessment. The National EMS Education Standards do not provide this scripted approach.
As an experienced EMT, you will notice new EMTs and reference sources using this new assessment terminology. It will not affect your assessment or your ability to work with new EMTs. Table 1 compares the old EMT-B curriculum with the education standards.
The scene size-up comprises the following components for the trauma patient:
- Scene safety
- Standard precautions
- Mechanism of injury
- Number of patients
- Hazards/resources needed.
The only area with a change to the science is mechanism of injury. In the past, mechanism of injury was used as a significant predictor of injury and was a formative part of the early decisions EMTs made in reference to the trauma patient.
Now, although mechanism of injury is still part of the puzzle, it is considered of less prognostic value than in prior years. In the past, mechanism of injury was a singular factor in determining whether a patient should receive a rapid examination and be expedited from the scene. Under new trauma triage guidelines issued by the Centers for Disease Control and Prevention (CDC), mechanism of injury is actually the third consideration in trauma triage. Examples of the guidelines are as follows. (The complete decision scheme can be found in Figure 1).
1. Physiologic criteria. Does the patient have physiologic signs of instability, including a diminished Glasgow Coma Scale (GCS) (< 14), a decreased systolic blood pressure (< 90 mmHg), or respirations < 10 or > 29 per minute? If so, the patient should be transported to a trauma center.
2. Does the patient have anatomic signs of serious injury? These include penetrating injuries to the head and torso, flail chest, multiple long bone fractures, and other significant injuries. These injuries indicate the need for transport to a trauma center.
3. Mechanism of injury. Has the patient experienced a fall (adult > 20 feet, child > 10 feet or two to three times the child's height), ejection from a vehicle, or a death in the same passenger compartment or significant intrusion of damage into the passenger compartment? In many cases you will have already decided to transport to a trauma center, but if not, these mechanisms will indicate a trauma center is warranted.
4. Special patient or scene considerations. These include the age of the patient, pregnancy, some additional specific injuries, and the judgment of the EMS provider.
Although the significance of mechanism of injury has been reduced, it has not been eliminated. The decision scheme simply places it in a more practical place--and more in line with the way we work in the field. Mechanism of injury still has a primary role in initially determining whether cervical spine stabilization should be maintained.
If your assessment reveals an unstable patient (altered mental status or hypotension), the patient is clearly injured. The same holds true for specific injuries found during assessment. When a patient has a significant mechanism of injury, he may or may not be injured. Research has yet to show a definitive correlation between mechanism of injury and actual injury.
The primary assessment remains the step during which we identify and treat threats to life. The primary assessment will differ among patients, based on their needs. An alert and oriented patient is less likely to need an aggressive primary assessment than a patient with an altered mental status.
Traditionally guided by the steps ABC--except in the case of an apparently lifeless person, when CAB is recommended by the American Heart Association--the primary assessment proceeds as follows:
General impression: How does the patient look?
This initial step helps to determine whether the patient appears responsive or not and provides a first glance at patient positioning (e.g., tripod position, clenched fist to chest) and general appearance (e.g., pale, anxious). Based on these observations alone, you can begin to determine the criticality of the patient and the pace with which you will assess and treat this patient.
Begin cervical spine stabilization if spine injury is suspected.
Airway: Is it open, and will it remain open if I divert my attention elsewhere?
If the patient is alert, oriented, and breathing, it is likely that you will need to take no action here. When a patient has an altered mental status or noisy (sonorous or gurgling) breathing, you must open the airway and suction as necessary. This is especially important in trauma patients who have facial trauma or direct laryngeal trauma that may bleed into the airway.
Oral or nasal airway
Breathing: Is the patient breathing? Is the patient breathing enough to support life?
As with the airway step, the assessment and care you give will depend on the patient's mental status. Patients who are alert, oriented, and not anxious likely have adequate breathing. Those who have an altered mental status or injury to any part of the face, neck, or chest will need further evaluation (see Figure 2).
In the trauma patient:
- Assess the chest to determine if it is intact and to examine for flail segments.
- Look for penetrating injuries and open wounds.
- Listen for lung sounds on both sides to determine whether a pneumothorax or tension pneumothorax is present.
Oxygen via cannula or mask
Positive pressure ventilation via BVM, FROPVD, or pocket face mask
Treating critical chest injury (e.g., occlusive dressing, stabilize flail segment).
Circulation: Does the patient have a pulse? Is the patient bleeding severely? Is the patient in shock?
Patients who are talking have a pulse, but they may be in shock. The fact that a patient is responsive does not eliminate the need for further assessment in this step. If the patient is responsive, continue to talk to him and ask where he is hurt. Look for obvious bleeding. If the bleeding is severe, stop it during the primary assessment. If it is not severe, it will be treated later. Then check the patient's pulse and skin color, temperature, and condition. If the patient is in shock, you should know that now rather than waiting until later in the assessment.
Control of severe bleeding
Treatment for shock.
Priority determination: What is my patient's status and transport priority?
Is my patient stable, potentially unstable, or unstable? At this point, you will decide on your patient's general status and make decisions based on that status. If your patient is unstable, he will be rapidly assessed and transported from the scene, with spinal considerations, to an appropriate destination. Stable patients will be assessed, fully immobilized, and transported routinely to the hospital. The wide range of potentially unstable patients will be treated more expediently than stable patients, who will receive more care on scene than unstable patients.
The secondary assessment is one head-to-toe exam, but it may be done in at least two ways, depending on the status of the patient determined at the end of the primary assessment. Patients who are unstable will receive this head-to-toe exam more quickly, whereas those who appear to be more stable (some of whom are potentially unstable) will receive the secondary exam proportionally more slowly (see Table 2).
If a patient appears to have a minor, isolated injury (such as an ankle injury), it is acceptable to assess and treat only that one injury or location.
Although the hands-on examination of a trauma patient offers the highest yield of information, there is still definitely a place for the history.
In addition to obtaining the signs and symptoms from the responsive patient, the history can serve to identify factors that may have caused the trauma or may be relevant to the patient's presentation or to identifying complications to his treatment. For example:
- You may find that a patient had a medical episode (syncope, seizure, hypoglycemia) that caused the patient's fall or motor vehicle collision.
- Medications may mask signs of shock. Beta blockers may prevent an increase in pulse, which will mask the progression of shock.
- The patient may have had a prior stroke, which has caused some weakness on one side of the extremities that could be mistaken during tests of grip strength.
Speaking to the patient, family, and bystanders who may have witnessed the event may provide significant information on the events surrounding the trauma.
SAMPLE remains the recommended mnemonic for remembering the components of the patient history.
Vital signs--or, more important, trends in vital signs (see Table 3)--are crucial in determining the severity and progression of your patient's condition. The traditional vital signs include the following:
- Skin color, temperature, and condition
- Blood pressure
Pulse oximetry is in such common use that it is frequently considered a sixth vital sign. Use caution when obtaining pulse oximetry readings on patients who are hypoperfusing, however, as the readings are frequently inaccurate. The hemoglobin in the blood may be 100% saturated, but this is of minimal value diagnostically when the patient is severely hypovolemic.
Pulse oximetry will likely have a greater role in patient assessment and care, as more protocols specify oxygen delivery amounts and devices based on oximetry readings. Unstable trauma patients and any patient suspected of being hypovolemic will still receive high-concentration oxygen via nonrebreather mask when breathing adequately, and positive pressure ventilation with oxygen when necessary for inadequate or absent breathing.
Vital signs are monitored frequently, depending on the patient's status. Generally, patient's vitals are rechecked approximately every 15 minutes (and at least twice) when the patient is stable and every 5 minutes when the patient is unstable--transport time and priorities permitting.
Noninvasive blood pressure (NIBP) devices (Figure 3) are being used more frequently in the field and are specifically mentioned in the Education Standards. NIBP devices are convenient in that they automatically measure the patient's blood pressure at preselected intervals.
You should always take one manual blood pressure during the call--preferably at the beginning--to compare with the NIBP reading. Because the NIBP is a mechanical device, it may occasionally display an incorrect or erroneous reading. Obtaining an occasional manual blood pressure will help reduce the impact of the erroneous readings, especially in hypotensive patients.
You should frequently reassess your patient while he is in your care. This will help to observe trends in the patient's condition. In the absence of higher priorities (e.g., suction or ventilating your patient), your reassessment will cover the following components when applicable and time permits:
- Reevaluate components of the primary assessment.
- Reevaluate the chief complaint and/or injuries.
- Recheck vital signs.
- Verify that all interventions (splinting, spinal immobilization) are still effective.
Reassessment should be performed approximately every 15 minutes for stable patients and every 5 minutes for unstable patients when time and priorities permit (Figure 4).
Coming in the April issue: Medical Assessment
|1994 EMT-B Curriculum||National EMS Education Standards|
|Scene size-up||Scene size-up|
|Initial assessment||Primary assessment|
|Rapid trauma exam||Secondary examination|
|Focused exam||Secondary examination|
|Detailed assessment||Secondary examination|
|Secondary Assessment-Unstable Patient ||Secondary Assessment-Stable Patient
Purpose: To perform a rapid exam that will help identify major injuries and end with the patient being placed on a spine board.
Further examination can be done en route if time permits.
Maintain c-spine stabilization throughout.
Rapidly examine the following:
Purpose: To perform a head-to-toe assessment on a stable patient to determine a full picture of the patient's injuries.
To assess a single injured area on a patient if the mechanism of injury and chief complaint indicate the injury is isolated.
Maintain c-spine stabilization if indicated.
Examine in detail (when indicated):
|PULSE||RESPIRATIONS||BLOOD PRESSURE||PULSE PRESSURE||SKIN|
|SHOCK||Increase||Increase||Decrease (late)||Narrows||Becomes cool and clammy|
|INCREASING INTRACRANIAL PRESSURE (LATE)||Decrease||Irregular||Increase||Widens||Varies|
|ANXIOUS, UNINJURED PATIENT CALMING DOWN||Decrease||Decrease||May decrease of remain the same||No significant change||Becomes warm and dry|
Click here for a Review Document on Part 1: Assessment of the Trauma Patient.
Joseph J. Mistovich, MEd, NREMT-P, is chair of the Department of Health Professions and a professor at Youngstown State University in Youngstown, OH. He has more than 25 years of experience as an educator in emergency medical services. He is an author or coauthor of numerous EMS books and journal articles and is a frequent presenter at national and state EMS conferences.
Daniel Limmer, AS, EMT-P, has been involved in EMS for 31 years. He is active as a paramedic with Kennebunk Fire-Rescue in Kennebunk, ME. A passionate educator, Dan teaches basic, advanced, and continuing education EMS courses throughout Maine.
Howard A. Werman, MD, FACEP, is professor of Emergency Medicine at The Ohio State University. He is a teacher of medical students in the College of Medicine and the residency training program in Emergency Medicine at The Ohio State University Medical Center. He has been active in medical direction of several EMS agencies and is medical director of MedFlight of Ohio, a critical care transport service that offers fixed-wing, helicopter and mobile ICU services.