ASSESSMENT OF THE TRAUMA PATIENT

April Morgenroth RN, MN

Initial AssessmentEarly recognition of injury + early intervention

= better patient outcomes

http://www.healthsavers.info/images/ist2_449711_healthy_heart.jpg

Primary Assessment

Airway

Breathing

Circulation

Disability

Remember …

• Airway

Is the patient stable?

• Breathing

Is the patient stable? • Circulation

Is the patient stable?

• Disability

Is the patient stable?

• Full set Vital Signs/Five interventions

Is the patient stable? • History/

Head to toe

Is the patient stable?

Airway• Inspect the patient’s airway

while maintaining cervical spine stabilization.

• Observe for speaking, tongue obstructing airway , bleeding , vomiting, and swelling.

Interventions for Ineffective Airway

• Maintain Cervical Spine Stabilization and/or immobilization

• Proper positioning for airway patency– Jaw thrust– Chin lift– Removal of or foreign objects or

debris– Suctioning

BreathingAssess for rise and fall of chest, respiratory rate

and pattern.

Signs of Ineffective Breathing

Restlesness, agitation,

altered mental status

Cyanosis, especially

around mouthAsymetrical

chest expansion

Use of Accessory

and/or abdominal muscles

Sucking chest wounds

Jugular veindistention

Tracheal shift deviation

Absent or diminished

breath sounds

Interventions for Ineffective Breathing

• Administer Oxygen via a mask or nasal cannula.

• Ventilate the patient via a non-rebreather mask.

• Insert Artificial Airway

http://uemshealthcare.org/images/basicairwaystill.jpg

Circulation • Palpate Pulses: Are they normal,

weak or strong?• Inspect skin: Is the color normal? Is

it warm or cold? Clammy or dry?• Look for obvious bleeding.• Obtain blood pressure.

Signs of Ineffective Circulation

Excessive sweating

Pale, cool, skin

Low blood

pressure

Uncontrolled External Bleeding

Altered Mental Status

Tachycardi

a

Interventions for Ineffective Circulation

• Control any uncontrolled bleeding by:– Apply direct pressure to

the wound and/or apply a pressure dressing

– Use a tourniquet only when other methods to control bleeding have failed

• Initiate IV access Fluid resuscitation with

Normal Saline or Lactated Ringer’s

• Consider planning for a blood transfusion, if ordered and available

Disability – Neurologic Status

The patient’s level of consciousness can show immediate signs of brain injury.

A – Alert and responsiveV – Responds to verbal stimuliP – Responds to only painful stimuliU - Unresponsive

Assess pupils for size, shape, equality, and reactivity to light

Pupils

Secondary Assessment

Obtain Vital Signs

Head to Toe Assessment

Medical History

Full Set Vital Signs

• Obtain vital signs: respirations, pulse, blood pressure, temperature, pulse oximetry, pain.

• Obtain Laboratory studies if necessary.

History• Mechanism of Injury and time it happened• Description of Injuries and pain• Past medical history, previous hospitalizations• Age• Medications / Allergies• Immunization history• Use of drugs or alcohol, smoking history• Last menstrual period

http://www.handcrafted-pens.com/img/PK-PEN.jpg

7. Head-to-Toe Assessment

Chest

Abdomen and flanks

Pelvis

Extremities

Back

Head and face

• General Appearance:– Take note of the patient’s level of distress (mild,

moderate, severe),– body position,– posture,– rigidity or flaccidity of muscles,– unusual odors (alcohol, gasoline, chemicals, body

fluids).

Head and Face

• Loose teeth or foreign objects which may compromise the airway

• Soft tissue injuries• Deformities• Eyes• Ears• Nose • Neck

http://www1.istockphoto.com/

Head and Face

• Assess for:– Gross visual acuity

– Bruising, bleeding, or swelling around the eyes

– Pupils: equal sizes, shape, reactivity

Eyes

http://upload.wikimedia.org/wikipedia/commons/6/65/Eye_iris.jpg

Head and Face• Inspect for:

– Bruising behind the ear (Battle’s sign)

– Soft tissue injury– Unusual drainage from ears

or nose, such as blood or clear fluid. DO NOT pack it to stop drainage as it may be cerebrospinal fluid (CSF).

– Avoid inserting a nasogastric tube if such drainage is present.

Ears/Nose

http

://w

ww

.imm

edia

teac

tions

ervi

ces.

com

/bat

tless

ign.

jpg

(Battle’s Sign)

Neck

• Inspect for:– Signs of trauma

• Observe position of trachea and appearance of external jugular veins.

n

Chest• Inspection

– Observe breathing for rate, depth, effort, use of accessory muscles, asymmetrical chest rise

• Auscultation– Note any abnormal lung sounds

• Palpation– Palpate clavicles, sternum, and

the ribs for bony crepitus or deformities

Abdomen/Flanks

• Inspection– Soft tissue injuries

• Auscultation– Bowel sounds

• Palpation– Rigidity, guarding,

masses, areas of tenderness.

Pelvis/Perineum

• Inspect for external soft tissue injuries, deformities, exposed bone, blood at the perineum

• Palpate for stability of pelvic bones

Extremities• Circulation

– Inspect color– Palpate skin temperature– Palpate pulses

• Soft tissue injuries• Bony injuries• Motor function:

– Check motor function on both sides – does the patient move both sides of the body equally?• Hand grasp and foot

strength

Inspect The Back• Maintain cervical spine

stabilization • Support extremities with

suspected injuries• Logroll patient with at

least 3 other team members

• Palpate all posterior surfaces for deformity and areas of tenderness

http

://w

ww

.itim

.nsw

.gov

.au/

imag

es/lo

grol

l-blo

ody_

back

.jpg

Glasgow Coma Scale

• A measure of the patient’s level of consciousness

• Score ranges from 3-15

• Severe head injury – <8

• Moderate head injury– 9-12

• Minor head injury– 13-15

Area of Response

Points

Best Eye Opening•Spontaneously•In response to voice•In response to pain•No eye opening

4321

Best Verbal Response•Oriented•Confused•Inappropriate•Incomprehensible•none

54321

Best Motor ResponseObeys commandsLocalizes painWithdraws from pain Flexion/decorticate posturingExtension/decerebrate posturingNo movement

654321