Pre-hospital trauma assessment

Pre-hospital trauma assessment is a set of skills used by emergency medical services technicians to analyze all threats to life that a patient could suffer due to a trauma incident. Pre-hospital trauma assessment is broken into two major types: basic trauma assessment and advanced trauma assessment. The basic assessment is provided by first responders and EMTs. The advanced assessment is provided by a paramedic.

1. Scene size-up
2. Initial assessment
3. Focused history and physical examination
4. Detailed physical examination
5. Ongoing assessment
6. Communications
7. Documentation

Scene size-up

Approaching and sizing up a trauma incident scene is one of the most important primary steps that a pre-hospital care provider carefully does. Within a critical trauma incident, seeing hazardous material and traffic in an uncontrolled environment is expected. These factors can cause life-threats for providers, coworkers, and bystanders. Therefore, controlling all these life-threats is initially accomplished even before patient contact.

After scene management, a pre-hospital care provider gets a general impression of the scene. A general impression is discovered by evaluating the mechanism of injury. For example, in a car accident, mechanism of injury is detected by estimating the speed at which the collision occurred, looking at the amount of damage, and looking for other factors that may affect the mechanism of injury, such as airbag deployment.

This general impression helps the provider to make some important decisions regarding the number and type of transport units needed, and also helps to determine how critical a patient is.

Scene size-up consists of several steps which may be performed in different orders dependent upon circumstance:

• Body substance isolation precautions
• Scene safety
• Mechanism of injury
• Number of patients and need for additional help

Critical to the scene size-up is the need for quick decisions to be made. In the absence of hazards delaying progress, such decisions should be made by the time the patient is reached.

Initial assessment

The initial assessment for trauma patients does not differ from medical patient assessment. The primary outcome of the initial assessment is to determine any "immediate life threats".

The first step in performing an initial assessment is forming a general impression - is this patient "sick", "not sick", or "not sure". Taking steps to immobilize the patient's head to prevent any or any further injury to the spine, the level of consciousness is assessed according to the AVPU criteria - Alert, responds to Verbal stimuli, responds to Pain stimuli, Unresponsive.

After checking the level of responsiveness, ABC is checked. ABC stands for airway, breathing, and circulation. In a trauma patient, sometimes the airway gets blocked due to facial injury or foreign body objects. According to Sanders, a patent airway should be maintained by positioning the patient properly, removing all blocking objects and carefully positioning the head using jaw-thrust technique.

The next step after maintaining a patent airway is checking breathing rate and quality. If the patient is breathing less than 8 times/minute or shallow more than 35/minutes, the patient then needs somebody to breathe for him using a [bag valve mask] attached to a high flow oxygen source.

Then, checking the pulse comes as the third step. For unresponsive adult patients, checking pulse is performed by palpating the carotid vein in the neck. For infants and small children, the pulse is usually assessed in the brachial artery in the upper arm. After confirming that the pulse is present, the final step in the initial assessment for a trauma patient is to check for any gross bleeding and to control it. Should a pulse not be detected, or in the case of a child or infant is present but at a rate less than 60, cardiovascular resuscitation will be commenced.

Steps:

• General impression of the patient
• Assessing the patient's mental status
• Assessing the patient's airway status
• Assessing the patient's breathing status
• Assessing the patient's circulation
• Identifying priority patients

Focused history and physical examination

In a critical trauma incident, more than one provider is needed to be available to perform an assessment on one patient. After the initial assessment, one of the providers checks vital signs and looks for any information about the patient's medical history. Other providers work on physically examining the patient to look for any life threats or other problems that can be fixed while en route to the hospital. A rapid head-to-toe exam is performed to look for any deformities, contusions, abrasions, punctures, burns, tenderness, swelling, and lacerations. If none of these are life-threats, they are ignored on scene and then begin immobilizing the patient on a long spine board.

The initial assessment, primary survey, and immobilization of the patient do not take more than ten minutes to achieve.

Steps:

• Mechanism of injury
• Evaluating patients with serious injuries or mechanisms of injury
• Evaluating patients with no significant mechanisms of injury

Ongoing assessment

The en route assessment starts when the patient is loaded in the ambulance. En route assessment begins with a repeat of the initial assessment and ensuring that the patient still has a patent airway, breathes or is being properly ventilated, and has a pulse.

References

• Sanders. Paramedic Textbook.