Trauma Assessment

1. Trauma Assessment The Beginning Toni L. Downen RN, MSN, CEN

2. Airway to Inspection • One of the most important aspects of trauma is the assessment of the person from head to toe and knowing what to do about it. This includes assessment of potentially life threatening injuries and appropriate interventions (Primary assessment). • Airway • Breathing • Circulation • Disability • Exposure and Environment • Full set of Vitals, Focused adjuncts, and Family presence • Give comfort measures • History and Head-to-toe • Inspect the posterior surface

3. Airway • Airway • Open the airway (Breathing OK? Move on, If not: • Is there anything in the mouth? • Tongue in way • Teeth • Vomitus • What color is the skin? • Pale • Dusky-grey • Cyanotic

4. Interventions • Allow a position for maximal airway potential • Jaw thrust or chin lift • Suction mouth and remove debris and loose objects • Use a nasopharyngeal or oropharyngeal airway to displace the tongue unless there is facial trauma • Prepare for intubation or other advanced airway techniques especially if burned and has a possibility for complete airway obstruction • Initiate and maintain cervical spinal immobilization

5. Breathing • Are they breathing? • Nice and easy? Or hard with retractions? • Are they grunting or gasping? • Breathing less than 8 breaths a minute? • Can they speak? • Is there blunt or penetrating trauma to the neck, chest, back or abdomen? • How are the breath sounds? • Clear, decreased or absent? • Is there paradoxical chest wall movement? • Signs and symptoms of a flail chest?

6. Interventions • Check pulse oximetry readings • less than 94% ( or less than patients baseline) • Check for abnormal Arterial Blood Gases • Give oxygen as needed • Assist ventilations with bag mask device if needed • Perform needle decompression of chest or chest tube insertion if needed • Pneumothorax or hemothorax • Cover any open wounds with a non-occlusive dressing • Sucking chest wounds, tape on 3 sides

7. Circulation • The exchange of gasses with breathing is useful only if the circulatory system can circulate those gases • Things that can prevent circulation • Shock (especially hypovolemic or obstructive) • Tension Pneumothorax or cardiac tamponade • Check quality of pulse • Weak and thready • Strong and bounding • Pallor or cool diaphoretic skin

8. Interventions • Check quality of vital signs • Systolic blood pressure <90 in adults • Capillary refill > 2 seconds • Heart rate < 60 or > 100 beats with circulatory compromise • Level of consciousness (restlessness or anxiety)

9. Disability • Disability has to do with neurologic status. Must be dealt with early to prevent long-term effects of head trauma. • Look for unequal pupils that are sluggish or slow to react or maybe fail to react • Altered level of consciousness (Glasgow coma scale) • One sided weakness or loss of function Abnormal posturing

10. Interventions • Maintain head alignment with bed flat or elevated 30-45 degrees • Consider Mannitol (Osmitrol) to decrease the increased intracranial pressure • Decrease external stimuli • Loud noise, music, too many people visiting • Glasgow coma scale-Severity of injury • Score of 13 to 15 is defined as a mild injury • 9-12 is a moderate injury • 8 or less indicates a severe injury and coma

11. Exposure and Environment • Remove all clothing and assess the body for wounds covered and deformities possibly caused by the trauma • Look at patients backside (logrolling if patient is in C-spine immobilization) • Keep the patient warm • Blankets • Warm fluids (room temperature can decrease body heat) • Keep patient dry (wet blood and body fluids)

12. Secondary Assessment F & G • Full set of vital signs • Temperature • Blood pressure (In both arms) • Pulse (Both central and peripheral) • Respirations • In patients with chest trauma and aorta damage is suspected, do blood pressure in both arms and one leg. Look for a difference in 10 mm of mercury or more in blood pressure and a difference in pulse quality in central and apical.

13. Focused Adjuncts • Continuous cardiac monitoring • Oxygen saturations • Placement of a gastric tube • Insertion of a urinary catheter (unless there is genitalia trauma) • Collection of Lab studies • Focused assessment with sonography for trauma (FAST)

14. Family Presence • Family presence during resuscitation of a trauma patient helps the family to cope • Family helps the patient heal

15. Give Comfort • Pain reduction is important (recognize signs and symptoms) • Medications • Ice and splinting • Reposition • Immobilization • Warm compresses • Distraction techniques • Reduce anxiety • Deep breathing techniques • Visualization • Hold a hand

16. History • If patient is awake, alert and cooperative, obtain information needed • Medications • Allergies • Medical history as well as family history • Involve the family as much as possible • Witnesses or bystanders can assist with mechanism of injury and suspected injuries as well as treatment provided prior to arrival

17. Head to Toe • Head and Scalp • wounds and deformities • Asymmetry • Lacerations, bony fragments, hematomas, tenderness • Ecchymosis or discoloration including areas behind the ears, over the mastoid process (battles sign), around eyes (raccoon eyes) (signs and symptoms of a basilar skull fracture.

18. Face • Note drainage from ears, nose, eyes or mouth • Reassess pupils for symmetry, light response and accommodation • Check gross visual acuity • Check mouth for lacerations, loose or missing teeth and foreign bodies. Can they open their mouth and close it without problems?

19. Neck • Palpate and inspect the neck • Ecchymosis • Neck vein distension • Subcutaneous air • Endotracheal deviation (pneumothorax) • Auscultate carotid arteries for bruits • Palpate for deformities, defects, cervical vertebra tenderness

20. Chest • Visualize for deformity, asymmetry, penetrating trauma and other wounds • Auscultate heart and lungs • Palpate the chest wall for deformities and tenderness • Obtain a chest x-ray • 12 lead Electrocardiogram • Arterial Blood Gas if needed or on a ventilator

21. Abdomen • Inspect the abdomen for bruising, masses, pulsations, and penetrating objects • Observe for distension and evisceration of bowel contents • Auscultate in all four quadrants • Gently palpate for rigidity and tenderness, rebound pain, or guarding • Obtain cat scan, Abdominal or kidney-ureter-bladder (KUB) x-ray series

22. Pelvis • Visualize for bleeding, bruising, deformities and penetrating trauma • Inspect perineum for blood, feces, and any obvious injury • Rectal exam is used to check sphincter tone, identify blood or check the prostate • Gently press inward and upward on iliac crest to assess pelvis stability • Palpate over the symphysis pubis • Stop palpation if pain or motion are present-Obtain x-ray

23. Extremities • Inspect all four limbs for deformity, bleeding, bruising, ecchymosis, swelling and other wounds • Palpate for areas of tenderness, crepitus, and temperature abnormalities • Check sensory, motor, and neurovascular status often • Obtain x-rays • Splint non open fractures • Perform wound care

24. Inspect Posterior Surface • 50 percent of the body's surface lays against the stretcher and many injuries can be missed if the patient is not log rolled • Maintain cervical spinal alignment when log rolling, use at least 1 other person to assist you • Look for bruising, discoloration, and any open wounds • Palpate bony prominences for deformity, movement and pain • Remove clothing or wet items under the patient • Once spine is cleared, remove backboard if possible, if not try to pad it

25. Reevaluate and reassess • Pain control is important (medication as needed watching respiratory depression) • Watch for further neurological deterioration (especially after medications-they can mask signs and symptoms) • Monitor urinary output • Document carefully, especially interventions, reassessments, and care performed. • Use a team approach to trauma care, intervene and correct the problems

26. Infection Control • Number 1 way of preventing infection and spread of disease is hand washing with soap and water in between patients • Number 2 way is to pretend all the patients you take care of is someone in your family and you will always do the right thing

27. An Assessment • Here is where I will add a small video…or Luis will LOL

28. References • Sheehy’s Manuel of Emergency Nursing (2013) • McQuillan, Von Rueden, Hartsock, Flynn and Whalen Trauma Nursing From Resuscitation Through Rehabilitation 3rd Edition (2009)