Chapter 15

1. Chapter 15 Detailed Physical Examination

2. Overview • Detailed Physical Examination

3. Detailed Physical Examination • Primary objective: Discover all signs of injury that may not have been uncovered during the rapid trauma assessment

4. Detailed Physical Examination • Goal of an EMT: Uncover those signs of injury that could not be treated while en route to the hospital

5. Detailed Physical Examination • Performed after the initial assessment and rapid trauma assessment have been completed • Measures the effectiveness of prehospital treatments that were initiated early in the assessment

6. Detailed Physical Examination • May discover changes in the patient condition prompting an ALS intercept or change in priority of the patient • The detailed assessment is a methodical head-to-toe physical examination • Ongoing treatment of life-threatening conditions may preclude the completion of this examination

7. Steps in the Detailed Physical Examination • Very much like the rapid trauma assessment • DCAP-BTLS is used to describe the signs of injury that should be sought

8. Steps in the Detailed Physical Examination • Head • Palpate the entire skull, starting from the rear of the skull in the occipital area (look for DCAP-BTLS) • Remove glass shards that might cause injury

9. Steps in the Detailed Physical Examination • Ears • Look for DCAP-BTLS • Look for drainage; clear fluid might indicate cerebrospinal fluid • CSF indicates a skull fracture • Do not attempt to stop the flow of CSF, because doing so can result in increased pressure inside the skull • Check for Battle’s sign behind the ears, indicative of fracture to the base of the skull

10. Steps in the Detailed Physical Examination • Watch this video showing how CSF can leak from the ears

11. Steps in the Detailed Physical Examination • Eyes • Compare one eye to the other to examine for differences while looking for DCAP-BTLS • Bruising around the eyes is sometimes called raccoon’s eyes; it may be indicative of a fracture to the base of the skull

12. Steps in the Detailed Physical Examination • Eyes • Assess pupils for size, shape, and reaction to light • Lack of constriction in response to light may indicate serious eye or brain injury • Any foreign material such as dirt or glass should be brushed away from the eyes, if possible • If it does not easily brush away, leave it alone and allow hospital staff to remove it

14. Steps in the Detailed Physical Examination • Nose • Check for DCAP-BTLS • Excessive bleeding may result if a NPA is inserted into a broken nose • Check nares with penlight; blood running down the back of throat may nauseate the patient and cause vomiting • Clear fluid running from the nose may be CSF

15. Steps in the Detailed Physical Examination • Face • EMT should next carefully assess the face for DCAP-BTLS

16. Steps in the Detailed Physical Examination • Mouth • Injury can cause airway problem • Assess for DCAP-BTLS inside and outside the mouth • Check for loose teeth or other foreign objects and remove to prevent aspiration • Dental hardware should be removed if it is loose; otherwise leave it in place

17. Steps in the Detailed Physical Examination • Mouth • Is the tongue swollen or the surrounding tissues reddened or discolored? • Swelling in the mouth from burns can mean swelling in the lower airways • Is voice hoarse after airway injury?

18. Steps in the Detailed Physical Examination • Neck • Assess for DCAP-BTLS • Determine position of trachea • Midline or deviated?

19. Steps in the Detailed Physical Examination • Chest • Should be thoroughly examined • Assess using DCAP-BTLS • Check breathing (observe for any difficulties or abnormalities); can the patient take a deep breath? • Listen to breath sounds (both anterior and posterior)

21. Steps in the Detailed Physical Examination • Abdomen • Explain to the patient what you are doing • Look for any injuries indicated by DCAP-BTLS • Check for distension (may indicate internal bleeding) • Note urinary incontinence

22. Steps in the Detailed Physical Examination • Abdomen • Listen to what the patient tells you • Where is the pain? Does one area of the abdomen hurt more than another? • Feel the anterior abdomen gently; does it feel soft? • A firm, tender abdomen indicates the natural muscular guarding of an injury; guarding may suggest abdominal bleeding

23. Steps in the Detailed Physical Examination • Abdomen • Don’t reassess areas where the patient has complained of abdominal pain or has shown signs of tenderness and guarding on previous physical exams • Little more can be gained from the information and the unnecessary creation of pain is cruel

25. Steps in the Detailed Physical Examination • Pelvis • Compression and flexion of pelvis • Pressing inward on the hips will help discover hip fracture • Press on the pubis to stress the bony pelvic ring • Tenderness during any part of this exam indicates possible fracture

27. Steps in the Detailed Physical Examination • Extremities • Look for DCAP-BTLS • Palpate each limb along the length of the bone • Compare one extremity with another • Reassess for pulses, movement, and sensation (PMS) • Check grip strength and equality of grasp

29. Steps in the Detailed Physical Examination • Vital signs revisited • Every exam should be followed up with a full set of vitals • Compare with baseline • Establish a trend • Any significant change in vital signs should be reported to the hospital staff

30. Steps in the Detailed Physical Examination • Back and buttocks • Check back and buttocks for DCAP-BTLS • Carefully examine the back and buttocks for injury • Do this while maintaining continuous manual stabilization of the head, preferably with a cervical collar in place

32. Stop and Review • On whom should EMTs perform a detailed physical examination? • What is the primary objective of the detailed physical examination? • What are some of the things an EMT should check for when examining the head, ears, and eyes?