WK 4 Assessment and Management of the Traumatized Patient

Introduce yourself

per your hospital's guidelines; ask how they wish to be addressed. Instruct them to lie still if possible; state what you intend to do. Gain consent for treatment if decisional. If awake, ask about chief complaint and history of present injury. During the rapid primary assessment, appropriate verbal responses to questioning suggest a patent airway, breathing that is not severely compromised and no major decrease in level of consciousness

Common problems that account for inaccurate BP readings

(1) Cuff over clothing: Higher by... 10-40 mmHg (2) A full bladder: 10-15 mmHg (3) Talking while reading is taken: 10-15 mmHg (4) Unsupported arm: 10 mmHg (5) Unsupported back: 5-10 mmHg (6) Crossed legs: 2-8 mmHg

Mean Arterial Pressure

(1) Better reflection of perfusion to (a) Coronary arteries; brain; kidneys (b) Peripheral tissues (2) Calculated value: MAP = DBP + 1/3 PP (a) DBP counts twice as much as SBP because 2⁄3 of cardiac cycle is spent in diastole (b) Automatically calculated by NIBP; number in brackets ( ) after systolic and diastolic readings 190/80 (94) (c) Normal 70-110 (d) Minimum acceptable MAP = 65. Newer research suggests this may be lower in penetrating chest trauma.

Orthostatic changes

(1) Definition: Decrease of 20 mmHg (or more) in SBP or a decrease of 10 mmHg (or more) in DBP following a position change. (2) Controversies exist regarding timing of assessments and whether to include changes in HR. A positional drop in BP accompanied by an increase in HR may indicate nonneurogenic causes (e.g., medication, volume deficit), while no increase in HR may indicate a neurogenic etiology (e.g., autonomic system failure). (3) Obtain BP and pulse after patient has been supine for 10 minutes. Take BP and HR immediately after the patient sits or stands and ask about dizziness. Positive if HR increases 15-30 BPM or if SBP drops 20 mmHg. May indicate a 15% volume deficit or blunting of homeostatic mechanisms (especially in elderly).

Percussion

The act of striking a part of the body with short, sharp blows in order to produce a sound. Place the 3rd finger of your non-dominant hand on the area you want percussed. Rapidly strike the nailbed of that finger with the 3rd finger of your dominant hand thereby creating vibrations that produce sound waves from four to six cm deep into underlying body tissue. Draw the striking finger back quickly to avoid dampening the sound. Always percuss over soft tissue (i.e., between ribs), never over bone. The sounds produced are classified as resonant, hyperresonant, flat or dull and depend on the amount of air present in the underlying tissues. The denser the tissue, the quieter the tone. Normal lung tissue = resonance. More air = hyperresonance. Less air/more solid = a dull or flat sound. Therefore, a pneumothorax elicits a hyperresonant note and a hemothorax elicits a dull note.

Expected outcomes for B = Breathing/ventilatory/oxygenation status

a. Spontaneous, unlabored ventilations b. Chest expansion equal bilaterally c. Breath sounds present and equal bilaterally d. Normal speech pattern; phonates well e. Gas exchange adequate with no signs of hypoxemia; hypo or hypercarbia

Head to toe review of systems; correlate findings to patient history and kinematics: Chest/thorax/pulmonary system: Percuss/Auscultate: Abnormal breath sounds

(a) Bronchial breath sounds (i) Sounds with little filtered loss. Resemble tracheal breath sounds or air blowing through a hollow pipe. (a) Loud (b) High-pitched; increased frequencies preserved (c) Remain audible throughout inspiration and expiration. Expiration phase is louder and longer than inspiration. (d) Normally present over the manubrium. Distinct pause can be heard between I and E. (ii) If heard in periphery, is associated with airless lung tissue and abnormal sound transmission as in consolidation, atelectasis, fibrosis, or pneumonia. (iii) May be heard over an airless upper lobe whether the bronchus is patent or obstructed. This is because the mediastinal surface of the upper lobe is in contact with the trachea which permits sound transmission directly to lung tissue. (iv) Conversely, there is no direct path of sound transmission to the lower lobes, so tracheal sounds do not run to the lower lobes unless the intervening bronchi are patent. Therefore, bronchial breathing is absent if lower lobe is consolidated or atelectatic as a result of bronchial obstruction. (b) Absent or diminished breath sounds: Most sinister of all. Absent or diminished breath sounds are usually associated with a pneumothorax, hemothorax, chronic obstructive pulmonary disease (COPD), severe airway obstruction or pleural effusion. Breath sounds will be diminished bilaterally in patients who have COPD or who are obese, but will differ from the right to left side with unilateral pneumo/hemothorax, or pleural effusion. (c) Even a shallow pneumothorax will reflect sounds away and result in diminished breath sounds over that area. Sounds will not return until all air is absorbed and the pleurae are in contact again. (9) Adventitious sounds: Crackles and wheezes are super-imposed on normal breath sounds. (10) Crackles (a) Definition - Short explosive sounds caused by sudden equalization of gas pressures between two compartments of the lung. Lower airways close first. Reopening results in popping sounds or crackles. (b) Described according to pitch, timing and location. Timing is indicative of underlying pathology. (c) Late inspiratory crackles: Sudden onset of collapsed peripheral airways and adjoining alveoli characteristic of fibrosing alveolitis, interstitial pulmonary edema or atelectasis from shallow breathing. Although they are usually associated with left-sided ventricular failure, they may be heard in poorly ventilated atelectatic lung areas. Characteristics (i) High-pitched, explosive (like ripping Velcro) (ii) Variable intensity (iii) Basilar and symmetrical (iv) Gravity-related traction on small peripheral airways (v) No change from coughing; secondary to left-sided heart failure, early pneumonia or pulmonary fibrosis. Crackles secondary to atelectasis usually clear with coughing. (d) Early inspiratory and expiratory crackles: Produced by wide-spread airflow obstruction in the central airways and are loud, low-pitched, scanty and well-conducted, especially to the lower lobes. Early inspiratory and expiratory crackles can be heard throughout both lung fields in patients with chronic bronchitis. (11) Wheezes (a) Definition: Harmonic, musical sounds (b) Described according to pitch, duration, timing and complexity. (c) Pathology: Wheezes are produced when air passes rapidly through a bronchus so narrowed that it is almost closed. As the bronchial walls fluctuate between closed and barely open, they generate audible sounds. (d) Complexity (i) Monophonic (ii) Polyphonic (e) Where heard: Wheezes produced in the large central airways are usually audible without a stethoscope at the mouth. Those produced in the peripheral airways are audible with a stethoscope only. (f) Disappearance of wheezes: Wheezes may dissipate if bronchoconstriction becomes so severe that airflow velocity diminishes below the level necessary to produce audible sounds. Correlate the disappearance of wheezes with the patient's ability to move a large enough volume of air. Assess their ability to speak in complete sentences without gasping for breath. (12) Accurate documentation: Lung sounds must be documented in all with a chief complaint or physical exam evidence of ventilatory, respiratory, or cardiovascular disease/distress, or chest trauma. Note the underlying sounds as normal, diminished, or absent for the both the left and right sides and any adventitious sounds.

Psychological stressors

A. Loss of control B. Fear of disfigurement, disability C. Financial concerns D. Responses to pain E. Significant others' reactions 1. Provide patient's family with timely reports on the patient's status. 2. Allow significant others to see patient as soon as possible and as patient's condition warrants. F. Care giver reactions - Consider need for counseling.

C = Circulatory status/hemorrhage control

Adequacy of cardiac output and rhythm, fluid volume, central and peripheral perfusion. 1. Assess for actual and potential compromise a. Bleeding: Significant hemorrhage occurs in any of five sites: external, intrathoracic, intraperitoneal, retroperitoneal, and pelvic or long bone fractures. (1) Exsanguinating external bleeding should already be controlled (2) Suspect concealed internal bleeding if shock is apparent without external hemorrhage. Occult hemorrhage can account for a major blood loss. b. Pulses: If unconscious or altered mental status (AMS), quickly palpate for a central pulse (carotid) bilaterally. If awake and talking with good skin color, palpate for a radial pulse. Note: Presence/absence, general rate (fast/slow- do not count yet), quality/character, rhythmicity. (1) The SpO2 monitor IS NOT a substitute for assessing the quality and rhythmicity of peripheral pulses. "Electronic vital signs" are not acceptable as baselines. (2) Rapid HR may be a sign of hypovolemia or may be due to dysrhythmia, pain or sympathetic NS stimulation. (3) A weak or absent radial pulse and presyncopal symptoms do not appear until just prior to the point of circulatory decompensation and cardiovascular collapse. Worsening radial pulse character is a late sign of decreased systolic BP. (4) Central pulses absent at more than one site, without obvious cause, necessitate immediate resuscitative measures to replace blood volume and/or restore effective cardiac output. (5) Be alert to patients with pacemakers, the elderly, or those on medications (beta/calcium blockers, digoxin) who may not have the usual tachycardic response to shock. Assess LOC carefully. (6) An irregular pulse is usually a warning of cardiac dysrhythmia c. Perfusion: In addition to pulses, perfusion can be rapidly assessed by evaluating mental status and observing skin color and temperature of extremities. The BP is initially misleading in evaluating perfusion and treating hypovolemic shock, as significant volume losses may occur depending on the patient's age and ability to compensate before a decrease is measured. Assessment of BP should occur at the beginning of the secondary survey. After an indwelling catheter is placed, urinary output is a good measure of peripheral perfusion. Be alert to those patients whose actual condition may be masked by physiologic reserves or robust compensatory mechanisms, i.e., athlete, child, or pregnant woman. d. Skin color, temperature, moisture: The skin is one of the first organs to lose blood flow due to vasoconstriction in the presence of hypovolemia, hypothermia, fear, or a stress response. A patient with normal mucous membrane color (conjunctiva of lower eyelid) or normal skin color, temperature, and moisture, especially in the face and extremities, is rarely critically hypovolemic. Conversely, ashen, gray skin of the face and pale or mottled skin of vasoconstricted extremities are ominous signs. These may indicate a blood loss of at least 30% if hypovolemia is the cause. If skin is moist, the sympathetic nervous system (SNS) has been activated. Patients in shock will c/o being cold and may have shaking chills. e. Capillary blanch test (capillary refill) (1) Most reliable in children 6 or under (2) Normal: less than 2 seconds (3) Capillary refill may be affected by smoking, meds, hypothermia, and chronic conditions. Not routinely checked in adults. f. Level of consciousness is a good indicator of central perfusion in the absence of traumatic brain injury. Assess carefully for any subtle changes in mental status or behavior. Altered mentation, with or without intracranial injury, accompanied by tachycardia and hypotension implies shock. g. ECG monitoring If the pulse is weak, very fast, very slow, irregular, central pulses are absent or there is evidence of cardiovascular, neurological, or respiratory compromise, monitor ECG immediately. Many injuries can present with dysrhythmias, including head trauma and subarachnoid hemorrhage. Observe for dysrhythmias or changes characteristic of cardiac ischemia. Obtain a 12 lead ECG if indicated. h. Laboratory values for hematocrit or hemoglobin concentration may be unreliable and should not be used to exclude the presence of shock. Massive blood loss may produce only a minimal acute decrease in the hematocrit or hemoglobin concentration. A very low hematocrit value obtained shortly after injury suggests either massive blood loss or a preexisting anemia, and a normal hematocrit does not exclude significant blood loss. Base deficit and/or lactate levels are generally useful in determining the presence and severity of shock but must be interpreted in light of co-founding factors.

Life-threatening injuries to be detected/resuscitated now for B = Breathing/ventilatory/oxygenation status

a. Tension pneumothorax b. Open pneumothorax c. Flail chest

Causes of Tachypnea

↑ Metabolic rate, Fever, infection, exertion, Stress, pain, Cardiac dysfunction, Abdominal distention, Obesity, ascites, pregnancy, Metabolic acidosis, Uremia, Poisoning, Salicylates, Encephalopathies, CNS dysfunction, Psychogenic, anxiety, Fear, Anemia, shock

Anticipate: for C = Circulatory status/hemorrhage control

(1) In patients in extremis with impending arrest, placement of a resuscitative balloon for occlusion of the aorta (REBOA) by those trained in this technique may be life-saving. Use of this device is most effective to temporize patients with intra-abdominal or retroperitoneal sources of hemorrhage until more definitive therapy with surgery or angioembolization is possible, and so rapid transport to the OR and/or angiographic suite is essential. REBOA is not appropriate for use in those with suspected thoracic sources of exsanguination or in patients in cardiac arrest, in whom ED thoracotomy (EDT) should be performed instead. (2) Reversal of anticoagulation: Be familiar with methods for reversing anticoagulants in cases of life-threatening bleeding. (a) Stop the anticoagulant (b) Provide hemodynamic support (c) Consider local and interventional hemostatic methods (d) Check labs: (i) CBC (ii) Coag. panel (INR, PTT, PT, and anti-factor Xa activity level) (iii) Serum BUN, creatinine, liver function tests (LFTs) (iv) Blood type and screen (e) Obtain patient consent for blood transfusion (f) Consider needed imaging, depending on the suspected site of bleeding (g) Give anticoagulant reversal agent, if available

Pulsus paradoxus

(1) Inflate cuff; deflate at 2-3 mmHg/heart beat (2) Confirm peak SBP during expiration (3) Listen again. Determine SBP when sounds audible during inspiration & expiration (4) OR - palpate pulse & detect fluctuations with ventilations (5) Serious sign if SBP drops >10 mmHg during inhalation. Patient has possible COPD, severe asthma, tension pneumo, pericardial tamponade, hypovolemia or pericardial effusion

Head to toe review of systems; correlate findings to patient history and kinematics: Chest/thorax/pulmonary system: Percuss/Auscultate: Normal breath sounds

(a) Definition: Breathing heard through the chest wall of a healthy individual. (b) Factors that influence normal breath sounds (i) Distance between the source of the sounds and the chest wall. Ex: Obesity. (ii) Path of sound transmission: Ex: Consolidation (c) Location: Should be heard throughout lung periphery. Listen over midaxillary lines to ensure adequate tidal volumes. (d) Intensity: Correlates with rate of air flow and is affected by position and auscultatory site. In the upright position, apex airways fill earlier than those at the base. This results in decreased intensity as breath sounds proceed. The bases fill later which produce an increased intensity to a maximum of 50% of the vital capacity. Expiration is much quieter than inspiration, almost inaudible. There is no pause between inspiration and expiration. (e) Duration: Normally should hear sounds throughout inspiration. Inspiration should sound two to three times as long as expiration during auscultation. (i) Sounds are shorter on expiration due to the reverse in airflow direction and drop in airflow rate and sound intensity. (ii) Over the sternum you should hear equal duration of inspiration and expiration. (f) Pitch: Acoustic frequency of sounds that reach the ears, like the pitch of a musical note. (i) Decreased frequency = decreased pitch (ii) Increased frequency = increased pitch (iii) Normal breath sounds heard over the chest have a soft low pitch on inspiration and expiration due to the muffling of high-pitched sounds by the lungs and chest wall tissue. Described as sighing or gentle rustling.

Hypertension

(a) Elevated BP: SBP: 120-129; DBP: <80 (b) Stage One HTN: SBP: 130-139; DBP: 80-89 (c) Stage Two HTN: SBP ≥ 140; DBP > 90 (d) Hypertensive crisis SBP >180; DBP of >110 Causes (i) CV disease (ii) Kidney disease (iii) Stroke (iv) ↑ ICP: Head trauma with traumatic brain injury

Causes of bradycardia

(a) Increase in parasympathetic NS stimulation (b) Head injury w/ ↑ ICP (c) Hypothermia (d) Severe hypoxia (e) Medication use: beta or calcium blockers, digoxin (f) Neurogenic shock (g) Cardiac rhythm disturbance (h) Sleep state (i) Well-tuned athlete

Tachycardia usually suggests the following

(a) Sympathetic NS stimulation compensatory mechanism (b) Cardiac rhythm disturbance (c) Shock (all but neurogenic) (6) Assess for paradox (speeding, slowing)

Records and Documentation

1. Chronological documentation of facts; include all pertinent positive and negative findings, precautions instituted or maintained. Include admission and discharge GCS, vital signs, and trauma scores, etc. 2. I&O, vital/neuro signs, and level of consciousness at least every 15 minutes or per local protocols until stable. Inform physician of all significant changes. 3. All items/interventions must be timed and signed by responsible nurse/physician 4. Flow sheets facilitate documentation and serve as useful guides for assessments/interventions. Must include all elements required by the current Illinois trauma registry.

Adjuncts to the primary survey and resuscitation

1. Definition of adjuncts: Those tools or procedures that may modify or monitor the progress of resuscitation efforts. 2. Pelvic and chest films: Plain radiography of the chest and pelvis is often obtained for trauma patients not thought to require CT imaging. Can be taken in ED, should not interrupt the resuscitation process. 3. FAST or DPL (physician performed). 4. Gastric tube if needed to decompress stomach (gastric distention or aspiration risk) or assess gastric contents unless contraindicated. Use orogastric (OG) tube for midface or above injury or suspicion of CSF rhinorrhea. Check placement and connect to suction as ordered. Assess drainage for volume, color, pH, and occult blood. Give antacids as ordered or unit protocol. Monitor I &O per unit protocols. 5. Urinary catheter as ordered and per protocol: Urinary output is best indicator of peripheral perfusion. a. Contraindicated with (1) blood at urinary meatus; (2) scrotal hematoma; (3) high riding prostate on rectal exam; and/or (4) gross perineal injury. b. If patient conscious/responsive consider use of Lidocaine 2% Jelly (UroJet) for instillation into urethra prior to catheter insertion 6. Laboratory tests a. The practice of obtaining routine "screening" laboratory tests on trauma patients is neither useful nor cost-effective. Testing should be performed based upon clinical suspicion and should be limited to those tests that may alter management. Ex: a pregnancy test (urine hCG) should always be performed on women of child-bearing age, and a blood type and screen or crossmatch should be obtained for patients with significant trauma who may reasonably be expected to require transfusion. b. Clinical circumstances determine the need for further testing. Patients taking warfarin likely need coagulation studies (prothrombin time) and patients found on the ground for an undetermined time need studies (e.g., creatine kinase) to determine if rhabdomyolysis is present. c. At initial presentation, the need for transfusion of blood products in the severely injured trauma patient is determined on clinical grounds, and may involve massive transfusion protocols. Thereafter, routine coagulation studies do not predict coagulopathy accurately in the acute trauma patient. Where available, thromboelastography provides a faster and more accurate means for detecting imbalances in the hemostatic system and assessing ongoing needs for treatment. d. Commonly obtained but rarely helpful tests include the metabolic panel (a fingerstick blood sugar will often suffice, provided the patient is not exhibiting signs of electrolyte abnormality or acidosis), alcohol level in a patient who is clearly intoxicated, Toxicologic screen when it is not relevant to clinical care, and cardiac biomarkers, unless blunt cardiac injury or ischemia is suspected. e. Elevation of both the serum lactate concentration and base deficit correlates with increased mortality in trauma patients. However, the base deficit is essentially a surrogate for lactate and an elevated base deficit in the absence of an elevated lactate is not predictive of increased mortality. Furthermore, while elevated levels should heighten suspicion for severe injury, a normal lactate and base deficit do not ensure the absence of significant injury, especially in geriatric trauma patients. In addition, laboratory values lag behind clinical improvement after aggressive resuscitation. Thus, the patient may no longer be in shock despite an elevated lactate suggesting otherwise. f. The white blood cell (WBC) count is nonspecific and of little value during the initial evaluation of the trauma patient. The positive and negative predictive value of, respectively, an elevated or normal WBC is poor. Epinephrine release from trauma can cause demargination and may elevate the WBC to 12,000 to 20,000/mm3 with a moderate left shift. Solid or hollow viscus injury can cause comparable elevations. 7. ECG monitoring if not done already 8. ABGs as ordered

Tertiary survey

1. Definition/purpose of the survey a. Patient evaluation that identifies and catalogues all injuries after the initial resuscitation and operative intervention b. Performed to discover any injuries missed during the primary and/or secondary surveys to reduce diagnostic oversight. (1) Such injuries are rarely life-threatening, but have potential to be clinically significant with regard to morbidity and mortality (2) Most commonly overlooked injuries: extremity and pelvic fractures, spinal cord and head injuries, and abdominal, retroperitoneal, and nerve injuries. (3) Goal: Minimize the disability that may arise from missed injuries. 2. Candidate patients: those most at risk a. Those who cannot cooperate with the physical exam or who have an altered LOC because of head injury or the effects of drugs/alcohol. b. Patients whose initial primary and/or secondary assessment is rushed or incomplete because of hemodynamic instability, i.e., those taken immediately/urgently to the OR. c. Patients with multi-system trauma d. Patients from a multi-casualty incident 3. Other reasons to perform survey a. Lack of symptoms at admission b. Technical problems c. Low index of suspicion by examiner d. Diagnostic errors: X-rays not read in a timely manner or misinterpreted; tests overlooked and/or not ordered or completed. e. Inappropriate admission: trauma patients admitted to inappropriate unit rather than to a trauma service or ICU setting if trauma service not available. These patients have higher rates of missed injuries. 4. When to perform survey a. Within 24 hours of admission and also at discharge to reassess identified injuries, to confirm suspected injuries, to identify occult injuries b. As patient regains consciousness or is able to participate in exam. c. After surgery is performed emergently, as patient becomes more stable and is able to participate in exam. d. As level of activity increases; subtle injuries may become more noticeable. e. If complaints arise at any time during the hospital course. 5. Components of survey a. May complete the primary and/or secondary surveys if initially unable to complete due to the instability of the patient. b. Frequent clinical reassessments; especially with any new complaints. c. Radiologic/lab studies obtained or repeated and compared with earlier results d. Serial monitoring of hematocrit e. Consultation with specialty services as indicated

Patients to be transferred

1. Identify the appropriate mode of transport to the receiving facility: ground or air. 2. Determine the level of care required enroute: BLS, ALS, Critical care. Request appropriate level from transporting agency. Determine if a nurse must accompany the transport team. 3. Notify the receiving facility of impending transfer; ensure patient acceptance and bed availability. 4. Assure physician-to-physician communication for patient acceptance and report. 5. Provide the transport crew (flight, EMS) with full report. 6. Copy and send all records, forms, and reports to the receiving facility per EMTALA requirements. 7. Notify family/significant others of transfer. 8. Call report to receiving nurse (ED RN, supervisor, ICU RN). 9. Assist in moving patient to transport vehicle with appropriate personnel while monitoring adjunctive tubes, machines, and devices.

Patients to be admitted

1. Identify the appropriate receiving unit. 2. Provide the nurse with a full report. Communicate the following: a. MOI and EMS course, including any loss of consciousness, its duration, and lowest BP b. All known injuries and resuscitative interventions provided c. Type of airway; FiO2; O2 delivery device; full or partial ventilatory support d. Estimated blood if applicable, hemorrhage control measures & their effectiveness e. Vascular access and placement (field vs. ED); amount & type of fluids infused (crystalloids, blood products) f. Patient's current condition; GCS; VS; RTS, SpO2 & ETCO2 readings; skin signs; glucose reading if applicable; amount and nature of drainage from any tubes (Suction, OG/NG; chest; urinary catheter) g. Pertinent PMH including tetanus immunization h. Diagnostic tests completed and significant results i. Lab results including blood alcohol levels and tox screens if done j. Summary of treatments (pain/sedative interventions) and patient responses up to time of admission k. Family interventions; whether notified and present 3. Monitor the patient until care is signed off to a nurse on the appropriate unit.

Palpation

1. Involves the use of touch to gather information. Hands/fingers touch each body area. Fingertip pads are best suited for detecting position, size, textures, moisture, pulsations, deformities, fluid, crepitus, masses, and consistency. The palm is better for sensing vibrations such as fremitus. The backs of the hands are best for noting temperature. 2. Steps to keep touch therapeutic and respectful a. Keep hands warm b. Keep fingernails short c. Be gentle to avoid unnecessary discomfort or injury d. Maintain patient modesty whenever possible 3. Palpation may be either light or deep. a. Always perform light palpation first. Use to assess skin and superficial structures. Depress the skin ~1⁄2 inch. Too much pressure will dull the examiner's perception, and in some cases, injure the patient. Can palpate for deformity, swelling (edema), point tenderness, instability, crepitus, etc. Abdominal palpation may need slightly more pressure to detect guarding, rigidity, pulsations, or other pathology. b. Deep palpation implies that the examiner depresses the abdominal wall 3" assessing for rebound tenderness (peritonitis) or to palpate organ margins. 4. Feel for areas of warmth that may reflect injury, inflammation, or infection 5. Watch the patient's face for expressions that may indicate pain due to palpation.

Auscultation

1. Listening for sounds with a stethoscope. One may auscultate breath, heart, and bowel sounds as well as the BP and perhaps an arterial bruit in the carotid artery. 2. Warm the stethoscope head before applying to the patient. Insert the ear pieces facing forward 3. Hold the end of the stethoscope between your second and third fingers and press the diaphragm firmly against the patient's skin. Make sure the head is rotated in the correct position to hear from the side you have against the patient. Avoid touching the tubing with your hands or allowing it to rub against a surface. 4. Listen for the presence or absence of sound and its intensity, pitch, duration, quality, and timing. For example; when noting abnormal breath sounds, report their locations (unilateral/bilateral, right/left; apex/base), and their timing during the ventilatory cycle (inspiratory/expiratory). See breath sound auscultation for details. 5. Closing your eyes may help to concentrate on the sounds by blocking visual stimuli

Patient death

1. Notify physician(s), law enforcement, or coroner/medical examiner per policy. 2. Notify family and assist as needed. 3. Notify in-house chaplain and/or other pastor/rabbi if requested/needed. 4. Facilitate approach for organ/tissue donation per hospital policy. 5. Preserve evidence (where applicable).

Decision to transfer and/or emergency exploration

1. Often made during primary survey when patient needs exceed the resources of the ED and/or receiving hospital. 2. Transfer arrangements should be made immediately as standards require transfer within 120 minutes. 3. Additional interventions should be directed towards physiologic resuscitation and normalization of vital functions. 4. Patients should be stabilized as well as possible without delaying transfer; delays are associated with increased mortality. Criteria for transfer are based upon the patient's demographics, mechanism of injury, and clinical findings. 5. It cannot be overemphasized that a complete workup is not a requirement for transfer; postponing transfer to obtain laboratory results or imaging studies only delays definitive treatment. Often such studies must be repeated at the receiving facility. 6. The decision of when to transfer an unstable patient should ideally be made by the transferring and receiving physicians in collaboration. Clear communication is critical. The transmission of vital information allows receiving clinicians to mobilize needed resources while the inadvertent omission of such information can delay definitive care. Information should be conveyed in both verbal and written (via the patient record) form and should include the patient's identifying information, relevant medical history, prehospital course, and ED evaluation and treatment (including procedures performed and imaging obtained). The use of a transfer checklist can help to ensure that important information is not omitted

Tools of the trade

1. Preferred characteristics of a stethoscope a. Latex-free, thick, heavy tubing conducts sound better with less distortion. Good length 27"; too short (25"); too long (30" plus) b. Soft ear pieces with good fit c. High acoustic sensitivity; dual-sided chest piece and a turnable diaphragm. Bell w/ non-chill rubber-ring edge to ensure good skin contact. d. Diaphragm width: Sensitivity grows with diaphragm diameter. Lower quality stethoscopes have diaphragms ~1.38" (3.5 cm). Good ones are ~1.7" (4.3 cm) 2. Sphygmomanometer: manual vs. automated 3. Penlight: Bright light source to inspect mouth and pharynx, ears, and eyes 4. Thermometer: NO MERCURY; tympanic membrane, temporal artery OK 5. Ophthalmoscope: Allows inspection of the retina, optic disc. Hand held device with a light source and a series of lenses and mirrors. 6. Otoscope: Used to visualize ear canal, tympanic membranes, and interior nose. Has a light source and speculum.

Inspection

1. Process of informed observation. One of the most valuable tools in rapidly assessing a patient's condition. Expose all areas to be examined. Anything you can see, hear without amplification, or smell is considered inspection. Look for color, contour, symmetry, obvious wounds; smell for abnormal odors; listen for abnormal sounds audible without a stethoscope. 2. Inspection depends on good lighting, adequate time, and a good index of suspicion. Draw on past clinical experiences to identify S&S of illness and injury. 3. Inspection is an ongoing process that continues until patient contact is completed.

Patients discharged home

1. Provide patient/family with verbal and written instructions. 2. Assure understanding of instructions by having patient repeat important points, answer questions. 3. Provide patient/care giver teaching, if applicable. 4. May assist in selecting follow-up physician and/or scheduling appointment.

Continued assessment/patient monitoring

A. Assess and document findings at least every 15 minutes while patient is unstable; then as ordered by physician or per department policy. B. Tertiary survey C. Standard monitoring D. Records and Documentation

E = Environment/exposure

1. Remove clothing; avoid cutting through holes created by penetrating trauma; preserve evidence as much as possible. Rapidly inspect entire body for obvious signs of injury. 2. Regions often neglected include the scalp, axillary folds, perineum, and in obese patients, abdominal folds. Penetrating wounds may be present anywhere. While maintaining cervical spine precautions, examine the patient's back; do not neglect examination of the gluteal fold and posterior scalp for life-threatening injury (additional wounds, posterior flail segment). Log rolling patients with possible acute spine injury and fractured hips is increasingly controversial. Increased roll for palpation rather than direct inspection prior to diagnostic radiology. 3. Assess for signs of chemical exposure or burn. Estimate % of total body surface area involved and depth of burns. Determine need for irrigation. 4. Prevent and aggressively treat hypothermia if appropriate: Hypothermia contributes to both coagulopathy and the development of multiple organ dysfunction syndrome. a. Hemorrhage control is the best way to prevent hypothermia b. Maintain warm environment: The United States Military Joint Theater Trauma System Clinical Practice Guideline on hypothermia prevention recommends emergency department (ED) and operating room (OR) temperatures of at least 29.4°C (85°F) during the treatment of these patients. c. Take measures to prevent heat loss: remove wet clothing, add blankets, warmers, warming lights, Bair hugger, etc. d. Warm all IV fluids including blood products e. Assess and document serial temperatures and routes; oral, rectal, tympanic, axillary, or core

Standard monitoring

1. Respiratory monitoring a. Signs of impaired airway/ventilatory distress b. Breath sounds c. Minute volumes (depth)/respiratory rates, effort d. Ventilatory pattern (if abnormal) e. Airway compliance if being ventilated f. Presence of sub-q emphysema g. Pulse oximetry and quantitative waveform capnography readings h. Amount and contents of airway/chest tube aspirate; chest tube drainage device for normal tidaling (if applicable); i. Periodic evaluation of ET cuff pressures and position (if applicable) 2. Cardiovascular/volume (perfusion) status monitoring a. Peripheral pulses: location, rate, quality, rhythmicity b. Skin color/temperature/moisture c. BP/MAP; CVP (if applicable) d. Temperature (per policy) e. Urinary output, specific gravity f. ECG: rhythm, intervals; evidence of myocardial ischemia g. Heart sounds (if chest trauma) h. Fluid volumes administered by type and amount i. Type and amount of drainage through dressings j. Amount and contents of gastric aspirate (if applicable) k. Lab values: serial H&H, base deficit, lactate levels (correlation) 3. Neurological monitoring a. Mental status/responsiveness to stimuli (GCS) b. Content & arousal; amnesia resolution c. Pupils d. Motor/sensory exam changes (including cerebellar dysfunction) e. Seizure activity: onset, duration, motor activity, postictal duration 4. Pain, response to distraction, application of cold/vibration, analgesia/sedatives 5. Desired outcomes a. Patent airway and adequate tissue oxygenation is maintained at all times b. Euvolemia is achieved/maintained or the physician is notified c. Physiological responses to trauma are monitored and complications recognized early. All significant changes are reported per unit protocols. d. Normothermia is achieved and/or maintained e. All injuries are identified f. Psychological support is provided and emotional needs are met g. Pain is minimized h. Family/significant others' fears are addressed and information is provided to help them cope with the trauma

Calculate a Revised Trauma Score

1. Respiratory rate 10 - 29= 4 > 29= 3 6 - 9= 2 1 - 5= 1 0= 0 2. Systolic BP > 89= 4 76 - 89= 3 50 - 75= 2 1 - 49= 1 0= 0 3. Glasgow Coma Score 13 -15= 4 9 - 12= 3 6 - 8= 2 4 - 5= 1 3= 0 Total 0 - 12

As you approach the patient observe/inspect for the following:

1. Severe external hemorrhage? Note location (sources), type, amount, and rate of loss. If present, immediately apply hemostasis measures. Priorities of primary assessment/care in cases of severe external bleeding change to C-A-B-C-D-E. 2. Initial observation of mental status/level of consciousness: Determine quick initial response to stimuli a. A: Alert b. V: Responds to verbal stimulus c. P: Responds to pressure/pain (supraorbital ridge; squeeze earlobe) d. U: Unresponsive to any stimulus e. If awake, are they oriented to person, place, time, and situation? f. Ability to follow simple commands g. Note quality and rapidity of responses 3. Causes of altered mental status to rapidly consider a. A: Alcohol; ingested drugs/toxins b. E: Endocrine/exocrine, liver, electrolytes c. I: Insulin; hyper/hypoglycemia d. O: Oxygen, opiates, OD e. U: Uremia, renal causes, HTN f. T: Trauma, temperature changes g. I: Infections h. P: Psych/poisoning i. S: Space occupying lesions, stroke, subarachnoid hemorrhage (SAH), shock, seizures 4. General patient appearance a. Affect, behavior, cognition b. Restlessness is one of the earliest signs of hypoxemia or internal hemorrhage and should suggest the possibility of serious underlying problems. c. How are they dressed? Appropriate for season, climate, and occasion? d. Grooming: Rapidly observe hair, teeth, nails, skin 5. Observe position a. Sitting or supine? Tripoding? Orthopnea? b. Head, neck, arms held in position suggesting injury or posturing? c. Knees drawn up? Any obvious distress or extreme pain? 6. Unusual odors; Stool/flatulence/urine; emesis; alcohol...risk for: a. Aspiration pneumonia b. F/B aspiration c. Alcoholic cardiomyopathy d. Respiratory infections e. Alcoholic ketoacidosis f. Hypoglycemia 7. Consider the following a. Age; gender; body mass index b. Developmental influences c. How injured do they appear? Potential injuries based on mechanism?

Continuous quality improvement/total quality management (FOCUS-PDCA)

A. Identify trends to be monitored (plan) 1. Rate-based indicators (examples) a. Sequential VS/I&O are documented for all trauma service patients from the time of E.D. arrival to OR/ICU admission or death (per department policy). b. All trauma service patients have an E.D. admission and discharge GCS and RTS documented. c. All trauma service patients have a progress note written by the trauma surgeon while the patient is in the ED. d. Tetanus toxoid immunity is documented on all trauma patients. 2. Sentinel events (examples) a. Trauma team is activated for all patients meeting Category I criteria. b. An ED bed is available for all trauma system patients upon arrival. c. A CT scan is available when needed. d. The OR is available for trauma system patients upon arrival. e. The appropriate physicians and services are available within the times listed in the EMS Act and Trauma Center Code. B. Data collection (do) 1. IDPH Trauma Registry 2. Retrospective chart review C. Analyze data, identify trends and root causes (check) D. Take action (act) 1. Communicate findings to all relevant parties. 2. Conduct educational programs to correct knowledge deficits. 3. Support trauma prevention legislation; reduce morbidity/mortality; facilitate research; establish processes to improve patient care/rehabilitation, etc. E. Review practice standards and initiate changes as necessary. F. Remeasure: Follow-up review to measure improvement.

Secondary survey/definitive interventions

A. The secondary survey does not begin until the primary survey is completed, resuscitative efforts are underway, and the normalization of vital functions has been demonstrated. In reality, some of these things may get done by other members of the trauma team while the primary survey is being performed. The secondary survey should never interfere with the primary survey. B. A thorough review of systems and targeted diagnostic studies play a crucial role in avoiding missed injuries. Commonly missed injuries include: 1. Blunt abdominal trauma: Hollow viscus injury, pancreatoduodenal injuries, diaphragmatic rupture 2. Penetrating abdominal trauma: Rectal and ureteral injuries 3. Thoracic trauma: Aortic injuries, pericardial tamponade, esophageal perforation 4. Extremity trauma: Fractures (especially in distal extremities), vascular disruption, compartment syndrome C. Vital signs: Obtain and document a full set of VS following the primary survey and at least every 15 minutes or more frequently while unstable (comply with unit protocols).

B = Breathing/ventilatory/oxygenation status

Airway patency alone does not ensure adequate ventilation. Gas exchange is required to maximize oxygenation and CO2 elimination. A primary concern with acute post-injury respiratory system insufficiency is hypoxemic hypoxia and subsequent hypoxic encephalopathy or cardiac arrest. Additional concerns are hypoventilation, hypercarbia and cerebral vasodilation and acidemia.

Primary survey

All trauma team members involved in the patient's care must don appropriate universal precautions against blood and fluid borne diseases including gloves, gowns, masks, and eye protection. Lead shields for staff should be available if portable x-rays are to be performed during resuscitation efforts. The primary survey may be completed at a glance if the patient is alert, communicative, and has minor injuries. The various elements may be done simultaneously, but each component needs to be addressed. Assess and reassess. Appreciate the value of time: examine, reexamine. Catastrophic conditions may present with immediately apparent clinical signs or symptoms. Others take time to reveal their true nature. It is not always easy to determine the presence of injuries that have the potential to create an unstable condition upon initial arrival in the ED. Use the passage of time as an ally and frequently reevaluate patients for the ABCDEs.

Head to toe review of systems; correlate findings to patient history and kinematics: Abdomen

Ask about pain, cramping, nausea, vomiting. The abdominal examination is often unreliable, particularly in the elderly, patients with distracting injuries or altered mental status, and patients late in pregnancy, and can change dramatically over time. a. Kehr's sign: Pain radiating to left shoulder from free blood in abdomen irritating the diaphragm (Phrenic nerve - C3, 4), often due to splenic injury. b. Inspect all 4 quadrants for the following: (1) Skin integrity; trauma, bruising, lesions, striae (a) Seat belt sign (b) Cullen's sign: Periumbilical ecchymosis due to retroperitoneal bleeding. (c) Gray-Turner's sign: Ecchymosis over flanks from retroperitoneal bleeding (renal trauma). (2) Contour/symmetry; flat, scaphoid, distended, pregnant (3) Old scars from previous surgeries, trauma (4) Visible pulsations; peristaltic and arterial; signs of hernia c. Auscultate bowel sounds in at least one quadrant for one minute d. Palpate Gently using pads of fingers almost parallel to patient's abdomen or side of hand perpendicular to abdominal wall. (1) Light (1⁄2 inch): Localized or diffuse tenderness, masses, guarding, or rigidity. Distracting a patient may overcome voluntary guarding but will not affect rigidity. (2) Deep (3 inches): Masses, bulging, swelling, organ margins, rebound tenderness. Deep palpation is contraindicated in abdominal trauma. e. Percuss: shifting dullness (Balance's sign) in splenic injury f. Anticipate (1) Plain radiographs, ultrasound FAST exam; contrast-enhanced CT and transcatheter arterial embolization (TAE) in hemodynamically stable patients with hepatic, splenic, and pelvic injuries. Current drawbacks for CT include marginal sensitivity for the diagnosis of diaphragmatic, pancreatic, and bowel injuries, and requirement for IV contrast administration. (2) Prepare for surgery if needed

Head to toe review of systems; correlate findings to patient history and kinematics: Chest/thorax/pulmonary system: Inspect

Ask about pain, dyspnea. a. Inspect for any changes from primary survey (1) Patient position, work of breathing; subcutaneous emphysema. (2) Contour and integrity of chest wall. Should be symmetrical with 2:1 lateral to anterior-posterior (AP) diameter. Abnormalities to note (a) Barrel chest (b) Kyphosis (c) Scoliosis (d) Hyperinflated hemithorax (3) Assess for equal bilateral chest excursion by placing your hands on each side of the chest with thumbs at the xiphoid process. (4) Inspiration to expiration (I / E) ratio; prolonged expiration indicates distress (5) Cough: May be due to aspiration, smoke, secretions, irritation, hyperreactive airways, and bronchospasm. Determine if productive or non-productive. If productive, describe sputum in terms of color, consistency, amount, and odor. (6) Note new or old chest wall lesions / scars (7) Abnormal odors on breath (a) ETOH: Alcoholic beverages may predispose patients to increased risk of the following: (i) Aspiration pneumonia from vomiting (ii) Foreign body aspiration (iii) Alcoholic cardiomyopathy (iv) Respiratory infections (v) Alcoholic ketoacidosis (b) Ketones (c) Bitter "almond" odor following smoke inhalation (cyanide poisoning)

Head to toe review of systems; correlate findings to patient history and kinematics: Neck

Ask about pain; maintain spine motion restriction until C-spine cleared. a. Inspect: May be necessary to temporarily remove the c-collar to fully examine the neck, but maintain manual stabilization. Categorize neck wounds into Zones of injury. (1) Symmetry, hematoma, deformity, or edema (2) Jugular veins; flat or distended (3) Skin integrity; wounds, bruises, subcutaneous emphysema (4) Tracheal tugging, use of accessory muscles (5) Listen for hoarseness, inability to talk b. Palpate (1) Posterior processes for deformity, muscle spasm, pain. Assume injury if any of these is present: trauma above the clavicles with midline pain, unconscious head injury, evidence of motor, sensory or proprioceptive deficiency, neurogenic shock, or deformities. (2) Trachea: midline or deviated (3) Carotid pulses: present/diminished/absent; abnormal pulsations (4) Subcutaneous emphysema, crepitus c. Assess for dysphagia d. Anticipate (1) Plain radiographs (C-Spine series); possible CT or MRI (2) Prepare for surgery or transfer if needed

Spine precautions

Assume cervical spine injury in any patient c/o neck pain with a mechanism of injury and/or multi-system trauma, particularly those with altered mental status or injury above the clavicles. Provide spine motion restriction above and below the suspected injury site by the most effective means during airway assessment and interventions until cleared by exam or imaging. a. Attempt to maintain axial alignment with manual in-line stabilization b. Apply an appropriately sized rigid c-collar or assess spine motion restriction applied prior to arrival for appropriate sizing. Remember - this does not ensure complete stabilization of the cervical spine. Never force the patient's neck into any position if movement causes resistance or pain. c. Apply/maintain lateral immobilization using tape, towel/blanket roll, or commercial device. d. Obtaining c-spine films early in the course of resuscitation is no longer emphasized. These films are secondary to protection and immobilization and may be obtained when convenient. Important to remember that a lateral film identifies only 85% of all injuries. CT of the cervical spine has supplanted plain radiography as the primary imaging means for screening suspected cervical spine injury after trauma.

D = Disability/neurological status

Brief assessment to discover potentially life-threatening neurologic deficits and lateralizing signs. Alteration in LOC is often the best indicator of central perfusion and deterioration in patient status. A more detailed neuro assessment is done during the secondary survey. 1. Assess glucose levels on all patients with altered mental status. Finger stick blood glucose testing may not be clinically appropriate when peripheral blood flow is decreased as in shock, cardiac arrest, severe hypotension, hypothermia, hyperosmolar hyperglycemia, and severe dehydration. In these patients, a venous sample may yield more accurate results. Glucometers are calibrated for capillary blood. 2. Glasgow Coma Score (Revised): A number of studies suggest that the initial GCS score is not predictive of outcome in patients with severe brain injury, and intubation, sedatives, and alcohol or other drug intoxication may interfere with its application. Assess carefully and accurately. Note patient's best response. a. Eye opening (1) 4 Spontaneous: Open before stimulus (2) 3 To sound after spoken or shouted request (3) 2 To pressure after fingertip stimulus (Trapezius pinch, pressure to supraorbital notch) (4) 1 None: no eye opening at any time; no interfering factor (5) NT Non-testable: closed by local factor b. Verbal response: Assess speech for content, articulation, repetition (1) 5 Oriented: Correctly gives name, place, and date (2) 4 Confused: Not oriented but converses coherently (3) 3 Words: Intelligible single words (4) 2 Sounds: Only moans/groans (5) 1 None: No audible sounds, no interfering factor (6) NT Factor interfering with communication c. Motor response: Determine if movement is purposeful or non-purposeful. Stimulate arms or legs simultaneously to test for equality of responses (1) 6 Obeys commands: Obeys 2 part request (2) 5 Localizes: Brings hand above clavicle to stimulus on head/neck (3) 4 Normal flexion: Bends elbow rapidly but not predominately abnormal (4) 3 Abnormal flexion: Bends elbow but features predominately abnormal (5) 2 Extension: Extends arm at elbow (6) 1 None: No movement in arms/legs; no intervening factor (7) NT Paralyzed or other limiting factor 3. Mnemonic for causes of altered mental status: (vowels and tips a. A Airway, apnea, arrhythmia, anaphylaxis b. E Endocrine/metabolic (pH, temperature, electrolyte) imbalances c. I Insulin (glucose imbalances) d. O Overdose: alcohol, drugs, poisons e. U Uremia (kidney) and hepatic (liver) disease; underdose f. T Trauma; tumors g. I Infection h. P Psychosis i. S Shock; seizures 4. Pupils: Size, shape, equality, and reactivity to light a. Technique for checking light response: Have patient look straight ahead at the most distant object possible, in as dim a light as possible. Beam light through the pupil from an angle (so penlight is not directly in field of vision). Observe that pupil for its direct response. Note as brisk, sluggish, or non-reactive. Should briskly constrict at least 1 mm. Beam light again from the side into the same pupil. Observe the opposite pupil for its consensual response. Repeat the procedure on the other eye b. Light impulses carried to occipital lobe by CN II. Pupillary constriction is controlled by CN III; which is easily compressed due to swelling or shifting of the medial edge of temporal lobe. Pupil responsiveness is affected by injury to either of these cranial nerves, ↑ ICP and cerebral hypoxia. c. If a dilated, non-reactive pupil is due to injury inside or outside of the brainstem, it is likely that this will be accompanied by other prominent neurologic symptoms, like diplopia or an altered state of consciousness d. If both pupils are dilated but reactive to light, injury is often still reversible. e. Unilaterally dilated or oval pupil that remains reactive to light may be the earliest sign of increasing ICP or herniation. f. If bilaterally fixed and dilated, patient probably has a brainstem injury or herniation is complete and the prognosis is grim. g. Other causes of dilated pupils that may or may not react to light: hypothermia, lightning strike, anoxia, optic nerve injury, drug effect, or direct ocular trauma. h. If patient is fully alert, a dilated pupil is likely not from a head injury i. Fluttering eyelids seen w/ hysteria. Slow lid closure rare with hysteria. Anticipate orders for naloxone or glucose/thiamine if assessment findings suggest opiate overdose or hypoglycemia is confirmed as co-morbid factors.

Head to toe review of systems; correlate findings to patient history and kinematics: Extremities upper and lower

Consider the 6 P's: pain, pallor, pulselessness, paresthesia, paralysis, and pressure. a. Inspect (1) Position, symmetry (compare sides) (2) Deformities/dislocation, contusions, abrasions, penetrating wounds, lacerations, swelling/edema, protruding bone, avulsions, amputations, and hematoma (3) Skin color: pallor, mottling, ecchymosis, and/or cyanosis b. Palpate: Grasp limbs proximally with both hands and thumbs. Palpate down the long bones to the most distal portion of the limb. If the hands do not break contact with the extremity, one is assured that the entire extremity and the joints are palpated. (1) Bones/joints: tenderness, instability, crepitation, pain, abnormal movements (2) Pulses, capillary refill in children, skin temperature (3) Motor exam: passive ROM; muscle strength to gravity/ resistance; muscle mass/spasm (4) Sensory exam: symmetry of sensation; paresthesias, hypoesthesias, hyperesthesias; two-point discrimination; sharp vs. dull perception c. Anticipate (1) Plain radiographs; CT (2) Rest/ice/compression/elevation (RICE) (3) Application of splints/fixators, casts (4) Pain management: pharmacologic and non-pharmacologic (5) Crush, compartment syndrome, and/or suspension trauma Rx (6) Patient teaching for motion assist devices- crutches/walkers (7) Prepare for surgery if needed

Pulse pressure

Difference between the systolic & diastolic pressures (1) Systolic BP is normally about 30-50 mmHg greater than diastolic (2) Abnormal (a) Widened pulse pressure: Difference of > 50 mmHg. Example: Increased intracranial pressure (b) Narrowed pulse pressure: Difference of less than 30 mmHg. Indicates ↓ CO in the face of peripheral vascular constriction (compensatory response). (i) Tension pneumothorax (ii) Cardiac tamponade (iii) Volume deficit of 15% or greater

Inspect B = Breathing/ventilatory/oxygenation status

Expose the chest. Observe the chest and abdomen for signs of ventilatory difficulty or impairment of gas exchange. a. General respiratory rate, pattern, depth (1) Ventilatory attempts: Present/absent. If present, are they generally fast or slow. Don't count actual rate yet. Tachypnea or bradypnea may both signal distress. (2) Depth: Should see visible chest rise: Tidal volume in an adult should be at least 500 cc as the first 150 cc fills dead space and is not exchanged. A 40% decrease in VT = a 60% decrease in air exposed to alveoli and circulating blood. b. Chest (abdomen) contour and integrity: Inspect chest for wounds - blunt or penetrating. A distended abdomen in morbidly obese patients and children will impair ventilations. c. Symmetry of expansion and adequacy of excursion: Assess for asymmetry, flail segments (paradoxical movements), and/or hyperinflation. d. Work of breathing (WOB)/muscles used to ventilate. Use of accessory muscles plus nasal flaring, tracheal tugging or retractions indicates airway resistance or ventilatory distress. Diaphragmatic ventilations suggest high spinal injury. Is the patient splinting from pain? e. Speech pattern: With severe dyspnea may speak in word clusters f. Skin color (Normal, pale, mottled, ashen, cyanotic; presence of petechiae? Correlate with S&S of hypoxia) (1) Cyanosis is divided into two categories: central and peripheral (a) Central: Lips, mucous membranes, conjunctiva. Late sign of hypoxia that develops when 5 g/dL of Hgb is desaturated in the capillaries. Central cyanosis can be apparent when a patient with a Hgb level of 15 g/dL has an SpO2 of 85%. (b) Peripheral: nailbeds. Peripheral cyanosis occurs when tissues extract more oxygen from the blood than normal. More common with ischemia and stasis. (2) Many factors influence detection of cyanosis including rate of blood flow, type of light, observer skill, thickness and color of skin, and degree of anemia. g. Jugular veins (1) Normal anatomic location of neck veins: (a) External jugulars are above the clavicle and cross over the sternocleidomastoid muscles. (b) Internal jugulars run parallel to the sternocleidomastoid muscles near the carotid arteries. (2) If a patient is positioned at a 45° angle, the venous pulses should not ascend more than one to two cm above the clavicle. Markedly distended neck veins may fill to the angle of the jaw. (3) If distended, immediately assess for tension pneumothorax and/or pericardial tamponade h. Cough: Response to bronchial irritation; note if productive or non-productive; type, nature, volume of sputum/hemoptysis

General resuscitative measures for B = Breathing/ventilatory/oxygenation status

Impaired gas exchange/ineffective breathing patterns a. Emergent intubation may be indicated for hypoxia, hypoventilation, or failure to maintain or protect the airway owing to altered mental status. More recent recommendations suggest a trial of CPAP prior to intubation if ventilatory effort is adequate and there are no S&S of pneumothorax. b. Oximetry: If actual or potential hypoxia: Apply a pulse ox (SpO2) monitor immediately and observe the room air (RA) reading and pleth waveform while preparing supplemental oxygen. SpO2 provides information about O2 transfer at the alveolar-capillary interface and the saturation of RBCs (oxygenation). Use an appropriate site and sensor (finger vs. central site). (1) No bedside device measures the oxygenation status of tissues or cells. Interpret SpO2 findings in light of the patient's clinical condition. A patient may be hypoxic with an SpO2 reading of 95%+ if anemia or abnormal forms of hemoglobin are present. (2) Beware! SpO2 of 90% = pO2 of 60 Torr c. Oxygen administration: All patients with signs of hypoxia need O2 titrated to correct but not overcorrect their hypoxia. This may be delivered via NC, NRM, or CPAP mask if indicated and not contraindicated. Assist ventilations in an adult with a BVM at 15 L/min at 10 BPM if RR is <10 or depth is inadequate. d. Quantitative waveform capnography is recommended for continuous monitoring of the adequacy of ventilations, pulmonary perfusion, and metabolism and can be used to suggest lactate levels; the amount of dead space, and to confirm ETT placement. If a trauma patient's ETCO2 is low (≤30), a TNS should check pt's RR & perfusion status e. Appropriate lab work (ABGs may be done now or after the secondary survey depending on etiology and severity of distress.)

Head to toe review of systems; correlate findings to patient history and kinematics: Integument (skin) and soft tissues

Inspect the skin for color, color variation, hair distribution and changes and lesions on all surfaces; front and back. a. Ask about skin changes: dryness, pruritus, wounds, rashes, or changes in skin pigmentation or color b. Inspect: DCAP, BLS, color; impaled objects; frostbite; gooseflesh, diaphoresis, anhidrosis (lack of sweating), clubbing. The color of skin and mucous membranes reflects the circulation immediately underlying the skin as well as the oxygen saturation of the blood. (1) Red/flushed: Fever, carbon monoxide poisoning in late stages, neurogenic shock, or allergic reaction/anaphylaxis (2) Pale: Peripheral vasoconstriction from cold or shock, excessive blood loss; peripheral perfusion deficit (3) Cyanotic: Shock, diffusion deficit, circulatory/hemoglobin deficit (4) Yellow (jaundice or icterus): Hepatitis, cirrhosis, neoplastic disease (5) Edema: Skin looks shiny or swollen (6) Burned tissue (a) Red; with or without blisters (b) Pale (c) Brown & leathery (d) Charred c. Palpate: Temperature, texture, moisture, turgor, edema, deformities, hematomas and crepitus (1) Turgor (a) Adults: Pull skin up on back of hand and look for tenting (b) Infants: Pull skin up on back of head or back (c) Elderly: Look at the thenar eminence of palm (2) Quadriplegics (tetraplegics) may be poikilothermic (body temperature assumes environmental temperature) due to absent input from periphery for temperature control. Temperature may decrease to 95.6° - 96° F or may elevate to 101°-102° F. Skin is warm, dry, and flushed in neurogenic shock due to vasodilation and absence of sweating (anhidrosis). (3) Cool/cold and dry: usually indicative of exposure to cold or poor perfusion to limb (4) Cool and wet (moist, diaphoresis): usually indicative of sympathetic nervous system response, shock, or hypoglycemia d. Calculate % total body surface area (TBSA) burned using the Rule of 9s or Rule of Palms; identify depth of skin injury (partial or full thickness) e. Inspect and palpate nails for color, shape, thickness, adhesion to the nailbed, lesions, clubbing, and capillary refill as needed. Clubbing is a classic sign of long-term oxygen deprivation and is seen as an enlargement of the fingertips and flattening of the angle between the fingernail and the nailbed. f. Anticipate (1) Cleansing/irrigation of wounds (2) Dressings/bandages; sutures/staples (3) Tetanus prophylaxis (4) Cooling/rewarming techniques (5) Pain management (6) Prepare for surgery or transfer if needed

Action sequence essential

It is essential that the trauma team develop and follow a systematic approach to assessing and treating all trauma patients regardless of the injury. This systematic approach includes the elements below. What may vary are the priorities and time frames in which some steps may be carried out. The components in this outline follow a sequential order, but are frequently carried out simultaneously. It is also important to obtain thorough patient and event histories as these provide invaluable information during assessment and subsequent treatment. Always consider the worst possible injuries based on the patient's age, gender, mechanism or injury, and clinical presentation. Build mental checklists of possible diagnoses and rule each in or out as you proceed. Assessment component overview 1. Occurs in two phases: prehospital phase and hospital phase. a. Prehospital phase Emphasis is placed on securing and maintaining an airway, ensuring adequate ventilations and oxygenation, rapid control of external bleeding, shock resuscitation, spine motion restriction and limb splinting if needed, pain management as indicated, rapid transport to closest appropriate facility; and on obtaining and reporting necessary information to the hospital. Scene time should be minimized as much as possible. Processes should be in place to notify the receiving hospital before personnel transport from the scene. Use of a field triage decision schematic should guide receiving hospital and transport decisions. Early notification enables ED staff to: • Notify additional personnel (e.g., ED staff, trauma surgery, obstetrics, orthopedics, radiology, interpreter services) • Assure resources are available (e.g., ultrasound, CT, OR) • Prepare for anticipated procedures (e.g., intubation, chest tube) • Prepare for blood transfusion b. Hospital phase: Advance planning is essential; resuscitation area, equipment, and personnel should be available and ready at all times. Regardless of setting or team composition, optimal care of a trauma patient requires effective and efficient communication and teamwork among all members Good care begins with a pre-arrival briefing and the assignment of general roles and specific tasks, and continues throughout the resuscitation as the team uses closed-loop communication and maintains a common vision of the plan of care. Notably, it is important to include the alert patient (or health care proxy) in this communication, keeping them informed of the plan of care and any changes. 2. Triage: The sorting of patients by acuity. EMS and hospital personnel should be knowledgeable re triage, whether single, multiple, or in a mass casualty situation, and available levels of trauma care at hospitals in immediate area. 3. Primary survey: Identify all clinically evident immediate life-threats and initiate resuscitative interventions as detected. The assessment should not proceed until all major deviations found in the primary survey are appropriately managed. a. Airway assessment/access/maintenance (spine precautions as needed) b. Breathing/ventilatory & oxygenation status: assess/support c. Circulation (perfusion status) and hemorrhage control; maintain adequate end organ perfusion d. Disability assessment: basic neurological exam e. Exposure with Environmental control: completely undress the patient to search for possible injuries, but prevent hypothermia f. Adjuncts to primary survey and resuscitation: Interventions and equipment that support assessment/interventions during the primary survey g. Consider need for patient transfer: May initiate immediately or at any time during assessment. 4. Secondary survey: Does not begin until the primary survey is completed and resuscitative efforts are underway to normalize vital functions. If additional personnel are available, part of secondary survey may be conducted while others continue the primary survey (ACS, 2018). History, baseline vital signs, and head-to-toe review of systems follows the primary survey. Performed systematically to discover other injuries sustained by the patient and to determine priorities of care. 5. Adjuncts to the secondary survey: Diagnostic tests performed during the secondary survey to identify specific injuries, minimize missed injuries. May require transport of patient to other areas of the hospital so should not be performed until the patient is carefully examined and their hemodynamic status has been normalized. 6. Continued monitoring/reevaluation to constantly ensure that new findings are not overlooked & to discover deterioration. 7. Definitive care a. Diagnostic studies completed and reviewed b. Emergent interventions performed: ED and/or OR c. Patient disposition: Who gets admitted, discharged, transferred and when? 8. Tertiary survey: Follow-up/ongoing assessments to find any injuries that may have been missed during the initial primary/secondary assessments (most frequently musculoskeletal injuries) and to monitor ongoing patient responses.

Drugs and toxins that affect pupil size/reactions: Dilation

SNS stimulants: Cocaine, ephedrine, phenylephrine, tyramine PNS blockers: Alpha-methyldopa, atropine, botulinus toxin, chlorpheniramine maleate, clonidine, curare, dopamine, doxepin hydrochloride, ibopamine, imipramine hydrochloride, jimson weed, methantheline bromide, scopolamine, toadstool toxin, wild sage Early and late barbiturate intoxication High blood alcohol levels over 300 mg/dl Other causes dilated pupils +/- reactive to light: hypothermia, lightning strike, anoxia, optic nerve injury, or direct ocular trauma

Current and past health history

Obtain this from the patient, family, significant others, bystanders, or personal belongings such as wallet, medic-alert cards, or jewelry during or after the secondary survey 1. S: Symptoms: History/assessment (pain) a. O: onset: abrupt or gradual b. P: precipitation; palliation c. Q: quality d. R: region/location; radiation; recurrence e. S: severity/intensity using a 0-10 scale f. T: time: onset/duration g. Other subjective findings: tachycardia, restlessness, irritability 2. A: Allergies 3. M: Medications: Legal and illegal a. Prescribed; It is particularly important to determine if patients are taking anticoagulants or antiplatelet agents, etc. b. Over-the-counter; homeopathic c. Use/compliance with prescribed dosing regimen d. Time and amount of last dose 4. P: Past Medical History a. Co-morbid conditions (1) Respiratory disease, smoking history (2) Cardiovascular disease (3) Endocrine disease (diabetes) (4) Neurological disease (5) Splenectomy or other immunosuppressed states (6) Coagulopathies b. Previous/current infectious diseases or IV substance abuse 5. L: Last oral intake, last tetanus immunization, Females: LMP; sexually active? 6. E: Events prior to/surrounding the incident; time since trauma; loss of consciousness before, during, after trauma; antegrade or retrograde amnesia; seizure activity before or after injury.

Systematic approach to trauma care

One of the most challenging aspects of trauma care is the development of a plan that addresses every component of a patient's needs in a logical, organized fashion to ensure continuity and coordination of all health disciplines. Collaborative practice is crucial and needs to involve all levels of care: prehospital, nursing, physicians, and ancillary departments, i.e., all members of the trauma team. It begins when the trauma occurs and continues into the rehabilitation phase.

Auscultate immediately if ventilatory distress

a. Audible sounds heard without a stethoscope (1) Snoring; gurgling, stridor (2) Hoarseness (3) Wheezing - inspiratory and/or expiratory b. Listen rapidly over each lobe for air entry and symmetry. Most ominous sound is silence due to tissue mismatch that reflects sound away from the chest wall, i.e., pneumothorax, hemothorax; bronchial obstruction; severe bronchospasm, or apnea. c. Heart sounds (S1, S2): strong/regular/muffled or displaced

Palpate B = Breathing/ventilatory/oxygenation status

Palpation plays a minor role in the exam of a normal chest as lungs are covered by ribs & aren't palpable. Useful in detecting chest wall trauma. a. Pain, point tenderness b. Deformity c. Chest wall expansion d. Rib mobility, instability, abnormal movements e. Crepitus: bony vs. subcutaneous f. Skin temperature/moisture g. Subcutaneous emphysema h. Tactile fremitus - vibration of chest wall i. Position of trachea: Tracheal deviation is more accurately observed on chest x-ray in the presence of a tension pneumothorax. The extrathoracic (palpable) portion of trachea is tethered to the spinal column and remains in the midline until a severe mediastinal shift occurs.

Causes of Bradypnea

Poisoning, Sedatives, Narcotics, Tranquilizers, Alcohol, Barbiturates, Endocrine, COPD with O2 retention, Diuretic therapy, Metabolic alkalosis, CNS dysfunction, Sleep, hypoxia/Severe hypoxia

Head to toe review of systems; correlate findings to patient history and kinematics: Chest/thorax/pulmonary system: Percuss/Auscultate: Heart sounds

Rate, rhythm, clarity (1) S1 (lub): Occurs at the beginning of ventricular systole with the closure of the mitral and tricuspid valves. Most audible at the apex and lower sternal border. Fairly high-pitched; harder to hear during tachycardia. If may be "split" or heard as two sounds clumped together in the presence of right bundle branch block. Varies in intensity with atrial fibrillation. (2) S2 (dub): Occurs at the beginning of diastole when the aortic and pulmonic valves close. Most audible at the base of the heart (aortic area). Higher in pitch than S1. May also be "split". Fixed splitting heard on both inspiration and expiration can accompany atrial septal defect or right bundle branch block. Intensity increases with aortic or pulmonic stenosis (3) S3 (ventricular gallop): May be heard during diastole. Thought to be caused by the early, rapid filling of a dilated left ventricle. Most audible at the apex with the patient on his left side. Dull, low pitched sounds, occur early in diastole. Normal in children and young adults. It is considered abnormal in patients over 30 and is an early sign of heart failure. (4) S4 (atrial gallop): Also normal in children and young adults. Associated with the forceful ejection of blood into a stiff ventricle. Most audible at the apex with the patient on his left side. Also dull and low pitched. It is especially hard to hear as it is very soft. Abnormal in mature adults. Occurs late in diastole and may be caused by pulmonic stenosis or any condition that affects left ventricular compliance, e.g., aortic stenosis, hypertension, MI, and cardiomyopathy. (5) Hint: Don't press too hard with the stethoscope head against the chest. You'll reduce the sensitivity and won't hear the sounds. f. Anticipate (1) Plain radiographs, CT; TEE; bedside echocardiogram (2) Pulmonary function tests (3) Chest tubes to drain pleural collections; autotransfusion (4) Dysrhythmia management (5) Ventilator use (6) Prepare for surgery or transfer if needed g. Other injuries to find at this time (1) Isolated rib fractures (2) Sternal fracture or dislocation (3) Closed simple pneumothorax/small hemothorax (4) Tracheobronchial tree injuries (5) Blunt cardiac injury (formerly known as myocardial contusion) (6) Blunt injury to the aorta (BAI) (7) Penetrating trauma to mediastinum

Hypotension

Relative based on patient's normal BP. Generally, considered to be a SBP less than 90 mmHg. This may not signal hypoperfusion in all patients. Examine mental status and physical responses and ask about normals for that person. Do not define hypotension by numbers as much as evidence of hypoperfusion. Causes (a) Cardiac insufficiency (b) Hypovolemia (c) Vasodilation (relative hypovolemia seen in distribute or low resistance shocks, vasovagal reactions) (d) Dysrhythmia (tachycardia/bradycardia) (e) Must always try to detect if CV compromise is due to a rate, rhythm, volume, vascular, or pump problem and treat inciting cause. (f) Monitor trends

Head to toe review of systems; correlate findings to patient history and kinematics: Chest/thorax/pulmonary system: Palpate

Ribs, clavicles, sternum, and scapulae for deformity, tenderness, instability, crepitus, tactile fremitus, and subcutaneous emphysema. (1) Palpate by compressing downward on sternum and inward on lateral chest wall. (2) Tactile fremitus - Increased vibration of chest wall when patient makes a vowel sound like "99" - indicates consolidation

Drugs and toxins that affect pupil size/reactions: Constriction

Sympathetic blockade: beta blockers, MAO inhibitors Parasympathetic stimulants: acetylcholine, methadone, neostigmine, nicotine, physostigmine, pilocarpine, tetraethyl ammonium Narcotics

Head to toe review of systems; correlate findings to patient history and kinematics: Chest/thorax/pulmonary system: Percuss/Auscultate

d. Auscultate for any changes from primary survey; presence/absence/equality of vesicular/abnormal breath sounds, adventitious sounds. (1) Purpose of chest auscultation: (a) Assess the patient's pulmonary status and function (b) Assess airflow through and patency of the airways. (c) Detect airway obstruction and assess the condition of the lung parenchyma and pleura. (2) Breath sound production (a) Breath sounds are produced by airflow patterns, associated pressure changes within the airways, and by solid tissue vibrations. Amplitude and intensity are affected by airflow patterns, regional lung volumes or distribution of ventilation, body position, and the sound production site. (b) Sounds are normally diminished and filtered when transmitted through air-filled alveoli, fluid accumulations in the pleurae, and solid structures such as bone. (3) Normal airflow patterns within the tracheobronchial tree (a) Turbulence is created in the trachea and larger bronchi from the random movement of air molecules that collide against airway walls and each other. The colliding molecules produce rapid pressure changes within the airway. These pressure variations produce audible sounds that are loud and harsh. (b) Transitional flow at airflow vortices separates the air stream into layers that move at different velocities. At the bronchial bifurcations, swirling airflow patters are created in more narrow airways. Energy is transferred between colliding gas molecules. This results in transient pressure variations capable of producing audible sound waves. (c) Laminar flow: The bulk of airflow is slow and laminar in terminal or smaller airways. No abrupt changes in pressure or airway wall movements occur to generate sound. At the alveoli, gas moves by diffusion not gas flow, thus, no sounds are produced. Alveoli are SILENT. (d) Breath sounds heard through the chest wall come mainly from the larger bronchi as they are transmitted through the lung tissues. (4) "Sound matching": When two media are well matched acoustically, sounds are transmitted readily between them. (a) Consolidated lung tissue enhances the transmission of sound generated in the trachea and bronchi. Sounds are louder than normal with higher frequencies preserved and can be heard throughout the respiratory cycle. (b) Conversely, when air or fluid separates the sound source from the chest wall, the sound is reflected rather than transmitted. Breath sounds are diminished or absent. Thus, in the presence of hyperinflated lungs, air, or fluid in the pleural space, a large proportion of the sound will be reflected inward at the pleural space producing no breath sounds during auscultation. (5) Auscultatory sites (a) Accurate interpretation requires the ability to describe the location of abnormal findings in relation to bony structure and anatomic landmark lines. Breath sounds should be auscultated over the anterior, lateral and posterior chest wall surfaces. (b) The sternum, ribs, scapulae, vertebrae, and intercostal spaces provide vertical and horizontal landmarks used to describe the location of breath sounds; the 2nd rib and 2nd intercostal spaces serve as reference points (6) Listening to breath sounds (a) Many sounds have frequencies near the lower threshold of human hearing. The environment needs to be as quiet as possible to hear sounds clearly and distinctly. (b) Press the diaphragm head firmly against the chest wall over an intercostal space. Do not listen directly over bone. Whenever possible, do not listen over clothing, which impedes or alters sound transmission. Avoid extraneous sounds caused by the stethoscope tubing rubbing against an object. (c) If the patient has a very hairy chest, hold the stethoscope firmly against the skin to minimize the crackling noises produced by the hair. (d) Ask the patient to take one normal breath through their mouth for each site examined. Deep breaths distort sounds. (e) If alert and hemodynamically stable, begin auscultation with the patient sitting up and leaning slightly forward. (f) If patient is comatose, critically ill or unable to sit up, roll from side to side to auscultate dependent lung regions posteriorly. Listen initially to the back as gravity-dependent secretions or fluids may produce abnormal sounds that disappear when pt is turned, breathes deeply or coughs.

A = Confirm airway is protected/maintain appropriate spine motion restriction

The first priority in the care of trauma patients without exsanguinating hemorrhage is to establish/maintain a patent airway and ensure adequate oxygenation and ventilation. Any decrease in oxygen delivery to the injured brain, precipitated by hypoxia or hypotension, or due to a failure to maintain or protect the airway increases morbidity and mortality, especially if severe traumatic brain injury is present. A second concern is the potential deterioration in clinical status, which may occur during the early phases of resuscitation. A patient's ability or inability to oxygenate and ventilate adequately may not be the only reason for advanced airway placement. Delays in adequate airway management may have devastating consequences, and this is one of the more common causes of preventable death in both the prehospital and ED settings. 1. Impairment/obstruction may be acute, insidious, progressive or recurrent. Maintain a high index of suspicion and vigilance. 2. Preventable deaths from airway/ventilation impairments a. Failure to recognize obstruction or impaired laryngeal reflexes and need for an airway b. Inability to establish an airway c. Failure to recognize incorrectly placed adjunct d. Airway displacement e. Failure to recognize hypoventilation f. Hypercarbia leading to cerebral vasodilation g. Aspiration leading to hypoxemia, pneumonia or ARDS

Injury scenario and mechanism of injury (MOI)

This assessment should include the following: a. Motor vehicle crashes (1) Type of vehicle (2) Velocity of acceleration/deceleration; collision speed (3) Type of collision; direction of force (4) Use of safety restraint, helmet or air bag (5) Ejection from vehicle (6) Position in vehicle before/after crash; intrusion into passenger compartment b. Fall (1) Precipitating event (2) Distance of fall (3) Position of landing (4) Type of surface c. Struck by blunt object (1) Precipitating agent (1) Impact force (2) Body area(s) involved b. Penetrating wounds (1) Precipitating agent (2) Velocity of projectile (3) Estimated depth of penetration (4) Entry angle, site; exit wounds (5) Position of assailant to victim (if known) c. Thermal wounds (1) Precipitating agent (a) Heat: dry or moist (b) Chemical: acid/alkaline; caustic (c) Electrical - power source; AC/DC; voltage (d) Radiation; type; rads received; distance from source (e) Cold: dry or moist (2) Length of exposure; enclosed or open space d. Violence/abuse (1) Abuse and neglect can be inflicted on persons of all ages. Illinois legislation defines abuse and neglect and specifies protections and treatments that should be given to all victims of abuse. (a) Child: Any person <18 unless legally emancipated (i) Infant: Birth to one year of age (ii) Child: One year - 12 years of age (iii) Adolescent: 13 - 17 years of age (b) Eligible adult (under the Elder Abuse Act): A person 60 years of age or older who is abused or neglected by another individual in a domestic living situation. (2) If not suspected, abuse can be easily overlooked. Physical abuse should be suspected in unusual and unexplained injury patterns; burns in unusual locations or with characteristic patterns suggesting intentional causes; fractures/bruises that are unexplained, in various stages of healing, or difficult to sustain by accident; and/or injuries that do not match the reported MOI. (3) Unexplained malnutrition, dehydration, poor personal hygiene, depression, withdrawal and misuse of medications should also alert the nurse to possible abuse or neglect. (4) Other forms of abuse include sexual, emotional, and economic. (5) Assessment/evidence collection: Be familiar with evidence collection procedures for abuse and sexual assault. Use resources such as SANE certified nurses as necessary. (6) Patient advocacy: If any form of abuse, maltreatment, harassment, intimidation, or willful deprivation are suspected: (a) Follow institutional policies with respect to patient questioning about abuse. (b) Provide psychological support (c) Take all possible means to protect an abused person from being returned to the abuser. Provide adults with information about services available to them and encourage them to create escape plans. Discuss need for temporary protective custody with police and/or the ED physician if necessary. (7) Nurses are mandatory reporters. A TNS is obligated by law to report suspected abuse or neglect per hospital policy. (a) Child abuse: Department of Children and Family Services (24 hour hotline number: 1 - 800 - 25 - ABUSE) (b) Elder Abuse/Neglect Hot Line Numbers: To report suspected abuse, neglect, or financial exploitation of an adult age 60 or older or a person with disabilities age 18- 59 call the statewide, 24-hour Adult Protective Services Hotline: 1-866-800-1409, 1-888-206-1327 (TTY). 2. Weight and height - especially children or those that meet obesity criteria 3. Use of appropriate analgesia is encouraged: Implement pain mitigation strategies and pain meds as indicated and/or ordered.

General resuscitative measures for C = Circulatory status/hemorrhage control

To maximize chances of survival, treatment priorities must focus on resuscitation of shock including rapid hemostasis, appropriate fluid resuscitation along with ensuring adequate oxygen carrying capacity, restoration of venous return to heart, and achieving required CO to maintain minimally required MAP and cellular/organ perfusion. a. Initiate CPR as indicated unless contraindicated b. Control external bleeding - Resuscitation from hemorrhagic shock is impossible without hemostasis. (1) Apply direct digital pressure using palm of hand over a single layer sterile dressing placed over wound unless contraindicated (deep open skull wound) (2) Bleeding persists: Direct pressure ineffective or impractical; wound not amenable to tourniquet e.g. trunk, groin, neck, head or other location where a tourniquet cannot be used) (a) Hemostatic gauze - Pack and press: Cover all bleeding surfaces (except the eyes, in the mouth, and non- compressible wounds) with hemostatic gauze. Pack deep wound cavities (will likely be painful during packing process) and mound up. Take care that granules that slough off of dressing do not get into the eyes. If they do, irrigate eyes.) Apply FIRM pressure using palmar aspect of hand over dressing for at least 1 min or until bleeding stops. Once bleeding stops, apply pressure bandage (if an extremity) to hold dressing in place. (b) No blind clamping into wounds; physicians should only use vascular clamps (3) Severe extremity bleeding: assess need for a tourniquet: Mangled extremity; amputation; arterial bleed; direct pressure ineffective or impractical; hemostatic dressing ineffective in hemostasis- Place 2-3 cm proximal to wound; not over joint; tighten until bleeding stops/distal pulse occluded. If bleeding continues, place 2nd proximal to 1st. It should be visible/well marked (time applied); do not remove. Anticipate severe pain following application. (4) Pelvic fx: Wrap w/ sheet (use appropriate technique), pelvic binder, or secure in upside down KED

Percussion B = Breathing/ventilatory/oxygenation status

While percussing the chest, compare sounds heard with what you know to be normal there. Example: If resonance is expected and hyperresonance is heard, anticipate a pneumothorax or emphysema. Dull percussion note suggests blood from a hemothorax.

Blood pressure/pulse pressure/MAP/pulsus paradoxus/orthostatic changes

a. Accurate BP measurement is important for the detection and treatment of hyper and hypotension. b. Every patient should have a manual BP taken at least once before an automated BP monitor is used. Despite widespread use of automated devices, there is limited published evidence for their reliability and accuracy. It is important to obtain manual BP measurements in trauma patients with SBPs below 90 mmHg, as automated cuffs often overestimate values significantly in these patients. Further, data suggest that the traditional threshold of a SBP below 90 mmHg to define shock is inaccurate. The appropriate systolic or MAP threshold for defining shock varies by age. A significant proportion of trauma patients with hemorrhagic shock have a SBP above 90 mmHg; using a cut-off of 110 mmHg is more appropriate in the elderly. c. Use an appropriate size cuff. Width should cover about 2/3 of the upper arm or thigh. For most adults, the large cuff (15 cm wide) is used. Using a cuff that is too wide (false low reading), too narrow (false high reading), too long, or too short will result in an inaccurate measurement. If patient is very obese, you may need to place the arm cuff around the forearm and auscultate over the radial artery. d. Auscultate (Korotkoff) sounds (1) First sound (Systolic BP) reflects pressure generated during ventricular systole. (2) Controversy as to whether a change in sound (diminishes or becomes muffled) or disappearance of sound signals the diastolic BP, which reflects peripheral vascular resistance when the heart is resting (diastole). Current convention favors disappearance of sound. (3) If readings are unclear or not heard, fully deflate the cuff. Wait 30 seconds before trying again. DO NOT pump the cuff up again from a partially inflated state. It may change the reading. e. A systolic BP may be obtained by palpation or Doppler if sounds cannot be heard. Continue to palpate the brachial artery as the cuff is slowly deflated. At the point where the pulse returns, note the systolic BP. f. Average norms vary based on age and gender. In a healthy adult, systolic normals should be less than 120 and diastolic normals should be less than 80.mmHg. Individuals with SBP and DBPs in 2 categories should be designated to the higher BP category. For diagnosis of HTN, the BP is based on an average of ≥2 careful readings obtained on ≥2 occasions

Etiologies of inadequate ventilations

a. Airway obstruction (should be resolved) b. Cardiac/respiratory arrest c. Chest wall injury or movement impairment d. CNS dysfunction: Severe cognitive impairment (GCS ≤ 8) or c-spine injury e. Diaphragmatic injury f. Parenchymal injury g. Pleural collections (air, blood)

Etiologies of hypoxia (pO2 < 80) or hypoxemia

a. Atmospheric deficiency of oxygen b. Ventilatory deficiency; airway obstruction, hypoventilation, severe cognitive impairment (GCS 8 or less), chest wall trauma c. Diffusion deficiency: lung injury (pulmonary contusion), aspiration d. Perfusion deficiency including pressure relationship changes in lungs e. Ventilation/perfusion mismatch f. RBC abnormalities g. Cellular inability to use the oxygen: cyanide poisoning

Airway Assessment

a. Begin by asking the patient a simple question (e.g., "What is your name? Or, "What happened today?"). A clear accurate response verifies the patient's ability to mentate, phonate, and to protect their airway, at least temporarily. b. Observe for spontaneous ventilatory efforts; apnea, agonal ventilations c. Inspect the naso and oropharynx for swelling, disruption, burns; blood, secretions, vomitus (aspiration risk), injuries to the teeth or tongue. Note if there are obstacles to the placement of an airway. d. Inspect face for symmetry, wounds, bleeding, or edema e. Inspect for use of accessory muscles: nasal flaring in infants, tracheal tugging, use of neck/ shoulder muscles; retractions f. Listen for audible sounds of ventilation: snoring, stridor, or wheezes. Ventilations should be quiet without any harsh or added sounds. g. Inspect and palpate the anterior neck for lacerations, hematomas, hemorrhage, crepitus, swelling, or other signs of injury. Palpation of the neck also enables identification of the landmarks for cricothyrotomy. h. Determine if patient is agitated or obtunded. Agitation suggests hypoxia, obtundation suggests hypercarbia. Abusive and belligerent patients may have hypoxia - do not assume intoxication. i. Assess for impaired laryngeal reflexes. Potential sequelae of aspiration are lung injury and non-hypercarbic, hypoxemia. Patients at risk for aspiration: (1) Cardiac arrest (2) Severe cognitive impairment (GCS 8 or less) (3) Cervical spinal cord injury j. Objective signs of airway obstruction: patient behavior - restlessness /agitation which suggest hypoxia and reduced responsiveness which suggests hypercarbia; cyanosis (a late finding); retractions and use of accessory muscles of ventilation; and abnormal sounds.

Signs of compromised ventilations/inadequate gas exchange

a. Dyspnea, respiratory distress, hypoventilation, apnea b. Bradypnea: adult RR < 10/min.; weak, shallow effort c. Tachypnea: adult RR > 24/min.; labored; d. Presence of cough e. Diminished or absent breath sounds f. External signs of trauma to chest; contusions, abrasions, open wounds g. Increased WOB: use of accessory muscles; retractions h. Subcutaneous emphysema i. Unequal pulmonary excursion; paradoxical chest wall movement j. Anxiety, restlessness, disorientation, confusion, stupor, or coma k. Evidence of hypoxia/cyanosis

Expected outcome of airway assessment: patent airway

a. Foreign material is not visible in the upper airway b. Ventilations are quiet without noise or increased effort c. If necessary, airway adjuncts are placed and air flows into and out of the lungs without impairment. d. Patient speaks or makes appropriate sounds

Head to toe review of systems; correlate findings to patient history and kinematics: HEENT

a. Inspect head (1) Size, shape, contour/symmetry of skull and face; deformities/depressions, contusions, abrasions, penetrating wounds, ecchymoses, burns, lacerations, scars, involuntary movements, and edema. Be attentive for foreign bodies, such as glass in the scalp following an MVC. (2) Note any signs suggesting basilar skull fracture (hemotympanum, telecanthus). Retroauricular (Battle's sign) and periorbital ecchymosis (raccoon's eyes) are also indicative of basilar skull fracture but generally do not appear until at least 24 hours after an injury. Look for nasal septal hematomas. (3) Skin color of face and neck (4) Presence or absence of glasses, contact lenses, hearing aids, wigs b. Inspect EYES (1) Both pupils simultaneously for size, shape, and equality. Reactivity to light is tested for direct and consensual responses. (2) Check each eye individually for visual acuity (a) Color and interpretation of visual image (read near card) (b) Count fingers and determine direction (c) Shape, shadow and motion (d) Light perception (3) Conjugate gaze/EOMs; fixed deviation; pupil height (4) Sclera, conjunctiva, cornea, lids: discoloration, hemorrhage, hyphema, ptosis, foreign bodies, penetrating trauma (open globe injury), contusions, lacerations (5) Optic fundi (physician or mid-level practitioner usually performs) (6) Dislocation/clouding of the lens (traumatic cataract) c. Face/nose: Symmetry, epistaxis, rhinorrhea d. Oral cavity: Broken, malaligned, missing teeth; trismus; bleeding gums; trauma to tongue or oral cavity e. EARS: External trauma, hearing deficit, otorrhea, Battle Sign. Hemotympanum is often a subtle finding that should prompt exploration for a basilar skull fracture or intracranial injury. It can also be caused by a lightning strike, acute pressure changes (descending during a flight or SCUBA diving). A unilateral hemotympanum will be accompanied by a one- sided conductive hearing loss with a Weber test lateralizing to the injured ear. f. Palpate (1) Skull, orbital rims, nasal bones, zygoma, maxilla, mandible for tenderness, deformity, instability, crepitus, hematoma, pain, neuro-vascular impairment, muscle spasm, false motion or motor impairment (2) Classify midface fractures: Le Fort I, Le Fort II, Le Fort III g. Anticipate (1) Plain radiographs/CT (2) Measures to optimize cerebral perfusion and ↓ ICP (3) Orders for anticonvulsants if early post-trauma seizures (4) Stabilizing impaled objects/eye shield application (5) Prepare for surgery or transfer if indicated (6) Possibility of organ donation, if indicated

Head to toe review of systems; correlate findings to patient history and kinematics: Back/spine

a. Inspect: If log rolled, have enough helpers and follow procedures; maintain spine alignment while tilting patient ~30°-45°. Ask about pain. (1) Contusions, wounds, deformities, undetected flail segment (2) Paravertebral muscle spasms b. Palpate posterior spinous processes and ribs for pain, deformity, abnormal movement, crepitation, paravertebral muscle spasms, and blood. c. Anticipate (1) Plain radiographs, CT, MRI (2) Application of spine motion restriction per national guidelines (3) Prepare for surgery if needed

Head to toe review of systems; correlate findings to patient history and kinematics: Neurological assessment

a. Mental status (1) Content & arousability (2) Alertness, judgment, orientation (3) Responsiveness to environment & commands (4) Amnesia b. Cranial nerves c. Motor exam - Assess extremities forspontaneous, purposeful movements; muscle mass, strength to gravity/resistance, abnormal tone or movements. d. Sensory evaluation - Assess for sharp/dull (pain) and two point discrimination; response to deep pressure; proprioception e. Reflexes (1) Protective: cough, gag, swallow, and corneal (2) Superficial (3) Deep tendon (4) Pathologic C. Facilitate completion of orders for plain radiographs, CT, MRI, interventional radiology, labs, ABGs, 12-L ECG, urgently needed meds prior to surgery or transfer if not already done. Note: Most patients should be hemodynamically stable before CT imaging is performed, and resuscitation should be sufficient to minimize the risk of decompensation while the patient is in the CT scanner. If the patient is unstable, CT imaging is usually deferred

Expected outcomes for C = Circulatory status/hemorrhage control

a. Patient is conscious, answers questions appropriately b. Skin is normal color, warm, dry; capillary refill ≤ 2 seconds c. Peripheral pulses are full and regular at age-appropriate rates d. There is no obvious uncontrolled bleeding

Interventions for ineffective airway clearance/potential for aspiration

a. Position patient appropriately based on age, size, and condition. b. Open airway as needed: Basic life support (BLS) maneuvers FIRST: Reposition mandible - use chin lift or jaw thrust maneuvers unless contraindicated. Do not use chin lift if suspected mandibular fracture. Do not hyperextend or hyperflex the patient's neck if spine injury is possible. c. Remove gross debris; suction secretions d. Maintain with adjuncts (1) BLS airways: NPA; OPA (2) Definitive guidelines for intubation in trauma do not exist. When in doubt, it is generally best to intubate early, particularly in patients with hemodynamic instability, or those with significant injuries to the face or neck, which may lead to swelling and distortion of the airway. Airway may be technically challenging to secure. Once an airway has been established, it is important to secure it well and to ensure it is not dislodged any time the patient is moved. Unintended extubation is the most common preventable cause of morbidity in trauma patients. If intubating: (a) Assess GSC before giving RSI medications (b) Report ET tube size, depth (c) Confirm ETCO2 reading on monitor (d) Order chest x-ray for placement confirmation (3) Alternate airways: Extraglottic, supraglottic; retroglottic devices (4) Cricothyrotomy: Needle or surgical e. Caveat: Unconscious patients with small pneumothoraces that are not visible or are missed on the initial chest xr may develop tension physiology after tracheal intubation from peep. It is important to reauscultate the lungs of trauma patients who develop hemodynamic instability after being intubated and to be attentive to ventilator pressure alarms.

Immediate life-threats to detect and resuscitate now C = Circulatory status/hemorrhage control

a. Pulseless electrical activity (PEA) (this is a condition, not a rhythm) (1) Search for and treat possible contributing factors (Hs & Ts): (a) Hypoxemia, hypothermia, hypovolemia, hyper/ hypokalemia, hydrogen ion (acidosis), hypoglycemia (b) Toxins, thrombosis (coronary or pulmonary), tamponade (cardiac), trauma, tension pneumothorax (c) True vs. pseudo PEA may be confirmed by ultrasound. (2) Treat the cause as directed by injury-specific interventions. b. Cardiac tamponade: Penetrating wounds medial to nipple lines anteriorly and medial to scapula posteriorly suggest the strong potential for great vessel injury and pericardial tamponade. c. Perfusion failure/Shock: Determine if hypoperfusion is primarily due to a rate, rhythm, pump, volume, or vessel dysfunction and treat inciting cause. (1) Cardiogenic: Pump failure (may occur secondary to any form of shock due to myocardial hypoperfusion). Reduced myocardial functioning in the elderly increases risk of pump failure in response to physiologic stress, shock, and trauma. (2) Hemorrhagic: Loss of whole blood (3) Hypovolemic: Loss of plasma only, e.g., burns (4) Obstructive: Impairment of venous return to right heart (tension pneumothorax/cardiac tamponade) (5) Neurogenic: Massive vasodilation due to loss of sympathetic nervous system (SNS) below level of injury in high SCI d. Myocardial rupture e. Commotio cordis: Blow to the chest that produces VF/cardiac arrest.

Temperature

a. Reflects a balance of heat production and loss b. Generally obtained orally, using an ear probe, rectally, or axillary. Become familiar with the device used by your unit. c. Normal oral temp = 98.6° F or 37° (1) Up to 102° F (38° C) metabolism increases (2) At 103° F (39° C) neurons begin to denature (3) At 105° F (41° C) neurons begin to die (It doesn't take long to cook an egg or a neuron - both are gelatinous proteins) (4) 95°- 87° F is considered mild to moderate hypothermia (5) < 30°C (86°F) or less is considered severe hypothermia d. There is a physiologic difference between hyperthermia (elevated core temperature) and hyperpyrexia (fever from an infection). Head trauma patients often become febrile due to damage to the hypothalamus. e. When hyperthermia occurs following TBI it is associated with increased metabolic expenditure - approximately 13%/°C in febrile adults. The additional metabolic demands of hyperthermia can lead to loss of muscle and fat stores, which may in turn, prevent or delay recovery from brain injury. Cold therapies to combat hyperthermia can cause shivering which can further increase the metabolic demands. If a head-injured patient begins shivering, the intensity and duration of shivering can be decreased by covering the patient's arms and legs during surface cooling.

Pulse

a. Technique: Conscious patient: palpate radial artery. Unconscious patient: palpate carotid pulse first. Children: palpate the brachial or auscultate an apical pulse just below the left nipple. Apical pulse reflects HR, does not assess pulse amplitude or cardiac output. b. Rate (1) If regular, count rate for at least 15-30 seconds and multiply to reach a 60 second rate. May need to count for a full minute in some patients, i.e., peds, hypothermia, irregular rhythms. (2) Rates must be interpreted within the context of the patient's age, developmental level, and circumstances. (3) Rates for adults normally range from 60-100 beats per minute. Rates in children will vary based on age and size. Rhythm (1) Pulse pattern and equality of intervals between beats (2) Regular, regularly irregular, irregularly irregular, or grossly chaotic (3) Irregular rhythms may be due to extra or skipped beats or dysrhythmias (4) Irregular pulses usually signal a cardiac problem and indicate a need for emergent ECG monitoring d. Quality: Indicates mean arterial pressure and is a valuable tool in the preliminary assessment of cardiac output. (1) Pulse strength (2) May be described as full, bounding, weak or thready (3) Weak or thready pulses indicate an impaired circulatory status (4) Strong, bounding pulses may indicate high BP or an increased CO e. Location (1) The adequacy of perfusion can be inferred by the location where pulses are palpated (2) Carotid pulse (a) Best correlates with central aortic pressure (b) Reflects cardiac function more accurately than peripheral vessels

Respirations (more technically, ventilations)

a. Technique: Observe the chest rise and fall or place one hand over the patient's chest and count the number of breaths. Try to be discrete as they may control their rate if they think you are counting. Count RR while you are pretending to count pulse rate. Better: observe ETCO2! b. Rate: Number of breaths per minute (1) Adult RR should be 12-20/min; faster for children and infants (2) Tachypnea: Over 20 (3) Bradypnea: Less than 10 c. Pattern: The normal tidal pattern of ventilations is called eupnea Abnormal respiratory patterns (1) Cheyne-Stokes: Crescendo/decrescendo respirations (waxing and waning depth and rate) with periods of apnea up to 20 seconds; seen with ↑ ICP. Due to increased sensitivity to CO2 that results in the change in depth and rate. Decreased stimulation from respiratory centers results in apnea. Lesions are most often located bilaterally deep within the cerebral hemispheres, diencephalon (thalamus and/or hypothalamus), or basal ganglia. (2) Kussmaul: deep, hyperpnea; seen in metabolic acidosis (3) Central neurogenic hyperventilation: Increased rate and depth of respirations. Thought to be due to release of the reflex mechanisms for respiratory control in the lower brain stem. Results in a decreased CO2 and an alkaline pH. Giving oxygen does not change the pattern. Lesion location is unclear, often in the midbrain and upper pons. (4) Apneustic: A pause of 2-3 seconds noted after a full or prolonged inspiration. May alternate with an expiratory pause. Lesion located in the lower pons, usually due to a basilar artery occlusion. (5) Cluster: Clusters of slow irregular breaths with periods of apnea at irregular intervals (gasping breathing has features similar to cluster breathing). Lesion in the lower pons or upper medulla. (6) Ataxic (Biot's) breathing: Completely irregular, unpredictable pattern with deep and shallow random breaths and pauses. Lesion located in the medulla. d. Depth should be at least 500 cc. A 40% decrease in tidal volume = a 60% decrease in inspired air exposed to alveoli and circulating blood.

Etiology of compromised/obstructed airway

a. Tongue (most common) b. Fluids: blood, secretions, vomitus c. Foreign debris/teeth d. Tissue trauma: airway, laryngeal, tracheal, neck, facial injury e. Inhalation injury f. Edema/spasm g. Malpositioned oropharyngeal airway h. Prolonged severe compression of chest i. Cervical spine injury (edema/cervical hematoma C2)

Head to toe review of systems; correlate findings to patient history and kinematics: GU/pelvis

ask about pain, urge to void, and possibility of pregnancy. a. Inspect (1) Integrity of skin/soft tissues, scrotal edema, discoloration, ecchymosis, hematoma, priapism (2) Blood at urinary meatus, vaginal outlet (3) Urine for pH, blood, glucose, protein, ketones, specific gravity, color, clarity, odor and amount b. Palpate (1) Iliac crests, symphysis pubis, femoral pulses. GENTLE inward/outward and downward compression; NO PELVIC ROCK (2) Suprapubic mass (bladder) c. Anticipate: (1) Plain radiographs, CT, interventional radiology, IVP, retrograde urethrogram, and cystogram (2) Pelvic binding/fixation for pelvic fracture (3) Prepare patient for digital rectal or vaginal exams: (a) Traditionally, the digital rectal examination (DRE) was considered an essential part of the physical examination for all trauma patients. However, the sensitivity of the DRE for injuries of the spinal cord, pelvis, and bowel is poor, and false positive and negative results are common. Thus, routine performance is unnecessary and generally unhelpful. The examination is warranted in cases where urethral injury or penetrating rectal injury is suspected. If the examination is performed (by physician or mid-level practitioner), they should check for an intact rectal wall, the presence of gross blood (sign of bowel injury), a high-riding prostate (sign of urethral injury), abnormal sphincter tone or sensation (sign of spinal cord injury), and bone fragments (sign of pelvic fracture) (b) Set up for a vaginal examination on all female patients at risk for vaginal injury (e.g., those with lower abdominal pain, pelvic fracture, or perineal laceration). (4) Prepare for surgery if needed

General resuscitative measures for C = Circulatory status/hemorrhage control Continued

c. Vascular access (peripheral/central/IO) (1) Establish vascular access if patient has an actual or potential volume deficit or needs IV medications. (2) Peripheral/central sites per institutional policy. (3) Number/size of lines: Number and size of IV catheters depends on the patient's age, size, nature of complaint, degree of shock, purpose of the line, volume needs, urgency of their condition or as ordered. (4) Poiseuille's law: Fluid flow through a catheter is dependent on the radius to the 4th power, the length of the catheter, the viscosity ofthe fluid, and the pressure at which the fluid is infused. If large fluid volumes are needed, use the largest, shortest catheter that will easily fit into the vessel. For adults: usually means 14-16 g. (5) Intraosseous (IO) infusion: Prepare IO infusion equipment if peripheral venous access is unsuccessful or not obtainable. May use proximal humerus or tibia sites approved at your institution. If patient is responsive, be prepared to push lidocaine slowly into medullary space prior to fluid admin. d. Fluid administration (1) IVF volumes should be based on clinical need/response and evidence-based guidelines. (2) Access lines for drugs are usually run TKO. (3) If volume deficits are present, an initial bolus of warmed isotonic electrolyte solution (LR or NS), is given. Adults, usual volume is up to 1 liter; children: 20 mL/kg given over 5-15 mins. Volumes to be infused should be based on patient response and maximum recommended amounts. ED initial fluid volumes must include any IVF given by EMS. (4) Permissive hypotension, controlled resuscitation, balanced resuscitation, or hypotensive resuscitation are all terms used for resuscitation that balances the goal of organ perfusion with the risks of increased bleeding by accepting a lower-than-normal BP. The goal of resuscitation in life-threatening hemorrhage is to restore organ perfusion, which for many years meant restoring normotension (MAP of 90 mm Hg) by rapid volume expansion. Fluids are now given judiciously because aggressive resuscitation that results in a MAP of 80 to 90 mm Hg or greater before surgical hemostasis is associated with increased bleeding and mortality. Increased intravascular volume affects active bleeding by hindering clotting and can also lead to hemodilution and hypothermia. The best way to manage life-threatening hemorrhage is surgical control in the OR. Until then, hemorrhage can also be managed bY permissive hypotension (SBP <80 mm Hg) while the patient is transferred to the OR. Evidence indicates that this hypotensive state may be more beneficial to patients by limiting coagulopathy and hypothermia. (5) Contraindications to permissive hypotension: Patients with traumatic brain injuries and pregnant women. It can be fatal in these patients because adequate perfusion pressure is crucial to ensure tissue oxygenation of the CNS and fetus. (6) Warm fluids: Room temperature IVF given to a patient in shock can produce hypothermia due to lack of ATP. All crystalloid fluids should be warmed to 39°C (102.2°F) prior to infusion. This can be done by storing in a warmer and/or using fluid-warming devices. Blood products can also be warmed by passage through intravenous fluid warmers (7) Coagulopathy associated with severe trauma can be fueled by resuscitative measures. Use of massive transfusion protocols with blood components administered in predefined low ratios may mitigate this condition. e. May obtain appropriate labs emergently or during secondary survey

Head to toe review of systems; correlate findings to patient history and kinematics

performed to detect non-life threatening injuries and to provide care for those injuries. Rapidly assess all body systems for DCAP, BLS, and TIC as below Deformities Burns Tenderness Contusions Lacerations Instability Abrasions Swelling/edema Crepitus Penetrations/punctures