2015 Trumbull Memorial Hospital Demo

Patient Assessment – Trauma

Patient Assessment – Trauma

Steps

Performed?

Yes No

Non-Priority Trauma Patients

1. Assess injuries based on chief complaint  Obtain Vital Signs  Provide care based on signs and symptoms  Continue with Detailed Assessment as appropriate

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Priority Trauma Patients Rapid Trauma Assessment 1. Rapidly assess the patient ‘head to toe’ (60-90 seconds total)  HEENT Exam: The head should be examined for signs of abnormality. The ears should be examined for presence of fluid and foreign bodies. The pupils should be checked for symmetry and response to light. The nose should be examined for presence of fluid and patency. Examine the throat for signs of obstruction, redness, and patency. The neck should be examined for pain, stiffness, or injury. The neck veins should be assessed for signs of extreme distention. If there is any evidence of neck injury, employ cervical spine precautions. Assess for any signs of trauma. 2. Chest and Abdomen  The chest should be examined for signs of visible injury. Assess for breath sounds as well as chest movement, symmetry, and effort. The chest should be palpated for pain. The abdomen should be assessed for signs of injury, pain, tenderness, rigidity, and guarding. The pelvis should be palpated for stability if any history of trauma. 3. Extremities and Back  The lower as well as the upper extremities should be examined and assessed for presence of pulses, sensation, and motor function. Note if edematous or signs of poor perfusion exist. The back should be examined for signs of pain. For patients with possible spinal injury, assess the back during the log roll procedure. 4. Neurological Survey  If not already done, a neurological evaluation as well as a history should be obtained. The pupils should be assessed for equality and reaction to light. The level of consciousness should be assessed using the AVPU method. 5. A SAMPLE history should be obtained if possible. This should include:  S – Signs and Symptoms  A – Allergies

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 M – Medications  P – Past illnesses  L – Last oral intake  E – Events of the injury or illness

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6. Exposure  A thorough exam cannot be accomplished without properly exposing a patient. Make sure to keep the patient warm in the process of exposure and examination.

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7. Perform a Continuous Reassessment as appropriate to identify change in status.

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144

EMR

EMT

AEMT

Paramedic

Extended