Clin approach Flashcards
Head-toe trauma
HEAD
Overall looking for
Lacerations/Deformity/Facial muscle/Asymmetry
General crepitus, bony tenderness, subcutaneous emphysema (air under the skin)
Irregular pupils (one really dilatated, bleeding – PEARL)
Racoon eyes (base skull fracture)
Bruising behind the ear (battle sign) – base skull fracture
CFS fluid/if bleeding will be a yellow colour
Halo sign – put cloths in ear and there may be blood in the centre and then yellow around the outside
Teeth – broken/smashed/missing (run tongue around the mouth) – bleeding cuts in the mouth or swelling of the tongue
Bleeding/cute/laceration
Boggy mass – skull fracture
La fate fractures/jaw (clench teeth and does it feel different)
Nose fracture/ deformity, bleeding
Headaches/amnesia/lightheaded/dizzie/tinnitus (ringing or buzzing in the ear)/photosensitivity
Singed facial hairs for burns, soot and swelling/oedema (also look in the throat)
NECK
Deformity/laceration/raised JVP (jugular venous pressure – not easy to see)
Bony tenderness, carotid pulse
Tracheal deviation – tension pneumothorax (signs = sharp chest pain, increased respiratory rate, shortness of breath, decreased BP)
Hoarseness voice (struggle to swallow)
C spine deformity/pain – feel the c spine itself (increased bumpiness, bone out of line, tenderness/pain
CHEST
Expansion/laceration/deformity/accessory muscle movement/tenderness
Paradoxical breathing (failed chest, rib fracture 3 ribs in 2 or more places) – due to the negative and positive pressure
C3/C4/C5 nerves – control the diaphragm (also paradoxical breathing)
Apply gentle pressure (spring the ribs)
Check the sternum
Look for fractures or dislocations
Shallow breathing/diminish breathe sounds
Subcut emphysema – air pockets under the skin (tension pneumothorax)
Heart sounds, air entry and breath sounds, or additional sounds
ABDOMEN
laceration/bruising/distension (bloating and swelling)
rigidity/guarding/grimacing
Check-in quadrants – 4 (right and left upper and lower)
The right upper – portion of the liver, gallbladder, right kidney, a small portion of the stomach, portions of the ascending and transverse colon, and parts of the small intestine
Left upper – the left portion of the liver, the larger portion of the stomach, the pancreas, left kidney, spleen, portions of the transverse and descending colon, and parts of the small intestine
Right lower – the cecum, appendix, part of the small intestines, the right female reproductive organs, and the right ureter
Left lower – the majority of the small intestine, some of the large intestine, the left female reproductive organs, and the left ureter
The liver and spleen are not hollow so are more likely to cause an issue
Distension (pushed outwards) – due to fluid retention in the bladder/peritoneal cavity (can hold 5 litres) (contains the organs??)
Roll motion to see whether it is soft or firm
PELVIS
Laceration/bruising/deformity
Checking for alignment
Checking for pain
Bony tenderness
LIMBS
Laceration/bruising/deformity
Shortening
Rotating
Pain
Open wounds
Check movement – does it hurt
Checking if not able to move a particular way
Neurovascular status
Check cap refill – checking blood supply to limbs
No cap refill (single) = Compartment syndrome, clots
No cap refill on both = may be an injury higher up, or there is a perfusion injury
Check sensation, push-pull, sensation
Compare limbs to each other
BACK
Laceration/deformity/bruising
Bony tenderness
Evidence of a bony step
Subcutaneous emphysema
Pain
Check spine is in place
Spine
neurological signs
Signs and symptoms include:
Pain
Paraesthesia - an abnormal sensation, typically tingling or pricking (‘pins and needles’), caused mainly by pressure on or damage to peripheral nerves
Paralysis
Priapism - A prolonged erection of the penis, usually without sexual arousal/ persistent and painful erection of the penis
Paradoxical respiration (diaphragm takes over)
Breathing movements in which the chest wall moves in on inspiration and out on expiration, in reverse of the normal movements
Poikilothermia (Loss of ability to sweat or shiver)
the inability to regulate core body temperature (as by sweating to cool off or by putting on clothes to warm up)
Also consider:
Bradycardia
Hypotension
Bladder distension / Loss of bladder and bowel control
5Heads
To determine TBI there could be any of the following
- GCS = 13-15
- Mechanism of injury of blunt head/face trauma
loss of consciousness and/or +/- amnesia
- With the following 1 or more of:
5Heads
- Any loss of consciousness exceeding 5 minutes
- Skull fracture (depressed, open or base of the skull)
- Vomiting more than once
- Neurological deficit/pupil action or decreased GCS or spinal issues
- Seizure
Neurological examination for the purpose of spinal clarence
Motor function
- Alarms – push, pull, and grasp
- Legs – push/plantar flex, pull/dorsiflex, and leg raise
Sensory function – reduced or no sensation when applying light tough to the following:
- Arms – palms and back of hand
- Legs – lateral aspect of the calcaneus
- Suprasternal notch
The patient reports numbness, tingling, burning, or any other altered sensation anywhere in the body
- If ANY of the above criteria are present, the patient should be considered to have a neurological deficit and CANNOT be spinally cleared
- Make sure to take into account that the limbs should be assessed simultaneously to compare the strength and whether there are any inability or weakness to perform particular movements due to pre-existing injury or illness
NEXUS
Does the patient have either
- Major trauma following blunt force trauma to the head or trunck
- Neurological deficits or changes
NO
Assess modified NEXUS criteria
Increased injury risk
- Age ≥ 65
- History of bone or muscle weakening disease/injury
Difficult patient assessment
- Altered conscious state
- Intoxication
- Significant distracting injury
Actual evidence of structural injury
- Midline pain/tenderness on palpitation of the vertebrate
Neck range of motion
- The patient is unable to actively rotate the neck 45 degrees left and right without pain
Allergy symptoms
RASH
Respiratory
- SOB, bronchospasm, wheeze, cough, stridor
(This would be due to inflammatory bronchoconstriction or upper airway oedema)
Abdominal
- Nausea, vomiting, diarrhea, abdo pain/cramps
(particularly to insect bites and systemically administered allergens (e.g. IV medications)
Skin
- Hives, welts, itch, flushing, angioedema, swollen lips/tongue
(This is due to vasodilation and vascular hyperpermeability)
Hypotension or Altered Conscious State
(This is due to vasodilation and vascular hyperpermeability - their guts let more than water and nutrients through)
Unconscious patient
AEIOUTIPS
A
- alcohol (Confusion, Dysphasia, Unsteady Gait, Aggressive/Bizarre behaviour)
- acidosis
- arrhythmia
- asthma (Difficulty breathing, Bronchospasm, Cough)
- anaphylaxis (Difficulty breathing, Nausea, Vomiting, Diarrhoea, Rash - Hives, Urticaria, Hypotension)
E
- epilepsy (Seizure activity, Rapid onset, Urinary incontinence)
I
- infection/sepsis (Tachypnoea, Tachycardia, Diaphoresis, Hypotension)
O
- Overdose (Opioids) - Hypotensive, Bradycardia
- Overdose (Amphetamines) - Anxiety, Tachycardia, Diaphoresis, Seizure
U
– underdose
- uremia (Uremia is a buildup of toxins in your blood. It occurs when the kidneys stop filtering toxins out through your urine) - Confusion, Fatigue, Cramping in legs
T
- trauma (Perform a Head-Toe Secondary Survey)
I
– insulin hypoglycemia (Abnormal respiratory pattern. Pale, cold and clammy skin, Tachycardia)
– insulin hyperglycemia (Increased respiratory rate, Polyuria, Polydipsia, Polyphagia, Dehydration)
- Infarction (Diaphoretic, Anxious, Pale, Tachycardic, Hypotensive)
P
– pain
– psychiatric/mental health (Bizarre Behaviour, Preform a Mental Status Assessment)
– pregnancy
S
– stroke (Dysphasia, Unsteady Gait, Facial droop, Unequal hand grip strength)
- TIA/syncope (fainting)
When giving medication what do you need to remember
5 rights
- Right Patient
- Right Drug
- Right Dose
- Right Route
- Rigth time (for the right disease)
- Right documentation
Also check with your partner about the medication you are giving
Handover
IMISTAMBO
I - Identification (name, age, nationality)
M - Mechanism/medical complaint (presenting problems)
I - Injuries/information (symptoms and/or injuries)
S - Signs (RSA/PSA/GWS)
T - Treatments and trends (treatment and patient response)
A - Allergies
M - Medication (regular medications taken)
B - Background history (patient medication history)
O - Other information (scene, relatives present)
Pause and Plan
Transport (patient safety and risks)
- Time critically
- Flags
- transport code (code 1/2)
Differential diagnosis
- Identify possible causes
- refine the list of possible cause
- prioritise based on urgency
- identify provisional diagnosis and/or clinical problems
Clinical judgment
- Patient risks
- Patients diagnosis
- Patients’ clinical problems
Plan
- discuss possible care pathways
- ask for consent to administer medication
- Decide on a plan amongst staff
- Prepare (resources (MICA), task allocation ect.)
Implement
- escalation of care
- treatment
- transport/referral
Reassess
- monitor (minimum every 12 minutes)
- Ideinftiy deterioration and escalate care
- review diagnosis and evaluate/adjust treatment
Transfer care
- IMISTAMBO
- refer to a/their doctor
Secondary assessment
Trauma head to toe
Palpate from the head down to the toes
Medical head-to-toe
Neurological
- any headaches, dizziness, blurred vision
Cardiovascular
- any pain, is it radiating
Pulmonary/respiratory
- Any cough? Mucous?
- Difficult breathing? Feel short of breath?
Gastrointestinal
- Any vomiting? Nausea?
- And changes in appetite?
Urinary
- Have you been going to the toilet more or less than usual?
- Any pain? Smell? Does it burn when peeing?
Reproductive
- Are you having a normal period?
- Are you pregnant?
Skin
- Do you have any rashes? Are you itchy?
- Is your skin colour normal for you?
- Do you have any oedema in your feet or lower legs?
Muscular
- Any injuries? Any pain in your muscles?
Trauma Assessment
PILSDUCT - assessment of trauma
Pain
Irregularity
Loss of function
Swelling
Deformity
Unnatural movement
Crepitus
Tenderness
Neurovascular Assessment
Pulse
Movement
Sensation
Temperature
Cap refill
Colour
Assess of vitals
PSA
Heart rate
Blood Pressure
Skin
Conscious state
RSA
Appearance
Sounds
Speech
Respiratory Rate
Work of Breathing
Rhythm
Skin
Heart Rate
Conscious State
GWS
Eyes
Verbal
Motor
Adjuncts
Blood Glucose Levels
SpO2
ECG
Pupils
Temperature
Pain
ECTO2
Primary assessment
CROPE
C - Consent (ask if conscious, implied if not)
R - Rest and reassure
O - Oxygen therapy (need to add a mask, check SPO2 levels)
P - Position (sit or lie down depending on the condition of comfort)
E - Extra resources - MICR/another truck
SAMPLER
S - Signs and symptoms (what is the issue, timeline when occurred, and how long and the nature of the signs and symptoms. Also what were the beginning issues)
A - Allergies
M - Medications (what they take if anything)
P - Past history (do they have a medical condition, have they had these signs and symptoms before or not/had any history of similar episodes)
L - Last oral intake/outtake (what was last eaten and then went to the toilet)
E - Events leading up to what happened (is anything associated with the circumstance (e.g. construction work overexerted themselves which turned into a heart issue, does anything aggravate it or relieve the symptoms/factors)
R - Risks factors (weight) - smoking, family history, hypertension
IF HAVE PAIN
DOLOR
D - Description
O - Onset
L - Location
O - Other signs and symptoms
R - Relief/aggravation
Rapid assessment
- PPE
- danger (gain 360 access)
- dynamic risk assessment from here and throughout
- Well or unwell - alertness, work of breathing, and skin
DRabCAB c/h/trauma
5. Response - to voice (hello can you hear me? How are you?)
6. check for hemorrhage (trauma), C spine
7. Airway
8. Breathing (hand over chest and look at the chest to see the movement of the chest and listen for breath sounds)
9. Circulation - (check for pulse)
10. Disability (Alert, Voice, Pain, Unresponsive)
11. Exposure (what they are wearing)
Are they aboriginal or Torres strate islands
Consider the cultural/social/environmental factors (are there family members around, where you are, and how that affects the care you are giving)
