Assessing a trauma patient requires a systematic approach. This will help us to find the external and internal injuries sustained by the victim and find the right techniques to manage his conditions.
In case of major trauma, stabilization techniques are used even before reaching a hospital to improve chances of survival of the victim. After ensuring scene safety and following universal precautions, First Responders should do a quick initial assessment following the ABC (A-Airway, B-Breathing, C-Circulation) protocol in that sequence. First responder should also look out for spinal injuries which can be expected in trauma cases. In such cases the victim has to be moved with utmost precautions using techniques such as “Log Roll” & “Cervical Collars” to immobilize the head and neck.
The following guidelines are based on the 2011 edition of Mosby’s EMT Basic Textbook (second edition)
Scene, Survey and Safety
Assess hazards and ensure safety – Your safety comes first! Do not enter the scene if it is not safe. Call emergency medical response immediately. Ensure safety at three levels:
1. General Impression of the patient
2. Checking mental status
6. Determine priority
1. General Impression of the patient
The first aid provider uses the general impression to determine whether the patient is conscious, unconscious, severely injured or facing a medical emergency etc.
2. Mental status assessment with Cervical Spine (C-Spine) control
In all cases of major trauma eg. Motor vehicle accidents (MVA), fall from height, adventure sport injuries such as rafting, hiking etc., always suspect a spinal injury.
In such cases priority is to stabilize the cervical spine. Cervical spine is the portion of our spine extending from below the skull to the level of the shoulders. Major trauma has the potential to cause spinal fracture and any movement can damage the spinal cord running within the spine. This can result in permanent paralysis and/or death.
Mental status assessment is done according to the AVPU scale
1. A – Alert and immediately responsive
2. V – Responds to voice
3. P – Responds to pain
4. U – Unresponsive
If the person is unresponsive and is not breathing, start CPR!!!
If the person is talking, it indicates a clear and protected airway.
In case a trauma victim is unconscious, the ‘Head-Tilt-Chin-Lift’ technique is not advisable to open the airway due to
suspected C- Spine injury. The technique used for opening the airway in case of trauma with suspected spinal injuries is called ‘Jaw Thrust’.This technique opens the airway without extending the neck.
Technique to do a Jaw Thrust :
Step 1 – Kneel at the victim’s head
Step 2 – Place each of your hand on each side of the victim’s face.
Step 3 – Place your index and middle finger behind the angle of the jaw on each side while placing your thumb on his chin as shown in picture.
Step 4 – With your index and middle finger pull the angle of the jaw forward. This will open the airway by moving the tongue forward. Also open the mouth slightly with the help of your thumbs.
If this does not open the airway, it is advisable to do the Head-Tilt-Chin-Lift technique because keeping the airway open takes priority over spinal injury care. This is in accordance with AHA guidelines 2010.
If a person is unresponsive, check breathing by looking at his face & chest (visible chest rise and fall), and if not breathing or only gasping, start CPR!
If a person is breathing, assess whether the breathing is normal or abnormal.
Normal Breathing rate for an adult is 12 – 20 breaths per minute. Normal breathing is regular, quiet and effortless. If available assist using oxygen therapy.
Signs of abnormal breathing :
1) Increased rate of breathing eg. more than 30 breaths per minute indicates severe respiratory distress in adults.
2) Use of accessory muscles for breathing eg. flaring of the nostrils, in drawing of chest muscles.
In case of medical emergencies, it is always advisable to feel for the Carotid pulse as it is more prominent and can be felt more easily and quickly.
– Never press too hard to feel the pulse and never try to feel both the Carotid pulses together, as this can disrupt the normal circulation to the brain.
– Normal pulse rate for an adult: 60–100 /min (72/min is the average pulse rate).
A weak rapid pulse with cold clammy skin indicates presence of shock (indicates low blood pressure and signifies blood loss which could be either external or internal).
Circulation also refers to checking for any obvious external bleeding due to trauma and appropriate measures should be taken to control the bleeding immediately.
6. Determine priority:
– Difficulty in breathing
– Chest pain
– Severe bleeding
– Severe pain
7. Rapid Trauma Assessment
– Rapid sweep to identify major injuries which can be life threatening.
– It is similar to the secondary survey which involves a rapid head to toe examination of the victim to detect major injuries. Attend to the injuries accordingly like apply pressure bandage to stop bleeding, splint the swollen deformed limbs etc.
– Briefly assess the body from head to toe.
– Look and feel for signs of injury (DOTS)
– Open injuries
8. Focused History and Physical Examination
This has to be done inside the ambulance during transportation
– Medical History (SAMPLE)
– Baseline vital signs
– Focus on and start treating found injuries during initial assessment and rapid trauma assessment as appropriate considering priority
9. Ongoing Assessment
– Reassess vital signs
– Reassess injuries
One of the key factors which improves survival in case of trauma victims is rapid transportation. The duty of a paramedics and emergency responders is to “load and go” to the nearest and most appropriate medical facility, preferably a trauma center.