Assessment of The Trauma Patient PDF

Chapter
Assessment of
the Trauma
Patient
OBJECTIVES
Upon completion of this chapter, the reader should be able to:
Identify the components involved in the scene size up.
Differentiate between the golden hour and the platinum ten minutes and discuss the importance of
each in providing care to the multisystem trauma patient.
Apply the trauma triage protocols, based on mechanism of injury and physical assessment findings.
Identify the components of the initial assessment using the acronym ABCDE.
Acquired systematic approach to performing a physical assessment of the trauma patient.
Differentiate singular system trauma from multisystem trauma.
Identify load-and-go patients based on assessment findings.
Identify conditions requiring immediate definitive field treatment from those requiring treatment once en
route to the most appropriate facility.
Identify and discuss the essential equipment required to handle multisystem trauma patients.
Identify the components of the focused assessment.
KEY TERMS
CUPS classification system
Decerebrate
Decorticate
Golden hour
Load and go
Multisystem trauma
Platinum ten minutes
Singular system trauma
Stick-em-up position
In the late 1960s, ambulance personnel began to actually treat seriously injured patients in the prehospital
setting, and the era of scoop and swoop began to disappear. However, many critically injured, multisystem
trauma patients received care for injuries that were
obvious, but minor, while they died from severe hypoxemia or shock prior to arrival at a medical facility. With
the indoctrination of the Advanced Trauma Life
Support (ATLS) course for emergency physicians, the

scoop-and-swoop form of prehospital care reemerged,
but with a new focus: the rapid identification and
resuscitation of life-threatening conditions prior to
transport that result in compromised airway, breathing,
circulation, and neurological status. No longer are
these patients grounded for long periods of time with
field personnel trying to stabilize these injuries prior to
91
92 Chapter 6
transport. The old credo, stabilize the patient before
leaving the scene, which had replaced scoop and
swoop, has been replaced by the battle cry load
and go.1 It is no longer acceptable for the paramedic
to delay transportation while attempting to start IVs,
auscultate a blood pressure, bandage simple soft tissue
wounds, or splint minor fractures when the patients
airway, breathing, circulatory, or neurological status are
severely compromised. Our load-and-go patients are
those who present with decreased level of consciousness (LOC), compromised airway or difficulty breathing, sucking chest wounds, large flail segments, tension
pneumothorax, signs or symptoms of shock, head injury
with altered LOC or unequal pupils, indications of
abdominal trauma, unstable pelvis, bilateral femur
fractures, or a combination of these criteria. In managing load-and-go patients appropriately, we have realized that these patients must be transported to the
most appropriate medical facility, which may not be
the closest medical facility, in order to decrease mortality and morbidity. A fact of considerable significance to
emergency medical service providers is that 70% of
trauma deaths occur in remote or rural areas where
patients are treated at medical facilities unable to
appropriately manage their multiplicity of trauma
injuries.1 The paramedic must be able to rapidly, systematically, and correctly identify load-and-go patients
and initiate transport to the most appropriate medical
facility if survival rates are to increase.
SCENE SIZE UP
The initial observation during the approach to the
scene will provide early clues regarding the potential
for multisystem trauma. Prearrival information provided by the emergency medical dispatcher (EMD)
will often provide patient information that will enable
the paramedic to predict what injuries may exist upon
arrival. Unfortunately, initial dispatch information is
often sketchy due to inadequate information from the
person reporting the incident. In any event, try to
obtain as much information regarding the scene from
the dispatcher as possible so that some prearrival decisions can be made regarding equipment and other
backup assistance.
Upon arrival make a quick assessment of the
scene. Ascertain if it is safe to proceed into the scene.
Determine if there are hazards that will require specialized equipment (e.g., fire apparatus, HAZ-MAT
specialists, rescue tools). Call for law enforcement to
contain the area prior to entry if needed. Ask the following questions:
Is there a fire or imminent danger of fire or
explosion?
Are any vehicles carrying hazardous materials?
Is there danger from oncoming vehicles?

Are all disabled vehicles out of the way ?
What is the mood of the bystanders? Do they
appear to be hostile or calm and approachable?
Is the vehicle or structure unstable, requiring special stabilizing equipment prior to approaching the
injured patient(s)?1
Once the scene has been deemed safe to enter,
determine the mechanisms of injury and the kinematics involved in producing the injury (see Chapter 5).
Based on the mechanism, determine the injuries that
may exist from the appearance of the scene, the
patients position or location, and bystander information obtained. Ask the following questions:
Are there obvious signs of injury that suggest lifethreatening injuries may exist?
How many patients appear to be involved and are
additional personnel, resources, and EMS units
needed?
Do you need to employ triage?
Upon arrival, the paramedic must gather the
equipment necessary to provide initial field care to lifethreatening injuries. With critically injured patients,
precious time is wasted returning to the ambulance
several times for equipment. Essential equipment that
should be carried to each scene includes:
1. Personal protective equipment (PPE)
2. Long spine board, straps, head-immobilizing
device, and cervical-immobilizing device
3. Oxygen (O2) and airway management equipment
[O2 delivery devices, bag valve mask (BVM), suction device, decompression supplies, intubation
equipment]
4. Trauma kit that contains dressing-bandage material, blood pressure cuff, stethoscope, IV equipment and other supplies for trauma care
5. Pneumatic antishock garment (PASG) per local
protocol
ASSESSMENT AND MANAGEMENT

PRIORITIES
The majority of trauma patients have singular system
trauma, that is, trauma that does not systemically
compromise the patient. Less than 10% of all trauma
patients are considered multisystem trauma, and
therefore, the paramedic must be able to quickly identify these load-and-go patients from those with minor
trauma.2 According to Donald D. Trunkey, the time of
death from trauma has a trimodal distribution:3
1. Within seconds to minutes
Assessment of the Trauma Patient
2. Within minutes to hours (golden hour)

3. Within several days or weeks after the initial
injury
Therefore, in dealing with multisystem trauma
patients, the paramedic identifies and manages lifethreatening conditions under specific time constraints.
This requires that assessment, diagnosis, stabilization,
management, and reassessment be performed rapidly
and systematically.
Time is the vital link to patient survival when
dealing with a multisystem trauma patient. The
golden hour, as publicized by the Maryland Institute
for Emergency Medical Services, is the accepted standard for these patients. R. Adams Cowley discovered
that when the critically injured, multisystem trauma
patient is received into surgery within an hour of injury,
approximately 85% survive.4 On-scene time, including
assessment, critical interventions, and packaging,
should not exceed the platinum ten minutes,
unless special circumstances dictate otherwise. These
special situations include extended disentanglement
time and unexpected dangers or hazard occurrence.
The average response time from the onset of the incident to the arrival of EMS is 89 minutes.2 Therefore,
EMS systems strive for an on-scene time of 5 minutes
or less. Response times in rural areas often exceed the
89 minute average, which eats deeply into the golden
hour. Therefore, the shorter the on-scene time, the
sooner the patient receives critical definitive care.
As trauma care has evolved, it has become evident that each patient must be transported to the most
appropriate medical facility capable of providing the
treatment required, rather than the closest facility.
Table 6-1 identifies the mechanisms of injury and physical findings that should prompt the paramedic to apply
triage protocols that will meet the objectives of the
golden hour and platinum ten minutes.
Therefore, the initial approach is directed toward
rapid identification and correction of the following four
major areas: airway, breathing, perfusion, and presence
or absence of significant external and internal hemorrhage.6 Trauma patients are not assessed as thoroughly
as are medical patients; therefore, the key words are
stabilization of the most immediate airway, breathing
and circulatory problems, and rapid transportation.6
INTERNET ACTIVITIES
Visit the Electronic Medicine Web site at
http://w w w.medicine.com. Click on the
Emergency Medicine folder. Then click on the
Trauma and Orthopedics on-line book. Review the
chapter on Hemorrhagic Shock.
93
Table 6-1
Indicators of Multisystem Trauma
Mechanism of injury
Falls greater than 20 feet for adults, greater than 10 feet for
infants or children, or three times the patients body
height
Death of any car occupant
Struck by a vehicle traveling greater than 20 mph
Ejection from a vehicle
Severe vehicle deformity
Rollover with signs of severe impact
Penetrating injuries to the head, chest, or abdomen
Physical findings
Pulse greater than 120 beats per minute (bpm) or less
than 50 bpm
Systolic blood pressure (BP) less than 90 millimeters of
mercury (mm Hg)
Respiratory rate less than 10 or greater than 30 breaths
per minute
Glasgow Coma Score less than 13
Penetrating trauma, excluding extremities
Flail chest
More than two proximal long-bone fractures
Burns greater than 15% total body surface area (TBSA)
Facial and airway burns
ASSESSMENT
The initial assessment addresses life-threatening conditions and employs the following sequential five-step
approach:2
AAirway management and cervical spine control
BBreathing (ventilation)
CCirculation and hemorrhage
DDisability
EExpose, examine, and evaluate
This assessment approach provides a systematic
and organized evaluation of the patients initial status
and allows for detection and stabilization of solely lifethreatening problems on-scene. The components of the
initial assessment must be internalized, not just memorized. Once internalized, the initial assessment should
immediately surface into an automatic response, without hesitating to recall what step of the assessment
should be performed next. The focus must be on what
the assessment data reveal in relation to the patients
94 Chapter 6
overall physiological status, and how the patterns of
injuries and conditions are affecting overall aerobic
metabolism and homeostatic well-being. The paramedic
must be able to analyze assessment data and, based on
that data, anticipate, predict, and appropriately manage
the patient in order to prevent further detrimental
effects. The paramedic should follow, as closely as possible, the order of the initial assessment, keeping in mind
there are circumstances that require deviation from the
survey format (e.g., severe external hemorrhage requiring immediate treatment when the patient is obviously
breathing upon initial approach). When the paramedic
must deviate from the order of the survey, vital organ
system assessment may be omitted; therefore, it is
important to go back to the previous steps if they were
omitted initially.
Multisystem trauma patients quickly deteriorate
into anaerobic metabolism as a result of inadequate tissue perfusion. This is described as a four-component
deterioration:
1. Inadequate oxygenation of the red blood cells
(RBCs) in the lungs
2. Inadequate delivery of the RBCs to the tissue
cells
3. Inadequate distribution of the oxygen to the
tissues
4. Inadequate availability of RBCs necessary to
deliver oxygen to tissue cells
The paramedic is able to appropriately and adequately
manage the first two phases of deterioration during the
first steps of the initial assessment by rapidly evaluating
and resuscitating those conditions that are physiologically linked to this deterioration. A clinically competent
paramedic, who has developed a consistent approach to
the assessment of every patient, will be able to determine whether or not the problem is immediately life
threatening and if it involves singular or multisystem
trauma in less than 2 minutes.4
The initial assessment begins upon arrival and
includes scene size up and a global evaluation of the
patients respiratory, circulatory, and neurological status. 2 Upon approaching the scene, the paramedic
answers the following: Does the patient appear to be
conscious? What is the patients position? Is the patient
moving or does he or she appear to be unresponsive?2
A sweeping glance over the patient may detect gross
external hemorrhage or deformity or extreme use of
accessory or neck muscles, possibly indicating severe
airway compromise. The paramedic may see that the
patient is extremely pale, exhibiting restlessness and
agitation, indicative of early signs of shock. A patient
with an injury around cervical spine vertebrae number
6 (C-6) often lies with forearms flexed across his or her
chest and hands half closed. Another position often
assumed with spinal injury is the arms flexed and

extended above the head, termed the stick-em-up
position1 (see Figure 6-1). Movement of the patient
out of this position should not be attempted, unless the
airway is compromised, until adequate personnel are
available to move the patient as a unit.1
While comparing the initial global assessment
findings with scene size up, mechanism of injury
(MOI), and kinematic findings, begin formulating an
initial impression of whether the patient is a singular or
a multisystem trauma patient. This global assessment
takes about 15 seconds and provides a rapid gross evaluation of the patients respiratory, circulatory, and neurological functions.7
It is a fundamental instinct to reach the injured
patient(s) as quickly as possible. However, if possible, it is
best to approach the patient from the front. If responsive
to verbal stimuli, the patient may turn his or her head or
body toward the sounds of approaching personnel. This
excessive or sudden body movement could produce further injury to the C-spine or other internal organ structures if injury is already present. If unable to assume a
frontal approach, the paramedic should avoid startling or
stimulating the patient during the approach. Often a simple statement, such as please dont move, we are here to
help, will prevent unnecessary patient movement.
FIGURE TO COME
FIGURE 6-1 Stick-em-up position often assumed by the

patient with a spinal injury.
It is important to repeat the phrase please remain

still as you approach and once you arrive at the patients
side. The lead paramedic should direct his or her partner or first responder to obtain manual stabilization of
the patients head and neck, using a trauma jaw thrust
procedure to open the airway. It is assumed that all
trauma patients have the potential for spinal injury and,
therefore, all suspected trauma patients should be manually stabilized in this manner (see Figure 6-2). Care
must be taken not to intentionally stimulate the patient
who appears to be unconscious until manual stabilization
has been obtained, because the patient may turn his or
her head laterally or rotate his or her body in an attempt
to locate voice or touch. If manual stabilization is
obtained before the LOC is assessed, the paramedic
may avoid a disastrous outcome for the patient.
95
Assessment begins with evaluation of the patients

LOC. If the patient is not verbally responding, the
paramedic must gently tap while verbally stimulating a
response from the patient. It is important not to shake
the patient because doing so could aggravate existing
injuries. A verbally responsive or moaning patient indicates an open airway. Any patient with a decreased
LOC is considered a load-and-go patient and should
receive immediate oxygenation with 100% oxygen
delivered by a nonrebreathing mask or, if respirations
are inadequate, by BVM assist. Paramedics should be
Airway
Airway management and control are two of the most
important priorities of care when confronted with a
multisystem trauma patient. The airway can be opened
using a trauma jaw thrust maneuver. If the patients
head is not in a neutral position, the paramedic must
gently move it into a neutral position unless resistance is
met with movement or the patient develops intolerable
pain. If the patient is in a seated position or lying on the
ground, someone may need to take frontal or lateral stabilization of the head and neck until another responder
can assume a posterior, kneeling, or on-ground position
(see Figures 6-3 and 6-4). When manual stabilization is
obtained, the paramedic places his or her fingers on the
mandibular curve, gently pushing forward to create an
open airway without hyperextension of the head.
FIGURE 6-2 Manual stabilization of the head and neck

using a trauma jaw thrust to manage the patients airway.
FIGURE 6-3 Manual stabilization of the head from behind

the seated patient.
FIGURE 6-4 Manual stabilization of a supine patients head

and neck.
96 Chapter 6
very attentive to the airway of a patient with an altered
mental status. These patients may have difficulty managing oral secretions. Once opened, the airway should
be immediately suctioned to clear blood, debris, and
secretions, if present.
The paramedic must gather further information
regarding the patients perfusion status if there is a verbal response elicited with the initial LOC assessment.
This assessment can occur simultaneously as the paramedic continues to assess the patency of the patients
airway by asking how the incident occurred, the general
time of day, general location, and the patients name. If
the patient is alert but confused, this is indicative of
early inadequate tissue perfusion. Again, immediate
resuscitation with 100% oxygen with a nonrebreathing
mask should be initiated.
During this initial assessment, the paramedic
must listen for signs indicative of airway compromise.
Are there silent, snoring, gurgling, or stridorous sounds
present that may require immediate action such as
repositioning the airway, removing a foreign body airway obstruction, suctioning, or immediate intubation?
Any delay in recognizing and resuscitating these conditions will lead to increased hypoxemia, anaerobic
metabolism, acidosis, and possibly death. Figure 6-5
provides an algorithm for assessment of the airway.
Algorithm
Breathing
Trauma patients revert to anaerobic metabolism primarily due to hypoxemia. Simultaneous assessment of the
patients breathing status is conducted while the
patients airway is being opened and during the initial
LOC evaluation. This initial evaluation focuses on the
patients relative respiratory rate (normal, fast, or slow)
and quality of ventilations, and employs the look, listen,
and feel method of evaluation.
First, the paramedic must determine if the
patient has spontaneous respirations. This is accomplished by looking, listening, and feeling for breathing
and chest excursion. Noisy or windy environments may
interfere with hearing or feeling the patients exhaled
air. Under such conditions it may be necessary to
auscultate breathing by placing the head of the stethoscope over the trachea at the suprasternal notch. This
will provide clear, audible air movement sounds upon
inspiration and expiration in breathing patients. 7
Immediate resuscitation is required if there are no
spontaneous respirations or if the patient has agonal
respirations. Initially, this should be accomplished by
insertion of an oropharyngeal or nasopharyngeal airway
and use of a BVM with 100% oxygen. If this method of
airway control and ventilation is effectively oxygenating
the patient, it is not necessary to immediately intubate.
Actions
Assessment
Control C-spine
Open airway
Establish LOC
Cervical spine MOI
Manual stabilization
Alert/responsive
Approach patient from front
Airway obstruction
Trauma jaw thrust PRN

Load and go?
Airway
compromise?
Resuscitate
FIGURE 6-5 Airway assessment algorithm.
Silent
Clear
Snoring
Obstruction/suction
Stridor
Bag-valve-mask
Gurgling
Load and go?
Intubation can be delayed until there are adequate

personnel on-scene to quickly accomplish this procedure or until the patient is loaded into the ambulance.
Patients with spontaneous respirations should be
evaluated for breathing difficulty. First, the paramedic
determines if the patient is experiencing an irregular
breathing pattern, apnea, bradypnea, hypopnea,
tachypnea, or dyspnea. Look for signs of respiratory
distress or compromise, which include pallor, cyanosis,
nasal flaring, tracheal tugging, use of accessory muscles, intercostal muscle retractions, and diaphragmatic
breathing. With a C-6 injury, intercostal muscles will be
paralyzed, severely compromising respiratory efforts.
An injury at C-4 will paralyze the diaphragm, making
breathing virtually impossible, and the patient will be
using accessory muscles in the neck to breathe.1 If any
of these signs are present, immediate resuscitative
efforts must be initiated. The patient will quickly deteriorate if allowed to continue this inadequate ventilatory process. An apneic, bradypneic, or hypopneic
patient must receive assisted ventilation with 100%
oxygen using a BVM. The tachypneic or dyspneic
patient may need assisted ventilation, or may only need
to be placed on 100% oxygen by a nonrebreathing
mask. The paramedic determines which oxygen delivery device is going to be the most beneficial to the
patients current ventilatory pattern and which device
the patient will tolerate. This determination is based on
the general rules of airway and breathing management
found in Table 6-2.
The initial goal of breathing assessment is to detect
life-threatening conditions. Therefore, the next step in
the assessment process should be to seek out the etiology
of the respiratory compromise, especially if tachypnea is
present. Remember, tachypnea is indicative of hypoxia,
acidosis, and anaerobic metabolism. The paramedic
should quickly expose and assess the patients chest for
symmetry, paradoxical movement, sucking chest wounds,
impalements, ecchymosis, hueing, deformity, or obvious
signs of blunt trauma to the chest wall. If the patient has
an injury to the lower cervical or upper thoracic spinal
cord, there may be paralysis of the intercostal muscles.
These types of injuries may present with abdominal
breathing, which may be detected during the assessment
for symmetrical movement of the chest wall.
Bilateral breath sounds should be auscultated to
determine if the breath sounds are clear, equal, diminished, or absent. This auscultation should be quick,
using a two-point midaxillary assessment (see Figure
6-6). Percussion can detect hyporesonance or hyperresonance but is often difficult to perform in the prehospital setting due to ambient noise. Pneumothorax, tension
pneumothorax, hemothorax, hemo-pneumothorax, and
flail chest are conditions often responsible for inadequate ventilation.
97
Table 6-2
General Rules of Airway and Breathing
Management
Adult respiratory rates
Less than 12 is considered slow and may be associated
with central nervous system (CNS) trauma.
Less than 10 is inadequate.
Twelve to 20 is considered a normal range but may have
inadequate tidal volume.
Greater than 20 and up to 24 is considered possible early
warning sign of developing respiratory/circulatory
compromise.
Greater than 24 and up to 30 indicates developing
respiratory and systemic compromise associated with
hypovolemia.
Greater than 30 indicates hypoxemia, acidosis, or
hypoperfusion.
Resuscitation rules of management
Respiratory rates less than 12 require assisted or total
ventilatory control with a fraction of inspired oxygen
(FiO2) of 0.85 or greater.
Respiratory rates of 1220 may need supplemental 100%
O2 by nonrebreather or assisted ventilations if the tidal
volume is very shallow or the LOC is depressed.
Respiratory rates of greater than 20 and up to 30 require
supplemental O2 or assisted ventilation.
Respiratory rates of greater than 30 should receive
assisted ventilation with 100% O2 and early intubation
may be required to maintain full ventilatory control.
Source: Adapted from PHTLS Basic and Advanced Prehospital
Trauma and Life Support. (4th ed.), by N.E. McSwain, J.L.
Paturas, E.M. Wertz, 1999, Mosby: St. Louis.
The final step of the breathing assessment involves

palpating the anterior neck for jugular venous distention
(JVD) or flatness and assessing the trachea for deviation
(see Figure 6-7). Jugular venous distention is associated
with a building tension pneumothorax, or pericardial
tamponade, whereas flat neck veins can indicate hemorrhage and hypovolemia. However, it must be remembered that approximately 34 cm of venous engorgement
is normal in patients lying supine. Venous engorgement
in excess of this amount signifies JVD while flat neck
veins in a supine patient may indicate hypovolemia.
If JVD or tracheal deviation is present, the patient
is severely compromised and must be transported as
soon as possible. Positive JVD associated with a tension
pneumothorax must be definitively resuscitated with
98 Chapter 6
Circulation and Hemorrhage
FIGURE 6-6 Auscultation of bilateral breath sounds utilizing

a two-point midaxillary assessment.
needle decompression and assisted ventilation with

100% oxygen. The paramedic must also decide
whether intubation can be delayed until the patient is
en route to the medical facility. Any patient who is
unable to maintain an airway, has a high risk of aspiration, displays a large flail segment, presents with airway
injuries or midface trauma, or has a Glasgow Coma
Score of less than 9 requires a definitively secured airway as soon as possible.2
If the patient must be assist ventilated or hyperventilated, the paramedic stabilizing the head and neck
can provide this treatment by placing his or her knees
on either side of the patients head. It will be important
that someone obtain manual stabilization frontally
while the paramedic assumes this position. This allows
all other treatment personnel to focus on completion of
the assessment process and preparation of the patient
for packaging and transport. Figure 6-8 presents an
algorithm for assessment of breathing.
Circulatory assessment is divided into three components: assessment of cardiac output, exsanguinating
hemorrhage, and, if internal hemorrhage is suspected,
PASG survey .9 Failure of the circulatory system results
in inadequate delivery of oxygen to the target tissue
cells, which leads to the signs and symptoms associated
with inadequate tissue perfusion. Initial assessment of
cardiac output, cardiovascular status, and perfusion status can be rapidly obtained during the initial assessment of central and peripheral pulses, skin color, skin
temperature, and capillary refill time. Quantitative vital
signs may be included during this phase of the initial
assessment only if adequate personnel are available to
perform this assessment without interruption of the
focused assessment process.
Assessment of Pulses The patients carotid and

radial pulse should be evaluated simultaneously for
presence, quality, equality, and regularity. At this time
only a relative rate and quality will be obtained. If a
radial pulse is palpable, this establishes an initial baseline estimate that the patients systolic blood pressure is
at least 8090 mm Hg depending on the strength of
the pulse (see Table 6-3 for a comparative analysis of
peripheral pulses and systolic blood pressure). A radial
pulse that is tachycardic and weak or weakening may
be the first indicator that the patient is experiencing
circulatory system failure or shock. Unexplained tachycardia may be indicative of internal hemorrhage, especially intra-abdominal hemorrhage. An absent radial
pulse indicates the patients blood pressure is below 80
mm Hg and that the patient is profoundly hypovolemic.
A radial pulse that is full, bounding, and bradycardic
may be suggestive of increasing intracranial pressure
(ICP). Refer to Chapter 11 for an in-depth discussion of
increased intracranial pressure and Cushings reflex.
The presence of a bounding radial pulse suggests the
systolic blood pressure (BP) is significantly above 100
mm Hg. A normocardic or bradycardic pulse rate could
Table 6-3
Estimating Systolic Blood Pressure Based on
Pulses
FIGURE 6-7 Jugular venous distention.
Pulse Palpable at
Systolic Blood Pressure of

at Least:
Radial
8090 mm Hg
Brachial
7080 mm Hg
Femoral
7080 mm Hg
Carotid
6070 mm Hg
Algorithm
Assessment
Assess breathing
Expose chest
Assess BBS
Assess anterior neck
99
Actions
Relative rate/rhythm/
quality
O2 NRB mask/OPA/NPA
Expose chest
BVM/ETI/cricothyrotomy
Chest symmetry/BBS
Breathing
difficulty?
Neck veins
Needle decompression
Tracheal deviation
Load and go?
Apnea
BMV with 100% O 2
Bradypnea
Assisted w/ BMV and 100%O2
Hypopnea
Assisted w/ BMV and 100%O2
Tachypnea
NRB mask/BVM with 100% O2
Dyspnea
Resuscitate
FIGURE 6-8 Breathing algorithm.
be suggestive of neurogenic shock associated with

spinal cord injury. The paramedic must begin to associate the mechanism of injury (MOI) with assessment
findings and analyze how these findings are directly
related to the physiological response the patient is
exhibiting. Definitive field treatment relates directly to
the ability to recognize and differentiate normal from
abnormal physiological responses and how these
responses relate to load-and-go patients.
Assessment of Skin Color and Skin

Temperature Skin color and temperature will provide a rapid initial assessment of peripheral perfusion status. This assessment can be simultaneously performed
during the carotid and radial pulse check. A hypovolemic
patient will normally present with pale, cool or cold,
clammy, and diaphoretic skin, whereas patients with neurogenic shock may present with normal to pink, warm,
and dry skin below the level of spinal cord injury and
pale, cool, clammy, and diaphoretic skin above the level
of cord injury. A patient with head injury may present
with warm, sometimes hot skin temperature, and skin
color can be normal to flushed in appearance due to the
increased systolic BP.
Assessment of Capillary Refill
The paramedic can quickly assess capillary refill time (CRT),
once the radial pulse check is completed, by exerting

pressure to the nail beds or hypothenar eminence causing the underlying tissue to blanche (see Figure 6-9). If
the patient is normovolemic, color will return within
2 seconds. However, if the sympathetic nervous system
has caused a sympathomimetic response due to hypovolemia, return of color will be greater than 2 seconds.
The paramedic must keep in mind that capillary refill
delay, without the presence of other associated signs and
symptoms, may be unreliable. Changes can be caused by
age, hypothermia, or simple fractures. Normal CRT may
occur in the presence of neurogenic shock, isolated head
trauma with increasing ICP, and pharmacological
vasodilatory medications.
Assessment of Hemorrhage
External exsanguinating hemorrhage must be rapidly detected and controlled to prevent deterioration of the patients cardiac
output and perfusion status. Severe external hemorrhage
may be detected and corrected by application of direct
pressure, prior to any other assessment, if the patient is
breathing or if there are adequate personnel present to
begin hemorrhage control. There are circumstances that
prevent the paramedic from detecting life-threatening
hemorrhage until a quick body sweep is performed (e.g.,
patients size or position or inadequate lighting). This
body sweep generally occurs once initial airway,
100 Chapter 6
FIGURE 6-9 Assessment of CRT by exerting pressure to the

nail beds or hypothenar eminence.
breathing, and circulatory status have been assessed. It

consists of running the hands, beginning at the head,
down the patient, paying particular attention to areas
where blood can pool (e.g., posterior scapular area, lateral axillary area, lumbar-sacral area, medial/inner thigh
area) (see Figure 6-10). As the quick sweep is performed,
the paramedic is looking at his or her gloved hands for
evidence of significant venous or arterial bleeding and
feeling for sudden warmth. If significant bleeding is
found, the area must be quickly exposed and the patient
positioned for visual examination of the area. Control
methods must be initiated if significant hemorrhage is
detected. Use of pressure bandages, PASG, or even air
splints may provide adequate control, freeing the paramedic to perform other critical interventions or to continue assessing the patient. Significant internal
hemorrhage can occur in four body areas: the chest, the
abdomen, the retroperitoneal/pelvic cavity, and the thigh.
If internal hemorrhage is suspected, based on the presenting MOI, unexplained restlessness, tachypnea, and
tachycardia, the paramedic must deviate from the strict
ABCDE assessment format and perform the PASG survey by exposing the abdomen, pelvis, and legs. He or she
must look for hueing or ecchymosis, edema, or signs of
blunt trauma and palpate for rigidity, swelling, or deformity. A quick palpation of the pelvic region should be
performed since pelvic fractures have a high percentage
of associated intra-abdominal hemorrhage. If internal
hemorrhage is detected, rapid immobilization onto a long
spine board with PASG in place, rapid transportation,
and resuscitation with warmed IV fluids should be initiated. The paramedic quickly completes the initial assessment while the patient is being readied for transport,
searching for any other life-threatening injuries that may
be present. Movement of the patient prior to completion
of the assessment could aggravate undetected injuries.
FIGURE 6-10 A quick sweep of the lumbar-sacral area for

gross exsanguinating hemorrhage.
Assessment of Vital Signs
Quantitative vital
signs (heart rate, respiratory rate, and blood pressure)
provide necessary baseline data, especially when the
patient is rapidly deteriorating. Therefore, quantitative
vital signs should be obtained as soon as possible but
should not take precedence over essential steps of
assessment, resuscitation, stabilization, and transport.
Continual reevaluation of relative rate and quality of
respirations and core versus peripheral pulses can provide adequate baseline data until the patient is en route
or adequate personnel are available to obtain quantitative vital signs. Figure 6-11 presents an algorithm for
assessment of circulation.
Disability
Rapid neurological evaluation is a very important part
of the initial assessment. It measures cerebral function
and indirectly measures cerebral oxygenation based on
the patients response to external stimuli and other
assessment data. This evaluation establishes the

patients level of consciousness, pupillary size and reaction, and motor and sensory response in upper and
lower extremities.
Assessment of Level of Consciousness
The
patients initial LOC is assessed by gently tapping or
verbally stimulating, not shaking, the patient to elicit a
response at the beginning of the initial assessment. At
that time a general idea of responsiveness is ascertained. Now the paramedic must perform a more definitive assessment using the AVPU scale (see Table 6-4).
If the patient is able to verbally respond, determine if
he or she is appropriately oriented by asking questions
Table 6-4
Scale Used to Determine a Patients LOC
AVPU SCALE
AAlert (to person, place, time, event)
VVerbal stimuli (appropriate or inappropriate response)
PPainful stimuli (appropriate or inappropriate response)
UUnresponsive
Algorithm
related to time, place, person, and event. As cerebral

function declines, the patient will begin to lose orientation to place and events prior to the injury. As the
patient worsens, orientation to person will decline, not
just to family members, but to self as well. At this point
the patient is moving toward unconsciousness. The
patient will respond to verbal stimuli by opening his
eyes and moving body parts when spoken to but is
unable to coherently communicate. Verbal responses
are not intelligible and sound garbled or moaned.
When the patient is no longer responsive to verbal stimuli, the paramedic must determine the depth of
unresponsiveness by eliciting a purposeful response to
pain. Several methods are discussed in the literature
that may be more appropriately used on medical
patients (e.g., sternal rub or ear lobe pinch).7 However,
these methods may produce unwanted movement in
the trauma patient. A sternal rub may cause the patient
to move the torso in an attempt to avoid/escape the
painful stimuli. This movement may aggravate chest,
spine, abdominal, and pelvic injuries. Pinching the ear
lobe could produce a severe lateral or twisting rotation
of the head in an attempt to move away from the pain.
Obviously, if there is cervical spine injury, this type of
movement could be disastrous, especially if the person
manually stabilizing the head and neck is not ready for
Actions
Assessment
Carotid/radial pulse
Assess
circulation
Hypoperfusion?
Relative rate/quality
Cardiopulmonary
resuscitation as
needed (PRN)
Skin temp/color/capillary refill
PASG
Exsanguinating hemorrhage
2 large-bore IVs en
route
PASG survey if internal

hemorrhage suspected
Fluid trial PRN
Quantitative vital signs
Rapid infusion PRN

Load and go?
Resuscitate
FIGURE 6-11 Circulation algorithm.
101
102 Chapter 6
this type of movement. For these reasons, the sternal
rub and ear lobe pinch are not recommended.
There are two methods that can be employed to
elicit a painful response with minimal risk for further
injury:
1. Pinch the patients upper arm, on the medial
aspect, mid-way between the antecubital space
and axilla in the softest portion of the skin (see
Figure 6-12).
2. Take the fleshy region between the patients
thumb and forefinger, preferably in an uninjured
extremity, and pinch or squeeze it forcefully (see
Figure 6-13).
Purposeful response to this painful stimuli is indicated
by patient movement away from the pain. A twitch, or
slight movement of the hand or forearm, indicates
severe cerebral dysfunction. Look for abnormal movements such as decorticate (rigid flexion of the arms
and extension of the legs) and decerebrate (rigid
extension of the arms and legs; the back and neck may
be arched) posturing with and without this stimuli (see
Figures 6-14 and 6-15).
A patient who does not exhibit any response to
painful stimuli is considered unresponsive. This is an
ominous sign and indicates profound hypoxemia, acidosis, total patient decompensation, and severe inade-
FIGURE TO COME
FIGURE 6-12 Painful stimuli applied by pinching the medial

aspect of the upper arm midway between the antecubital
space and axilla.
quate tissue perfusion, especially cerebral hypoperfusion. Obtaining initial baseline data regarding the
patients LOC with frequent reevaluation establishes a
fairly clear picture of how rapidly the patient is deteriorating. As the patient slips down the AVPU scale, he or
she may become combative, display irrational
responses, exhibit uncooperative and belligerent behavior, and refuse medical help. The paramedic must try
not to antagonize the patient, knowing that the patients
behavior may be the result of head injury, hypoxemia,
and hypoperfusion. This type of behavior requires
immediate or continued treatment with 100% oxygen.2
During this evaluation it is very important to
determine the history of the event. Specific questions
would include: Did the patient lose and regain consciousness prior to EMS arrival or since the injury
occurred? Does the patient have any preexisting medical conditions that might be responsible for altered
LOC (e.g., diabetes, epilepsy, heart problems)? Could
there be toxic substances involved (e.g., drugs, alcohol,
or other chemical substances)? The paramedic must
gather this history from the patient, family members, or
bystanders, without interrupting the initial assessment.
Assessment of Pupils
The pupils, controlled by

higher cranial nerves, are a direct link to the brain and
provide invaluable information concerning cerebral
FIGURE TO COME
FIGURE 6-13 Painful stimuli applied by pinching or squeezing

the fleshy region between the patients thumb and forefinger.
FIGURE 6-14 Decorticate posturing.
FIGURE 6-15 Decerebrate posturing.
perfusion. Under normal conditions pupils react

quickly and consensually to changes in light intensity. A
quick pupil evaluation to determine if the pupils are
equal, round, and reactive to light (PERRL) will provide important baseline information regarding intracranial pathology and cerebral perfusion. A sluggish pupil
reaction may reflect CNS depression from hypoxia,
hypercarbia, injury, or the effects of drugs. Unequal
pupils (anisocoria) may indicate eye trauma, head
trauma, or cerebrovascular accident (CVA). Dilated or
fixed pupils are indicative of hypoxia, severe ICP, or
CNS injury.2 Pupils are usually equal to within 1 mm,
remain equal, and constrict equally when exposed to
light. Abnormal or sluggish reactions to light, significantly unequal pupils, or lack of consensual reaction
usually results from insult to the brain or one of the
oculomotor nerves in the absence of direct eye injury.7
Assessment of Pulse, Motor, and Sensation

The paramedic should quickly perform a pulse, motor,
and sensation (PMS) assessment of the upper and
lower body extremities (PMS 4) during the disability
assessment. (Note: The lower extremity PMS evaluation can be integrated into the expose, examine, and
evaluate component of the lower extremities to save
time.) This is not an in-depth evaluation, but rather a
quick determination of neurological intactness prior to
moving the patient to a long spine board (LSB). This
will establish baseline assessment data for motor or
sensory deficits in the extremities of a responsive
patient, which may indicate brain injury, spinal cord
injury, or injury to a limb. A deficit in distal circulation
may reflect a reduction in systemic circulation or compromised circulation in that limb.7 Evaluation in a verbally responsive patient consists of:
1. Having the patient unilaterally, then bilaterally,
squeeze one of your fingers, to compare the pres-
103
ence and equality of strength in the other extremities (see Figure 6-16). This detects paralysis or paresis (weakness) in one or both upper extremities.
2. Having the patient unilaterally, then bilaterally,
push and pull back on your hands with the feet as
you compare the strength and quality of the
movement (see Figure 6-17). Impairment may
indicate a spinal cord injury.
3. Having the patient wiggle the fingers and toes,
which indicates the motor nerves are intact.
4. Asking the patient if he or she feels you touching
his or her fingers and toes to rule out numbness,
tingling, or decreased sensation.
Evaluation of the unresponsive patient consists of:
1. Pinching the fingers and toes or running a blunt
object along the palms and soles of the feet to
determine if the patient withdraws or localizes
the pain. Intact motor and sensation usually indicates normal or minimally impaired cortical function, whereas a positive Babinski response
indicates spine injury. A positive Babinski is present if the big toe turns upward when a blunt
object is introduced to the sole of the foot (see
Figure 6-18). Normally the big toe will turn
downward.
2. Exerting pressure with your thumb into the
patients palm, which should produce curling,
withdrawal, or flexion.
During this evaluation the paramedic should note
any posturing displayed when painful stimuli are initiated. If there is no movement produced with painful
stimuli, the paramedic should assess for flaccid paralysis by lifting the patients forearm slightly, if there is no
sign of extremity injury, and then let it fall. Absence of
any muscle tone usually denotes spinal cord injury.
Distal pulses should be assessed in each extremity
and should be compared. Simultaneous assessment of
the radial pulses and then pedal pulses can provide
invaluable assessment data regarding circulatory function. The paramedic is able to determine the presence,
absence, equality, and relative pulse rate, which may
indicate hypovolemia, undetected fractures, cardiac
tamponade, or aortic aneurysm. Remember, lower
extremity PMS assessment can be carried out with the
lower extremity quick initial assessment.
Assessment of Cervical Spine The paramedic

will want to apply a cervical collar (C-collar) at this point.
Prior to application, assessment of the posterior neck
must be performed to determine if there is tenderness,
deformity, edema, muscle spasms, palpable vertebral
step-offs or gaps, impaled objects, or soft tissue injury.
One should assume a cervical spine fracture in any
104 Chapter 6
FIGURE 6-16 Assessment for paralysis or paresis by having the patient squeeze two to three of your fingers.
patient with an injury above the clavicle as 10% of all

patients with head injuries will have cervical spine fracture.9 If the paramedic suspects chest trauma, a quick
reevaluation of the anterior neck for JVD and tracheal
deviation should be performed before applying the
C-collar. Application of the C-collar can be delayed if
continued reevaluation of the anterior neck is warranted.
For more complete stabilization of the head and neck the

C-collar should always be applied prior to movement of
the patient onto the LSB. Once the cervical collar has
been applied, the paramedic manually stabilizing the
head and neck must continue this stabilization until the
patient is fully strapped to an LSB with head-immobilizing devices in place.
FIGURE 6-17 Assessment for lower extremity paralysis or

paresis by having the patient push, then pull back on your
hands.
FIGURE 6-18 A positive Babinski; the big toe turns upward

when a blunt stimulus is applied to the sole of the foot.
Glasgow Coma Score
The paramedic should

obtain a Glasgow Coma Score (GCS) on all trauma
patients. This scale provides a numerical measure
based on an assessment of the patients eye opening
and verbal and motor responses. If the score is less
than 9, this implies severe neurological insult, which
requires airway support with hyperventilation and
rapid transport. Do not stop the evaluation process to
score the patient; instead, obtain baseline assessment
data and record these data as soon as possible, usually
after the patient is in transit. The GCS is usually used
in conjunction with the revised trauma score, which
measures on the severity of trauma. For a detailed discussion of these trauma-scoring systems, refer to
Chapter 7. Figure 6-19 presents an algorithm for
checking disability.
Expose, Examine, and Evaluate

The last step in the expanded initial assessment
involves a quick assessment of all systems not previously exposed. It is important to expose the patient
when assessing each system for severe soft tissue injury,
open and closed fractures, and undetected hemorrhage, especially when the patient is wearing bulky
clothing. It is very important to keep in mind that a
patient experiencing anaerobic metabolism becomes
hypothermic quickly. Preserve body heat by covering
the patient once body parts are exposed and examined
or expose only what is necessary, especially if the outside temperature is cold. If the patient is not fully
exposed prior to movement, complete exposure and
examination must take place once in the EMS unit.
Usually this assessment involves the chest, if not

previously evaluated, abdomen, flanks, pelvis, lower
extremities, and back. All injuries should be located
prior to PASG application and, hopefully, prior to
patient movement since movement can aggravate existing injuries (e.g., pelvic, femur, and lower leg fractures). Based on assessment findings, conventional
movement strategies may have to be modified to
accommodate the type of injury detected (e.g., utilizing
a scoop stretcher instead of the log roll to place a
patient with an unstable pelvic fracture onto an LSB).
Chest and Thorax Evaluation If the paramedic has not exposed and examined the chest during
the breathing assessment or if there is reason to quickly
reevaluate the chest, this quick evaluation should be
performed at this time. As the chest is exposed, look
for signs of injury such as hueing, ecchymosis, deformity, impalements, asymmetrical movement, soft tissue
injuries, and intercostal retractions. Quickly feel for
symmetrical expansion and movement of the chest wall
(see Figure 6-20), paradoxical movement, crepitus, and
instability. Finally, listen for bilateral breath sounds and
reevaluate endotracheal tube placement if the patient
has already been intubated. If this assessment has been
performed as part of the breathing assessment, the
evaluator can proceed on to the abdominal evaluation.
Abdominal Evaluation
Rapidly expose the

abdominal area and look for evidence of internal hemorrhage in the form of abrasions, hueing, ecchymosis,
edema, swelling, lacerations, penetrating wounds, and
eviscerations. The abdominal area superior and inferior
Algorithm
Assess
disability
FIGURE 6-19 Disability algorithm.
105
Assessment
Actions
AVPU
Apply cervical collar
Pupils
Unequalhyperventilate?
All extremities
Pulse/motor/sensation
Spinal injurySolu Medrol?
Examine posterior neck
Load and go?
106 Chapter 6
Remember that unexplained tachycardia may be the
first indicator of intra-abdominal hemorrhage.
Management priorities include consideration of
PASG application, especially if intra-abdominal hemorrhage is suspected. This treatment may help tamponade significant hemorrhage long enough for the patient
to be received into surgery. Initiation of 100% oxygen
should occur immediately if not already initiated. Two
large-bore IVs should be established once the patient is
en route, unless an extended extrication time is anticipated, which may warrant initiation of IV therapy prior
to loading the patient. It is important to keep in mind
that this patient needs definitive surgical treatment as
soon as possible, and time spent trying to initiate IVs
prior to loading the patient for transport may unnecessarily delay this definitive treatment.
Pelvic Evaluation
FIGURE 6-20 Assessment for expansion and movement of

the chest wall.
to the umbilicus should be carefully evaluated for signs

of contusion, often initially showing as a hued area
about 4 cm wide lying transversely across the abdomen.
This is indicative of an incorrectly worn seat belt and
may result in hollow viscus injury in the abdomen or a
lumbar spine fracture.2
Assessment includes palpation of all four quadrants of the abdomen. Observe any painful response or
guarding reaction. Feel for rigidity, spasms, edema,
local warmth, coolness, or masses. If a painful response
is elicited, such as voluntary or involuntary guarding,
do not continue to palpate that area because further
injury can occur to the patient. The paramedic should
not be concerned with auscultating the abdomen for
bowel sounds since this is not a reliable or easily performed prehospital evaluation. During the abdominal
examination remember to quickly feel laterally around
the patientss flank area to check for deformity, edema,
impalements, or undetected hemorrhage that may be
pooling in the curvature of the lumbar-sacral area.
Pelvic fracture is most commonly caused by motor vehicle trauma, crush injury, or
a fall. Internal hemorrhage is the major cause of death
in patients with pelvic fractures. Thirty percent of the
total blood volume may be lost into the surrounding
soft tissue of the pelvic cavity and retroperitoneally.1
Initial scene evaluation, MOI, and patient position can
often provide early clues that there might be an underlying pelvic fracture or dislocation present, such as
when the patients knees have impacted the vehicles
dashboard.1
The paramedic may notice, with a patient lying
on the ground, lateral or medial rotation of one leg suggestive of hip dislocation. Once the patient is exposed,
the paramedic may observe ecchymosis, swelling, or
deformity. The patient may complain of pain in that
area. Palpation of the pelvic region begins with compression of the iliac wings laterally and inwardly. If
there is no crepitus heard or felt and the pelvis feels
stable, exert gentle downward pressure on the iliac
crests, again noting any crepitus, instability, or painful
response from the patient. If this assessment is
negative, then place gentle downward pressure on the
pubis, feeling for instability on crepitus (see Figure 621). If evidence suggestive of pelvic fracture is present,
do not palpate any further. Movement of the patient
onto an LSB can often produce further injury, and
therefore, the patient may need to be moved onto the
LSB by use of a scoop stretcher. Patients with an
unstable pelvis should not be log rolled except when an
alternative method would result in a life-threatening
delay. The paramedic must assume that any patient
with an unstable pelvis has a high potential for intraabdominal or retroperitoneal hemorrhage. Therefore,
the LSB should already have PASG in place for immediate stabilization of the fracture as well as control of
internal hemorrhage (see Figure 6-22). Spinal immobilization must be provided because an unstable pelvis
107
often presents with associated spinal injuries, especially

to the lumbar and lower thoracic spine.
Lower Extremity Evaluation Evaluation of the

lower extremities begins with the initial assessment of
the MOI. Any patient who has been involved in a motor
vehicle crash (MVC) or fall may have sustained hip,
femur, knee, or lower leg injury, which must be
detected prior to movement and prior to application of
the PASG. Hands-on assessment begins with palpation
of the hip area to determine if there is an anterior or
posterior hip dislocation. Dislocations frequently occur
in MVCs, especially when the knees hit the dashboard,
resulting in the femur being forced back into the hip
joint. This may result in disruption of the blood supply
to the femoral head and/or sciatic nerve damage. Basic
assessment includes looking for hip flexion, adduction
and internal rotation, shortening of the leg, and palpating for a bony prominence posteriorly. Noticeable
prominence in the inguinal area is indicative of an anterior hip dislocation. The patient is often positioned with
the leg and foot laterally rotated (see Figure 6-23). If
FIGURE 6-22 Utilization of a scoop stretcher with an unstable pelvic fracture to place the patient onto an LSB. The
PASG should be placed and secured on the LSB prior to
placement of the patient on the board.
FIGURE 6-21 Assessment for pelvic injury by compression

of the iliac wings.
the head of the femur has dislocated posteriorly, the

paramedic may palpate a bony prominence in the buttocks area and the patients leg may be rotated medially.
This injury is an orthopedic emergency because the
blood supply to the femur may be obstructed, leading to
avascular necrosis of the femoral head.1 The patient
may have his or her leg flexed in order to relieve the
pressure and pain. The paramedic must assess distal
pulse, motor, and sensation with this injury by checking
the dorsalis pedus pulse and having the patient dorsiflex
and plantar flex the foot if conscious. In an unresponsive patient, provide a painful stimuli with a blunt
object to the sole of the foot to elicit a reflex response.
This type of injury does not take precedence over airway, breathing, or circulatory problems. It may be necessary to stabilize the hip in the position found, but with
a multisystem trauma patient requiring rapid transportation this is not always possible.
108 Chapter 6
FIGURE 6-23 Foot and leg rotation indicative of a hip dislocation. Courtesy of Deborah Funk, MD. Albany Medical
Center, Albany, NY.
Femur fractures can be life threatening and therefore must be detected during the initial assessment.
Assessment begins with exposure of the area. Once the
area is exposed, the paramedic looks for hueing or
ecchymosis, shortening of the leg, deformity, and
swelling. Palpation should be gently applied, and if
crepitus or shifting of the bone is felt, measures to stabilize the extremity should be initiated. In the multisystem
trauma patient, this can be accomplished by application
of PASG for femoral stabilization. Prior to application of
the PASG, assessment of distal PMS for neurovascular
impairment must be performed. If the paramedic elects
to utilize a traction splint for stabilization along with
application of PASG, the traction splint must be placed
over the PASG after inflation. During inflation of the
PASG, traction should be applied to the fractured femur
to prevent spiraling or twisting of the femur.
The knee must be quickly palpated for dislocation
or fracture. A dislocation can be an orthopedic emergency, especially if the popliteal artery or peroneal
nerve is damaged. Assessment findings include the
presence of ecchymosis, swelling, deformity, crepitus
with palpation, and decreased or absent distal PMS in
that extremity. Again, this injury must not take precedence over ABCD problems, but the paramedic must
detect and report this injury to the receiving facility.
Direct and indirect forces produce fractures to
the tibial and fibular area and the paramedic must
again relate this injury with the MOI. Any direct blow
is likely to result in open fractures requiring hemorrhage control. Closed fractures can develop into compartment syndrome, and the paramedic must quickly
assess for the 5 Ps of ischemia: pain, pallor, paresthesia, paresis, and puffiness.1 See Chapter 16 for further
discussion.
Often, especially in multisystem trauma patients,

the paramedic will take short cuts and fail to expose
and evaluate the lower extremities. Because these
injuries often produce orthopedic emergencies, they
must be detected. During this quick examination it is
very important to assess for and detect deformity,
shortening, swelling, ecchymosis, tenderness, grating,
crepitus, and exposed bone ends prior to placing the
patient on an LSB. It is also important to note skin
temperature, presence or absence of distal pulses,
CRT, and motor and sensory function and to compare
the extremity findings. Remember, it may not be possible to perform a complete focused assessment en route
to the medical facility. These injuries may not be
treated for several hours, or even days, once the patient
has arrived at the receiving facility, but the paramedic
must report his or her findings to the receiving nurse
or physician. If the PASG is applied, the paramedic will
not be able to assess the lower extremities after application; therefore, it is essential that assessment be
quickly performed during the PASG survey segment
and prior to movement of the patient. Failure to assess
the lower extremities could result in further injury during movement of the patient onto the LSB. Alternative
packaging techniques may be necessary to prevent further patient compromise. Figure 6-24 provides an algorithm for exposure assessment.
Remember: If you have not assessed distal PMS in
the lower extremities, quickly perform this evaluation
prior to movement of the patient. Movement of the
patient could produce further injury and result in
decreased or absent PMS once the movement is completed. The paramedic should be able to report to
medical control any changes noted in neurological and
circulatory function after patient movement.
RAPID PATIENT PACKAGING AND

TRANSPORT
The paramedic is now ready to package the patient for
transport. This involves placement of the patient onto
an LSB with complete cervical immobilization. If your
system uses PASG, this device should already be placed
on the LSB. Movement of a supine patient will require
log rolling the patient onto the side and lowering the
patient onto the board, unless there exists an unstable
pelvic fracture, which will require a scoop stretcher for
placement onto the board. Refer to Chapter 19, for a
complete description of immobilizing devices and techniques. As the patient is log rolled, assessment of the
entire back must be performed to detect any injuries.
The paramedic should palpate from the occipital area
down to the lower leg area. At this time removal of
clothing should be completed if it has not already been
Algorithm
Expose
109
Actions
Assessment
Abdominal quadrants
Bruising, tenderness,
rigidityIV
Flanks
PASG survey/PASG
Pelvis
IV fluids
Back
Spinal injurySolu-Medrol?
LSB
Load and go?
FIGURE 6-24 Expose, examine, and evaluate algorithm.
removed. If the patient is extricated from a sitting position, the back should be quickly assessed prior to lowering the patient onto the LSB. Paramedics often
forget this important assessment step and miss injuries
that may be life threatening. Steps involved in rapid
extrication techniques are found in Chapter 19.
With multisystem trauma patients time should
not be spent splinting/stabilizing fractures or dressing
and bandaging soft tissue injuries. The initial goal is to
stabilize only what is necessary to prevent further
injury. Once the patient has been placed on the LSB,
treatment team members must secure the patient to
the board and secure the PASG around the patient.
The patients body is secured to the board first and the
head is secured last. During this time the lead paramedic should reassess the patients LOC, airway,
breathing, circulatory, and neurological status. As soon
as the patient is fully secured onto the backboard, he or
she is quickly transferred into the ambulance or helicopter for immediate transportation.
Paramedics must remember they are working
against the clock with a patient who has sustained critical injuries. Therefore, transport to the most appropriate definitive care facility is imperative. This may
involve an actual increase in overall initial transport
time, but the patient will be received by a facility with a
trauma and surgical team.
ON-SCENE RESUSCITATION VERSUS EN

ROUTE RESUSCITATION
Critical trauma patients rapidly decompensate and die
due to hypoxemia and shock. Therefore, prioritize
patients using the CUPS classification system
(Table 6-5). Patients who fall into the urgent category
have injuries or conditions that, regardless of interventions provided in the field, continue to be life threaten-
ing and require definitive care such as blood replacement or surgical intervention. 7 The elapsed time
between onset and definitive care is a paramount factor
affecting these patients morbidity and survival. 7
Nonurgent patients have no life-threatening injuries or
conditions, and therefore, further examination can be
done prior to packaging and transport.7
The paramedics initial goal is to provide early airway management, oxygenation, and ventilatory support
as soon as the problem is identified. A suction unit
should always be part of the initial equipment taken to
the patients side in case there are immediate and ongoing problems with secretions, debris, vomit, or blood in
the airway. Early resuscitation consists of applying 100%
oxygen by a nonrebreathing mask, BVM, or early intubation if the patients condition warrants field intubation. If the paramedic detects a tension pneumothorax,
immediate pleural decompression should be performed
and intubation should follow as soon as possible. The
paramedic must reevaluate the patients airway and
breathing status frequently during the initial assessment
and patient packaging, constantly assessing for compliance problems if the patient is being assist ventilated
with a BVM. Compliance problems may indicate the
need to decompress the pleura, reposition the patients
airway, or perform immediate oral or nasal intubation.
If the patients airway and breathing can be managed
effectively with assisted ventilation until he or she is
loaded into the ambulance or helicopter, intubation can
be delayed. It is often easier to intubate once the
patient is in a more controlled environment and in a
better position for visualization of anatomical landmarks. If the patient does not require immediate intubation to secure the airway but requires assisted
ventilation or hyperventilation, do not forget to use an
oropharyngeal or nasopharyngeal airway. Use of these
adjunctive devices is often forgotten, resulting in an
inadequately opened and maintained airway.
110 Chapter 6
Table 6-5
Classification System for Determining Patient Priority for Transport Decisions
Category
Action
Examples of Patient Condition
CCritical
Airway and spinal control, treat only

immediate threats to life, then rapid
transport
Cardiac or respiratory arrest
UUnstable
Same as above
Respiratory distress and/or shock
PPotentially unstable
Rapid assessment, treatment of potential

threats to life, airway and spinal control,
then expedient transport
Marginal vital signs
SStable
Continue with focused assessment
Normal vital signs, no apparent distress,

no major mechanism of injury
Severe exsanguinating hemorrhage should be

immediately controlled using basic techniques of direct
pressure, pressure dressings, or pressure points. Volume
resuscitation may be delayed until the patient is en route
to the hospital unless a prolonged disentanglement is in
progress. When there are adequate personnel on scene,
someone can prepare two large-bore, 1416-gauge IVs
of normal saline or lactated Ringers in the ambulance or
helicopter. As soon as the patient is loaded, resuscitation
can be initiated. The IV fluid should be warmed, if possible, to prevent hypothermia. It is no longer acceptable
to delay transport to initiate fluid resuscitation in the
field, for the critical trauma patient generally requires
blood transfusion to restore the cardiovascular system
and maintain adequate perfusion status.
The use of PASG should be considered when the
patients systolic blood pressure is 6080 mm Hg, especially if there are abdominal or pelvic injuries.2 Specific
criteria for inflation will be based on local medical protocols. The PASG is an excellent immobilizing device
for stabilization of femur and pelvic fractures. Refer to
Chapters 15 and 21 for further discussion regarding
use and application of this device with these injuries.
As soon as the patient is loaded for transport,
reevaluation of the ABCs begins, intubation is performed if the airway is unstable, two large-bore IVs are
initiated preferably with trauma tubing, quantitative
vital signs are obtained, and the patient is completely
stripped of all clothing and covered to prevent
hypothermia. All multisystem trauma patients are
placed on a cardiac monitor as soon as possible to monitor for dysrhythmias that often accompany head and
thoracic trauma. Some EMS systems require a nasogastric (NG) tube to be placed to reduce the incidence of
aspiration. Nasogastric tube placement is contraindicated in patients with cribriform fractures and cerebrospinal fluid (CSF) drainage.9
INTERNET ACTIVITIES
Visit the British Trauma Society Web site and
review the material on the organization of the
trauma team at http://www.trauma.org/resus/
traumateam.html. How is this system of trauma
resuscitation similar to that of the field resuscitation team? How does it differ?
FOCUSED ASSESSMENT
Once definitive treatment has been provided for all initial problems, the paramedic can begin to perform a
detailed physical examination. The purpose of the
focused assessment is to detect other potentially lifethreatening injuries missed in the initial assessment, to
obtain a more detailed analysis of existing injuries, and
to detect other non-life-threatening minor injuries.
Often this survey is performed en route to the emergency department or sometimes it is not completed at
all while all energies and time are spent managing lifethreatening injuries.
When the focused assessment is performed, the
paramedic obtains quantitative assessment information
and a patient history and performs a complete physical
examination. The focused assessment consists of the
criteria found in Table 6-6. Begin this survey by obtaining, if possible, information regarding the patients history, using the acronym AMPLE (Table 6-7). During
the head-to-toe survey, look for medic alert necklaces
or bracelets that could provide some of the AMPLE
information. Quantitative vital signs, if not obtained
soon after the patient was loaded for transport, should
be performed and recorded now, and every 35 minutes throughout transport.
111
Table 6-6
Criteria for Performing a Focused Assessment
Table 6-8
Algorithm for Performing Focused Assessment
See
Region
Assessment
Head
Soft tissue injuries,* raccoons eyes, Battles

sign, cerebrospinal fluid or blood from nose
and/or ears, skull deformity, eye orbits,
stability of nasal and facial bones, foreign
bodies or blood in the oral cavity, stability
of mandible, pupillary response,
extraocular movements
Neck
Soft tissue injuries,* jugular venous

distention, tracheal deviation, carotid pulse,
subcutaneous emphysema, cervical spine
deformity or tenderness
Chest
Soft tissue injuries,* stability of ribs, sternum,

and clavicles, chest symmetry and
expansion, bilateral breath sounds, open
pneumothorax, subcutaneous
emphysema, flail segments, heart sounds,
electrocardiogram
Abdomen
and pelvis
Soft tissue injuries,* distention, tenderness,

guarding, pulsatile masses, rigidity, bowel
sounds, rebound tenderness, pelvic stability,
priapism
Extremities
Soft tissue injuries,* bony instability, pulses,

motor, sensation, range of motion,
tenderness, crepitus, deformity, malrotation,
shortening, lengthening, open fractures
Back
Soft tissue injuries,* vertebral deformity or

tenderness, stability of ribs, stability of
sacrum, buttocks
Inspect-look-observe for contusions,

abrasions, lacerations, ecchymosis, edema,
hemorrhage, deformity (angulation shortening,
abnormal position)
Listen
Auscultate for breath sounds, heart sounds
Feel
Palpate for tenderness, deformities, crepitus,

masses, edema, subcutaneous air, instability,
rigidity
Source: Adapted from The Paramedic Manual, by J.

Greenwald, 1988, Englewood, CO: Morton Publishing Co.
Table 6-7
Use of the Acronym AMPLE in Gathering
Pertinent Patient Information
AAllergies
MMedications
PPast and present pertinent history
LLast meal
EEvents leading up to the incident
Using the look, listen, and feel methods of assessment, perform the focused assessment, region by
region, as found in Table 6-8. If PASG has been
applied, the survey will examine down to the diaphragm
level. If PASG has not been applied, the survey will
include the entire anterior and lateral body. Look for
signs of ecchymosis, deformity, hemorrhage, masses,
swelling, abnormal indentations, or abnormal skin color
that would indicate injury or underlying medical problems. Listen for abnormal breath sounds or abnormal
heart sounds (e.g., muffled heart tones). Feel all areas
of the body for the presence of pulses in all extremities;
for skin temperature; and for abnormal findings such as
the presence of abnormal pulsations, crepitus, abnormal
movement of long bones or joints, deformity, subcutaneous emphysema, depressions in the skull, abdominal
rigidity, or impaled fragments of glass or metal.
Reassessment of the patients previous ABCD vitals will
be performed during this assessment phase. Reassess
the patients respiratory status, ECG, vital signs, neurological status, skin color, and temperature at least every
35 minutes while en route. It is equally important to
closely monitor fluid replacement by frequently
reassessing the patients pulse strength, LOC, and lung
sounds.
*Soft tissue injuries include lacerations, contusions, abrasions,

incisions, penetrating injuries, burns, edema, hematoma,
hueing, and amputations.
RADIO AND REPORT

COMMUNICATION
As soon as the paramedic can establish radio communication with the emergency department, vital patient
information should be communicated. It will be very
important to communicate specific information regarding the patients MOI and the kinematics involved, ventilatory, circulatory, and neurological status, treatment
and response to treatment, and estimated time of
arrival (ETA). Be as short and concise as possible. Try
to paint a realistic picture of the patients overall status.
This will allow emergency department personnel time
to prepare for the patients arrival and alert the surgical
team. Upon arrival at the medical facility, verbally
112 Chapter 6
transfer the patient to the receiving physician or nurse,
providing a detailed account of the patients injuries
and treatment.
Finally, provide a written ambulance call report
to the receiving hospital. This report is important
because it gives the hospital staff a thorough understanding of the events surrounding the incident and a
progressive account of the patients condition and
response (or lack of response) to treatment initiated on
scene and en route to the hospital.
2.
3.
CONCLUSION
The multisystem trauma patient must be rapidly, systematically, and thoroughly evaluated. Paramedics
must develop an organized and consistent approach to
the trauma patient that outlines priorities of care (refer
to Figure 6-25 for a complete patient assessment algorithm). These priorities are found during the initial survey, which evaluates the MOI and kinematics of the
injuries, airway and C-spine control, breathing, and circulatory and neurological status and includes completely exposing the patient. Definitive field treatment
revolves around rapid recognition and treatment of
hypoxemia and shock resulting from inadequate airways, compromised ventilatory and circulatory status,
and inadequate cerebral perfusion.
The paramedic must be able to systematically
evaluate and constantly reevaluate the patient every
35 minutes, providing immediate definitive treatment
for airway, breathing, and circulatory problems as they
are encountered. Needlessly delaying transportation of
the trauma patient may increase the patients morbidity
and severely decrease his or her chances for survival.
Finally, initiate transportation to the most appropriate
medical facility with treatment teams trained to manage the critically injured trauma patient.
4.
5.
6.
7.
8.
9.
10.
INTERNET ACTIVITIES
Review the prehospital trauma resuscitation
protocols of the Nor th Central Texas Trauma
Regional Advisory Council at http://www.dfwhc.
org/ncttrac/protocols.htm. To review the protocols,
you will need Acrobat Reader, which can be downloaded free of charge from http://w w w.
adobe.com/.
REVIEW QUESTIONS
1. Which of the following represents a load and go
patient?
11.
12.
a. A patient with an isolated radius/ulna fracture

b. A patient with a large flail segment
c. A patient with venous bleeding that is controlled by direct pressure
d. A patient with a dislocated shoulder
It is acceptable to bypass the local hospital in
favor of transporting a critically injured patient
directly to a trauma center.
a. True
b. False
List several questions that should be incorporated
into the scene size up.
List several questions that should be incorporated
into the global assessment upon approach of the
scene.
Overall, what percentage of patients are truly
load and go?
a. 5
b. 10
c. 15
d. 20
Compare and contrast the golden hour and platinum ten minutes.
List five mechanisms of injury that suggest major
trauma.
List five physical findings that suggest major
trauma.
Which oxygen delivery device is most appropriate
for a patient with a C-4 spinal injury?
a. Nasal cannula
b. Nonrebreather mask
c. BVM
d. Simple mask
Bulging neck veins may indicate which of the following pathologies?
i. Simple pneumothorax
ii. Tension pneumothorax
iii. Cardiac tamponade
iv. Myocardial contusion
a. i and ii
b. ii and iii
c. iii and iv
d. ii and iv
If a radial pulse is palpable, a crude estimate of
systolic blood pressure is:
a. At least 50 mm Hg
b. At least 60 mm Hg
c. At least 70 mm Hg
d. At least 80 mm Hg
The most likely source of unexplained internal
hemorrhage is the:
a. Abdomen
b. Chest
Algorithm
S
c
e
n
e
Assessment
Scene
survey
Establish LOC
Control C-spine
Open airway
A
i
r
w
a
y
Airway
compromise?
Resuscitate
N
I
T
I
A
L
A
S
S
E
S
S
M
E
N
T
B
r
e
a
t
h
i
n
g
C
i
r
c
u
l
a
t
i
o
n
D
i
s
a
b
i
l
i
t
y
Assess breathing
Expose chest
Assess anterior neck
Assess bilateral breath sounds(BBS)
Breathing
difficulty?
Resuscitate
Assess
circulation
Hypoperfusion?
Resuscitate
Actions
Hazards/body fluids/PPE
Number of patients
Mechanism of injury
Extrication
Remove hazards or patient/PPE

Mutual aid
Predict injuries
Notify rescue
Alert/responsive
C-spine MOI
Airway obstruction
Approach from front

Manual stabilization
Modified jaw thrust PRN
Load and go?
Silent
BVM/ETI/clear obstruction/
cricothyroidotomy
Modified jaw thrust
Intubate
Suction/endotracheal intubation
Load and go?
Snoring
Stridor
Gurgling
O2 nonrebreathing mask/BVM
Expose chest
Chest symmetry/BBS
Neck veins
Tracheal deviation
Needle decompression
Load and go?
Apnea
Bradypnea
Hypopnea
Tachypnea
Dyspnea
BVM with 100% O2

Assisted with BVM and 100% O2
Assisted with BVM and 100% O2
NRB mask with 100% O2
Carotid/radial pulse
Skin temperature/color/
capillary refill
Exsanguinating hemorrhage
PASG survey if internal
hemorrhage is suspected
Quantitative vital signs
Cardiopulmonary resuscitation
PRN PASG
2 large-bore IVs en route
Fluid trial PRN
AVPU
Pupils
Pulse/motor/sensation
Examine posterior neck
Apply C-collar
Unequalhyperventilate
Spinal injurySolu Medrol
Load and go?
Abdominal quadrants
Flanks
Pelvis
Back
Bruising/tenderness/rigidityIV
PASA/survey/PASA as needed
IV fluids
Spinal injurySoluMedrol
LSB
Load and go?
Rapid infusion PRN

Load and go?
Assess
disability
Expose
E
x
p
o
s
e
Determine
patient
status
CUPS
Critical?
S
t
a
t
u
s
Secondary
survey
FIGURE 6-25 Patient assessment algorithm.
Load and go
113
Critical
Unstable
Potentially unstable
Stable
Transport immediately
Continue with secondary survey
Go to secondary survey
114 Chapter 6
13.
14.
15.
16.
17.
18.
19.
20.
c. Retroperitoneal space
d. Epidural space
Normal capillary refill time is less than or equal
to:
a. 1 sec
b. 2 sec
c. 3 sec
d. 4 sec
Unequal pupils may indicate:
a. Head trauma
b. Cerebrovascular accident
c. Eye trauma
d. All of the above
Upon applying lateral and inward pressure on the
iliac wings, crepitus and instability are noted. The
paramedic should next:
a. Palpate the iliac wings in a downward and posterior direction
b. Palpate the symphysis pubis
c. Rock the pelvis to confirm instability
d. Recognize the pelvic fracture and discontinue
further palpation of the pelvis
The most immediate life threat from bilateral
femur fractures is:
a. Fat emboli
b. Deep vein thrombus
c. Hemorrhage
d. Femoral nerve injury
Following the initial examination at the scene, the
critical patient should be packaged and transport
initiated with continued assessment conducted
while en route to the trauma center.
a. True
b. False
The letter M of the pneumonic AMPLE
represents:
a. past Medical history
b. last Meal
c. Medicine allergies
d. Medications the patient is currently taking
Subcutaneous emphysema may indicate which of
the following?
a. Pneumothorax
b. Tracheal disruption
c. Bronchiole disruption
d. Any of the above
Quantitative vital signs must be obtained during
the initial assessment even if it is necessary to
delay airway and hemorrhage control.
a. True
b. False
CRITICAL THINKING
Correlate the etiologies of death in the trimodal
distribution of time of death (Chapter 3) with the

rapid trauma assessment. Why do you think the
assessment sequence is ABCDE as opposed to
some other priority? How do the treatment priorities of the rapid trauma assessment impact each
mode of the distribution?
Think back to your last EMS response to a multisystem trauma patient. Was an organized assessment plan implemented? Were the on-scene
treatments properly prioritized? Based upon your
understanding of rapid trauma assessment, what
would you now do differently if faced with a similar
scenario? Why?
For the following scenario, describe your assessment plan and treatment priorities: You are called
to the scene of an MVC. A single car left the roadway at a high rate of speed and struck a tree. There
are no skid marks on the road, and there is approximately 36 inches of crush to the front of the vehicle. The driver is slumped over the steering wheel
and appears unconscious. There is obvious deformity to the steering wheel and windshield. No
restraints were worn and the car was not equipped
with airbags.
REFERENCES
1. Caroline NL. Emergency Care in the Streets. 5th
ed. Philadelphia, Pa: Lippincott Williams and
Wilkins, 1995.
2. Paturas JL, Wertz EM, McSwain NE Jr. PHTLS
Basic and Advanced Prehospital Trauma and Life
Support. 4th ed. St. Louis: Mosby-Year Book, 1999.
3. Trunkey, DD. Trauma. Sci Am. 1983; 249:28.
4. Campbell, JE. Basic Trauma Life Support.
Englewood Cliffs, NJ: Prentice-Hall, 1998.
5. Bledsoe BE, Porter RS, Shade BR. Paramedic
Emergency Care, 3rd ed. Englewood Cliffs, NJ:
Prentice-Hall, 1997.
6. Miller RH, Wilson JK. Manual of Prehospital
Emergency Medicine. St. Louis: Mosby-Year Book,
1992.
7. Butman AM, et al. Comprehensive Guide to PreHospital Skills: A Skills Manual. Akron, Ohio:
Emergency Training, 1995.
8. Pons P, Cason D, eds. ACEP Paramedic Field Care.
St. Louis: Mosby, 1997.

9. Trauma: Review of Initial Management, Initial
Assessment and Management Priorities. Internet:
http://www.mc.vanderbilt.edu/surgery/backup/trau
ma.html, 1997.
10. Cleveland Clinic Foundation: Spine and Spinal
Cord Trauma, Department of General Anesthesiology. Internet: http://www.anes.ccf.org.8080/
PILOT/NEURO/SCI.html, 1997.
115
11. Campbell JE. Basic Trauma Life Support, 3rd ed.

Englewood Cliffs, NJ: Prentice-Hall, 1995.
12. Greenwald J. The Paramedic Manual. Englewood,
Col.: Morton Publishing, 1988.

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Chapter

Support (ATLS) course for emergency physicians, the

Is there danger from oncoming vehicles?

ASSESSMENT AND MANAGEMENT

Assessment of the Trauma Patient

2. Within minutes to hours (golden hour)

assumed with spinal injury is the arms flexed and

FIGURE 6-1 Stick-em-up position often assumed by the

Assessment of the Trauma Patient

It is important to repeat the phrase please remain

Assessment begins with evaluation of the patients

FIGURE 6-2 Manual stabilization of the head and neck

FIGURE 6-3 Manual stabilization of the head from behind

FIGURE 6-4 Manual stabilization of a supine patients head

Cervical spine MOI

Approach patient from front

Trauma jaw thrust PRN

FIGURE 6-5 Airway assessment algorithm.

Load and go?

Assessment of the Trauma Patient

Intubation can be delayed until there are adequate

The final step of the breathing assessment involves

Circulation and Hemorrhage

FIGURE 6-6 Auscultation of bilateral breath sounds utilizing

needle decompression and assisted ventilation with

Assessment of Pulses The patients carotid and

FIGURE 6-7 Jugular venous distention.

Systolic Blood Pressure of

Assessment of the Trauma Patient

Load and go?

BMV with 100% O 2

Assisted w/ BMV and 100%O2

Assisted w/ BMV and 100%O2

NRB mask/BVM with 100% O2

NRB mask/BVM with 100% O2

FIGURE 6-8 Breathing algorithm.

be suggestive of neurogenic shock associated with

Assessment of Skin Color and Skin

Assessment of Capillary Refill

The paramedic can quickly assess capillary refill time (CRT),

once the radial pulse check is completed, by exerting

FIGURE 6-9 Assessment of CRT by exerting pressure to the

breathing, and circulatory status have been assessed. It

FIGURE 6-10 A quick sweep of the lumbar-sacral area for

Assessment of Vital Signs

Assessment of the Trauma Patient

assessment data. This evaluation establishes the

Assessment of Level of Consciousness

related to time, place, person, and event. As cerebral

Skin temp/color/capillary refill

PASG survey if internal

Fluid trial PRN

Quantitative vital signs

Rapid infusion PRN

FIGURE 6-11 Circulation algorithm.

FIGURE 6-12 Painful stimuli applied by pinching the medial

The pupils, controlled by

FIGURE 6-13 Painful stimuli applied by pinching or squeezing

Assessment of the Trauma Patient