Trauma Scenario - ITLS.pdf

ITLS ITLS Scenario 1 - GSW with Dyspnea, Hemothorax, Extremity Injury Scene Size Up

Transport Decision / Packaging / No tif ic ation

Standard Pr ec autions

Gloves. Goggles.

Scene Hazar ds ds

None. The police have secured the scene.

Transport Decis ion

Unstable, load and go.

Number of Pat Patients

One.

Pack aging

Need for more help or equi pment

Police are on scene and can assist.

Check posterior during roll onto bo ar d. No exit wound is f ound ound.

Notif ication

Mechanism of In ju jur y

You have been called to the scene of a murder / suicide. The male has injuries not compatible with life. A female has also been shot and the police lead you over to her.

Notify hospital immediately. Notification should include that you are en route with the victim of a gunshot wound (GSW) to the right anterior chest. Vent Ventila ilati tion ons are being being assis ssiste ted, d, the the suck sucking ing ches chestt wou woun n d has has bee been seale sealed, d, and and the the patient ient als also o has a clos closed ed ext extre remit mity y frac fractu ture re..

 Initial Ass ess m en t General Impr essi ss ion - Age, sex, position - Patient activity - Obvious Bleeding?

Pt. is found supine, conscious, with obvious dyspnea. Pt. states “I….. “I….. can’t…… breathe”. A large contusion is noted on the patient’s forehead.

LOC (AVPU)

Alert. Direct team member to apply c- spi ne.

Delegate Spine way Ai r wa - Snoring? Gurgling? Stridor? Silence?

eathing Br eat - Rate, Depth, Effort Cir cul culation - Pulse rate rate / rhythm / quality - Skin color / cond / temp - Deadly bl eeding ?

Clear and open.

Rapid, shallow, gasping respirations. Direct team to assist v entilations. Rapid radial pulses present. Cyanotic, cold, clammy. Spot of blood visible on R anterior chest.

 Ongoing Exam (every 5 minutes for unstable pt) LOC (AVPU)

Alert.

way Ai r wa - Snoring? Gurgling? Stridor? Silence?

Clear and open.

eathing Br eat - Rate, Depth, Effort

Rapid, shallow, gasping respirations. Continue assisting ventilations .

culation Cir cul - Pulse rate / rhythm / quality - Skin color / cond / temp

Rapid, weak radial pulses. Cyanotic, cool, clammy.

Reassess Vital Signs

* In repeat ongoing assessments

Reassess Neck

No change.

Reassess Chest

No change.

Reassess Abdo men

No change.

Reassess inter v entions

Ensure ventilations still eff ec tive. ve.

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

Sur r v ey Secondary Su

Rapid Trauma Su r ve ve y Head - DCAP-BLS-TIC - Fluid leaks (ears / nose) - Raccoon Eyes - Battle’s Signs

Contusion on forehead. No. No. No.

Neck - DCAP-BLS-TIC - Tracheal Deviation - JVD - Collar once check ed

No obvious injury. Midline. Flat neck veins. Direct team member to appl pply.

Ches t - Expos e. - DCAP-BLS-TIC

Expose chest. Sucking chest wound on right anterior chest. Crepitus felt on right side. Direct team member to s eal.

Breath Sounds (2 poi po ints )

No breath sounds on right side.

Abdo men - Expos e. - DCAP-BLS-TIC - Rigidity or distention

Expose abdo men. No injuries noted. Soft, non-tender.

Pelvis (DCAP-BLS-TIC)

Stable.

emities Lower Extr em - DCAP-BLS-TIC - Distal PMS

No injuries noted. Good distal PMS.

Upper Extr emities - DCAP-BLS-TIC - Distal PMS

Deformity of left forearm. Sta Stabili ze. Good distal PMS.

Histor y - Signs & Symptoms - Allergies - Medications - Past Medical History - Last Oral Intake - Events

SOB. Tetanus toxoid. None. None. 3 hours ago. GSW as described above.

Vital Signs - Blood pressure - Heart rate / quality - Resp rate / quality - SPO2 - Capillary blood glucose - LOC / GCS - Skin - Pupils

90/60 130, weak at radial. 36 and shallow if not assisted. 92% with O2 (if assisted). N / A. 4/5/6 = 15. Cyanotic, cool, clammy. Both 5mm, equal and reactive. Note: It is acceptable to initiate IV access at this time.

Head to Toe - Head - Neck - Chest - Breath sounds - Abdomen - Pelvis - Lower extremities - Upper extremities

No injuries noted. No injuries. No tracheal shift shift or JVD. Sealed chest wound on right anterior chest No breath sounds on right side. Soft, non-tender. No injuries noted. No injuries noted. Good distal PMS. Closed left forearm forearm fracture. fracture. Good distal distal PMS. 87

ITLS Scenario 2 - MVC, Pregnant Pt with Dislocated Hip, Fractured Pelvis, Chest Injuryy Scene Size Up



Gloves. Goggles.

Scene Hazar ds

None. The vehicle is stable.

Transport Decision


Number of Patients

One.

Pack aging



Extricate patient onto board. Ensur e posterior is checked during move.

Notif ication

Mechanism of In jur y

The patient is an unrestrained pregnant driver of a car that went off the road at 90kph and hit a tree head on. The patient is still in the driver’s seat. ** Simulate vehicle in classroom with ch air s .

Notify hospital immediately. Notification should include that you have a conscious pregnant female involved in a high speed MVI, with chest, abdominal, hip and pelvic injuries.

 Ongoing Exam (every 5 minutes for unstable pt)

 Initial A ss ess m en t General Impr ession - Age, sex, position - Patient activity - Obvious bleeding? LOC (AVPU)

Pt. is found sitting in the driver’s seat of the car, conscious, complaining that “my hip hurts so bad! My chest and stomach hurt too. I’m concerned about my baby!” ** Simulate vehicle in classroom with chair s. Alert.

Delegate Spine

Direct team member to apply c- spi ne.

Ai r way - Snoring? Gurgling? Stridor? Silence? Br eathing - Rate, Depth, Effort Cir culation - Pulse rate / rhythm / quality - Skin color / cond / temp - Deadly bl eeding?

Clear and open.

Normal rate and quality. Direct team member to apply O2. Rapid radial pulses present.

No external bleeding.

Rapid Trauma Su r v ey Head - DCAP-BLS-TIC - Fluid leaks (ears / nose) - Raccoon Eyes - Battle’s Signs

No obvious injury. No. No. No.

Neck - DCAP-BLS-TIC - Tracheal Deviation - JVD - Collar once ch ecked

No obvious injury. Midline. Flat neck veins. Direct team member to apply.


Expose chest. Contusion on sternum. Tender, no instability.

Breath Sounds (2 points )

Present and equal. Expose abdo men. Obvious late pregnancy. Distended and tender.


Pain on palpation. Unstable.

Lower Extr emities - DCAP-BLS-TIC - Distal PMS

Left leg flexed at hip and knee, internally rotated. Right leg normal. Stabili ze. Good distal PMS.


No injuries detected. Good distal PMS.

Alert.

Ai r way - Snoring? Gurgling? Stridor? Silence?

Clear and open.

Br eathing - Rate, Depth, Effort

Normal rate and quality.

Cir culation - Pulse rate / rhythm / quality - Skin color / cond / temp

Rapid, weak radial pulses. Pale, cool, clammy. * Deterioration.



Reassess Neck

No change.

Reassess Chest

No change.

Reassess Abdo men

No change.


Ensure immobilization still ef f ective.



Normal, warm and dry.

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LOC (AVPU)

Secondary Sur v ey Histor y - Signs & Symptoms -

Allergies Medications Past Medical History Last Oral Intake Events


“My hip hurt so bad! My chest and stomach too”. Penicillin. Prenatal vitamins and Dilantin. Epilepsy. 7 months pregnant. 5 hours ago. “I was driving down the road and woke up like this. I think I had a seizure.” 100/60. 140, weak at radial. 24, shallow but effective. 98% with O2. N / A. 4/5/6 = 15. Pale, cool, clammy. Both 4mm, equal and reactive. Note: It is acceptable to initiate IV access at this time, and bolus if required.

Head to Toe - Head - Neck - Chest - Breath sounds - Abdomen -

Pelvis Lower extremities Upper extremities

No injuries noted. No injuries. No tracheal shift or JVD. Sternal and anterior rib tenderness. Breath sounds present and equal. Distended. Pregnant. Increasing tenderness. Do not r eex amine. Unchanged from above. Good distal PMS. No injuries note. Good distal PMS. 88

ITLS Scenario 3 - Motorcycle Rollover, Conscious Pt with Pelvis and Lower Extremity Injuries ies Scene Size Up



Gloves. Goggles.

Scene Hazar ds

None.

Transport Decision


Number of Patients

One.

Pack aging


The police are on scene and can assist.

Direct member to strap legs together . Ensure posterior i s checked dur ing mov e.


The patient was thrown from a mo torcycle that crashed into a tree at high speed. The rider was killed instantly, with obvious signs of death. The patient was thrown into a ditch.

Notif ication

Notify hospital immediately. Note that you have a conscious patient with pelvis and lower extremity injuries that was thrown off a motorcycle at high speed. The accident also included a fatality.

 Initial A ss ess m en t General Impr ession - Age, sex, position - Patient activity - Obvious Bleeding? LOC (AVPU)

Pt. is found supine in the ditch, complaining of right leg pain. The patient is wearing a helmet and a small amoun t of blood is noted on the right leg. Alert. Direct team member to apply c- spi ne. Remove helmet.

Delegate Spine


Clear and open.

Normal rate and depth of ventilations. Direct team member to apply O2. Rapid radial pulse present. Normal, warm, and dry.


No sign of trauma (was wearing helmet). No. No. No.




Expose chest. No obvious injuries found.


Present and equal.

Pelvis (DCAP-BLS-TIC) Lower Extr emities - DCAP-BLS-TIC - Distal PMS Upper Extr emities - DCAP-BLS-TIC - Distal PMS

Ongoing Exam (every 5 minutes for unstable pt) LOC (AVPU)

Expose abdo men. Slight tenderness of lower abdomen. None. Unstable and tender. Stabilize. Open fracture of right lower leg with small amount of bleeding. Good distal PMS. Direct member to cover and stabilize. No injuries detected. Good distal PMS.

Localizes to pain.


Open and clear.




Radial pulse present, very rapid. Pale, cool, clammy. * Deterioration



Reassess Neck

No change.

Reassess Chest

No change.

Reassess Abdo men

More tender in lower abdomen.


N/A

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Slight bleeding from right lower leg.

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Secondary Sur v ey Histor y - Signs & Symptoms - Allergies - Medications - Past Medical History - Last Oral Intake - Events


“My leg is killing me. Please help!” None. None. None. 2 hours ago. “I was on the back with my sister and we hit a tree. How is she doing? I want her with me!” 90/70. 160, weak at radial. 32, shallow but effective. 99% with O2 and assisted ventilations. N / A. 4/5/6 = 5. Pale, cool, clammy. 4mm, equal and reactive. Note: It is acceptable to initiate IV access at this time, and bolus if needed.


No injuries noted. No injuries. No tracheal shift or JVD. No injuries detected. Breath sounds present and equal. Tender lower abdomen. No distention. Do not r eexamine. Unchanged from above. Good distal PMS. No injuries note. Good distal PMS. 89

ITLS Scenario 4 – Marathon Runner Struck with Dyspnea / Tension Pneumothorax Scene Size Up



Gloves. Goggles.

Scene Hazar ds

None.

Transport Decision


Number of Patients

One.

Pack aging

Check posterior during roll onto boar d.


You and your partner have arrived first on scene. Fire department is en route, and there is a first aider on scene.

Notif ication

Notify hospital immediately. Note that patient is SOB, with a tension pneumothorax requiring decompression.


A young male was struck on a marathon route by a vehicle travelling approximately 80kph.

 Ongoing Exam (every 5 minutes for unstable p t) Eyes open to verbal, patient appears more confused.

LOC (AVPU)

 Initial Ass ess m en t General Impr ession - Age, sex, position - Patient activity - Obvious Bleeding?

Patient is found lying semi-prone on his left side. His eyes are closed on approach and obvious respiratory distress is heard. No obvious bleeding is observed.

LOC (AVPU)

Eyes open to verbal, patient appears confused.

Delegate Spine

Direct team member to a p p l y c - s p i n e.


Clear and open.

Rapid resps with shallow air movement. Requires ventilations .

Rapid respirations with shallow air movement. Continue ventilations .


Radial pulses now absent. ** Change ** Carotid pulses still rapid and present. Cyanotic, cool, clammy skin.



Reassess Neck

Visible tracheal deviation to right si de. Increased jugular vein dis tentio n

Reassess Chest

Absent air entry on left side

Reassess Abdo men

No changes


Ventilations still effective but decr eased com pl iance.



No major bleeding observed.

Matted blood in hair. None observed. None observed. None observed. No injuries observed. Possibly tracheal deviation to right side. Distended jugular veins Direct team member to apply collar .


Expose chest. Contusions on left side of chest. Crepitus and tenderness felt on palpation. Hyper-resonant if percussed.


Decreased air entry on left side.



Cyanotic, cool, clammy skin.

Rapid Trauma Su r v ey


Clear and open.

Weak, rapid pulses at radial and carotid.

 Head - DCAP-BLS-TIC - Fluid leaks (ears / nose) - Raccoon Eyes - Battle’s Signs


Expose abdo men. Tender to palpate. Slight distention.


Nothing significant found.


Left femur swelling, tenderness, deformity. Expose. Direct team member to stabilize if resources available.


No upper extremity injuries noted.


“Can’t breathe” Penicillin Insulin Diabetes Unknown “He drove right over me!”


90/50 150 36, shallow unless ventilated 91% with assisted ventilations 5.6 if taken 3/4/5 = 12 Cool, pale, clammy Equal and reactive Note: It is acceptable to initiate IV access and treat the hypovolemia (N/S bolus) at this time.

Head to Toe - Head - Neck - Chest - Breath sounds - Heart sounds - Abdomen - Pelvis - Lower extremities - Upper extremities

As before. Increased tracheal deviation and J VD. As before. Absent air entry on left side. As before. Increased abdominal distenti on. As before. As before. As before.

90

ITLS Scenario 5 - Fall from Balcony on 3

rd

Floor, Hypoglycemic Pt with Scalp, Abdominal, Femur Injuries ies

Scene Size Up

Transport Decision / Packaging / No tif ication


Gloves. Goggles.

Scene Hazar ds

None.

Transport Decision


Number of Patients

One.

Pack aging


None.



The patient was leaning over a third floor balcony and fell.

Notif ication

Notify hospital immediately. Note that you have a confused patient with scalp, abdominal and extremity injuries resulting from a sign ificant fall.

 Initial Ass ess m en t General Impr ession - Age, sex, position - Patient activity - Obvious Bleeding? LOC (AVPU)

Pt. is found lying on left side hol ding onto his left upper leg. A small amount of blood is visible on the patient’s scalp. The patient is obviously conscious and talking. Alert but CONFUSED.

Delegate Spine

Direct team member to apply c -spi ne.


Clear and open.

Normal rate and depth of ventilations. Direct team member to apply O2. Rapid radial pulse present. Normal, warm, and dry. Slight bleeding from scalp wound.





-

Fluid leaks (ears / nose) Raccoon Eyes Battle’s Signs

Slight bleeding from scalp lac. Contr ol. Otherwise normal. No. No. No.






Present and equal.

Abdo men - Expos e. - DCAP-BLS-TIC - Rigidity or distention Pelvis (DCAP-BLS-TIC) Lower Extr emities - DCAP-BLS-TIC

-

Distal PMS


Expose abdo men. Diffusely tender to palpation. None.

No injuries detected. Good distal PMS.



Radial pulse weak and rapid. Pale, cool, clammy. ** Deter ior ation



Reassess Neck

No change.

Reassess Chest

No change.

Reassess Abdo men

More tender in lower abdomen.


N/A

 Secondary Sur vey Histor y - Signs & Symptoms - Allergies - Medications - Past Medical History - Last Oral Intake - Events


“I hurt all over”. Penicillin. Insulin. Diabetes. Last night. Did not eat breakfast today. “I was standing on the balcony and fainted”.

110/70. 100, weak at radial. 22, normal rate and depth. 99% with O2. 2.2 mmol/L 4/4/6 = 14. Pale, cool, clammy. 4mm, equal and reactive. Note: It is acceptable to initiate IV access at this time, and bolus if needed. Glucose should be administer ed.

Stable and non-tender. Closed fracture of left femur with s welling and deformity. Direct member to st abilize. Good distal PMS.

Clear and open.


Rapid Trauma Su r v ey Head - DCAP-BLS-TIC

Patient INCREASINGLY confused. Pt. states “abdominal pain is worsening”.

LOC (AVPU)


Scalp wound. No injuries. No tracheal shift or JVD. No injuries detected. Breath sounds present and equal. Increasing abdominal tenderness. No changes. Unchanged from above. Good distal PMS. No injuries note. Good distal PMS. 91

ITLS Scenario cenario 6 – Gang Assault with Multi-system Trauma Scene Size Up No movement / sensation, good distal circ.


Gloves. Goggles.

Scene Hazar ds

None.

Number of Patients

One.

Transport Decision




Pack aging


The patient is a young male who is found in an alley. The police state that the patient is a known criminal who has been attacked by a gang.

Strap legs together to stabilize injuries. Check posterior during roll onto boar d. Pt has a gunshot wou nd with moder ate bleeding over right kidney. Contr ol.

Notif ication

Notify hospital immediately.

 Initial A ss ess m en t General Impr ession - Age, sex, position - Patient activity - Obvious Bleeding?

Patient is lying supine on the ground in the alley. The eyes are closed, contusions are noted on the face, minor blood is observed on the left forearm and right lower leg.

LOC (AVPU)

Moans to pain.

Delegate Spine



Clear and open.


Slow, shallow respirations. Direct team member to assist v ent ilations.

Cir culation - Pulse rate / rhythm / quality - Skin color / cond / temp - Deadly bl eeding?

Distal PMS


Clear and open.


Slow, shallow respirations (rate of 8/min if not ventilated). Continue v entilations .


Radials absent, rapid at carotid. Pale, cool, clammy.



Reassess Neck

No change.

Pale, cool, clammy


Ensure ventilations still eff ec tive.



Moderate bleeds at left forearm and right lower leg. Direct member to con tr ol.

Facial contusions noted. Bleeding from right ear. No. Present on right side. No obvious injury. Midline. Flat neck veins. Direct team member to apply.

Clear air entry bilaterally.

-


No change.

Breath Sounds (2 points)

Lower Extr emities - DCAP-BLS-TIC

Moans to pain.

Reassess Abdo men

Expose chest. No injuries noted.


LOC (AVPU)

No change.



Ongoing Exam (every 5 minutes for unstable pt)

Reassess Chest

Rapid Trauma Su r v ey




Radials absent, rapid at carotid.

 Head - DCAP-BLS-TIC - Fluid leaks (ears / nose) - Raccoon Eyes - Battle’s Signs


Secondary Sur v ey Histor y - Signs & Symptoms - Allergies - Medications - Past Medical History - Last Oral Intake - Events Vital Signs - Blood pressure - Heart rate / quality - Resp rate / quality - SPO2 - Capillary blood glucose - LOC / GCS - Skin - Pupils

Deformed closed left femur fracture. Moderately bleeding gunshot wound right lower leg. Direct member to control and stabilize. Good distal PMS. Bleeding gunshot wound on left forearm. Direct member to control and stabilize.

70/40. 140. 8 if unassisted. No capture. N / A. 1/1/5 = 7. Pale, cool, clammy. Left: 5mm and normal. Right: 8mm and sluggish. Note: It is acceptable to initiate IV access and treat the hypovolemia (N/S bolus) at this time. Target BP should be 110 systol ic.

Expose abdo men. No injuries noted. Soft, no tenderness. Stable.

Head and extremity trauma. Unknown. Unknown. Unknown. Unknown. Found post assault in alley.

Head to Toe - Head -

Neck Chest Breath sounds Abdomen Pelvis Lower extremities

-

Upper extremities

Multiple contusions, blood from right ear, battle’s signs on right side. Unchanged. No injuries noted. Equal air entry to bases. Unchanged. As before. Deformed left femur. Dressed gunshot wound on right leg. Good distal PMS. Dressed gunshot wound on left forearm. 92

ITLS Scenario 7 - Scooter Collision, Conscious Pt with Spinal & Tibia Injuries ies Scene Size Up



Gloves. Goggles.

Scene Hazar ds

None.

Transport Decision


Number of Patients

One.

Pack aging


The police are on scene and can assist.



The patient on a scooter lost control on a curve and collided with a guard rail. Police called for EMS when they determined that the patient couldn’t move.

Notif ication

Notify hospital immediately. Note that you have a conscious patient with spinal deficits and a compound tibia fracture.


Pt. is found supine lying next to the guard rail, wearing a motorcycle helmet. The police have moved the scooter out of the way. The pt states “I can’t feel anything. I can’t move”. Alert. Direct team member to apply c -spi ne. Remove helmet.

Delegate Spine


Clear and open.

Normal rate, VERY shallow, diaphragmatic breathing only. Direct member to assist ventilations . Rapid radial pulse present.


None.


No sign of trauma (was wearing helmet). No. No. No.


Tender at base of neck. Midline. Flat neck veins. Direct team member to apply.


Expose chest. No injuries noted. No rib movement with breathing. No sensation.


Present and equal. Expose abdo men. No injuries. No sensation. Soft.


Stable to palpation. No sensation.


Right tibia protruding. Good distal pulse. Direct member to cover and stabilize. No sensation or movement.


No injuries detected. Weak grips bilaterally. Good distal circulation.

Alert. Still no feeling from neck down.


Clear and open.


Unchanged. Continue ventilations .


Radial pulse present. Normal, warm, dry. * Change



Reassess Neck

No change.

Reassess Chest

No change.

Reassess Abdo men

No change.


Ensure ventilations remain eff ec tive.



Normal, warm, sweaty.






Secondary Sur vey Histor y - Signs & Symptoms - Allergies - Medications - Past Medical History - Last Oral Intake - Events

“I can’t feel anything. I can’t move”. None. None. None. 6 hours ago. “I was practicing so I could pass the test”.


70/50. 72. 12, very shallow if not assisted. No capture. N / A. 4/5/6 = 5. Normal, warm, dry skin. 4mm, equal and reactive. Note: It is acceptable to initiate IV access at this time, and bolus if needed.


No injuries noted. Tender at base of neck. No injuries detected. Still only diaphragmatic breathing. No injuries noted. No injuries noted. Unchanged from above. G ood dis tal circ. No injuries note. Good distal circ.

93

ITLS Scenario 8 – Bombing at Office Building (Paralysis, Facial Burns with Airway Compromise) Scene Size Up


Standard Pr ecautions

Gloves. Goggles.

Scene Hazar ds

None.

Transport Decision


Number of Patients

One.

Pack aging


You and your partner arrive on scene shortly after the fire department.

Cool burns for 1-2 minutes. Cover with clean sheet. Manually stabilize forearm. Check posterior during roll onto boar d.


There was a bombing of an office building. Fire is on scene inside the building. The patient is crumpled on the ground just outside of an open door, yelling “get me out of here, my face is burning and I can’t move!”

Notif ication

Notify hospital immediately. Note that patient has facial and airwa y burns, with paralysis.


Patient is crumpled on the ground, yelling “get me out of here, my face is burning”. What is left of the patient’s shirt is smoldering. Emergency Move Requir ed. Alert Direct team member to apply c-spine once saf e.

Delegate Spine


Open. Pt. has a hoarse voice, and is complaining that his face is burning. Red burns are noted at nose and mouth.

Br eathing - Rate, Depth, Effort Cir culation - Pulse rate / rhythm / quality - Skin color / cond / temp - Deadly bl eeding?


Alert


Stridor is noted with respirations. Hoarse when speaking.


Diaphragmatic but normal.


Present, rate seems normal. Normal, warm, dry (in unburned areas).



Reassess Neck

No change.

Diaphragmatic but normal. Direct team member to apply high flow O2 via NRB.

Reassess Chest

No change.

Reassess Abdo men

No change.

Present, rate seems normal.


No ongoing interventions.



Normal, warm, dry (in unburned areas). No major bleeding observed.



Rapid Trauma Su r vey Head - DCAP-BLS-TIC - Fluid leaks (ears / nose) - Raccoon Eyes - Battle’s Signs

Facial burns, singed nasal hairs, burns inside mouth. No fluid leaks, raccoon eyes, or battle’s signs noted.


Blistering burns of the anterior neck. Midline. Flat neck veins. Direct team member to apply.


Expose chest. Burns on anterior chest. No movement of ribs during breathing, only diaphragm.






Expose abdo men. No injuries noted. Soft, no tenderness.


Stable.


No sign of trauma. No movement / sensation, good distal circ.


Obvious open fracture of left forearm. No movement / sensation, good distal circ.

Secondary Sur v ey Histor y - Signs & Symptoms - Allergies - Medications - Past Medical History - Last Oral Intake - Events Vital Signs - Blood pressure - Heart rate / quality - Resp rate / quality - SPO2 - Capillary blood glucose - LOC / GCS - Skin - Pupils

“I can’t feel anything from m y neck down” NKA None Patient states healthy 6 hours ago “I had just entered the lab when an explosion threw me out the door way” 70/40 65 12, diaphragmatic breathing No capture N/A 4/5/6 = 15 Normal, warm, dry (in unburned areas) Equal and reactive Note: It is acceptable to initiate IV access and treat the hypovolemia (N/S bolus) at this time.


Neck

-

Chest Breath sounds Abdomen Pelvis Lower extremities Upper extremities

Facial burns, singed nasal hairs, burns inside mouth. Blistering burns of the anterior neck, tenderness with palpable step off. Anterior chest burns. Equal air entry. No sign of trauma. As before. As before. Still no movement o r sensation Left forearm fracture. Still no movement o sensation. 94

ITLS Scenario enario 9 – Vehicle Collides with Power Plant, Driver near a Vehicle with Hazards Scene Size Up Standard Pr ec autions

Gloves. Goggles.

Scene Hazar ds

There is an obvious gas leak underneath the vehicle, and thick smoke is visible coming out of the engine compartment. Pt. requires emergency mov e.

Number of Patients

One.




Head on collision, car into a power plant. Unrestrained driver was thrown from vehicle and is found lying on the ground approximately 6’ from the vehicle.



Initial A ss ess m en t General Impr ession - Age, sex, position - Patient activity - Obvious Bleeding?

Unresponsive patient initially found lying on ground approximately 6’ from vehicle. ** Pt. should have been rapidly mov ed.

LOC (AVPU)

Localizes to pain. Direct team member to apply c -spine.

Delegate Spine


Clear and open. ** Gag reflex present if OPA attempted. Normal rate and depth. Direct team member to apply O2.

Transport Decision


Pack aging

Check posterior during roll onto boar d.

Notif ication

Notify hospital immediately. No tification should include that you are en route with the unrestrained driver of a high speed MVI. Patient has an altered LOC with head, chest, and abdominal trauma.

 Ongoing Exam (every 5 minutes for unstable pt) LOC (AVPU)

Localizes to pain.


Clear and open. ** No gag reflex if airway adjunct re-attempted at this time.


Normal rate and depth.


Rapid, weak radial pulses. Pale, cool, clammy. ** Deterioration



Reassess Neck

No change.

Reassess Chest

No change.

Reassess Abdo men

No change.


None performed at this time.



Rapid radial pulses present.

Secondary Sur v ey

Normal, warm, dry skin. No external bleeding noted.

 Rapid Trauma Su r v ey Head - DCAP-BLS-TIC - Fluid leaks (ears / nose) - Raccoon Eyes - Battle’s Signs

Contusion on forehead. No. No. No.




Expose chest. Sternal contusions. Crepitus over sternum and anterior ribs, Moans when palpated.





Expose abdo men. Painful, moans when palpated. Rigid and distended.


Stable.



Upper Extr emities - DCAP-BLS-TIC / PMS


Histor y - Signs & Symptoms - Allergies - Medications - Past Medical History - Last Oral Intake - Events

Head, chest, abdominal trauma. Unknown. Unknown. Unknown. Unknown. Unrestrained driver in head on MVI.


80/60 130, weak at radial. 20, regular 98% with O2. N / A. 2/1/5 = 8. Pale, cool, clammy. Both 5mm, equal and reactive. Note: It is acceptable to initiate IV access and treat the hypovolemia (N/S bolus) at this time. Target BP should be 110 systolic due to potential head injur y.


Neck Chest Breath sounds Abdomen Pelvis Lower extremities Upper extremities

Contusion on forehead. No fluid leaks, no raccoon eyes or battle’s signs. No injuries. No tracheal shift or JVD. Sternal contusions. Equal air entry to bases. Rigid, distended, painful to palpation. No injuries noted. No injuries noted. Good distal PMS. No injuries noted. Good distal PMS. 95

ITLS Scenario 1 0 - Fact ory Incide nt with C rush, Pt with Skull #, Abdominal Protrusion, Pelvic #, Crushed Legs gs Scene Size Up



Gloves. Goggles.

Scene Hazar ds

None. The machine is stopped.

Transport Decision


Number of Patients

One.

Pack aging


Co-workers are on scene and can assist.

Ensure posterior i s checked dur ing move (minor abrasions on back ).

Notif ication


The patient fell into heavy machinery at a factory. Co- workers stopped the machine, removed the patient, and laid him on the floor.

Notify hospital immediately. Note that you have an unconscious crush injury patient with head, open abdominal, pelvic and lower limb injuries.


 Initial A ss ess m en t General Impr ession - Age, sex, position - Patient activity - Obvious Bleeding?

Pt. is found supine on the ground next to the stopped machine. The patient’s eyes are closed, there is no movement, and blood is visible on the shirt and pants.

LOC (AVPU)

Localizes to pain.

Delegate Spine


Ai r way - Snoring? Gurgling? Stridor? Silence? Br eathing - Rate, Depth, Effort Cir culation - Pulse rate / rhythm / quality - Skin colour / cond / temp - Deadly bl eeding?

Clear and open.

Normal depth of ventila tions, but very slow. Direct member to assist ventilations . Radial absent, carotid weak and rapid. Pale, cold, clammy skin.

LOC (AVPU)


Very slow rate if not assisted. Continue assisted ventilations .


Radial absent, carotid weak and rapid. Pale, cool, clammy.



Reassess Neck

No change.

Reassess Chest

No change.

Reassess Abdo men

No change.


Continue assisted v entilations .



From abdomen and both legs.

Rapid Trauma Su r vey Head - DCAP-BLS-TIC - Fluid leaks (ears / nose) - Raccoon Eyes - Battle’s Signs

Bruising to right side of face. Bloody fluid from right ear. No. No.






Present and equal.



Expose abdo men. Protruding viscera with moderate bleeding. Tender. Cov er .


Very unstable.


Both legs crushed and mangled from upper thighs down. Severe bleeding. Control bleed and stabilize. Dir ect pressure ineffective, tourniquets required. No distal pulses, motor, or sensation.


Clear and open.





Localizes to pain.

No injuries detected. No distal pulses, motor, or sensation.

Patient unresponsive. None. None. Diabetic. 4 hours ago. “The supervisor saw him fall in and yelled to stop the machine. By the time we got him out he was badly hurt!” 50/0. 160, weak at radial. RR=8 if not assisted. No capture. N / A. 2/1/5 = 8. Pale, cool, clammy. Left: 4mm and reactive. Right: Dilated and non-reactive. Note: It is acceptable to initiate IV access at this time, and bolus to a maximum systolic pressure of 110mm/Hg (due to head inj ur y).


Neck Chest Breath sounds Abdomen Pelvis Lower extremities Upper extremities

Battle’s Sign behind R ear. Bloody fluid from R ear. Bruising to R side of face. No injuries. No tracheal shift or JVD. No injuries detected. Breath sounds present and equal. Bleeding controlled with dressings. Do not r eex amine. Unchanged from above. Good distal PMS. No injuries note. Good distal PMS. 96

ITLS SCENARIO GRADE SHEET Student Name:

Date:

Time Started:

Time Primary completed: ACTION

9

Time Transported: COMMENTS

Scene Hazards

[ ] Practice

[ ] Test

[ ] RT

Time Secondary completed : ACTION

PATIENT ASSESSMENT — PRIMARY SURVEY Scene Size-up Standard Precautions

[ ] Basic [ ] Advanced

Scenario #:

9

COMMENTS

Baseline Vital Signs HR, RR, BP History SAMPLE IF ALTERED MENTAL STATUS

Number of Patients

Pupils Size? Reactive? Equal?

Need for More Help or Equipment

Glasgow coma scale

Mechanism of Injury

Orientation, emotional state

General Impression Age, Sex, Weight

Signs of cerebral herniation

General Appearance

Blood glucose

Medical identification devices

Body Position Position in Environment Patient Activity

Critical transport decision ACTION

Obvious Severe Injury or Major Bleeding

(If major bleeding, go to CABC)

Subjective Ask patient if changes in how feels

LOC AVPU

Reassess mental status LOC, pupils

Airw ay Snoring, Gurgling, Stridor, Silence

If altered mental status Recheck GCS

Breathing Present? Rate, Depth, Effort

Reassess airway

Radial/Carotid Pulses Present? Rate, Rhythm, Quality

Reassess breathing and cir culation

Skin Color, Temp, Moisture, Capillary Refill Uncontrollable External Hemorrhage? Head and Neck Major facial injuries Bruising, swelling, penetrations Subcutaneous emphysema? Neck vein distention? Tracheal deviation?

9

COMMENTS

ONGOING ASSESSMENT

Recheck vital signs Skin color, condition, temperature Check for neck vein distention Check for tracheal deviation Recheck chest Breath sounds Quality? Equal? Reassess heart sounds Reassess abdomen — if possi ble injury Development of tenderness, distention, rigidity

Chest Look: Asymmetry, Contusion, Penetrations, Paradoxical Motion, Chest Rise Feel: Tenderness, Instability, Crepitation Breath Sounds Present? Equal? If decreased breath sounds, percussion Heart Tones Abd om en Look: bruising, penetration/evisceration Gently palpate: tenderness, rigidity, distention Pelvis Deformity, penetrating wounds, TIC Lower Extremities Upper: swelling, deformity, TIC Lower: scan wounds, swelling, deformity

Check all identified injuries For example: Lacerations for bleeding PMS distal to injuries on extremities Flail segments Pneumothorax Open chest wounds Check all interventions For example: ET tube for patency and position Oxygen for flow rate IVs for patency and fluid rate Seals on sucking chest wounds Patency of decompression needle Splints and dressings Impaled objects for stabilization If pregnant, body position Cardiac monitor, Sp02, EtCO2

Motor, sensory before transfer to backboard Upper Extremities Scan wounds, swelling, deformity Motor, sensory before transfer to backboard Posterior Penetrations, deformity, edema IF CRITICAL, TRANSFER TO AMBULANCE

GRADE KEY:

[ 9 ] Completed, skill performed in sequence [ D ] Delayed, performed out of sequence [ X ] Skill not performed, too late or incorrectly

June 2011

97

Trauma Scenario - ITLS.pdf

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