Critical Decisions

CONTINUING EDUCATION FROM EMS

This CE activity is approved by EMS Magazine, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS), for 1.5 CEUs. To earn your credits, go to www.rapidce.com, or to print and mail a copy, download the test here. The deadline to take the test is September 30, 2009.

ARTICLE OBJECTIVES

• Discuss scene size-up at motor vehicle crashes
• Review general patient assessment
• Outline the components of a rapid trauma assessment

INTRODUCTION

As a responder, your actions within the first few moments of arriving on the scene of a motor vehicle crash are crucial to the success of managing the situation. Within these moments, you must size up the situation, mitigate as many hazards as possible, establish incident command, rapidly triage patients and ultimately assess, treat and extricate patients from the scene. In doing so, you must decide when to extricate a patient and what treatment is essential to improve the patient's chances of survival, based on your knowledge, previous experience and a problem-based assessment algorithm.

SCENE SIZE-UP

Assessment of the situation begins from the moment of first dispatch. You must not only consider the information received, but take into account the time of day, traffic, weather, safety issues and potential resources that may be required. Prior to arriving at the scene, put on personal protective equipment, such as body substance isolation, helmets, eyewear, outerwear, safety gloves, boots and reflective vests, as it may be chaotic upon arrival and responders often fail to don appropriate safety equipment as they become distracted with managing the situation.

As you arrive, assess the scene through the windshield of your vehicle to develop an index of suspicion for potential injuries based upon damage to the vehicle and mechanism of injury.¹ Patients involved in front-end collisions may have head, neck, chest, abdominal, pelvic and extremity injuries, whereas a patient from a lateral collision may have injuries localized on the side of impact. Patients involved in rollover crashes may have any number of injuries, especially if they are thrown from the vehicle, which significantly increases their chance of dying.

The "windshield assessment" also allows you to evaluate for scene hazards, such as other traffic, wires, spilled liquids or hazardous materials. Evaluate the scene for any immediate life-threats that would require an emergency rescue and removal of the patient from the vehicle, such as fire or any other environmental threats to the patient and/or responder. Move to an area that is safe for all.

Not only should each responder perform this assessment upon arrival, the incident commander should continually reassess the safety of the operations. Throughout the extent of the operation, the incident commander must weigh the risk of injury and death to his or her providers against the likelihood of being successful and is responsible to pause or terminate operations if they are deemed unsafe. One way to accomplish this is to assign a dedicated safety officer to provide the needed focus to ensure this task is always completed. However, it is everyone's responsibility to continually reassess the scene and situation for safety. If at any point during the operation anyone feels there is a safety issue, they should immediately stop, retreat to a safe area and notify the incident commander. Always be cautious when using the phrase "scene is safe," as it may give a false sense of security when operating at a scene that is vulnerable, such as a motor vehicle crash. Even with the best traffic control, there are still hazards from fire, trips and falls, and vehicles driving around or through traffic control measures. All responders should develop a culture of situational awareness where they use all of their senses to continually evaluate the surrounding scene for safety, planning each and every movement before it is initiated.

Once it is determined that the scene is manageable, begin patient triage. There has been some controversy as to which triage method or methods should be used, as there are at least nine different triage tools available worldwide, including two pediatric versions,² but there is little evidence supporting one method over the other.³ The most common methods found in literature are Simple Triage and Rapid Treatment (START) and JumpSTART (the pediatric version of START), which are both used in North America; Triage Sieve used in the U.K. and Australia; CareFlight Triage used in Australia; Sacco Triage Method (STM) developed in North America; and pediatric triage tape, which is also used in the U.K. and Australia.^2,3 With the exception of STM, all of these triage methods are based upon an algorithm that uses physiological parameters to categorize patients as dead or expected to die (black), needing immediate care (red), care can be delayed (yellow), or ambulatory (green).³ The physiological factors used by many of these assess the patient's ambulatory status, breathing, perfusion and ability to follow commands.³ STM is a software-based system that uses mathematical models to identify survivability based upon available resources and has shown some success in a recent study,² but remains costly proprietary software that requires data entry personnel at the scene communicating with incident command or dispatch to obtain real-time system information.³

No matter which model is chosen, you must still identify those patients who are most severely injured but salvageable, and prioritize them so other responders can begin further assessment, treatment and extrication. An expedient way of identifying these patients is by tying the appropriate colored ribbon around the patient's left thumb or hand, followed by placing the highest priority ribbon on the exterior of the vehicle, such as on an antenna or windshield wiper. This tells incoming responders which vehicles and patients within take priority.

PRIMARY ASSESSMENT

Only when the hazards have been mitigated and you can safely function should you continue on to the primary assessment to look for any life-threatening injuries. These are injuries that would most likely be fatal within minutes if they are not immediately found and corrected. As you approach the patient, look at the damage to the vehicle. A spidered windshield (Figure 1) might suggest head injury, a bent steering wheel a chest injury, or intrusion of the door into the passenger compartment thoraco-abdominal injuries.

GENERAL PATIENT IMPRESSION

Your general impression of the patient allows you to quickly determine the severity of injury. If the patient is awake, moving and talking as you approach, he may not be as critical as the patient who is not moving or looking around, or appears to be unconscious (Figure 2). As you approach, look at the quality of the patient's breathing. Patients who are struggling to breathe or have abnormal airway sounds when they inhale are in distress.

LEVEL OF RESPONSIVENESS/CONSCIOUSNESS, CERVICAL STABILIZATION AND AIRWAY

These three activities should occur as a simultaneous event. Talking to the patient as you initiate manual stabilization will help calm the patient and allow you to determine their level of consciousness and responsiveness. If a patient presents with an altered mental status, consider a significant head injury, hypoxia or shock. This patient should receive immediate treatment while you remain vigilant to impending issues like aspiration from vomiting, respiratory failure or seizures.

A patient who is talking generally has an adequate airway, but a patient who is lethargic, obtunded or even comatose needs to have his airway opened via a jaw-thrust maneuver and assessed for patency. Commonly found in severe trauma are oral and facial injuries, which can cause significant hemorrhage and increase the chance of airway occlusion and aspiration. Always be ready to suction an airway with a large-bore suction device.

Occasionally a conflict may arise between in-line cervical stabilization and maintaining an airway. A trauma patient is always presumed to have a cervical spine injury, so responders are taught to maintain in-line stabilization of the cervical spine at all times as they provide airway and ventilatory management. However, if you are faced with a situation where you are unable to maintain an airway or ventilate the patient in a neutral position, you must decide what is more important: repositioning the head to allow for oxygenation and ventilation, or the possibility of worsening a possible cervical spine injury. Without the former, the patient will almost certainly die; the latter is an unknown.

BREATHING

Once the airway is assessed and managed, do a quick assessment of the patient's breathing. If weather permits, and a chest injury is suspected, exposing the chest is prudent. With a stethoscope in one hand, wrap both hands around the patient's chest high along the midaxillary line, then repeat on the other side. This allows you to assess for the presence or absence of breath sounds and to feel for equal expansion, crepitus and/or flail segments while visualizing for any injuries. Treatments that may be initiated here include high-flow oxygen, manual ventilations, stabilizing flail segments, sealing penetrating chest wounds and decompressing a suspected tension pneumothorax.

CIRCULATION

A rapid assessment of circulation comes from checking for a patient's pulse. A patient with a radial pulse is thought to have a systolic blood pressure of at least 80mm/Hg, 70mm/Hg at the femoral pulse, and 60mm/Hg if only the carotid pulse can be palpated (figure 4).

Although this is a traditional dogma of blood pressure estimation, it has come into question as the result of a study published in 2000. This study demonstrated that the actual systolic blood pressures were significantly lower than the estimated pressures obtained based upon the location of individual pulses.⁴ However since this study was limited, more research will be needed before this belief is entirely refuted. In the meantime the use of this estimation, when coupled with other physical findings including the patient's mental status, will assist in determining if the patient's systolic blood pressure is adequate to provide sufficient cerebral perfusion.

By using this assessment, taking a formal blood pressure can be deferred until later in the assessment. Assessing a general rate, as in too slow or too fast, can assist in determining underlying conditions. A slow, steady, strong pulse may indicate a head injury; a weak rapid pulse may mean the patient is in shock. Another early sign of shock occurs as the body shunts blood away from the skin, redirecting it to more vital organs causing the skin to become pale, cool and diaphoretic.

Generally, just looking around the patient is enough to discover gross hemorrhage, but always consider that heavy coats, grass and other soft porous materials may absorb blood, giving a falsely low estimated blood loss. In these circumstances, perform a quick body sweep starting at the head and working toward the feet, checking at natural voids, such as behind the neck or knees.

A patient found in cardiac arrest during a multipatient incident requires numerous resources that the operation cannot spare. These patients are deemed unsalvageable and tagged black, allowing responders to focus their attention on patients who are salvageable. However in a smaller incident, when resources are plentiful, responders may feel compelled to begin CPR. Many cases of traumatic cardiac arrest are thought to be a result of prolonged hypoxia, and resuscitative measures would be futile.¹ A joint statement by the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma states that resuscitation should be withheld or terminated in cases of blunt trauma where the patient is apneic, pulseless and has no organized cardiac rhythm upon EMS arrival.¹ Usually, these patients die as a result of major hemorrhage. Be cautious, however, when encountering a patient in cardiac arrest when the mechanism of injury does not appear to match the clinical condition. There may be a medical/cardiac cause, and normal resuscitative efforts should be initiated or continued.¹

The primary assessment is a fix-as-you-go process and complications require your immediate attention, making every effort to correct them before moving onto the next section of the assessment (see Table I). When a problem is identified during the primary assessment, immediately declare the patient as high-priority and begin rapid extrication.

RAPID TRAUMA ASSESSMENT

As others are preparing for the extrication, do a very rapid trauma assessment looking for gross injuries that may pose a problem during extrication, such as multiple long bone or pelvic fractures that may cause pain, further injury and hemorrhage if care is not taken when moving the patient from the vehicle to a backboard. Although this maneuver is "rapid," it does not allow for compromise of the cervical spine. Place a cervical collar on the patient's neck after palpating the cervical spine and move the patient onto a long backboard as a single unit while maintaining in-line manual cervical stabilization. Secure the patient to the backboard, starting with the torso and ending with the head, then move immediately to the ambulance for further assessment and care.

As the primary assessment is meant to look for injuries and conditions that may be fatal in minutes, the rapid trauma assessment looks for injuries or conditions that are more subtle or may not be evident for a longer period (15-30 minutes). Closed head injuries with the potential for intracranial hemorrhage, increased intracranial pressure and brain stem herniation may initially present with the patient awake and talking. Thoraco-abdominal injuries, such as tension pneumothorax (Figure 4), pericardial tamponade or hemoperitoneum, may only initially reveal as bruising on the chest or a seat belt sign across the abdomen.

To properly perform the rapid trauma assessment, the patient must be fully exposed. Do not feel guilty about cutting away obtrusive clothing if there is a high index of suspicion for injuries based upon the mechanism; however, take into account when and where you expose the patient. If there is a large crowd, maintain the patient's modesty by exposing only what is vital to the assessment and treatment and/or shielding the patient from the crowd with sheets or tarps. Also consider body temperature during exposure, as patients rapidly lose body heat through convection and radiation to the surrounding environment. No matter the temperature outside, always cover the patient with sheets or blankets and consider turning down, or off, the air-conditioning in the ambulance, as cold blood is less likely to clot.

If any serious conditions are found during the rapid trauma assessment, stabilize the patient as soon as possible, but determine to what extent. Look at the patient's overall condition and perform a risk-benefit analysis to determine if the proposed treatment would make a difference in the outcome versus how long it would take to accomplish that treatment considering the patient's other injuries (see Table 2). If the patient is in shock with an open-book pelvic fracture, applying a sheet or pelvic belt not only reduces pain and further hemorrhage but is a fairly quick application that can make a difference. On the other hand, splinting individual multiple fractures in a multi-systems trauma patient would be a poor use of time and resources and is best accomplished using the body, backboard and padding as splints. Also consider whether the desired treatment could be done safely en route. This may entail beginning transport while preparing the necessary equipment and pulling over when ready to administer treatment, such as starting an IV or performing a rapid sequence induction intubation on a head-injured patient whose jaw is clenched.

Always be aware of the time you are spending on scene or on a particular task and be ready to transport if the patient's condition changes. Patients should be rapidly transported via appropriate means to an appropriate receiving center, with triage to specialty centers (burn, pediatric, trauma) based upon regional protocol. Transport to the closest hospital is always warranted if you are unable to obtain or maintain an airway. Notify the hospital of the airway problem so they can have the appropriate equipment, medications and personnel in place prior to the patient's arrival.

SECONDARY ASSESSMENT

Typically, the secondary assessment begins once any life threats to the patient's airway, breathing and circulation have been managed and any major injuries are stabilized. In a trauma situation, parts of the secondary assessment may have to occur simultaneously with other assessments, but should never interfere with them. The ability to do this is directly dependent upon the number of people available and the space they are working in. The lead caregiver should assign these duties to others so they are able to focus upon managing patient care.

GATHERING HISTORY

Do this any time and in any order during the assessment using the mnemonic SAMPLE (signs/symptoms, allergies, medications, past medical history, last oral intake, events prior). Symptoms are what the patient tells you, and can be further broken down into onset, palliation, provocation, quality, region, radiation, severity (0-10) and time.

Although the patient may be unresponsive, always try to obtain information on allergies, medications and a medical history through any means possible. This may be accomplished by having a law enforcement officer look through the patient's wallet or other belongings, or looking for a medical alert tag containing this information when assessing the ankles, wrists and neck.

Obtaining information about the patient's last oral intake yields important facts about their stomach contents in case they need surgery or emergency intubation or become nauseated. Amnesia regarding events leading up to the emergency may help determine if there was a loss of consciousness. Asking the patient the last thing he recalls before the accident and the first thing afterward can help develop a timeline about how long the patient may have been unconscious.

OBTAIN VITAL SIGNS

When and where you obtain vital signs is directly related to the severity of the patient's condition, the number of responders on scene and access to the patient. Vital signs are commonly left until the patient is in the ambulance and all critical and essential treatment has been established. Occasionally, when there are enough responders, one person may be delegated to obtain vital signs, but remember that this should not delay transport.

Vital sign trending is the practice of continually retaking vital signs to identify changes in patient condition. In the trauma patient, this occurs minimally every five minutes, or whenever the patient's condition changes. Trending will help to determine patient stability and alert responders to impending problems. A head-injured patient who develops hypertension and bradycardia is most likely experiencing an increase in intracranial pressure. Watch for brain stem herniation as signified by pupils that are dilated, unreactive or asymmetrical, extensor posturing or no response at all, or a progressive decrease in the Glasgow Coma Scale (GCS) of 2 or more points from their baseline.⁵ A thready or weakening radial pulse is a potential sign that the patient is going into decompensated shock, and you must intervene quickly to improve the patient's hemodynamic status.

FOCUSED ASSESSMENT

If you find no life-threatening injuries on the rapid trauma assessment, you must decide whether to perform a detailed or focused assessment. Again, base this decision on the mechanism of injury: A patient with a cut hand from a low-speed motor vehicle crash may call for a focused assessment; a motorcyclist who struck a guardrail and is now complaining of leg pain should receive a more detailed assessment, even if the rapid trauma assessment did not reveal any injuries.

ONGOING ASSESSMENT

The ongoing assessment involves continually reassessing the patient any time his or her condition changes, an intervention is performed, or after any movement. This includes asking the patient if he is feeling better or worse. Assessing mental status, Glasgow Coma Scale and pupils will help determine any changes in the patient's neurologic status. Also regularly reassess the patient's ABCs. Constant assessment of neurovascular status will alert you to developing paralysis, shock or a splint that is improperly applied. Finally, reassessing after interventions is important and may include effectiveness and tightness of splints, patency and flow rates of intravenous lines, and confirmation of endotracheal tube placement.

CONCLUSION

The scene of a motor vehicle crash is one of the most dynamic incidents you will encounter, with the first few moments being the most critical. Proper scene management consisting of establishing incident command, designating a dedicated safety officer and performing patient triage is vital to its success.

Combining previous experience with a problem-based patient assessment algorithm allows you to become less distracted by severe-looking but non-life-threatening injuries and focus more upon critical life-sustaining treatment for injuries found during the primary assessment. A rapid trauma assessment, which should be routine, will help locate any additional injuries that may cause further pain, trauma or hemorrhage during extrication, or indicate that the patient's condition may deteriorate. Reassessment of initial and physical assessments, as well as obtaining frequent vital signs and recognizing a trend, will allow you to be proactive and prepared to handle any deterioration in the patient's condition.

Many educational programs do a fantastic job of teaching incident management, extrication or trauma care, but few put all of these concepts together. Training officers should begin incorporating the key components of these courses into their training programs and drills to allow responders to practice and learn.

REFERENCES

1. Campbell J, ed. International Trauma Life Support for Prehospital Care Providers, 6th ed. New Jersey: Pearson, 2008.

2. Lerner E, Schwartz R, Coule P, et al. Mass casualty triage: An evaluation of the data and development of a proposed national guideline [electronic version]. Disaster Medicine and Public Health Preparedness 2:S25-S34, 2008.

3. Jenkins J, McCarthy M, Sauer L, et al. Mass-casualty triage: Time for an evidence-based approach [electronic version]. Prehosp Dis Med 23:3-8, 2008.

4. Deakin CD, Low JL. Accuracy of the advanced trauma life support guidelines for predicting systolic blood pressure using carotid, femoral, and radial pulses: observational study. BMJ 321:673-674, 2000.

5. Badjatia N, Carney N, et al. Guidelines for prehospital management of traumatic brain injury, 2nd ed. [electronic version]. Prehosp Emerg Care 12(1): S37-S38, 2007.

OTHER SOURCES

United States Fire Administration. (2008) Traffic Incident Management Systems. Retrieved September 9, 2008 from www.usfa.dhs.gov/downloads/pdf/publications/tims_0408.pdf.

Kyle David Bates, MS, NREMT-P, CCEMT-P, FP-C, is a paramedic for the Town of Tonawanda Emergency Medical Unit in Tonawanda, NY, and EMS education coordinator for the Lake Plains Community Care Network in Batavia, NY.