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TRAUMA SECONDARY ASSESSMENT - Coggle Diagram
TRAUMA SECONDARY ASSESSMENT
HISTORY TAKING (SAMPLE)
Past medical history
: Inquire about chronic medical conditions (e.g., hypertension, diabetes, heart disease), as well as any prior surgeries.
Hypertension management: Ensure blood pressure is controlled. If the patient is hypotensive, aggressive fluid resuscitation may be necessary.
Cardiac evaluation: Given the coronary artery disease, assess for signs of cardiac injury (e.g., chest pain, ECG changes). Initiate cardiac monitoring and check troponins as appropriate
Pre-existing conditions: Manage any ongoing conditions that could affect trauma care, such as cardiovascular or renal concerns (e.g., monitor renal function due to the potential use of contrast in imaging)
Allergies
: Ask about any known allergies, especially to medications
Confirm medical record: Check for any potential cross-reactivity with drugs that may be administered (e.g., check for aspirin/NSAIDs if a history of peptic ulcers or bleeding disorder exists).
Continue to monitor for any signs of allergic reactions to drugs, fluids, or latex during subsequent interventions (e.g., while giving blood products or medications).
Events leading up to the injury
: Obtain details of how the trauma occurred (e.g., car accident, fall, gunshot wound), and any other relevant circumstances that might influence treatment.
Spinal precautions: If there’s any suspicion of spinal injury, continue with cervical spine immobilization using a hard collar and backboard.
Triage and transfer: If injuries are significant, prepare for transfer to a trauma center or a surgical unit for further management.
Immediate imaging: Given the mechanism of injury (side impact MVC), consider CT imaging of the head, neck, chest, abdomen, and pelvis to rule out injuries such as brain hemorrhage, spinal fractures, organ injuries, and internal bleeding.
Abdominal monitoring: As the patient is complaining of abdominal pain after trauma, continue to monitor for signs of hemorrhagic shock or peritonitis. Initiate a FAST exam or CT scan to assess for abdominal trauma.
Signs & Symtoms
: Severe abdominal pain with dizziness and shortness of breath, abdomen appears distended and there is visible bruising on the chest and upper abdomen.
Pain management: Administer analgesia (e.g., opioids or nonsteroidal anti-inflammatory drugs [NSAIDs]) for abdominal pain, based on severity.
Monitoring: Initiate continuous monitoring of vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation) and urine output for signs of shock.
Abdominal examination: Further palpation to assess for peritonitis or organ injury. If tenderness or rigidity is noted, prepare for imaging (e.g., FAST exam or CT scan) to assess for internal bleeding or visceral injury.
Medications
Determine if the patient is taking any regular medications.
Current medication: Ask the patient about any medications they are currently taking, including prescription, over-the-counter, herbal supplements, and recreational drugs.
Pain medications (e.g., opioids, NSAIDs) may affect their pain response.
Anticoagulants (e.g., warfarin, aspirin) or blood thinners can complicate the management of bleeding.
Chronic medications like those for hypertension, diabetes, or asthma may impact their response to trauma and influence treatment.
Over-the-counter and recreational drugs: Assess for the use of alcohol, illicit drugs, or other substances that might affect consciousness or cause injury.
Last oral intake
: Determine when the patient last ate or drank, particularly if surgery or anesthesia is needed.
Fasting for surgery: As the patient may require surgical intervention (e.g., laparotomy for internal bleeding or organ injury), ensure the patient has fasted for a sufficient period and avoid oral intake until surgical consultation is complete.
Aspiration risk management: If the patient requires anesthesia or sedation, consider endotracheal intubation to protect the airway and prevent aspiration during surgery.
NPO status: Maintain the patient on nothing by mouth (NPO) status until further surgical or diagnostic management is determined.
HEAD TO TOE ASSESSMENT
Back and Spine:
Check for any spinal tenderness or deformities; palpate along the spine for potential fractures, and assess for neurological deficits..
Management
Spinal immobilization should be maintained using a backboard and cervical collar until spinal injury is ruled out.
Monitor for neurological changes, and consult with a neurosurgeon or orthopedic specialist for any suspected spinal injury.
Pain management may be required but should be used cautiously in patients with potential spinal injury.
Chest:
Look for chest deformities, listen for abnormal breath sounds, palpate for crepitus (suggesting fractures), and check for rib fractures.
Management
If pneumothorax or hemothorax is suspected, perform needle decompression for tension pneumothorax and follow with chest tube insertion.
Provide pain management (e.g., NSAIDs, opioids) for rib fractures.
Monitor oxygenation and provide oxygen therapy for any signs of respiratory distress or hypoxia.
In cases of flail chest, administer pain control and consider positive pressure ventilation to assist breathing.
Abdomen
: Inspect and palpate for distension, tenderness, guarding, or rigidity. Perform a focused abdominal ultrasound (FAST) if internal injury is suspected.
Management
If peritonitis is suspected or FAST suggests free fluid, immediate surgical consultation is needed for laparotomy.
Administer IV fluids to prevent shock and manage potential internal bleeding.
Pain management should be administered cautiously to avoid masking signs of worsening internal injury.
Pelvis:
Inspect for deformities or pain, and palpate for instability, which may suggest fractures.
Management
If peritonitis is suspected or FAST suggests free fluid, immediate surgical consultation is needed for laparotomy.
Pain management should be administered cautiously to avoid masking signs of worsening internal injury.
Administer IV fluids to prevent shock and manage potential internal bleeding.
Extremities:
Inspect and palpate limbs for swelling, deformities, and open fractures. Check circulation and neurovascular status (pulse, capillary refill, sensation, movement).
Management
Spinal immobilization should be maintained using a backboard and cervical collar until spinal injury is ruled out.
Monitor for neurological changes, and consult with a neurosurgeon or orthopedic specialist for any suspected spinal injury.
Pain management may be required but should be used cautiously in patients with potential spinal injury.
Head and Neck:
Inspect and palpate for injuries, check for cervical spine tenderness, and assess neurological status (pupillary reaction, GCS).Look for signs of trauma such as raccoon eyes (bruising around eyes) or Battle’s sign (bruising behind the ear). Check for any blood or cerebrospinal fluid leakage from the ears or nose.
Management
Immobilize the cervical spine with a cervical collar until cervical spine injury is ruled out.
If neurological impairment is suspected (e.g., signs of spinal cord injury), avoid manipulating the spine and keep the patient in a neutral position.
Administer IV fluids cautiously, monitor for signs of intracranial pressure (ICP), and consult for neurosurgical intervention if indicated.
DIAGNOSTIC TESTS
X-rays
: Chest, pelvis, and long bones are often imaged to identify fractures.
CT scans
: If indicated, CT scans of the head, chest, abdomen, or spine may be performed to look for internal injuries.
Ultrasound
: Focused Assessment with Sonography for Trauma (FAST) can be used to detect free fluid (blood) in the abdomen or around the heart.
REASSESSMENT
Ongoing monitoring
of vital signs, mental status, and physical examination findings is essential.
Re-evaluate
the patient frequently for any changes in condition. New injuries or complications can arise, and reassessment ensures that they are addressed promptly.