Transcript

0:11

Right. Alright. Very good. As you can see, we are moving progressively through this whole secondary assessment. And so I am just a disclosure, a co owner of action medical consultants as well as my sports dietitian, the images that you'll see where were mostly obtained from the prehospital emergency care 11th edition.

0:40

So we're going to talk a we'll take a look at this head to toe assessment, take a look at the purpose of it, how to do it, and then what does it matter when we actually find information that's related to our assessment. We keep repeating this for a purpose to show you where we're adding this sequence, but also to sural like drill and practice, emergency medicine, you have to establish yourself in order. Have to establish yourself in priorities, and then you have to execute each of these steps. You can't jump ahead. Now within a space, you can jump around, but you can't jump ahead.

1:18

And so we have to remind ourselves to be prepared ahead of time that includes equipment, staffing, medical timeouts, prepare, training, then we get into the actual evaluating the scene, and Ray talked a little bit about that in in reference to a typical athletic trainer on the field assessment. And that goes into another lecture that we had last month. We expanded that out, and we'll talk about that some more in this afternoon session, the same size up. And then we get down to the primary assessment, and this is where we really look for life threats. What's gonna was going to be the cause of my patient dying quickly on me and and what interventions can I do rapidly to try to counteract that that process of decompensation?

2:17

And so that will also be the discussion of this afternoon session as well as we take a look at a couple cases of athletes And then we in the middle of all that, we have our interventions. So here's where we're at today. We're in the secondary assess man. Ray just covered the OP QST sample. I'm in the head, the toe, and then Ray will follow vital signs.

2:39

And, again, it sounds sort of basic, but at the same time, a lot of times, equity traders forget these steps and are they really haven't had it drilled into And so we're just going to, like we say, go back and get the fundamentals here. So I put this information up here because it reminded me of the reasoning that we do this head to toe. Head to toe is a systematic examination of the body, specifically in trauma cases, trauma indicating some kind of significant mechanism of injury. For us, in sport, we quite often think of spinal injuries. We think of any type of contact collisions, with walls, with surfaces, and with other human beings.

3:29

And so significant in the lives can happen in sport. And every sport brings about its own risk toward physical trauma. But on here, it it says, you know, the Easter egg hunt this year, I I won't dye eggs, and I'll just be like, good luck. When I teach my students about the head to toe, I tell them I have hidden an Easter egg somewhere in this person's body and you gotta go find it. It's not obvious.

3:59

And that's what head to toe is. It's you're trying to find things that aren't obvious. Make a note of what is obvious. But you can't oversell what is not obvious because this thing called adrenaline, which is a wonderful drug, will make you look silly, and you will get burned. And then once you get burned, meaning you skip this step, And then all of a sudden, you found underlying conditions that a drilling covered up, then you won't do it again.

4:35

For a while. And then you'll get lazy like me, and you will try to shortcut and take the shortcut through the path, and then you will Yeah. So it seemed like I cycled through this my whole career thinking I had it all figured out and only to recognize that I didn't go back and stayed according to the details. And that's true at any physical examination. Sometimes shortcut my examination.

5:01

I'm in a hurry. I'm in a rush. Like, like like I'm playing a game. Like, let me ask 3 questions, and I can do your diagnosis and and give you a treatment plan within 2 minutes in. Now let's move on to the next one, and it's the same process.

5:17

So when we take a look at this head to toe assessment. Again, we're looking for Easter eggs. We're looking for things that are hidden. Now this is done after the scene is safe. It's done after.

5:32

We have accommodated all life threats, so this is not a rapid trauma assessment. A rapid trauma assessment is done in the primary survey, and they only give you one minute to do a rapid trauma assessment to look for life threat. It looks like a head to toe, but it's a different level of evaluation. This one in a head to toe, you're slowing down and you're making sure you examine the entire body. So rapid trauma assessment head to toe don't get those 2 confused even though there's the the the processes are very similar.

6:07

One's done crazy fast, still systematically, and then one is done in more detail as you go through. So when we take a look at this process of going Easter egg hunting, they will want us to start at the head and go to toad. Now if you're working with pediatrics, they'll say, let's start at the toe and work at the head mostly for trust purposes. Sometimes, with an adult who might be conscious, they don't mind you feeling, touching, looking at their head. As a matter of fact, they would probably expect that whereas a pediatric you might work from the from the bottom up because it might be not as awkward because you're about to fill this person up That's a weird way to say that, but you are about to put your hands all over this person's body, and it gets to be very personal as you shop for this these hidden these hidden gems that a drilling has covered up.

7:02

So here we here we go. We start the head, and the the skull has the parietal temporal funnel. I separate regions, and you have to touch and feel. What are you looking for? You're looking for this acronym that is common in EMS called dots or no dots.

7:19

Dots, deformities, open innerness, tenderness, and swelling. So you are looking, you are touching, and you are failing. All at the same time for dots, deformities, open injuries, tenderness, and swelling. And you have to go section by section by section on the brain again. We all if you work in allied training, you respect what a drilling can cover up, and somebody can have a significant head trauma.

7:45

Significant trauma in general and not feel it at all and tell you where it's at. So we have to take each section and palpate clearly in look slowly and carefully and not make any assumptions. As we work our way down the body, we, again, we we touch and we feel the mandible, the maxillah, the zygomatic arch, and we could have a complete fracture and not even know it. And again, this is significant MOIs and significant trauma. We will stop by the nose looking for fluids, deviation, deformities.

8:22

Again, all this really comes under dots and no dots. And we we touch all of the major structures of the head Once we get to the mouth area, we wanna open the mouth. We wanna look, make sure there's nothing potentially blocking the airway that the airway is still open, the airway is still clear. Remember, if it's not, then that's the primary assessment. So we've already established that the airway is open, and it's clear.

8:50

And we're just now looking for any kind of objects such as pieces of a mouthpiece or or knocked out tooth or any trouble to the tongue or inside the jaw and make sure once again that we're clear of any fluids. They're gonna stop by the odds. You know, now we're sort of jumping into the nervous system because this head to toe is an evaluation of three body systems. Number 1, it is the muscle skeletal service, the integumentary system, and the nervous system. So we're we're We're doing these 3 systems all in one package called ahead of the toe.

9:27

So this is more in line with the nervous system where we're gonna stop and we're going to take a look at the pupils. And, of course, we're looking for typical pupillary action of to ensure that they are evil and reactive to light and then get a size. On the pupils, making sure to announce to our patient what we're doing. And then we can't forget the ears for battle signs, which is the bruising behind the ear and cerebrospinal fluid, which could be seeping out of the ears and laying in a gravity dependent position like that. That's where the fluid if you have head trauma is coming out, it's going to come out of the ears.

10:07

And so we are looking for those potential indications when we're looking in and around the ear area. So we're moving on down the body, and this is where we palpate, we touch, we feel, specifically with when we were looking at spinal motion restrictions, Now, again, this is not rapid trauma assessment. There was an element of this being done in the primary assessment where you did rule out c spine. So I'm not talking about that. This is the this is the sweet back through to double triple check.

10:41

That you do not that you're not dealing with a potential spinal condition because you can have a spinal condition and you can ask the athlete on your initial rapid trauma assessment or you can do quick wide threat evaluation or primary assessment. And life threats might not show up, and this is one that might not show up. It might not show up until you make this pass where you're where you have a little bit more deliberate pass coming back through the cervical spine, and this is where you palpate even in more greater detail as you run your hands. Up and down the spine as far as you can go, trying to feel for dots and no dots. We cannot forget the the jugular vein distension and tracheal deviation.

11:27

Why? Because if there is chest trauma, and there is pressure in the cardiothoracic region, then it's going to alter the the vein, the jugular vein where we start distending and or the tracheal will move to one side. Why am I call soluble pressure inside the cardiothoracic region is shifting? Those two items, changing those. And those are indicators that we have some chest trauma that might be hidden in there.

11:60

When we take a look at the chest, we're going to expose it absolutely as much as we can. We're going to take a look at the how patient of the chest in the sternum starting off would do a ribs squeeze test. We take our hands on outside of ribs and we squeeze tightly to try to see if we can get any kind of crepitas or grinding. Then we will stop and listen to long sounds again. Now we already listened to long sounds once up at the beginning.

12:30

Of the primary assessment. But here we stop and we'll get another evaluation of lung sounds. On both sides, mid axillary in 2 inches below the collabicle and mid axillary right under the nipples is where we would get, say, times 4. Two places on the lungs where we stop when we get lung sounds. The moves we come down through the abdomen, and we're gonna palpate all of the board quadrants with tenderness and rebound tenderness, we also took 2 different evaluations, tenderness.

13:06

Typically, will give us an indication of solid organs where rebound tenderness will will be more indicative of a hollow organ. Nonetheless, we're still going to do tenderness and rebound tenderness, and we remind ourselves what anaphne is under each section, understanding that that upper white right quadrant is the scary place. With the liver being the major organ and a lot of the liver is not protected. So if we get any kind of dots or no dots in the upper right, it's significantly different than if we found something in the lower left. So understanding your basic anatomy as you go through this process, stomach being in the upper left with the majority of the fleeing in the upper left as well.

13:55

A lot of crossover and all of this, and then, again, the appendix and large and smaller tests with the appendix being a major item that is small and large intestine. So as we do a abdominal evaluation where we go tenderness and rebound tenderness, only abdominal quadrants, you draw a line just like we saw on that graph, and you treat each area independent. Then you take your hands and you run as far around the back as you can, looking for dots and no dots. Again, taking your time we will stop at the pelvic and do a pelvic squeeze test. And in this pelvic squeeze test, we're looking for that potential pelvic fracture that is hidden.

14:36

That did not show up on the initial. We would say, why don't we just ask the athlete, does their pelvis hurt? And again, a drilling? Adrenaline will cover it up sometimes and you need to make sure that you account for a pellet squeeze test. As you come them down.

14:55

And as you move down through the legs, the extremities, We're looking for again dots and no dots, but now we're going to mix in the the integumentary system where we're looking for pulse motor sensation. Or you might call it sensation motor. Impulse PMS, CMS, you're trying to say, can you feel can you touch it as blood flow moving? Those are 3 evaluations as we move down through the extreme disinformation getting to where it needs to get to. And again, that is 8 different tests.

15:26

Because every lamb is independent, not only in their century, but also in their motor, as well as their circulation. And so we wanna fill for pulse and or have capillary refill to ensure that we have adequate in all four linems. So make sure that you treat all four items independent. Then we get 2 deep back. This every time I see this slide in my first EMT class, way back in 1983.

15:57

I'm dating myself. This is where I failed my practical was I did it. I was so proud I did it. Phenomenal, had to tell evaluation, so proud of myself. And then they said, oh, you got trauma on the back.

16:09

You totally missed it. And so that is stuck with me not to ever do that again. However, you kinda wanna gauge, when is it appropriate to evaluate the back? Sometimes, you need to do it immediately because you potentially have issues that you feel were impacting the back, and then you might wait until you're ready to transfer to the patient along DMS to whatever device that they wanna put them on, and and then take a look into the back. I prefer not to roll somebody, but I don't have an indication to roll over way and be patient, and we'll do this together when we actually transfer somebody.

16:50

You just can't forget it because the worst case scenario is that the trauma is in the back area, and everybody missed it, and then you deliver them to the ER, and you will not do that again if you ever have done that before. So Easter egg hunting, that's what this is about. It's looking for the hidden egg. Drillum will cover it up. You're trying to identify everything that you're up against.

17:18

Some things will be obvious. You might see an obvious deformity. It's called a distracting injury. Somebody says, my ankle hurts. My ankle hurts.

17:26

My shoulder. My knee. They're declaring what hurts. However, that might not be everything and you will make a note of that and we have a tendency to run and jump to those injuries, which in some cases it is okay because that's called a focused injury and you go and you determine the severity of that injury and began to put the things in motion to identify and treat that injury like getting your splints or getting somebody to get your splinting material out. But then you cannot go you cannot forget that you were responsible for all injuries and conditions, and they might be hiding.

18:05

Gonna establish a baseline. Like like, this is this is the beginning part, and adrenaline begins to fade away all of a sudden, things start showing up sometimes. Specifically in the abdominal region or the chest region, which which aren't as obvious and and not as easy to pull out when it comes to doing a head to toe evaluation like the extremities are. It helps you put a priority of care like Like, once you get a big picture idea of what all you're up against, then you start to prioritize what I'm gonna work on first. So if you see a gross deformity or swelling or dots in the upper right quadrant of a of an athlete that had trauma And he he also heard his ankle, well, you're going to focus on the upper right quadrant, which is a liver and possible laceration internal.

18:55

Bleedy, and you're focused on vital signs and other things, and that ankle would just have to wait. Enhancing patient safety, improving patient communication, comparator additional things that can come about when it's time to through our key takeaways with this particular like this quote, Right? And it is yeah. You you rise to the level of training, and that is so true. And that means this is like a robot.

19:28

You have to become elements of a robot. You can't skip steps. You can skip steps, but you'll get embarrassed. You'll miss things. And in emergency medicine, unlike somebody walking in your out body training room and say, my back hurts, my knee hurts, and you can sometimes shortchange those evaluations because of time, because of because of the history you have with that particular athlete.

19:55

But when it comes to emergency medicine, you cannot skip open CureSD. You cannot skip sample. You cannot skip head so. You have to be diligent even though it doesn't quite make sense sometimes.

20:08

That's so true. Especially, you know, with this the head to toe assessment, and thank you, Ronnie, for information you provided. I think the one you know, I'll I'm gonna have a I have a question for you. And, again, audience, if you have a question, we prefer you raise your hand. We'd rather talk to you.

20:26

It's all people don't wanna we used to One thing we like to do is have a those would be on our calls report. We'll turn the mic on to anyone, and especially if you have your experiences, then please we wanna hear from you, or just type your message into white. The one question I have is really, I think that that I see a lot that is, okay, how how fast does a head of toe assessment take? And in a difference of you're doing the doing the secondary, the first the first round you do it like in a rapid trauma versus Okay. I'm going back again as a as a follow back because, you know, you're reevaluating again to make sure you're missing things.

21:08

You can just kinda talk on that for a minute. Just to discuss what that looks like.

21:16

If they're conscious, unconscious is what separates how fast you do it. If they're conscious, it's slow because you're saying, do you does this hurt? Yes or no? Does this hurt? Yes or no?

21:25

Do you feel this? You put pressure on things. You squeeze things. You stress things out. When you're unconscious, you got your eyes, you got your your your touch, and that's about it.

21:37

You know, you have to become more reviewing sometimes on unconscious by taking clothes off, by removing equipment because you that's all you have. So that takes time if you gotta start removing things with an unconscious patient. The rabbit trauma assessment, they want you to be in and out in less of one minute because it's live threats. Head to toe, you can you can take as much time as you want, as it takes to get the job done, and what all of the other elements of this scene are you trying to process says, sometimes I start a head to toe, and I go like, man, I really wanna know their blood pressure, and I will stop and get a blood pressure. And are sometimes I would go like, man, I need to circle back through that sample.

22:26

I'll procure a t, and I'll stop ahead of toe. However, you have to pick back up where you left off in your head and toe. And don't forget where you left off and make sure you're responsible for the rest of the body and not overlooked that.

22:44

So with the head to toe, I guess there's a follow-up, and I I probably I've never even thought of this until just now. Is there a difference in just doing starting at the at the feet first. No difference. Fingers. Yeah.

22:59

No difference. Typically, because we're at the head already, if I you could do that or have somebody start away from you moving either way, it's it's rapid. You know, I think the as I'm listening to what you your your presentation and really and focusing on what you've mentioned a a minute ago, is you think about whether they're conscious or unconscious or, like, just say, for example, if they're unconscious and you aren't certain, you have to assume they have a head and spot injury. Until otherwise proven. So you're not getting pain response that you may do that.

23:29

So you're just doing it. If not, you have to do it under a minute, But if you're doing it efficiently and you've practiced it, you'll probably get well under that and not trying to do that. It's just the rep. How you're moving down to identify that already. And it's worked as if you haven't done it in a while, just go back and do it once or twice.

23:50

On a person who's conscious or that as well, not like as well. So

23:55

I know when I do a rapid trauma, except when I when I have an athlete with trauma, the first thing I'll start telling myself is adrenaline, you are lying to me. You you are a liar. You cover things. Now, You're hiding something. Now play a mental game with myself.

24:11

You're hiding something for me. Where is it at? I've gotta go shopping for it, and and and I have a plan to go try to expose it.

24:21

Okay. So Christa has a is really excellent question. So if you can see I'm a read I'm a read it out. So with the rapid trauma assessment, what are the key points we need to hit? I might have missed it early in the beginning, and I'm just returning to the pre profession.

24:40

Welcome back. And and looking for a good review.

24:44

So the rapid trauma assessment, that's in the primary scene under circulation. So we have the CAB in the primary circulation airway breathing. It's under the circulation, which is looking for live threats, which are typically related to bleeding even though it's more than just bleeding. It's typically related to bleeding, and that is looking for terrible bleeding, looking for open chest wounds, and looking for skin color and temperature. Mhmm.

25:15

And we're looking for the quality of the pulse rate. And so those are the quick, fast, like, go find those, hurry up, like Easter egg hunting will speed down. And and you have to do it really fast systematically, but it's large you're actually looking at your hands. Like like you put your hands down, you're looking for blood, like like you're looking for evidence of that. So that's in the rapid.

25:42

It's in the primary assessment sequence.

25:45

Yeah. So I think that's a Chris, that's an excellent question you had there because, you know, we we don't see this. You know, you may not be in that situation too often for most times for athletic settings, but it's the other the outline things where you're not expecting to see that. So, for example, if you were in a mass casualty situation where there is a there's multiple people, blood, etcetera. You can't figure out one way or the other where it's coming for it because you see or it's or they're in a mud or something like that.

26:19

You would have to do that, as doctor Harper said, you can you know that they're having You gotta hit those initial threats, the circulation airway breathing, and they may be bleeding from multiple locations. Or minor things that are causing a lot of that seepage of blood, but collectively, it doesn't look like major trauma, but they are bleeding out significantly internally, externally. So I've seen that before, and it it's a you know, you have in a mass casual situation, and it's it's pretty hard to do that, but you have to like, you wipe an area, like like doctor said, you roll the chest, wipe the area, and then you're gonna see the bleeding. And if it is, then you can identify where that is, and you start to treat that according.