Chapter 20Chapter 20Primary and Secondary Survey

ObjectivesObjectives Explain the difference between primary and secondary

assessment. Explain the difference between signs and symptoms. Explain the ABCs of a life-threatening emergency. Define the procedure used to restart breathing once it

has stopped. Explain the types of illnesses or injuries that cause

breathing and the heart to stop. Explain when cardiopulmonary resuscitation is used. Explain how external bleeding is controlled. Explain what precautions can be taken to prevent

communicable diseases. Ask the basic questions for obtaining the history of an

injury or illness. List the common vital signs and explain how they help

identify an injury or illness. Determine whether an injury can cause shock. Describe the procedures that the athletic trainer uses

when testing an athlete’s injury.

Emergency Procedures and Emergency Procedures and AssessmentAssessment

1. Introduction2. Permission to

treat3. Document

refusal4. Questions5. Observe for

signs/symptoms

Sign vs. SymptomSign vs. Symptom

Sign: a sense, like sweating, temperature, blood pressure, breathing rate, etc. can be observed by ATC

Symptom: cannot be seen, smelled, or heard such as nausea, headache, anxiety

Primary AssessmentPrimary Assessment

AirwayBreathingCirculation

◦Deals with life threatening injuries

Steps of primary assessmentSteps of primary assessmentCheck responsiveness by tapping or

shaking (do not jolt neck)Check Airway

◦Make sure it is openCheck BreathingCheck Circulation (pulse)Check for severe bleeding

ResponsivenessResponsivenessGently tap, do not shake!May not respond verballySpeak positively, may be able to hear

w/out being able to respond

AirwayAirway

One hand on forehead, two fingers of other hand under chin

BreathingBreathing

Look-for chest to rise and fall

Listen- for breath sounds

Feel-for breath on cheek (10 seconds)

TAKE YOUR TIME

CirculationCirculation

Take pulse◦Carotid artery◦Next to Adam’s

apple in the groove towards the side of the neck

◦Check for at least 10 seconds

What would you do???What would you do???

You are a spectator at a soccer game. The temperature is cool. A parent who is videotaping the game is pale and sweating. The man’s wife, who knows that you are a student assistant, asks you to take a look at her husband. You check his pulse. It’s so rapid you cannot count that fast. The man insists there is nothing wrong with him. The athletic trainer is on the sideline, watching the game.

Breathing EmergenciesBreathing EmergenciesCan involve any part of the respiratory

systemCan cause deathExamples

◦Ruptured diaphragm◦Punctured lung◦Anaphylaxis◦Asthma◦Airway obstruction

Breathing emergenciesBreathing emergenciesAs little as 4 minutes without oxygen can

cause permanent brain damageIf person has immediate proper care,

survival rate is 98%Significantly reduced if care is delayed by

4 minutes after breathing has stopped

Mouth-to-mouthMouth-to-mouthAKA-rescue breathingEach breath lasts 1 second1 breath every 5 seconds (after initial 2)

◦ Watch for chest to fall after giving breath◦ Use barrier device

Obstructed airwayObstructed airway Tongue is #1

obstructer

Others: food, gum, mouth guards, broken teeth, blood, vomit, & chewing tobacco.

If conscious, most will grab throat

Obstruction can be partial or total

Partial Airway ObstructionPartial Airway Obstruction

Ask athlete if they can speak, cough, or breathe

If they can, it is partial… allow them to try to expel the object them self

Total Airway obstructionTotal Airway obstructionAirway completely blocked, unable to

breathe, speak, or coughMay experience high-pitched whistling

noise from throat

What would you do?What would you do?

In the cafeteria a student tells a joke and another begins to cough forcefully just after laughing. The student continues to cough, her face is turning red, and tears are rolling down her cheeks. The athletes next to you say, “She is choking. Do something!”

Other breathing emergenciesOther breathing emergencies

Asthma◦Medication

Punctured lung Call EMS

Cardiopulmonary Cardiopulmonary EmergenciesEmergencies

Heart Attack◦Heart muscle is

damaged by : blockage of a vessel

to the heart A clot Stress over a period

of time Injury to the heart

muscle itself

Signs of a heart attackSigns of a heart attackBreathing difficultyShortness of breathBreathing faster than normalHigh, low, or irregular pulse ratePale or blue skinProfuse sweatingVomiting Sudden unexplained fainting (syncope)Elevated blood pressure

Symptoms of a heart attackSymptoms of a heart attackNauseaPersistent chest pain or discomfortAnxietyGeneral feeling of weaknesslightheadednessPersistent chest pain, not relieved by

position changes

Heart attack (myocardial Heart attack (myocardial infarction)infarction)

Angina pectoris: crushing chest pain felt by a person suffering from a heart attack

Best treatment: early recognition

Cardiac ArrestCardiac ArrestOccurs when the heart is damaged by

blockage of a vessel to the heartImmediate CPR crucial life of the victimAutomated external defibrillator (AED)

should be used if available

Hemorrhage and external Hemorrhage and external bleedingbleeding

Hemorrhage: A discharge of blood, internal or external, can cause death

External Bleeding: usually caused by a laceration, incision, amputation, avulsion, puncture, or abrasion

Control of BleedingControl of BleedingApply direct pressureElevate the body partApply a pressure bandageApply pressure to a pressure point if other

methods unsuccessful

Communicable Disease Communicable Disease TransmissionTransmissionCan be transmitted

directly or indirection by contact with an infected person

Do not allow athletes to share water bottles or towels

Universal precautionsUniversal precautions1. Wash hands after any and all contact with

an injured athlete2. User rubber gloves to create a barrier3. Clean tables, counters, etc. with a

disinfectant (1:10 bleach and water)4. Use biohazard bags for saturated

materials5. Dispose of needles or syringes in a sharps

container

Other precautionsOther precautions

Do not allow players to dip cups into a water cooler

Athletes should avoid sharing food, utensils, or drinking glasses

Athletes should avoid sharing personal items: combs, towels, clothes, etc.

Athletes should shower after each practice

Secondary AssessmentSecondary Assessment

Completed after primary assessment for non-life threatening injuries

HIT/HOPSHIT/HOPS History –first step

in determining facts

Questions- ◦ What happened? ◦ When? ◦ Previous injury? ◦ Where was the pain

initially? ◦ Did you hear or feel

a pop, snap, crack, slip, or give?

◦ Were you able to continue to participate?

◦ Medication?◦ How soon did it

swell?◦ Does it feel

unstable?

Vital SignsVital Signs Heart rate

◦ Pulse points – Carotid artery, Radial artery

◦ Pulse rate –normal for teens 60-80 beats per minute (bpm), athletes can be as low as 40 bpm

Abnormal vitalsAbnormal vitals

◦ Other abnormalities can be from medication, internal injuries, or heart abnormalities

◦ Rapid pulse- shock, hyperventilation medication, anxiety, or physical activity

Vital SignsVital SignsBreathing rate

◦Normal- 12-20 breaths/min

◦Dyspnea-difficulty breathing-common w/asthma, allergies, colds

◦Apnea-temporary stopping of breathing-may indicate head injury

Blood PressureBlood PressureBlood pressure –the

pressure exerted by the blood on the walls of the blood vessels.

Systolic pressure –heart contracting

Diastolic pressure –heart is relaxed

Pulse pressure-the difference between the diastolic and systolic

Blood pressureBlood pressure

Normal 110mm Hg systolic, and 65-80 mm Hg diastolic

Increases -head injury, activity,medication, or illness

Decreases-heart failure, hemorrhage, shock, medications, or illness

Vital SignsVital Signs

Body temperature – 98.6◦Rises-infection,

heat stroke◦Drop-shock, cold

exposure

Vital signsVital signs

Skin color ◦Bright red- heat

stroke or carbon monoxide poisoning

◦Bluish- poor oxygen supply

◦Yellow-liver illness◦Pale-shock or lack of

circulation

Vital signsVital signs

Capillary refill –check for circulation to fingers/toes◦Should not take

more than 2 seconds to return to normal

◦Abnormality can indicate fx or blood clot

Vital SignsVital Signs

Pupil Response◦Constrict –get

smaller◦Dilate –get larger◦Unequal –suspect

head injury◦Constrict in

darkness = heat stroke or poisoning

Ability to moveAbility to move

Paralysis – injury to brain or spinal cord

Hemiplegia –inability to move one side of body, indicates head injury of opposite side

Paraplegia –inability to move legs

Quadriplegia –inability to move arms and legs

Pain responsePain response

cannot be used to determine severity of injury

Inspection/ObservationInspection/ObservationObserve

surroundingsObserve the

athlete◦Limping◦Bleeding◦Swelling◦Redness

Testing/Palpation & StressTesting/Palpation & Stress

Palpation –touch

◦ Depression◦ Fluid leakage◦ Bumps◦ Crepitus◦ Asymmetry◦ Watch athlete’s

face

testingtesting

Listening to the heart – establish heartbeat, take heart rate

Range of motion testing (ROM)◦Test joints above

and below◦Active and passive◦Compare to

opposite side

TestingTesting

Strength testing ◦Manual Muscle

Testing (MMT)◦Always compare

both sides

Grading scale of strength testingGrading scale of strength testing

◦Zero to Normal grading Zero (0)-inability to move or even twitch Trace (1)-can perform a twitch Poor (2)-full ROM with gravity eliminated Fair (3)-full ROM, against gravity, no resistance Good (4)-full ROM, against gravity, some

resistance Normal (5)-full ROM, against gravity, full

resistance

Neurological testingNeurological testing

Testing to rule out neurological problems ◦Inability to feel or

move a part◦Can determine

spinal nerves involved

ShockShock

Recognizing shock◦Shock is the body’s

way of protecting the vital organs (heart, brain, lungs, liver, and kidneys)

◦Blood flow increases to these organs and away from the rest of the body

3 reasons for Shock3 reasons for Shock

Enlargement of the system ◦Imbalance of blood supply due to blood vessels

of head, chest, and abdomen enlarging and extremities constricting. Blood pressure then decreases due to lack of blood volume, therefore oxygen to vital organs is reduced.

◦Heart failure ◦Vessel failure (loss of blood)

Shock can cause DEATH

Shock S&SShock S&SSigns of shock

◦ Agitation, rapid weak pulse, decreased blood pressure, cold clammy skin, sweating, pale, cyanosis, increasing unconsciousness

Symptoms◦ Nausea, thirst, anxiety, and dizziness

Treating shockTreating shock

◦Treat original injury◦Keep athlete warm◦Elevate arms and legs if not broken◦Measure breathing and pulse every 5 minutes◦No food or drink◦If vomiting, turn on side and clear airway◦Take athlete to hospital◦Head/Neck injury-backboard, send to hospital

Assessing and managing a Assessing and managing a fracturefracture

Check capillary refill

Pulse rate of extremity

Sensation◦ Lack of pulse or

sensation may indicate serious nerve or vessel damage. Immediate referral necessary

Types of splints Types of splints

Traction splints –femur fx

Rigid splints –box, board, aluminum

Semirigid splints –moldable, vacuum◦ Moving after splinting

keep athlete comfortable, no bouncing

PRICEPRICE Protection-from further injury

Rest –for healing Ice -20 minutes, 1

hour between, 3x/day max

◦ CABN-cold, aching, burning, numbness

Compression –prevent excess swelling

Elevation-10-12 inches above heart

No HARMNo HARMDuring the first

48-72 hours◦No Heat◦No Alcohol (causes

swelling)◦No Running◦No Massage

(increases swelling)

ScenariosScenarios A 14-year-old athlete, who has an

obviously broken leg, refuses treatment. The athletic trainer cannot find a

stethoscope to use during a blood pressure test. What would you recommend?

An athlete who is in shock with an unsplinted fracture begins to vomit.

An athlete has a fracture. When the athletic trainer begins to splint the site, she discovers the air splint has a leak. There are no other splints.