Primary and Secondary Assessment (A-I)
A= airway
B=breathing
C=circulation
D=disability- brief neurological assessment
E= exposure and environmental
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F= full set of vital signs, focused adjuncts, and family presence
G= give comfort measures
H= head-to-toe assessment
I= inspect posterior surfaces
Airway: Assessment (at least 3)
-vocalization
-tongue obstruction
-loose teeth or foreign objects
-vomitus, blood or secretions
-edema
-preferred posture
-drooling
-dysphagia
-abnormal airway sounds
Airway: Interventions (at least 1)
-open the airway with jaw thrust or chin lift
-repositions head to neutral position
-suction
-remove foreign objects
-OP/NP airway
-prepare for endotracheal intubation/rapid sequence intubation
-prepare for needle or surgical cricothyroidotomy
Breathing: Assessment (at least 3)
-level of consciousness
-spontaneous respirations
-rate and depth of respirations
-symmetric chest rise and fall
-presence and quality of breath sounds
-skin color
-work of breathing: nasal flaring, retractions, head bobbing, expiratory grunting, accessory muscle
Breathing; Interventions (at least 1)
-maintain position of comfort
-provide supplemental O2
-provide bag-mask ventilation: reassessment of breathing effectiveness should occur prior to proceeding with primary assessment
-prepare for ET intubation/rapid sequence intubation: assessment of tube placement should be done prior to proceeding with primary assessment, insert gastric tube for abdominal distention
Circulation: Assessment (at least 2)
-central AND peripheral pulse rate and quality
-skin color AND temperature
-capillary refill
-jugular vein distention and tracheal position in the trauma patient
Circulation: Interventions
-perform CPR and advanced life-support measures
-control any obvious bleeding
-prepare for defibrillation/synchronized cardioversion
-obtain IV or IO access
-administer 20 ml/kg fluid bolus of isotonic crystalloid solution
-administer medications
-administer blood and blood products
-correct electrolyte and acid-base imbalance
-prepare for needle thoracentesis
Disability: Assessment
-level of consciousness (AVPU)
-pupils
Disability: Interventions
-perform further investigation during secondary assessment
-administer pharmacological therapy
Exposure and Environmental Control: Assessment
-obvious skin abnormalities
-sources of heat loss
Exposure and Environmental Control: Interventions (at least 1)
-apply warm blankets
-provide overhead warm lighting
-provide radiant warmer or approved warming device
-maintain warm ambient environment
-increase room temperature as needed
-administer warm IV fluids
-administer warm humidified O2
Full set of vital signs: Assessment
-HR
-RR
-BP
-SpO2
-Temp
-Weight
Full set of vitals: interventions
-obtain a weight: use a scale for a measure, estimate a weight using a length-based resuscitation tape (Broselow)
Family presence: Assessment
-identify family members and their relationship to child
-needs of the family
-need for additional support and desire to be in resuscitation room
Family presence: Interventions
-facilitate and support family involvement
-assign healthcare professional to liaison with family and proved explanation of procedures, plan of treatment
-assign a staff member to provide family support
Focused adjuncts: interventions
-place on dynamic cardiopulmonary monitor
-obtain bedside glucose
-insert gastric tube if indicated, if there are no contraindications and if not already done with ET tube intubation
-insert a urinary catheter if indicated and if not contraindicated
-obtain blood samples to send to laboratory for analysis
Give comfort measures: assess
-presence and level of pain
Give comfort measures: interventions
-facilitate family presence for support of the child
-initiate pain management measures: use age-appropriate non-pharmacological methods to facilitate coping, administer analgesics and other appropriate medications, initiate physical measures (splints, dressing, ice)
Head-to-toe assessment: Assess
-Head-to-toe assessment using inspection, palpation, and auscultation techniques for signs and symptoms of illness or injury such as rashes, lesions, petechiae, edema, ecchymosis or tenderness
-reassessment of airway, breathing, circulation status once head-to-toe assessment is completed
Head-to-toe assessment: Interventions
-initiate appropriate interventions based on findings
History: assessment
-MIVT
-complete history (CIAMPEDS)
-focused history
-social history
-family history
History: interventions
-initiate social service consult as needed [Show Less]