ITLS Patient Assessment and Management 2 — Questions and Answers

Question 1: During scene size-up, you notice a car with severe intrusion into the driver's compartment and a spider-web pattern on the windshield. The driver is ambulatory and denies injury. How should this mechanism of injury influence your assessment?

Since the patient is ambulatory, mechanism is irrelevant
High-energy mechanism warrants a full rapid trauma survey regardless of the patient's initial presentation, as occult injuries are likely (Correct answer)
Only perform a focused assessment on the area where the patient hit the windshield
Mechanism of injury is not used in clinical decision-making

Correct answer: High-energy mechanism warrants a full rapid trauma survey regardless of the patient's initial presentation, as occult injuries are likely

ITLS teaches that significant mechanism of injury (compartment intrusion, windshield impact) mandates a full rapid trauma survey even in patients who initially appear well, as compensated shock and occult injuries frequently present with minimal early symptoms.

Mechanism of injury is a predictive tool in ITLS assessment. Significant mechanisms include: compartment intrusion >12 inches (indicates extreme deceleration forces), windshield starring (head impact with potential TBI and cervical injury), high-speed impact, rollover, ejection, and pedestrian/bicycle struck. The ambulatory patient with a significant mechanism may have: compensated hemorrhagic shock (maintaining BP through vasoconstriction), concussion with intact GCS but impaired judgment about their own condition, intra-abdominal bleeding not yet producing symptoms, aortic injury (15% initially stable then suddenly fatal), or spinal injury masked by adrenaline. ITLS protocol dictates that mechanism alone can trigger the rapid trauma survey pathway, bypassing the focused assessment. The rapid survey evaluates the entire body systematically for injuries the patient cannot feel or report. Multiple studies confirm that patients with significant mechanisms who are undertriaged (assessed as minor) have higher mortality than those receiving appropriate full assessment and trauma center transport.

Question 2: What is the difference between a rapid trauma survey and a focused assessment in ITLS, and when is each performed?

They are the same assessment performed at different speeds
The rapid trauma survey is a systematic head-to-toe evaluation for unstable or significant-mechanism patients; the focused assessment targets specific injury sites in stable patients with isolated mechanisms (Correct answer)
The focused assessment is always more thorough than the rapid trauma survey
The rapid trauma survey is only for unresponsive patients

Correct answer: The rapid trauma survey is a systematic head-to-toe evaluation for unstable or significant-mechanism patients; the focused assessment targets specific injury sites in stable patients with isolated mechanisms

ITLS uses two assessment pathways based on patient stability and mechanism: the rapid trauma survey (complete head-to-toe for unstable/significant mechanism) and the focused assessment (targeted evaluation for stable patients with isolated, minor mechanisms).

ITLS's dual assessment pathway optimizes time use. The Rapid Trauma Survey is performed on patients who are: altered mental status, unstable vital signs, significant mechanism of injury, or multiple complaints. It is a systematic head-to-toe evaluation taking 60-90 seconds, checking head (DCAP-BTLS), neck (JVD, trachea, crepitus), chest (breath sounds, stability), abdomen (distension, rigidity), pelvis (stability), extremities (pulses, deformity), and back (log-roll). The goal is finding ALL life threats. The Focused Assessment is for patients who are: alert, stable vital signs, isolated minor mechanism, single complaint. It evaluates only the area of complaint plus adjacent structures. Example: a patient who tripped and hurt their wrist—assess the wrist, forearm, and hand; no need for a full body survey. The key decision point is the mechanism: did sufficient energy transfer occur to cause occult injuries? If yes → rapid survey. If no → focused assessment. Either pathway is followed by ongoing reassessments: every 5 minutes for unstable patients, every 15 minutes for stable patients.

Question 3: During the circulation assessment of a primary survey, what four things should be evaluated?

Blood type, clotting time, hemoglobin level, and platelet count
Pulse (rate and quality), skin (color, temperature, moisture), capillary refill, and major external hemorrhage control (Correct answer)
Heart sounds, lung sounds, blood pressure, and oxygen saturation
ECG rhythm, pulse oximetry, blood glucose, and temperature

Correct answer: Pulse (rate and quality), skin (color, temperature, moisture), capillary refill, and major external hemorrhage control

The ITLS primary survey circulation assessment includes: pulse rate and quality, skin signs (color, temperature, moisture indicating perfusion), capillary refill time, and control of any major external hemorrhage found.

ITLS circulation assessment uses clinical findings that are immediately available without equipment: (1) Pulse: rate (tachycardia suggests compensation), quality (thready/weak suggests low stroke volume; bounding suggests adequate volume or early sepsis), regularity (irregular may indicate cardiac cause). Central vs. peripheral: presence of radial pulse roughly correlates with SBP >80 mmHg, femoral >70 mmHg, carotid >60 mmHg. (2) Skin: color (pale/mottled = vasoconstriction; cyanotic = hypoxia; flushed = vasodilation), temperature (cool = poor perfusion; warm = adequate or vasodilated), moisture (diaphoretic = sympathetic activation = shock). (3) Capillary refill: >2 seconds in adults suggests poor peripheral perfusion (less reliable in cold environments or elderly). (4) Hemorrhage control: address any major external bleeding found. These assessments take seconds and provide more real-time perfusion information than a blood pressure reading alone. Blood pressure, pulse oximetry, and ECG are secondary assessments performed after the hands-on primary survey.

Question 4: A multi-vehicle accident has 12 patients. As the first arriving unit, what ITLS triage system should you implement?

Treat the most severely injured first
Implement START triage to rapidly categorize patients into immediate, delayed, minor, and expectant/deceased categories (Correct answer)
Transport all patients simultaneously
Wait for additional resources before beginning any assessment

Correct answer: Implement START triage to rapidly categorize patients into immediate, delayed, minor, and expectant/deceased categories

START (Simple Triage and Rapid Treatment) is the standard mass casualty triage system used in ITLS, allowing rapid categorization of multiple patients based on ability to walk, respiratory status, perfusion, and mental status.

START triage enables rapid patient categorization when casualties exceed resources. The algorithm: (1) Direct all walking patients to a designated area—these are GREEN (minor). (2) For remaining patients, assess Respirations: if not breathing after opening airway → BLACK (deceased/expectant). If breathing >30/min → RED (immediate). If breathing <30/min → proceed to: (3) Perfusion: check radial pulse or capillary refill. If absent/delayed (>2 sec) → RED (immediate). Control major hemorrhage. If present → proceed to: (4) Mental status: 'Can you follow this command?' If unable to follow simple commands → RED (immediate). If able → YELLOW (delayed). Each assessment takes ~30 seconds. RED patients need immediate life-saving intervention and transport. YELLOW patients have serious injuries but can wait. GREEN patients are ambulatory with minor injuries. BLACK patients are dead or have injuries incompatible with survival given available resources. ITLS teaches that triage is fluid—patients are reassessed regularly, as GREEN patients can deteriorate to YELLOW or RED.

Question 5: What mnemonic does ITLS use for the detailed secondary survey assessment of each body region, and what does each letter stand for?

ABCDE - Airway, Breathing, Circulation, Disability, Exposure
DCAP-BTLS - Deformities, Contusions, Abrasions, Punctures/Penetrations, Burns, Tenderness, Lacerations, Swelling (Correct answer)
SAMPLE - Signs, Allergies, Medications, Past history, Last meal, Events
OPQRST - Onset, Provocation, Quality, Radiation, Severity, Time

Correct answer: DCAP-BTLS - Deformities, Contusions, Abrasions, Punctures/Penetrations, Burns, Tenderness, Lacerations, Swelling

DCAP-BTLS is the ITLS mnemonic used during the secondary survey to systematically assess each body region for: Deformities, Contusions, Abrasions, Punctures/Penetrations, Burns, Tenderness, Lacerations, and Swelling.

DCAP-BTLS provides a systematic framework for the hands-on physical examination during the ITLS secondary survey. Applied to each body region (head, neck, chest, abdomen, pelvis, extremities, back): Deformities—abnormal shape suggesting fracture, dislocation, or structural disruption. Contusions—bruising indicating subcutaneous bleeding from blunt force. Abrasions—superficial skin loss indicating mechanism direction and contact point. Punctures/Penetrations—violations of skin integrity suggesting deep tissue or cavity penetration. Burns—thermal, chemical, electrical, or radiation injury. Tenderness—pain on palpation suggesting underlying injury not visible externally. Lacerations—full-thickness skin tears requiring hemorrhage assessment and wound management. Swelling—tissue edema suggesting hemorrhage, fracture, or inflammatory response. By methodically checking each letter at each body region, the examiner avoids the common error of being distracted by one dramatic injury and missing others. DCAP-BTLS pairs with SAMPLE (patient history) and OPQRST (pain assessment) to create a comprehensive patient evaluation.

Question 6: How often should reassessments be performed on unstable and stable trauma patients during transport according to ITLS guidelines?

Every 30 minutes for all patients
Every 5 minutes for unstable patients and every 15 minutes for stable patients (Correct answer)
Only once during transport regardless of patient status
Continuously without pause for the entire transport

Correct answer: Every 5 minutes for unstable patients and every 15 minutes for stable patients

ITLS requires reassessment of vital signs, mental status, and primary survey findings every 5 minutes for unstable patients and every 15 minutes for stable patients to detect deterioration or improvement.

Serial reassessment is a cornerstone of ITLS patient management because trauma patients are dynamic—they can deteriorate (progressing shock, expanding intracranial hemorrhage) or improve (successful hemorrhage control, fluid resuscitation). The reassessment includes: mental status (GCS trending), vital signs (heart rate, blood pressure, respiratory rate, SpO2), primary survey findings (airway patency, breathing adequacy, circulation), any intervention effectiveness (splint neurovascular status, tourniquet efficacy, fluid response), and comparison to baseline. For unstable patients (altered mentation, abnormal vital signs, significant mechanism), every 5 minutes is required because deterioration can be rapid—a developing tension pneumothorax or expanding epidural hematoma can progress from compensated to critical in minutes. Stable patients are reassessed every 15 minutes to catch any change in status. Trending is key: a heart rate going from 88 to 96 to 108 over three assessments reveals developing tachycardia even though each individual reading appears near-normal.

ITLS Patient Assessment and Management 2

During scene size-up, you notice a car with severe intrusion into the driver's compartment and a spider-web pattern on the windshield.
The driver is ambulatory and denies injury.
How should this mechanism of injury influence your assessment?