DCAP-BTLS: The Trauma Assessment Mnemonic, Explained
What DCAP-BTLS stands for, where it fits in the rapid and secondary trauma assessment, how to use it head to toe with TIC, and the findings it is most often used to miss.
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DCAP-BTLS is the mnemonic for what you look and feel for during a hands-on trauma assessment. It stands for Deformities, Contusions, Abrasions, Punctures or penetrations, Burns, Tenderness, Lacerations and Swelling. You apply it to each body region in turn, usually head to toe, so that every area is checked for the same eight findings.
The eight letters
| Letter | Finding | What you are looking for |
|---|---|---|
| D | Deformities | Anything out of its normal shape: angulation, depression, asymmetry |
| C | Contusions | Bruising, which may be early and faint |
| A | Abrasions | Scrapes, often a clue to the direction of force |
| P | Punctures or penetrations | Holes, including small ones, and impaled objects |
| B | Burns | Thermal, chemical or electrical, including entry and exit wounds |
| T | Tenderness | Pain when you palpate, which only a responsive patient can report |
| L | Lacerations | Cuts, and how deep and how much they bleed |
| S | Swelling | Edema or a hematoma developing under the skin |
Some programs add a second P for paradoxical motion, the chest wall segment that moves the wrong way with breathing, and write the mnemonic DCAPP-BTLS. Check for it at the chest whichever version you learned, because it is a finding you need either way.
Where DCAP-BTLS fits in the assessment
DCAP-BTLS is not the first thing you do. Scene size-up and the primary survey come first: scene safety and the mechanism during the size-up, then a general impression, catastrophic bleeding, airway, breathing and circulation. Life threats are managed as you find them. DCAP-BTLS belongs to the secondary assessment, the term the National EMS Education Standards use, which older textbooks split into a rapid trauma assessment, a focused assessment and a detailed assessment. In practice the secondary assessment runs at different speeds:
- A quick head-to-toe sweep on a patient with a significant mechanism or an altered mental status, looking for anything else that is life threatening before you package and move.
- A focused exam on a patient with an isolated injury and no significant mechanism, applied to the injured area and the areas around it.
- A slower, complete head-to-toe exam, often done en route when time allows.
The same eight letters work at all three speeds. What changes is how long you spend on each region.
TIC: three more findings for bones and joints
Many programs add TIC when assessing the extremities, the pelvis and anywhere a fracture is possible: Tenderness, Instability and Crepitus. Tenderness overlaps the T in DCAP-BTLS. Instability is abnormal movement where there should be none. Crepitus is the grating sensation of bone ends moving against each other.
Head to toe with DCAP-BTLS
Apply the eight findings to each region, and add the region-specific checks that DCAP-BTLS does not cover:
| Region | Beyond DCAP-BTLS |
|---|---|
| Head and face | Fluid from the ears or nose, bruising behind the ears or around the eyes, pupils, the airway |
| Neck | Tracheal position, jugular vein distention, the cervical spine, before a collar is applied if one will be |
| Chest | Equal rise, paradoxical motion, breath sounds on both sides, open wounds |
| Abdomen | Rigidity, distention, guarding |
| Pelvis | Stability, assessed once and gently according to your protocol, never rocked repeatedly |
| Extremities | Distal pulse, motor function and sensation in each limb, plus TIC |
| Back | Checked when the patient is rolled, so it is not missed altogether |
Expose to assess. Clothing hides injuries, and an injury you did not see is an injury you did not assess. Protect the patient's privacy and body temperature as you go, and cover each area again once it is checked.
Burns, punctures and the findings that hide
Two letters deserve extra attention because they are easy to miss. Small punctures can look trivial and sit over serious internal injuries, especially in the chest and abdomen. Electrical burns often show small contact points where the current entered and left the body, and there may be more than one, so look for all of them. Any object impaled in the patient is stabilized in place, not removed, unless your protocol makes a specific exception.
Estimate burn surface area once you have found the burns
Tenderness needs a patient who can tell you
Tenderness, and much of TIC, depends on the patient reporting pain. An unresponsive patient, an intoxicated one or one distracted by a more painful injury cannot reliably do that, so an absence of tenderness tells you less than it seems to. Record the patient's mental status alongside your findings so the next clinician knows how much weight to give them.
Score and record the patient's level of consciousness
Common mistakes
- Starting DCAP-BTLS before the scene size-up and primary survey are complete.
- Assessing through clothing.
- Forgetting the back.
- Reciting the letters aloud without actually looking and feeling, which is common in skills testing and is not an assessment.
- Missing distal pulse, motor and sensation in the extremities, which DCAP-BTLS does not prompt for.
- Treating no tenderness as reassurance in a patient who cannot reliably report pain.
The short version
- Deformities, Contusions, Abrasions, Punctures or penetrations, Burns, Tenderness, Lacerations, Swelling.
- Use it region by region in the secondary assessment, after the scene size-up and primary survey.
- Add TIC for bones and joints: tenderness, instability, crepitus. Never try to produce crepitus.
- Add the region-specific checks: breath sounds, tracheal position, pelvis once, distal pulse, motor and sensation.
- Expose to assess, then cover again.
- Stabilize an impaled object; do not remove it.