DCAP-BTLS¶

Category: Concepts Sources: raw/supplemental/patient-assessment-sequence.md, raw/nremt/psychomotor-skills.md Last updated: 2026-04-05

Overview¶

DCAP-BTLS is an 8-letter mnemonic used during the physical examination component of trauma assessment. Each letter represents a specific type of finding you are looking for by inspection (looking) and palpation (feeling) at each body region. It is the systematic framework for the rapid trauma assessment in the secondary-assessment and is applied head-to-toe on all patients with significant mechanism of injury (MOI).

The mnemonic exists for one reason: under stress, providers miss injuries. DCAP-BTLS gives your hands and eyes a job description at each body region so nothing gets overlooked in 90 seconds of rapid assessment.

The Eight Components¶

D — Deformities¶

Any change in the normal shape or contour of a body part. Bones should be straight; joints should look symmetrical; the skull should be smooth.

What you're looking for: - Angulation of an extremity (fracture) - Asymmetry in the chest (flail segment, tension pneumothorax with mediastinal shift) - Skull depression or step-off (skull fracture) - Joint deformity (dislocation — hip, shoulder, knee) - Facial asymmetry (facial fractures, stroke — though stroke is a medical finding, not DCAP-BTLS)

Clinical significance: Deformity = mechanism of force transmission. A deformed femur means the leg absorbed significant energy — think hemorrhage (up to 1–1.5 L into a mid-shaft femur fracture), neurovascular injury distal to the fracture.

C — Contusions¶

Bruising from blunt force — subcutaneous hemorrhage causing discoloration. Contusions appear as blue, purple, or red discoloration from blood leaking into tissue.

What you're looking for: - Seatbelt sign: bruising across the lower abdomen or chest along the seatbelt path — associated with bowel injury, mesenteric tear, chance fracture of lumbar spine - Steering wheel imprint on chest — associated with rib fractures, pulmonary contusion, myocardial contusion, aortic injury - Raccoon eyes (periorbital ecchymosis) — basilar skull fracture; may not appear for hours - Battle's sign (mastoid ecchymosis, behind the ear) — basilar skull fracture; may not appear for hours - Flank bruising (Grey Turner sign) — retroperitoneal hemorrhage; also delayed

Clinical significance: Contusions visible at the scene are fresh. They represent the injury you can see. Deeper injuries (aortic tear, liver laceration) may have no visible surface finding yet — especially in the early minutes. A significant contusion tells you the force was there; it does not tell you the full damage.

A — Abrasions¶

Superficial wounds where the skin surface is scraped or worn away without full skin penetration. "Road rash."

What you're looking for: - Pattern abrasions from specific surfaces (gravel road, grass, pavement) indicating sliding/ejection - Airbag abrasions on the face, forearms, or hands — indicate airbag deployment and high-speed contact - Abrasions overlying joints or bony prominences — may indicate underlying fracture - Location helps reconstruct mechanism (abrasion on the occiput of a fall victim = fell backward)

Clinical significance: Abrasions themselves are minor wounds. Their value is in telling you where force was applied. An abrasion on the left temple of an unresponsive patient tells you where the head struck — which tells you the brain experienced a coup-contrecoup pattern.

P — Punctures / Penetrations¶

Any wound that penetrates the skin surface — stab wounds, gunshot wounds (entrance and exit), impaled objects, shrapnel.

What you're looking for: - Entry wounds (may be small, deceptively so for bullets and stab wounds) - Exit wounds (may be larger, irregular — especially for high-velocity rounds) - Impaled objects (do NOT remove; stabilize in place) - Multiple penetrations (blast injury may create many small wounds) - Sucking chest wounds (open chest wound that produces audible air movement with breathing)

Clinical significance: You cannot assess internal damage from a penetrating wound at the surface. A small entry wound can conceal transected aorta, liver laceration, pneumothorax, or bowel perforation. Location of the penetration determines the possible organs injured — any wound between the nipple line and the umbilicus should raise concern for both chest and abdominal injury (diaphragm moves with breathing; a low chest stab can penetrate abdominal organs and vice versa).

Sucking chest wound management: Apply 3-sided occlusive dressing (seal three sides; leave one open as flutter valve). See chest-trauma.

B — Burns¶

Thermal, chemical, electrical, or radiation burns. Burns are assessed here as part of the trauma physical exam — especially in structural fires, industrial accidents, explosions, or electrical contacts.

What you're looking for: - Depth (superficial/partial/full thickness) - Location (airway burns are immediate priorities) - TBSA estimate — see rule-of-nines - Singed nasal hair, soot in nares or mouth, hoarseness, stridor — inhalation injury - Circumferential burns on extremities (compartment syndrome risk)

Clinical significance: The presence of burns in a trauma patient often indicates a blast or fire mechanism that may have caused concurrent blunt and penetrating trauma. An explosion burns everything it touches — also creates blast wave injury (barotrauma to hollow organs, especially lungs and ears) and fragments as projectiles.

T — Tenderness¶

Pain on palpation. You cannot see tenderness — you assess it by pressing on each body region and asking "does this hurt?" or watching for the patient to react.

What you're looking for: - Point tenderness over the spine (cervical, thoracic, lumbar) — may indicate fracture; if present, immobilize - Rib tenderness on chest compression — rib fractures - Abdominal tenderness in specific quadrants — may indicate organ injury - Pelvic tenderness on gentle compression — pelvic fracture - Extremity tenderness proximal to a deformity or injury

Clinical significance: Tenderness over the spine is a spinal immobilization criterion in NM protocol. Abdominal tenderness, especially with guarding (patient tenses abdomen when you press), suggests peritoneal irritation — blood, bowel contents, or infection in the peritoneum. This is a priority transport finding.

Pelvic compression technique: Apply gentle inward compression to the iliac wings ONCE. If painful or unstable, stop — do not repeat pelvic compression (can worsen hemorrhage from pelvic ring fractures). A positive pelvic compression test with hypotension is a red flag for massive pelvic hemorrhage.

L — Lacerations¶

Full-thickness cuts through the skin. Lacerations are open wounds — skin integrity is broken and bleeding is present.

What you're looking for: - Depth: shallow (dermis only) vs. deep (fascia, muscle, visible bone, or joint space) - Length and width: larger lacerations may require suturing - Wound edges: jagged (blunt mechanism) vs. clean (sharp mechanism) - Active bleeding: is it controlled? Arterial (bright red, pulsatile) vs. venous (dark red, steady flow) - Scalp lacerations: scalp is highly vascular — even small scalp lacs bleed dramatically; significant blood loss possible - Skull visible in scalp lac: indicates fracture may be present; do not probe

Clinical significance: Lacerations tell you the exact point of surface contact with a force. A laceration with bone visible or joint space visible is an orthopedic emergency — joints must not be contaminated (infection risk). Control bleeding with direct pressure; do not explore the wound depth in the field.

S — Swelling¶

Edema, hematoma formation, or tissue swelling from fluid accumulation. Swelling appears as fullness, firmness, or asymmetry compared to the opposite side.

What you're looking for: - Periorbital swelling (lid swelling) — trauma, facial fracture - Extremity swelling around a joint or along a bone (fracture, sprain, hematoma) - Neck swelling (subcutaneous emphysema — feels like bubble wrap under skin — from tension pneumothorax or tracheal injury) - Abdominal distension (intra-abdominal hemorrhage — especially in splenic or liver rupture) - Ankle/foot swelling in lower extremity trauma (fracture, crush injury)

Subcutaneous emphysema is a specific swelling pattern — it feels like crackling (crepitus) under the skin, like rice krispies. This finding in the neck or chest wall indicates air is dissecting through tissue — usually from a pneumothorax or tracheobronchial injury. It is a critical finding.

How to Apply DCAP-BTLS¶

Rapid Trauma Assessment (Significant MOI)¶

Apply DCAP-BTLS at every body region in sequence. The full head-to-toe sequence should take under 90 seconds:

Region	What to Check
Head	Scalp lacerations, skull deformity, facial fractures, raccoon eyes, periorbital swelling
Neck	JVD, tracheal deviation, crepitus, swelling, tenderness, penetrating wounds
Chest	Symmetry, paradoxical movement, rib tenderness, breath sounds (bilateral), contusions, open wounds
Abdomen	Guarding, rigidity, tenderness (all 4 quadrants), distension, seatbelt sign
Pelvis	Gently compress iliac wings once; check for instability and tenderness
Lower extremities	Deformity, swelling, tenderness, pulse/motor/sensation (PMS) bilaterally
Upper extremities	Deformity, swelling, tenderness, PMS bilaterally
Posterior	Inspect back during log roll; look for spinal tenderness, posterior chest wounds, flank bruising

Focused Physical Exam (Medical Patient / Minor MOI)¶

DCAP-BTLS applies to the specific body region related to the chief complaint. For a patient with ankle pain after a twisted ankle, you apply DCAP-BTLS at the ankle and foot — not the entire body. The scope of the exam is determined by MOI and chief complaint.

Rapid Trauma vs. Focused Exam Decision¶

Situation	Exam Type
High-speed MVC, rollover, ejection	Rapid head-to-toe DCAP-BTLS
Fall >15 feet, penetrating torso trauma	Rapid head-to-toe DCAP-BTLS
Blast injury, significant MOI	Rapid head-to-toe DCAP-BTLS
Ankle sprain, isolated extremity injury, no significant MOI	Focused exam of affected region
Medical patient (chest pain, SOB, etc.)	Focused exam on relevant system
Pediatric patient with any significant MOI	Always rapid head-to-toe — children underreport injuries

Common Misses¶

Posterior assessment — Rolling the patient during the secondary assessment is easy to skip when you're busy. Battle's sign, posterior chest wounds, spinal tenderness, and flank bruising are all on the back. If you don't look, you miss them.
Seatbelt sign — Students see the bruising and note it. Few follow up by asking about abdominal tenderness and documenting the specific pattern. The seatbelt sign is a red flag for hollow organ injury — the bruise is secondary.
Subcutaneous emphysema — Crepitus on neck or chest wall is an emergency finding. First-timers mistake it for something benign. If you feel bubble wrap under the skin, call it out and act on it.
One pelvic compression — NM protocol and standard practice is to compress the pelvis ONCE. If there's no instability or pain on the first compression, document it and move on. Repeating it if it was positive can displace a pelvic ring fracture and worsen hemorrhage.
Not checking PMS before and after splinting — Pulse, Motor, Sensation must be documented before any splint is applied and after. Worsening PMS post-splint means the splint is too tight or there is vascular injury.
Finding DCAP-BTLS and not treating — DCAP-BTLS is a discovery tool. When you find a puncture in the chest, treat it (occlusive dressing). When you find deformity with swelling and tenderness, splint it. The mnemonic finds the problem; you still have to fix it.

NM Protocol Notes¶

NM EMS protocols require documentation of the secondary assessment using standard trauma exam terminology — DCAP-BTLS findings are part of the expected patient care report (PCR) documentation.
Spinal immobilization criteria: tenderness at any point along the spine during DCAP-BTLS palpation is one of the indications for spinal motion restriction (SMR) under NM protocols.
Pelvic ring fractures: if significant pelvic instability is found, contact Medical Control — pelvic binders may be authorized (ALS or per protocol).
All DCAP-BTLS findings should be trended in the reassessment — new or worsening swelling, expanding contusions, or changing tenderness patterns en route may indicate ongoing hemorrhage.

NREMT Relevance¶

High-yield exam and psychomotor skill topic:

Know all 8 letters and what each means — the cognitive exam may present a trauma scenario and ask which DCAP-BTLS finding is present
Know the head-to-toe sequence and what's assessed at each region
DCAP-BTLS is verbalized in the NREMT Trauma Patient Assessment/Management skill station — examiners expect you to verbalize it at each region
Common NREMT critical fail: skipping the posterior assessment (back and posterior head)
Know the difference between contusion (closed/bruise), abrasion (superficial scrape), laceration (open cut), and puncture (penetrating wound) — these are distinct terms
Know that DCAP-BTLS is applied differently in rapid trauma (all regions) vs. focused exam (chief complaint region)

secondary-assessment — DCAP-BTLS is the core framework of the rapid trauma assessment
primary-assessment — life threats found before secondary begins; DCAP-BTLS doesn't replace the primary
chest-trauma — chest DCAP-BTLS findings (paradoxical movement, open wound, absent breath sounds)
head-injury-tbi — head DCAP-BTLS (Battle's sign, raccoon eyes, skull deformity)
rule-of-nines — burn assessment within the DCAP-BTLS B component
spinal-injury — spinal tenderness on DCAP-BTLS drives immobilization decision

Sources¶

raw/supplemental/patient-assessment-sequence.md — Section 4: Secondary Assessment
raw/nremt/psychomotor-skills.md — Patient Assessment/Management (Trauma)