EMT 052 Winter 2004

1
EMT 052 Winter 2004

• Assessment
• Review

2
Scene Size-Up

• Determine the of Patients
• Call for additional help if necessary
• Can my unit handle this scene?
• ALS/BLS
• Can my agency handle this scene?
• Should I initiate MCI Protocols?
• Is my crew responding ok to this call?
• Are bystanders going to be affected soon?
• Temperature?
• Water needs of crew members?

3
Patient Assessment Can be confusing duh

• Lots of information
• Lots of input from everyone?
• You NEED to practice!
• Learn the skill sheets!
• As you gain experience, develop your own
  assessment process
  
• Some of you are finding out how much you dont
  know thats good

4
Patient Assessment

• Algorithm-floor plan
• Emphasis on critical thinking
• Flexibility is essential
• Practice, Practice, Practice!

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Lets Look at the Basics..Medical and Trauma

• BSI
• Scene Safety
• MOI/NOI
• Number of patients
• Need for additional help ALS, other?
• C-spine PRN

• General impression
• LOC - AVPU
• C/C, life threat
• A B O2, tidal
• C blood? Pulse? Skin? Cap refill?
• ID transport priority

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Trauma or Medical?

• Medical S/S
• Respiratory
• Cardiac
• Altered mental status
• Allergic reaction
• Poisoning/OD
• Environmental
• OB
• Behavioral

• A - Allergies
• M - Medications
• P - Pertinent hx
• Last oral intake
• Events leading up to illness (trauma?)

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Complications

• Factors that can influence your findings
• Weather
• Scene not safe or not secure
• Lack of resources
• Your own stress or stress of emergency workers
• Multiple patients
• Components you are not prepared for
• Fire
• Hazmat
• Multiple patients
• Disruptive bystanders, family
• Kids, death, gross stuff, etc.
• Altered LOC injury, drugs, disease. Etc.

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And now

• Focused P.E.
• V.S.
• Interventions
• Transport necessary to reevaluate original
  decision?
  
• Consider completing detailed assessment

• On going assessment reevaluating the finding
  and interventions performed to this point
  
• Repeat focused assessment with C/C in mind

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On-Going Assessment

• Depending on patient condition
• Re-assess vital signs every 5 minutes for
  critical patients
  
• Primary survey with special attention to the
  airway and breathing as often as necessary to
  insure its patent and adequate.

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Trauma..

• Detailed Physical Exam
• Head
• Neck
• Chest
• Abdomen/Pelvis
• Extremities
• Posterior
• Manage secondary injuries
• Reassess VS and interventions

• Focused Physical exam and history/rapid trauma
  assessment
  
• Obtains Baseline VS
• SAMPLE Hx

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Trauma Significant MOI

• Assess DECAP-BTLS
• Head
• Neck
• Chest
• Abdomen
• Pelvis
• Extremities
• Posterior body

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Trauma Significant MOI

• Assess baseline vital signs
• Obtain SAMPLE history
• Transport
• Perform detailed exam secondary survey
• Perform on-going assessment

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ABCs Determine Priorities

• Conscious or unconscious?
• Altered LOC?
• Airway open and secure?
• Breathing present and adequate?
• Pulse? Quality/rate? Adequate?
• Shock?
• Corrections required?

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Priority Transport

• Poor general impression
• Unresponsive
• Difficulty breathing
• Shock/Hypoperfusion
• Complicated Childbirth
• Chest pain with BP
• Uncontrolled bleeding
• Severe Pain Anywhere
• Can you think of others?

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Dont forget

• All life threats must be discovered and treated
  as they are found
  
• Everything else, secondary
• Rapid transport and ALS intervention if required,
  must be initiated ASAP
  
• In the event of a difficult airway, you may never
  get passed the ABCs

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Some Things to Consider

• Get close to the patient
• Identify yourself avoid clichés
• Explain what you are doing
• SAMPLE/OPQRST
• Be suspicious poor historians
• What does your patient look like?

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SKIN

• Importance of examination of the skin
• Easily accessible
• Highly visible
• Easily palpable
• Will demonstrate many signs of illness/injury
• Expose it
• Utilize a good light source
• Racial/Ethnic limitations
• Alternatives Where do I look?
• Important factor is change

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SKIN

• Abnormal colors
• Dusky/gray/blue cyanosis
• Lips, nail beds, mucous membranes
• Cherry red
• Carbon monoxide
• Sallow (milk/yellow)
• Anemia or blood loss
• Yellow (Icteric)
• Jaundice - liver
• Often noticed first in sclera

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SKIN

• Pale (whitish)
• Vasoconstriction
• Sympathetic discharge
• Mottling patchy discoloration
• Serious vascular impairment
• Wide range of normal exists for temperature and
  moisture
  
• Repeat most important factor is change!

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SKIN

• Normal vs. Abnormal
• Everything normal? Keep looking!
• Warm/moist Febrile, heat injury
• Hot/moist High fever, heat injury
• Warm/dry febrile, dehydration
• Hot/dry Heat stroke
• Cool/dry Hypothermia
• Cool/cold/moist sympathetic discharge
• Texture Turgor/Edema/crepitus
• Lesions/Rashes/Wounds/Scars
• Tattoos/Nicotine/Jewelry

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Helpless?

• Pulse less/ apneic 7 year old boy
• Grandmas dying and half the family wants you to
  help, the other half is blocking the door to
  grandmas room
  
• You are not feeling well and you cant get a
  really sick patient to go to the hospital. The
  phone are not working and the HEAR system in your
  unit is malfunctioning
• You arrive on a burning house before the fire
  department and bystanders tell you that the
  family is unaccounted for. You have no protective
  clothing

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Elderly Assessment Considerations

• Bucket next to be
• Tripod position
• Hospital bed
• Nebulizer set-up
• Oxygen
• Medications
• Night clothing during the day

• Patient propped up on pillows
• Heat in rooms
• Cold in rooms
• Condition of home
• Weapons
• Mail unopened
• Other signals?

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Elderly Assessment

• Live alone?
• Incontinent?
• Immobile?
• Recently hospitalized?
• Recently bereaved?
• Altered mental status?
• Hearing and/or vision issues?

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Review of Assessments

• Separated into several sub-assessments
• Remember priorities
• Differences between medical and trauma patients
• Re-assess, Re-assess, Re-assess

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Stop!

• See you on Wednesday!

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The Medical Patient

• Left off with
• ABCDs Were OK?
• Transport decision
• Stay Play
• Load Go

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Scene Size-up

• Process begins when?
• ASAP Never too early
• Starts with?
• BSI Enroute
• Scene Safety
• All available resources!!!

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Scene Size-Up

• Time to arrive
• Not time to touch a patient yet!

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Scene Size-UpDetermine Mechanism of injury /
Nature of Illness

• Mechanism of Injury
• Blunt Trauma
• Penetrating Trauma
• Nature of Illness

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Scene Size-Up

• Bunches of Patients?
• Triage
• Call for Police, Fire and EMS resources
• Err on the side of the patient.

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Scene Size-Up

• Evaluate need for C-spine precautions

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Scene Size-Up

• How Will it Sound?
• Paint a clear picture of what you
• See
• Doing
• Want

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Initial Assessment

• General Impression
• Establishes relationship
• At a glance, What do you see???
• Determine Level of Consciousness/ Responsiveness
  AVPU
  
• Estimate patients age
• Patients gender

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Initial Assessment

• Determine Chief Complaint (Term)
• Determine Apparent Life Threats

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Initial Assessment

• Now for the ABCs (Expanded)
• Airway and Breathing
• Evaluate
• Find it and Fix it
• Assemble and Deliver Appropriate Oxygen
• Circulation
• Any Major Bleeding?
• Pulse
• Skin Condition

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Initial Assessment Variation

• Frequently seen as
• Airway
• Breathing
• Circulation
• Disability
• Expose

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Initial Assessment

• Make a decision
• Stay Play?
• Load Go?

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Initial Assessment

• What not to do
• Forget BSI
• Make sure the scene is safe
• Provide High Concentrations of Oxygen
• Evaluate A,B,Cs
• Make the wrong load decision
• Do secondary assessment before primary assessment

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Patient Assessment

• Focused History Physical Exam
• Trauma vs Medical

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Objectives

• Understand the components of
• Focused history
• Physical Exam
• Detailed Exam
• Ongoing Assessment
• Understand the appropriate times to complete a
  secondary assessment
  
• Understand the differences in secondary
  assessments of medical and trauma patients

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The Medical Patient

• Focused History (Key Terms)
• OPQRST
• Onset
• Provokes
• Quality
• Radiation
• Severity
• Time

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The Medical Patient

• Focused History
• Onset
• When did this problem start?
• What made you call today?
• What time did your symptoms begin?
• Provokes
• What makes the problem get worse?
• Anything make it feel better?

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The Medical Patient

• Focused History
• Quality
• What does it feel like?
• Can you describe to me what you are feeling?
• Document their words!!! (C/C)
• Region or Radiation
• Does this problem move anywhere?
• Where else do you feel this?

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The Medical Patient

• Focused History
• Severity
• Beware of Perception
• How bad does it feel?
• On a scale .?
• Compare this time to the last time that you had
  this problemBetter Or Worse?

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The Medical Patient

• Focused History
• Time Treatment
• What have you done for this condition so far? In
  the past?
  
• Beware of self-medicated patients
• Beware of home remedies
• What else could we do to make you feel more
  comfortable?
  
• How would you like to sit? Up or down?

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The Medical Patient

• SAMPLE Hx
• Symptoms/Signs
• Allergies
• Medications
• Past Medical History
• Last Oral Intake
• Events Leading up to current situation

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The Medical Patient

• Focused Physical Exam
• Examine logical areas (Examples)
• Chest Pain with Trouble Breathing
• Headache (Severe)
• Abdominal Pain
• Dizziness

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The Medical Patient

• Baseline Vital Signs
• Might be repeat
• Interventions
• What to do?
• Transport Decision
• Re-evaluate
• Detailed Physical Exam
• En Route PRN

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The Medical Patient

• Ongoing Assessment
• Repeat Initial Assessment
• Repeat Vital Signs
• Repeat Focused Assessment
• Re-check interventions

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Assessment of the Unconscious Medical Patient

• Perform rapid medical assessment
• Head
• Neck
• Chest
• Abdomen
• Pelvis
• Extremities
• Posterior

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Medical Assessment, cont.

• Baseline vital signs
• Position patient
• Perform sample history
• Transport
• Perform detailed physical exam

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Medical Assessment for the Responsive Patient

• Assess chief complaint - C/C, C/O
• OPQRST
• SAMPLE
• Perform focused medical assessment
• Obtain baseline vital signs
• Make transport decision
• Perform components of detailed physical exam
• Perform on going assessment

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Switch Gears

• Medical to Trauma

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The Trauma Patient - Initial Review

• Scene Size-up
• MOI
• What are the significant ones?
• Considered use of c-spine precautions
• Initial Assessment
• ABCDs OK?
• Make a transport decision

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The Trauma Patient

• Focused History Physical Exam
• Rapid Trauma Assessment (RTA)
• DCAPP-BTLS
• Deformities
• Contusions
• Abrasions
• Punctures / Penetrations
• Burns
• Tenderness
• Lacerations
• Swelling

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The Trauma Patient

• Rapid Trauma Assessment
• Looking Feeling for DCAPP-BTLS
• Head
• Neck
• C-collar
• Chest
• Abdomen
• Pelvis
• Extremities x 4
• Back

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The Trauma Patient

• Rapid Trauma Assessment
• Baseline Vital Signs
• SAMPLE History

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The Trauma Patient

• The Detailed Physical Exam
• The Sequence
• Always completed on a trauma patient en-route to
  the hospital unless there is a reason for
  prolonged scene time

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Switch Gears Again

• A close up look at the detailed physical exam

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The Detailed Physical Exam

• HEENT Face
• Head
• Eyes - pupils
• Ears
• Nose
• Throat Mouth
• Face

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The Detailed Physical Exam

• Neck
• DCAPP-BTLS
• Subcutaneous Emphysema
• Jugular Vein Distention
• Tracheal Shift
• Crepitus

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The Detailed Physical Exam

• Shoulders
• DCAPP-BTLS
• Stability
• Chest
• DCAPP-BTLS
• Crepitus
• Paradoxical Motion
• Breath Sounds

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The Detailed Physical Exam

• Abdomen
• DCAPP-BTLS
• Firmness
• Softness
• Tenderness
• Distension
• Evisceration

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The Detailed Physical Exam

• Pelvis
• DCAPP-BTLS
• Pain
• Tenderness
• Instability
• Crepitus
• Priapism

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The Detailed Physical Exam

• Extremities
• DCAPP-BTLS
• Distal Circulation
• Sensation
• Movement
• Back
• Use proper roll
• May have already done

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Back to the Trauma Patient

• Manage any minor injuries
• Ongoing Assessment
• Repeat initial assessments
• Repeat focused assessment
• Re-assess interventions
• Contact medical control (again)
• Repeat Vital Signs Q5 / Q15

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Focused History and Physical Exam Trauma Patient

• Reconsider MOI
• Patient with significant MOI
• Continue spinal immobilization
• Consider ALS request
• Reconsider transport
• Reassess mental status
• Perform rapid trauma assessment

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Patient without significant MOI

• Perform focused trauma assessment
• Obtain baseline vital signs
• Obtain SAMPLE history
• Perform components of detailed physical exam
• Transport
• Perform ongoing assessment