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Goal Directed Patient Assessment Dan Batsie

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Presentation on theme: "Goal Directed Patient Assessment Dan Batsie"— Presentation transcript:

1 Goal Directed Patient Assessment Dan Batsie

2 How is an EMT different than a taxi driver?

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4 Goals of the EMT Go home Identify resuscitation Identify/intervene in immediate life threats Identify ongoing (subtle) life threats Symptom relief Customer service

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8 Dr Reuben Strayer

9 Bottom Up Approach

10 Final diagnosis Ancillary testing Differential diagnosis Diagnostic testing Comprehensive physical examination Comprehensive history

11 S ymptoms A llergies M edications P ast medical history L ast meal E vents

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14 What’s wrong with the patient? What does the patient need?

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19 iv.Specific respiratory conditions—definition, causes, assessment findings and symptoms, complications, and specific prehospital management and transport decisions A. Asthma B. Pulmonary Edema C. Chronic Obstructive Pulmonary Disease D. Pneumonia E. Spontaneous Pneumothorax F. Pulmonary Embolism G. Epiglottis H. Pertussis I. Cystic Fibrosis J. Environmental/Industrial Exposure/ Toxic Gasses K. Viral Respiratory Infections

20 Asthma Pulmonary edema COPD Pneumonia Spontaneous pneumo. PE Epiglottitis Cystic fibrosis Pertussis Respiratory infections Toxins

21 Although there are many pathologies to consider, the emergent needs of the patient are relatively few.

22 Interventions 1.Restraints 2.CPR 3.Defibrillation 4.Hemorrhage control 5.Foreign body airway/suction 6.NPA/OPA 7.BIAD 8.PPV 9.CPAP 10.Supplemental O2 11.Splinting/immobilization 12.Cool/warm 13.Childbirth 14.Transport 15.Request ALS 16.PASG 17.Wound care/bandaging Medications 1.O2 2.Epi auto-injector 3.Albuterol 4.Charcoal 5.Aspirin 6.Nitronox 7.Glucose 8.NTG

23 Simple ≠ Dumb

24 Top Down Approach (What does the patient need?) Safety Identify the need for resuscitation/correction of a primary assessment problem Identify the need for other immediate action Identify life threatening conditions Symptom relief Customer service

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26 Primary Assessment 1.Airway 2.Breathing 3.Circulation 4.Disability

27 Primary Assessment 4.Circulation 1.Airway 2.Breathing 3.Disability

28 Primary Assessment Circulation Airway Breathing Disability Circulation

29 Airway Breathing Circulation Disability Secondary Assess. History Phys. Exam Diagnostic tests Interventions

30 What are the goals of our assessment? Primary Assessment

31 Is it safe?

32 Primary Assessment ID Resuscitation Prevent Hypoxia Prevent Hypoperfusion Goals

33 E X sanguinating hemorrhage A irway B reathing C irculation D isability M assive hemorrhage A irway R espiration C irculation H ypothermia/Head injury

34 Is it open? Is it open? Will it stay open? Will it stay open? Airway XABCD

35 Prevent Hypoxia

36 Initial Assessment Revisited Breathing Is it adequate?

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38 Breathing Adequacy Oxygenation Ventilation

39 Identify Respiratory Failure Bad signs Hypoxia despite O2 Hypercapnia Poor tidal volume Anxiety/Combativeness Super bad signs Tiring Rate changes Respiratory pattern changes Lethargy, somnolence Silent chest

40 Are the perfusing?

41 Prevent Hypoperfusion

42 Do we need to leave right now?

43 Airway Breathing Circulation Disability Expose Fit into CUPS Get Vitals History/Head to Toe

44 Scene Survey Primary Assessment –A–ABCD Secondary Assessment –H–History OPQRST, SAMPLE –P–Physical Diagnostic testing Reassess Safety Resuscitation Correction of a primary assessment problem Identification of life threatening condition Symptom relief Customer service

45 Secondary Assessment Not important if interventions are necessary or ongoing May not be an achievable goal.

46 Assessment is more than just identifying interventions

47 N Engl J Med, Vol. 345, No. 19

48 Every 10 minute increase in the time to reperfusion therapy increases mortality by 1%

49 Missed AMI doubles mortality

50 Eastern Maine Medical Center Average Door to Balloon Time 2011: Self transported min. EMS Transported with activation min. ED Bypass- 16 min. EMS transported without activation min.

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52 EMT’s don’t diagnose!

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56 Cardinal Presentations

57 iv.Specific respiratory conditions—definition, causes, assessment findings and symptoms, complications, and specific prehospital management and transport decisions A. Asthma B. Pulmonary Edema C. Chronic Obstructive Pulmonary Disease D. Pneumonia E. Spontaneous Pneumothorax F. Pulmonary Embolism G. Epiglottis H. Pertussis I. Cystic Fibrosis J. Environmental/Industrial Exposure/ Toxic Gasses K. Viral Respiratory Infections

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59 iv.Specific respiratory conditions—definition, causes, assessment findings and symptoms, complications, and specific prehospital management and transport decisions A. Asthma B. Pulmonary Edema C. Chronic Obstructive Pulmonary Disease D. Pneumonia E. Spontaneous Pneumothorax F. Pulmonary Embolism G. Epiglottis H. Pertussis I. Cystic Fibrosis J. Environmental/Industrial Exposure/ Toxic Gasses K. Viral Respiratory Infections

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61 Asthma Pulmonary edema COPD Pneumonia Spontaneous pneumo. PE Epiglottitis Cystic fibrosis Pertussis Respiratory infections Toxins

62 Ask questions to get answers Use history to make decisions One question leads to the next Questions are used to narrow your focus

63 Don’t ask a questions if you already know the answer.

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65 1 Question

66 Are you sexually active?

67 Is there a wheeze?

68 How long has this been going on? Do you still have your appendix? Did you just eat a greasy meal? Any hives? Do you have CHF? Have you had a fever? When did this start? Ripping or tearing pain? Have you ever had kidney stones? Do you feel the urge to push? Are you able to speak? Do you still have your appendix? How far did you fall? How fast were you going? How big was the knife? Have you ever had a seizure before? Is anyone else sick in the house? Do you have asthma? Are you a smoker? Do you have any pain? Have you urinated/moved your bowels recently? Were you trying to hurt yourself? Are you allergic to… What exactly did you take and how much? When was the last time you were normal? Are you a diabetic? Do you take an ED medication? Has this ever happened before? Are you sexually active? Any recent injuries/illness? Do you have a history of alcohol abuse? Can you describe the pain? Have you been coughing?

69 Turn possibilities into probabilities

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71 General Impression Primary Assessment History Field Diagnosis History Physical Exam Better Diagnosis

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74 Assemble the Pattern

75 Use physical exam and specific diagnostic testing to prove your conclusions

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77 Other Important and often forgotten goals

78 Patient safety

79 Symptom Relief

80 Symptom relief? Can be done without diagnosis Not always an ALS procedure

81 Cool Air and Dypsnea Stimulation of mechanoreceptors mediated through the trigeminal nerve on the face may alter afferent feedback and modify the perception of dyspnea. Shown to reduce dyspnea in normal volunteers in response to hypercapnia and inspiratory resistive loads Schwartzstein, R. et al. Cold facial stimulation reduces breathlessness induced in normal subjects. Am. Rev. Respir. Dir

82 Customer service

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85 Questions? Dan Batsie

86 Scene Survey Primary Assessment – ABCD Secondary Assessment – History OPQRST, SAMPLE – Physical Diagnostic testing Reassess Safety Resuscitation Correction of a primary assessment problem Other immediate action Identification of life threatening condition Symptom relief Customer service

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89 What are the goals of our assessment?

90 Primary Assessment CPR Airway PPV Hemorrhage control Seal chest wounds Transport Airway Breathing Circulation Disability

91 N Engl J Med 2004;351:

92 Symptoms Allergies Medications Past medical history Last meal Events What’s wrong? (symptoms/events) Has this ever happened before? (PMHx) Allergies Medications Last meal

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