EMT 052 – Winter 2004 Assessment Review
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?
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 don’t know – that’s good
Patient Assessment Algorithm-floor plan Emphasis on critical thinking Flexibility is essential Practice, Practice, Practice!
Let’s 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
Trauma or Medical? Medical – S/S Respiratory Cardiac Altered mental status Allergic reaction Poisoning/O D Environment al OB Behavioral A - Allergies M - Medications P - Pertinent hx Last oral intake Events leading up to illness (trauma?)
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.
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
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 it’s patent and adequate.
Trauma….. Focused Physical exam and history/rapid trauma assessment Obtains Baseline VS SAMPLE Hx Detailed Physical Exam Head Neck Chest Abdomen/Pelvis Extremities Posterior Manage secondary injuries Reassess VS and interventions
Trauma – Significant MOI Assess DECAP-BTLS Head Neck Chest Abdomen Pelvis Extremities Posterior body
Trauma – Significant MOI Assess baseline vital signs Obtain SAMPLE history Transport Perform detailed exam – secondary survey Perform on-going assessment
ABC’s Determine Priorities Conscious or unconscious? Altered LOC? Airway open and secure? Breathing present and adequate? Pulse? Quality/rate? Adequate? Shock? Corrections required?
Priority Transport Poor general impression Unresponsive Difficulty breathing Shock/Hypoperfusion Complicated Childbirth Chest pain with BP<100 Systolic Uncontrolled bleeding Severe Pain Anywhere Can you think of others?
Don’t 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
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?
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
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
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!
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
Helpless? Pulse less/ apneic 7 year old boy Grandma’s dying and half the family wants you to help, the other half is blocking the door to grandma’s room You are not feeling well and you can’t 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
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?
Elderly Assessment Live alone? Incontinent? Immobile? Recently hospitalized? Recently bereaved? Altered mental status? Hearing and/or vision issues?
Review of Assessments Separated into several sub- assessments Remember priorities Differences between medical and trauma patients Re-assess, Re-assess, Re- assess
Stop! See you on Wednesday!
The Medical Patient Left off with: ABCD’s Were OK? Transport decision Stay & Play Load & Go
Scene Size-up Process begins when? ASAP – Never too early Starts with? BSI – Enroute Scene Safety All available resources!!!
Scene Size-Up Time to arrive Not time to touch a patient yet!
Scene Size-Up Determine Mechanism of injury / Nature of Illness Mechanism of Injury Blunt Trauma Penetrating Trauma Nature of Illness
Scene Size-Up Bunches of Patients? Triage Call for Police, Fire and EMS resources Err on the side of the patient.
Scene Size-Up Evaluate need for C-spine precautions
Scene Size-Up How Will it Sound? Paint a clear picture of what you: See Doing Want
Initial Assessment General Impression Establishes relationship At a glance, What do you see??? Determine Level of Consciousness/ Responsiveness – AVPU Estimate patient’s age Patient’s gender
Initial Assessment Determine Chief Complaint (Term) Determine Apparent Life Threats
Initial Assessment Now for the ABC’s (Expanded) Airway and Breathing Evaluate* Find it and Fix it Assemble and Deliver Appropriate Oxygen Circulation Any Major Bleeding? Pulse* Skin Condition
Initial Assessment Variation Frequently seen as: Airway Breathing Circulation Disability Expose
Initial Assessment Make a decision Stay & Play? Load & Go?
Initial Assessment What not to do: Forget BSI Make sure the scene is safe Provide High Concentrations of Oxygen Evaluate A,B,C’s Make the wrong load decision Do secondary assessment before primary assessment
Patient Assessment Focused History & Physical Exam Trauma vs Medical
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
The Medical Patient Focused History (Key Terms) OPQRST Onset Provokes Quality Radiation Severity Time
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?
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?
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 problem…Better Or Worse?
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?
The Medical Patient SAMPLE Hx Symptoms/Signs Allergies Medications Past Medical History Last Oral Intake Events Leading up to current situation
The Medical Patient Focused Physical Exam Examine logical areas (Examples) Chest Pain with Trouble Breathing Headache (Severe) Abdominal Pain Dizziness
The Medical Patient Baseline Vital Signs Might be repeat Interventions What to do? Transport Decision Re-evaluate Detailed Physical Exam En Route PRN
The Medical Patient Ongoing Assessment Repeat Initial Assessment Repeat Vital Signs Repeat Focused Assessment Re-check interventions
Assessment of the Unconscious Medical Patient Perform rapid medical assessment Head Neck Chest Abdomen Pelvis Extremities Posterior
Medical Assessment, cont. Baseline vital signs Position patient Perform sample history Transport Perform detailed physical exam
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
Switch Gears Medical to Trauma
The Trauma Patient - Initial Review Scene Size-up MOI What are the significant ones? Considered use of c-spine precautions Initial Assessment ABCD’s OK? Make a transport decision
The Trauma Patient Focused History & Physical Exam Rapid Trauma Assessment (RTA) DCAPP-BTLS Deformities Contusions Abrasions Punctures / Penetrations Burns Tenderness Lacerations Swelling
The Trauma Patient Rapid Trauma Assessment Looking & Feeling for “DCAPP-BTLS” Head Neck C-collar Chest Abdomen Pelvis Extremities x 4 Back
The Trauma Patient Rapid Trauma Assessment Baseline Vital Signs SAMPLE History
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
Switch Gears Again A close up look at the detailed physical exam
The Detailed Physical Exam HEENT & Face Head Eyes - pupils Ears Nose Throat & Mouth Face
The Detailed Physical Exam Neck DCAPP-BTLS Subcutaneous Emphysema Jugular Vein Distention Tracheal Shift Crepitus
The Detailed Physical Exam Shoulders DCAPP-BTLS Stability Chest DCAPP-BTLS Crepitus Paradoxical Motion Breath Sounds
The Detailed Physical Exam Abdomen DCAPP-BTLS Firmness Softness Tenderness Distension Evisceration
The Detailed Physical Exam Pelvis DCAPP-BTLS Pain Tenderness Instability Crepitus Priapism
The Detailed Physical Exam Extremities DCAPP-BTLS Distal Circulation Sensation Movement Back Use proper roll May have already done
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
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
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