2. EMT 052 – Winter 2004 Assessment Review

3. 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?

4. 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

5. Patient Assessment  Algorithm-floor plan  Emphasis on critical thinking  Flexibility is essential  Practice, Practice, Practice!

6. 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

7. 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?)

8. 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.

9. 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

10. 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.

11. 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

12. Trauma – Significant MOI  Assess DECAP-BTLS  Head  Neck  Chest  Abdomen  Pelvis  Extremities  Posterior body

13. Trauma – Significant MOI  Assess baseline vital signs  Obtain SAMPLE history  Transport  Perform detailed exam – secondary survey  Perform on-going assessment

14. ABC’s Determine Priorities  Conscious or unconscious?  Altered LOC?  Airway open and secure?  Breathing present and adequate?  Pulse? Quality/rate? Adequate?  Shock?  Corrections required?

15. 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?

16. 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

17. 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?

18. 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

19. 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

20. 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!

21. 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

22. 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

23. 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?

24. Elderly Assessment  Live alone?  Incontinent?  Immobile?  Recently hospitalized?  Recently bereaved?  Altered mental status?  Hearing and/or vision issues?

25. Review of Assessments  Separated into several sub- assessments  Remember priorities  Differences between medical and trauma patients  Re-assess, Re-assess, Re- assess

26. Stop!  See you on Wednesday!

27. The Medical Patient  Left off with:  ABCD’s Were OK?  Transport decision  Stay & Play  Load & Go

28. Scene Size-up  Process begins when?  ASAP – Never too early  Starts with?  BSI – Enroute  Scene Safety  All available resources!!!

29. Scene Size-Up  Time to arrive  Not time to touch a patient yet!

30. Scene Size-Up Determine Mechanism of injury / Nature of Illness  Mechanism of Injury  Blunt Trauma  Penetrating Trauma  Nature of Illness

31. Scene Size-Up  Bunches of Patients?  Triage  Call for Police, Fire and EMS resources  Err on the side of the patient.

32. Scene Size-Up  Evaluate need for C-spine precautions

33. Scene Size-Up  How Will it Sound?  Paint a clear picture of what you:  See  Doing  Want

34. 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

35. Initial Assessment  Determine Chief Complaint (Term)  Determine Apparent Life Threats

36. 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

37. Initial Assessment Variation  Frequently seen as:  Airway  Breathing  Circulation  Disability  Expose

38. Initial Assessment  Make a decision  Stay & Play?  Load & Go?

39. 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

40. Patient Assessment Focused History & Physical Exam Trauma vs Medical

41. 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

42. The Medical Patient  Focused History (Key Terms)  OPQRST  Onset  Provokes  Quality  Radiation  Severity  Time

43. 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?

44. 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?

45. 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?

46. 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?

47. The Medical Patient  SAMPLE Hx  Symptoms/Signs  Allergies  Medications  Past Medical History  Last Oral Intake  Events Leading up to current situation

48. The Medical Patient  Focused Physical Exam  Examine logical areas (Examples)  Chest Pain with Trouble Breathing  Headache (Severe)  Abdominal Pain  Dizziness

49. The Medical Patient  Baseline Vital Signs  Might be repeat  Interventions  What to do?  Transport Decision  Re-evaluate  Detailed Physical Exam  En Route PRN

50. The Medical Patient  Ongoing Assessment  Repeat Initial Assessment  Repeat Vital Signs  Repeat Focused Assessment  Re-check interventions

51. Assessment of the Unconscious Medical Patient  Perform rapid medical assessment  Head  Neck  Chest  Abdomen  Pelvis  Extremities  Posterior

52. Medical Assessment, cont.  Baseline vital signs  Position patient  Perform sample history  Transport  Perform detailed physical exam

53. 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

54. Switch Gears Medical to Trauma

55. 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

56. The Trauma Patient  Focused History & Physical Exam  Rapid Trauma Assessment (RTA)  DCAPP-BTLS Deformities Contusions Abrasions Punctures / Penetrations Burns Tenderness Lacerations Swelling

57. The Trauma Patient  Rapid Trauma Assessment  Looking & Feeling for “DCAPP-BTLS”  Head  Neck C-collar  Chest  Abdomen  Pelvis  Extremities x 4  Back

58. The Trauma Patient  Rapid Trauma Assessment  Baseline Vital Signs  SAMPLE History

59. 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

60. Switch Gears Again A close up look at the detailed physical exam

61. The Detailed Physical Exam  HEENT & Face  Head  Eyes - pupils  Ears  Nose  Throat & Mouth  Face

62. The Detailed Physical Exam  Neck  DCAPP-BTLS  Subcutaneous Emphysema  Jugular Vein Distention  Tracheal Shift  Crepitus

63. The Detailed Physical Exam  Shoulders  DCAPP-BTLS  Stability  Chest  DCAPP-BTLS  Crepitus  Paradoxical Motion  Breath Sounds

64. The Detailed Physical Exam  Abdomen  DCAPP-BTLS  Firmness  Softness  Tenderness  Distension  Evisceration

65. The Detailed Physical Exam  Pelvis  DCAPP-BTLS  Pain  Tenderness  Instability  Crepitus  Priapism

66. The Detailed Physical Exam  Extremities  DCAPP-BTLS  Distal Circulation  Sensation  Movement  Back  Use proper roll  May have already done

67. 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

68. 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

69. 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