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 don’t know – that’s good

4. Patient Assessment • Algorithm-floor plan • Emphasis on critical thinking • Flexibility is essential • Practice, Practice, Practice! Overdose Trauma Asthma Medical Respiratory

5. 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 Let’s Look at the Basics…..Medical and Trauma

6. 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?) Trauma or Medical? Medical Trauma

7. 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.

8. 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 And now……

9. 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.

10. 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…..

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

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

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

14. 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?

15. 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

16. 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?

17. 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

18. 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

19. 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!

20. 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

21. 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

22. 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 Considerations

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

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

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

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

27. Scene Size-Up • Time to arrive • Not time to touch a patient yet!

28. Scene Size-UpDetermine Mechanism of injury / Nature of Illness • Mechanism of Injury • Blunt Trauma • Penetrating Trauma • Nature of Illness

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

30. Scene Size-Up • Evaluate need for C-spine precautions

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

32. 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

33. Initial Assessment • Determine Chief Complaint (Term) • Determine Apparent Life Threats

34. 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

35. Initial Assessment Variation • Frequently seen as: • Airway • Breathing • Circulation • Disability • Expose

36. Initial Assessment • Make a decision • Stay & Play? • Load & Go?

37. 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

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

39. 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

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

41. 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?

42. 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?

43. 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?

44. 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?

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

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

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

48. The Medical Patient • Ongoing Assessment • Repeat Initial Assessment • Repeat Vital Signs • Repeat Focused Assessment • Re-check interventions

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

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