“it’s amazing what you can see when you look” yogi berra

“It’s amazing what you can see when you look”

Yogi Berra

Patient Assessment

not a basic skill

do not diagnose

the question is ...

Do I have a critical patient?

Patient Assessment

Scene size-up Initial assessment Focused history and physical exam

– Vital signs– History

Detailed physical exam Ongoing assessment

Scene Size Up

Body Substance Isolation/Standard Precautions Safety, Safety, Safety, Safety, ... Mechanism of injury

or Nature of illness # of patients Need for additional resources Need for extrication / spinal precautions

Body Substance Isolation

Assumes all body fluids present a possible risk for infection

Protective equipment– Latex or vinyl gloves should always be

worn– Eye protection– Mask – Gown – Turnout gear

Scene Safety

Look for danger Park in a safe area Speak with law enforcement first if present. The safety of you and your partner comes

first! Next is safety of patient(s) and bystanders. Request additional resources.

Mechanism of Injury

Force body was exposed to– Chief complaint

Evaluate:– Amount of force applied– Length of time it was applied– Area involved

Nature of Illness

Search for clues This is chief complaint Gather information from the

patient/bystanders Observe the scene.

Chief Complaint

Most serious problem voiced by the patient

May not be the most significant problem present

Number of Patients

# of patients and condition.

Additional resources needed?

Triage to identify severity of each patient’s condition.

Additional Resources

Medical resources– Additional units– Advanced life support

Nonmedical resources– Fire suppression– Rescue– Law enforcement

Spinal Immobilization

Consider early during assessment. Do not move without immobilization. Err on the side of caution.

Initial Assessment

Develop a general impression

Assess mental status Assess airway Assess the adequacy of

breathing Assess circulation Establish patient rapport Identify patient priority

Develop a General Impression

As you approach the scene

– Assessment of the environment

– Patient’s chief complaint

– Presenting signs and symptoms of patient

• No vitals yet, only skin signs/cap refill

Assessing Mental Status

Checking responsiveness

Check for orientation

Checking Responsiveness

A - Alert V - Verbal P - Pain U - Unresponsive

Checking Orientation

Person Place Time Event

Glasgow Coma ScaleMore advanced LOC indicator

EyeVerbalMotor

point scale 15 - 3

GCS

Eye Opening

spontaneous = 4

to voice = 3

to pain = 2

none = 1

GCS

VERBAL

Oriented = 5Confused = 4Inappropriate words = 3Incomprehensible sounds = 2None = 1

GCS

MOTORobeys command= 6localizes pain = 5withdraws (pain) = 4flexion (pain) = 3extension (pain) = 2none = 1

Assessing ABC’s We know how to assess the unresponsive More evaluation needed in responsive pt. Is patient speaking to you?

– A and B– Full sentences– 2 or 3 word

What are skin signs like? Cap refill?– C– Indicates perfusion

Establish Patient Rapport

People Skills Do what you can to make the patient comfortable Listen to the patient Make eye contact Base questions on the patient's complaint

– More to follow Mentally summarize before starting treatment Obtain consent

Decision point

Regardless if trauma or medical

Is patient critical?

Do they need rapid transport?

Identifying Priority Patients

Poor general impression

Unresponsive with no gag or cough reflexes

Responsive but unable to follow commands

Difficulty breathing Signs of poor

perfusion

Complicated childbirth

Uncontrolled bleeding

Severe pain Severe chest pain Inability to move any

part of the body

The Golden Hour

Medical vs. Trauma

Determination should come after initial assessment is finished.

Patients may have traumatic injuries caused by a medical reason.

Initially assume all patients have both medical and traumatic aspects to their condition.

Trauma Patients

With significant MOI Unresponsive or disoriented Extremely intoxicated Patients whose complaint cannot be

identified or understood• Proceed with rapid trauma assessment• Rapid transport• Consider ALS backup

Significant Mechanism of Injury

Ejection from vehicle Death in passenger compartment Fall greater than 15´-20´ Vehicle rollover High-speed collision Unresponsiveness or altered mental status Penetrating trauma to head, chest, or

abdomen

Auto vs auto

SAFETY observe/ask questions about mechanism Speed position of patient before accident

(driver, backseat, etc..) KO? restrained? airbag? Passenger space intrusion?

Auto vs pedestrian or bicycle/motorcycle

SAFTEY observe/ask questions about

mechanism helmet? KO? Injuries more likely to be severe

Rapid Physical Exam

60-90 seconds

head-to-toe exam– Significant trauma

patients– Unresponsive

medical patients

DCAP-BTLS

D Deformities

C Contusions

A Abrasions

P Punctures/ Penetrations

B Burns

T Tenderness

L Lacerations

S Swelling

Rapid Physical Exam (1 of 3)

Maintain spinal immobilization while checking patient’s ABCs.

Use DCAP BTLS Assess the head. Assess the neck. Apply a cervical spine

immobilization collar.

Rapid Physical Exam (2 of 3)

Assess the chest.

Assess the abdomen.

Assess the pelvis.

Assess all four extremities.

Rapid Physical Exam (3 of 3)

Roll the patient with spinal precautions.

Assess baseline vital signs and SAMPLE history.

Detailed Physical Exam

more in-depth only performed if time allows performed en route to the hospital have system - head to toe practice same way every time always check area before covering for our lab, rapid trauma assessment

and detailed physical exam are same (Head to Toe)

Focused History and Physical Exam (medical)

Medical history Baseline vital signs Physical exam

Focused History and Physical Exam (Trauma-no significant mechanism)

Assess the chief complaint.– Chest pain– Shortness of breath– Abdominal pain– Any pain associated with bones or

joints– Dizziness

Obtain baseline vital signs and SAMPLE history

SAMPLE SAMPLE History

S Signs and symptoms

A Allergies

M Medications

P Past medical history

L Last oral intake

E Events leading to the episode

Alternate

HAM– History– Allergies– Medications

Vital Signs

After rapid assessment, obtain baseline vital signs and a SAMPLE history.

Vital signs of stable patients should be reassessed every 15 minutes.

Vital signs of unstable patients should be reassessed every 5 minutes.

Focused Physical Exam

Investigate problems associated with chief complaint.

Examine abnormalities. Assess vital signs.

– Skins– Chest Auscultation

Make transportation decision. Document findings.

Assessing the Responsive Medical Patient

Ask general questions May not be obvious Use patient’s own words Multiple complaints?

Questions to ask: Chest pain

OPQRSTShortness of breath also?Medication?

OPQRST

O Onset P Provoking factors Q Quality of pain R Radiation / Region S Severity T Time / Treatment

Questions to ask: Shortness of breath

How long? Sudden or slow onset? Chest pain also? Chest auscultation

Questions to ask: Abdominal pain

OPQRST N/V Normal bowel movement & urination? GI bleed? FEMALES

– pregnant?– LMP, normal?

Assessing the Unresponsive Patient (Medical)

Perform a rapid medical assessment. Obtain baseline vital signs. Obtain SAMPLE history from family if

available. Provide emergency care and transport. Document findings.

Questions to ask: Altered level of consciousness

DERMAEIOU TIPSSudden or Slow?Ask bystanders

DERM

D - depth of consciousnessE - eyesR - respirations (abnormal patterns)M - motor function

AEIOU TIPS

A - alcohol, apnea, arrhythmia, anaphylaxis

E - epilepsy/environment I - insulin O - overdose U - uremia/underdose

AEIOU TIPS

T - trauma I - infectionP - psychogenicS - stroke

Questions to ask: Overdose - Poisonings

whathow long ago routeany other?

Questions to ask: Diabetes

Taken your medicine?Eaten normally?Slow or fast onset?

its a balance!

Questions to ask: Seizures

How long did it last?Fall?More than 1?How did it start

What is status epilepticus?

Questions to ask: Syncope

out how long? fall?chest pain? irregular heart beat?

Questions to ask: Shootings - a.k.a. GSW

SAFETY# shots heard type of gun (caliber)distanceother associated trauma?

Questions to ask: Stabbings - a.k.a. “cutting”

SAFETY type of knife? (size)associated trauma?

Questions to ask: Assaults

SAFETYhit with what?where?# of times?KO?

Questions to ask: Falls

trip & fall? or dizzy & fall?how far?how did they land?What did they land on?KO?

Ongoing Assessment

Is treatment improving the patient’s condition?

Has a problem gotten better? Worse?

Any newly identified problems?

Steps of the Ongoing Assessment

Repeat the initial assessment.

Reassess vital signs.

Repeat focused assessment.

Check interventions.

Documentation

Skin color, temperature, and moisture Initial assessment findings Baseline and subsequent vital signs

and SAMPLE history Circulation, sensation and movement in

all extremities Breath sounds

That’s all folks!!

questions?