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Goal Directed Patient Assessment Dan Batsie dbatsie@apems.org Slide 2 How is an EMT different than a taxi driver? Slide 3 Slide 4 Goals of the EMT Go home Identify resuscitation Identify/intervene in immediate life threats Identify ongoing (subtle) life threats Symptom relief Customer service Slide 5 Slide 6 Slide 7 Slide 8 Dr Reuben Strayer Slide 9 Bottom Up Approach Slide 10 Final diagnosis Ancillary testing Differential diagnosis Diagnostic testing Comprehensive physical examination Comprehensive history Slide 11 S ymptoms A llergies M edications P ast medical history L ast meal E vents Slide 12 Slide 13 Slide 14 Whats wrong with the patient? What does the patient need? Slide 15 Slide 16 Slide 17 Slide 18 Slide 19 iv.Specific respiratory conditionsdefinition, 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 Slide 20 Asthma Pulmonary edema COPD Pneumonia Spontaneous pneumo. PE Epiglottitis Cystic fibrosis Pertussis Respiratory infections Toxins Slide 21 Although there are many pathologies to consider, the emergent needs of the patient are relatively few. Slide 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 Slide 23 Simple Dumb Slide 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 Slide 25 Slide 26 Primary Assessment 1.Airway 2.Breathing 3.Circulation 4.Disability Slide 27 Primary Assessment 4.Circulation 1.Airway 2.Breathing 3.Disability Slide 28 Primary Assessment Circulation Airway Breathing Disability Circulation Slide 29 Airway Breathing Circulation Disability Secondary Assess. History Phys. Exam Diagnostic tests Interventions Slide 30 What are the goals of our assessment? Primary Assessment Slide 31 Is it safe? Slide 32 Primary Assessment ID Resuscitation Prevent Hypoxia Prevent Hypoperfusion Goals Slide 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 Slide 34 Is it open? Is it open? Will it stay open? Will it stay open? Airway XABCD Slide 35 Prevent Hypoxia Slide 36 Initial Assessment Revisited Breathing Is it adequate? Slide 37 20 20 Slide 38 Breathing Adequacy Oxygenation Ventilation Slide 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 Slide 40 Are the perfusing? Slide 41 Prevent Hypoperfusion Slide 42 Do we need to leave right now? Slide 43 Airway Breathing Circulation Disability Expose Fit into CUPS Get Vitals History/Head to Toe Slide 44 Scene Survey Primary Assessment AABCD Secondary Assessment HHistory OPQRST, SAMPLE PPhysical Diagnostic testing Reassess Safety Resuscitation Correction of a primary assessment problem Identification of life threatening condition Symptom relief Customer service Slide 45 Secondary Assessment Not important if interventions are necessary or ongoing May not be an achievable goal. Slide 46 Assessment is more than just identifying interventions Slide 47 N Engl J Med, Vol. 345, No. 19 Slide 48 Every 10 minute increase in the time to reperfusion therapy increases mortality by 1% Slide 49 Missed AMI doubles mortality Slide 50 Eastern Maine Medical Center Average Door to Balloon Time 2011: Self transported - 70.56 min. EMS Transported with activation - 40.29 min. ED Bypass- 16 min. EMS transported without activation - 77.69 min. Slide 51 Slide 52 EMTs dont diagnose! Slide 53 Slide 54 Slide 55 Slide 56 Cardinal Presentations Slide 57 iv.Specific respiratory conditionsdefinition, 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 Slide 58 Slide 59 iv.Specific respiratory conditionsdefinition, 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 Slide 60 Slide 61 Asthma Pulmonary edema COPD Pneumonia Spontaneous pneumo. PE Epiglottitis Cystic fibrosis Pertussis Respiratory infections Toxins Slide 62 Ask questions to get answers Use history to make decisions One question leads to the next Questions are used to narrow your focus Slide 63 Dont ask a questions if you already know the answer. Slide 64 Slide 65 1 Question Slide 66 Are you sexually active? Slide 67 Is there a wheeze? Slide 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? Slide 69 Turn possibilities into probabilities Slide 70 Slide 71 General Impression Primary Assessment History Field Diagnosis History Physical Exam Better Diagnosis Slide 72 Slide 73 Slide 74 Assemble the Pattern Slide 75 Use physical exam and specific diagnostic testing to prove your conclusions Slide 76 Slide 77 Other Important and often forgotten goals Slide 78 Patient safety Slide 79 Symptom Relief Slide 80 Symptom relief? Can be done without diagnosis Not always an ALS procedure Slide 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. 13658-61 1987 Slide 82 Customer service Slide 83 Slide 84 Slide 85 Questions? Dan Batsie dbatsie@apems.org Slide 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 Slide 87 Slide 88 Slide 89 What are the goals of our assessment? Slide 90 Primary Assessment CPR Airway PPV Hemorrhage control Seal chest wounds Transport Airway Breathing Circulation Disability Slide 91 N Engl J Med 2004;351:647-56. Slide 92 Symptoms Allergies Medications Past medical history Last meal Events Whats wrong? (symptoms/events) Has this ever happened before? (PMHx) Allergies Medications Last meal Slide 93 Slide 94 Slide 95 Slide 96 Slide 97 Slide 98