130 page Physical Exam EMS EMT PATIENT ASSESSMENT Medical Presentation on CD

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Contains the following key public domain (not copyrighted) U.S. Government publication(s) on one CD-ROM in both Microsoft PowerPoint and Adobe Acrobat PDF file formats: TITLE: Patient Assessment (EMT-B), 130 pages SLIDE TOPICS, SUBTOPICS and CONTENTS: Patient Assessment (EMT-B) Terminal Learning Objective Given a (simulated) patient with a medical condition or traumatic injury in a pre-hospital environment, perform an initial patient assessment and discuss the decision making process based on your assessment findings IAW Chapter 8, Emergency Care and Transportation of the Sick and Injured, 9th Edition, American Academy of Orthopedic Surgeons (AAOS). Enabling Learning Objectives Given a (simulated) patient with a medical condition or traumatic injury in a pre-hospital environment, describe the appropriate initial patient assessment principles and techniques for the specific illness or injury IAW Emergency Care and Transportation of the Sick and Injured, 9th Edition, American Academy of Orthopedic Surgeons (AAOS). Enabling Learning Objectives Given a (simulated) patient with a medical condition or traumatic injury in a pre-hospital environment, demonstrate the appropriate techniques and procedures for conducting an initial patient assessment, a focused-history and physical examination for medical and trauma patients and a detailed and ongoing assessment IAW Emergency Care and Transportation of the Sick and Injured, 9th Edition, American Academy of Orthopedic Surgeons (AAOS). Patient Assessment Process Patient Assessment Process Scene size-up Initial assessment Spinal immobilization Identify and treat life threats Focused history and physical exam Transport if needed Detailed physical exam Reassess vital signs Ongoing assessments Patient Assessment Process Scene Size Up Scene safety - quick assessment: Personal safety, including BSI Patient safety Bystander safety Scene Size Up Mechanism of injury? Nature of Illness/chief complaint? Number of patients? Additional resources needed? Consider stabilization of spine. 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 Gowns Body Substance Isolation Scene Safety Oncoming traffic Unstable surfaces Leaking gasoline Downed electrical lines Potential for violence Fire or smoke Hazardous materials Other dangers at crash or rescue scenes Crime scenes Scene Safety Park in safe areas. If present, talk with law enforcement. Follow protocols at a crime scene. The safety of you and your partner comes first! Request additional resources? Helps determine the possible extent of injuries on trauma patients. Evaluate: Amount of force applied to body Length of time force was applied Area of the body involved Trauma Blunt trauma Force occurred over broad area. Skin is not broken, however, the tissue and organs below the area of impact might be damaged. Trauma Penetrating trauma Force occurs in a small point of contact between the skin and an object. The skin is pierced. The severity of injury depends on the characteristics of the penetrating object, the amount of force or energy and the part of the body effected. Nature of Illness Search for clues to determine the nature of illness. Often described by the patient’s “chief complaint.” Gather information from the patient, family, or bystanders at the scene. Observe the scene. Considering the MOI or NOI early will help you prepare for the rest of your assessment. Number of Patients Accurately identify the total number of patients. Determine what additional resources will be needed. Triage to identify severity of each patient’s condition. Patients needs are greater than the available resources, activate MASCAL plan. Additional Resources Fire. Rescue. Haz-Mat. Utility Company. Additional Units. Consider Spinal Stabilization Patient Assessment Process Initial Assessment Components: Form a general impression Obtain c-spine control Assess mental status Assess airway Assess the adequacy of breathing Assess circulation Identify patient priority Initial Assessment Form a general impression: Occurs as you approach the scene and the patient. Includes a persons age, gender, race, level of stress and overall appearance. A visual assessment, gathering information as you approach the patient. Approach patient from the front. Place yourself at a lower position if possible. Initial Assessment Introduce yourself and ask permission to treat. Tell them who you are and what you are doing. Use patients name frequently. Obtain consent to care for the patient. Conscious patient, formally ask. Unconscious patient, implied. Initial Assessment Determine Chief Complaint. Ask the patient if conscious. Signs and Symptoms. Reference point to begin assessment. Determination should come after assessment has been completed. Patients may have traumatic injuries caused by a medical reason. Initially assume all patients have both medical and traumatic aspects to their condition Assessing Mental Status Mental status reflects the functioning of the brain. Checking responsiveness: Assess how well the patient responds to external stimuli Use the “AVPU” scale Evaluate Responsiveness A: Alert V: Responsive to Verbal stimulus P: Responsive to Pain U: Unresponsive Assessing Mental Status Check for orientation: Check the patient’s memory to person, place, time, and event. If they recall all four, they are “fully alert and oriented x four” Evaluate Responsiveness Assessing the Airway Airway compromise: Be alert for signs of respiratory compromise May cause permanent damage to the brain, heart, lungs, or death Assessing the Airway Responsive patients: Patients of any age who are talking/crying have an open airway Listen to how the patient speaks If an airway problem is identified* Airway and breathing problems not the same but their signs and symptoms may overlap * Stop the assessment and open the airway Assessing the Airway Unresponsive patients: Immediately assess the airway. If clear, continue assessment. If not clear: Open airway using head tilt-chin lift or jaw-thrust maneuver. Airway most commonly obstructed by the tongue. Assessing the Airway Unresponsive patients: Signs of obstruction: Obvious trauma, blood or other obstruction Noisy breathing such as bubbling, gurgling, crowing, or other abnormal sounds Extremely shallow or absent breathing Assessing the Airway Spinal Considerations Trauma patients conscious or unconscious protect their spine. Consider spinal precautions during scene size up. If uncertain assume the worst Medical patient with no spinal injury needs to be place in a recovery position or side lying position to protect the airway. Assessing the Breathing Normal respirations are not unusually shallow or excessively deep. Rate varies from 12-20 breaths/min. Identify and treat airway, breathing, and circulation problems as soon as possible. Assessing the Breathing Look for signs of airway compromise: Retractions Use of accessory muscles Nasal flaring and see saw breathing in pediatric patients Two-to-three word dyspnea Accessory muscle use: Assessing the Breathing Does the patient appear to be choking? Is the respiratory rate to fast or to slow? Are the patient’s respirations shallow or deep? Is the patient cyanotic? Do you hear abnormal sounds when listening to the lungs? Is the patient moving air into and out of the lungs on both sides? Assessing the Breathing Unresponsive patient: If breathing is adequate, maintain airway, use airway adjuncts and provide O² If breathing is inadequate, maintain airway, use adjuncts and provide ventilations Assessing the Circulation Assess the pulse: Rate, rhythm and strength. Radial or Carotid arteries in adults/children; brachial in infants. No pulse in unresponsive patient begin CPR. Assessing the Circulation Assess and control external bleeding: Identify any major bleeding Signs of blood loss BSI Direct pressure / elevate Pressure points Assessing the Circulation CCT: Evaluate skin color: Cyanotic, flushed, pale or jaundiced Evaluate skin condition: Dry or moist? Evaluate skin temperature: Your skin is an organ Evaluate capillary refill: Should be less than two seconds Assessing the Circulation Conditions and factors affecting capillary refill: Patient’s age and gender Cold exposure Frozen tissues Circulatory compromise Restoring Circulation Control bleeding and improve oxygen delivery. If unresponsive and pulseless, begin CPR. Apply and operate the AED as quickly as possible. Do not use AED on patients with a catastrophic traumatic injury. Identifying Priority Patients Difficulty breathing Poor general impression Unresponsive with no gag or cough reflexes Severe chest pain Signs of poor perfusion Complicated childbirth Uncontrolled bleeding Responsive but unable to follow commands Severe pain in any area of the body Inability to move any part of the body The Golden Hour Patient Assessment Process Focused History & Physical Examination Goals of the exam: To understand the specific circumstances surrounding the chief complaint Obtain objective measurements of the patients condition To direct further physical examination Focused History & Physical Examination Three Components Evaluation of the patient’s medical history SAMPLE OPQRST Obtaining Baseline Vital Signs Stable patient V/S every 15 minutes Unstable patient V/S every 5 minutes Physical exam based on patient’s complaint Rapid physical exam Focused physical exam Rapid Physical Exam A rapid head to toe exam used to detect injuries which may later threaten life or life-threatening injuries not identified during the initial assessment. Rapid Physical Exam Rapid Trauma Assessment DCAP-BTLS: D: Deformities C: Contusions A: Abrasions P: Punctures/ Penetrations B: Burns T: Tenderness L: Lacerations S: Swelling The victim above was assaulted. The first picture shows the victim with extensive injuries including various DCAP-BTLS; the second picture shows a fully recovered victim. Rapid Trauma Assessment Components of a Rapid Trauma Assessment: Maintain spinal immobilization while checking the patient’s A-B-Cs Assess the head Assess the neck Apply a cervical spine immobilization collar Rapid Trauma Assessment Components of a Rapid Trauma Assessment (cont’d): Assess the chest Assess the abdomen Assess the pelvis Assess all four extremities Log-Roll with spinal precautions Baseline vital signs / SAMPLE history Rapid Trauma Assessment Head: DCAP-BTLS + Crepitation: Feel head for deformity, tenderness or crepitus Check for bleeding Ask about pain or tenderness Rapid Trauma Assessment Neck: DCAP-BTLS + Crepitation: Feel neck for deformity, tenderness or crepitus Check for bleeding Ask about pain or tenderness Rapid Trauma Assessment Neck: DCAP-BTLS + Crepitation (cont’d): Assess for Jugular Vein Distension (JVD) Assess for tracheal deviation *Do not apply a C-collar until the neck has been assessed! Rapid Trauma Assessment Chest: DCAP-BTLS + Crepitation: Observe chest rise and fall during breathing Feel for crepitus as the patient breathes Listen to breath sounds Rapid Trauma Assessment Flail chest with paradoxical motion: Three or more ribs, broken in two or more places Rapid Trauma Assessment Listen to both sides of the chest: Is air entry present? Absent? Equal? Compare left side to right side Do not listen for type of sound at this time; do not listen over bone Rapid Trauma Assessment Abdomen: DCAP-BTLS: Look for obvious injuries, bruising or bleeding Evaluate for any tenderness signs of bleeding Do not palpate too forcefully; palpate painful areas last Rapid Trauma Assessment Pelvis: DCAP-BTLS: Look for obvious injuries, bleeding or deformity Press gently inward and downward on pelvic bones Rapid Trauma Assessment Extremities: DCAP-BTLS: Look for obvious injuries Feel for deformities Assess PMS: Pulse Motor function Sensory function Rapid Trauma Assessment Back (posterior) and Buttocks: Look for obvious injuries Feel for tenderness, deformity and open wounds Carefully palpate from neck to pelvis (cervical to sacral) Do not log-roll the patient if there’s pelvic pain or instability Focused Physical Exam Uses specific assessment techniques to evaluate the patient’s chief complaint. The exam generally focuses on the location or body system related to the chief complaint. Focused Physical Exam Head, neck, and C-spine. Chest and breath sounds Abdomen Pelvis Extremities Pulse Motor function Sensory function Posterior body Focused Physical Exam Chief complaint Chest pain Shortness of breath Abdominal pain Any pain associated with bones or joints Dizziness Physical Exam Techniques Inspection Palpation Auscultation DCAP-BTLS Physical Exam Techniques Head, Neck, and Cervical Spine Crepitus Subcutaneous Emphysema Chest and Breath Sounds Retractions Paradoxical motions Auscultate Physical Exam Techniques Abdomen Pelvis Extremities Pulse Motor Function Sensory Function Posterior Body Steps in a Focused History and Physical Exam Three Components Baseline Vitals SAMPLE History Rapid or Focused Physical Exam Patient Assessment Process Significant MOI (Trauma) Significant MOI (Trauma) Reconsider the MOI Significant MOI for adults and children Ejection from a Vehicle Death of another occupant of the vehicle Fall greater than 15’ to 20’ or three times the patients height Vehicle rollover Significant MOI (Trauma) Significant MOI for adults and children (cont.) High speed vehicle collision Vehicle – pedestrian collision Motorcycle or bicycle crash Unresponsive or altered mental status following trauma Penetrating trauma to the head, chest, or abdomen Unresponsive or altered mental status following trauma. Penetration trauma to head, chest or abdomen. Significant MOI (Trauma) Rapid Trauma Assessment Baseline Vital Signs SAMPLE History Reevaluate Transport Decision Reconsider the MOI. Perform a focused physical exam based on: MOI Chief Complaint Obtain baseline vital signs. Take a SAMPLE history. Reevaluate Transport Decision. Patient Assessment Process No Significant MOI (Medical) Responsive medical patient: Obtain history of present illness (OPQRST) Obtain SAMPLE history Perform a Focused Medical Assessment based on Chief Complaint. Obtain baseline vital signs Reevaluate transport decision No Significant MOI (Medical) Assessing the responsive patient: Ask general questions to find out the chief complaint Listen to the patient Record the chief complaint in a few of the patient’s words Use OPQRST to gather history of present illness No Significant MOI (Medical) OPQRST: O Onset: When did the problem first start? P Provoking factors: What creates or makes the problem worse? Q Quality of pain: Description of the pain No Significant MOI (Medical) OPQRST (cont’d): R Radiation of pain or discomfort: Does the pain radiate anywhere? S Severity: Intensity of pain on 1-to-10 scale T Time How long has the patient had this problem? No Significant MOI (Medical) SAMPLE History. S: Signs and Symptoms: What signs and symptoms occurred at onset? A: Allergies: Is the patient allergic to medications, foods or other? M: Medications: What medications is the patient taking? No Significant MOI (Medical) P: Pertinent past history: Does the patient have any medical history? L: Last oral intake: When did the patient last eat or drink? E: Events leading to injury or illness: What events led to this incident? No Significant MOI (Medical) Unresponsive medical patient: Perform a rapid medical assessment Obtain baseline vital signs Obtain SAMPLE history from family if available Reevaluate Transport Decision. Tying it Together Patient Assessment Process Detailed Physical Exam Detailed exam will provide you with more information on the patients problem. Be prepared to: Return to initial assessment if potential life threatening condition is identified. Perform spinal immobilization. Modify any treatment. Provide treatment for any new problems. Provide transport to appropriate facility or call for ALS backup. Detailed Physical Exam More in-depth exam based on focused history and physical exam. Should only be performed if time and patient’s condition allows. Usually performed en route to the hospital. Detailed Physical Exam Steps: Visualize and palpate using DCAP-BTLS Detailed Physical Exam Steps: Look at the face Inspect the area around the eyes and eyelids Examine the eyes Detailed Physical Exam Steps: Pull the patient’s ear forward to assess for bruising Detailed Physical Exam Detailed Physical Exam Detailed Physical Exam Look at the chest Gently palpate over the ribs Listen for breath sounds Listen also at the bases and apices of the lungs Look at the abdomen and pelvis Detailed Physical Exam Gently palpate the abdomen Gently compress the pelvis Gently press the iliac crests Detailed Physical Exam Inspect all four extremities Detailed Physical Exam Assess the back for tenderness or deformities Reassess Vital Signs Patient Assessment Process Ongoing Assessment Is treatment improving the patient’s condition? Has an already identified problem gotten better? Worse? What is the nature of any newly identified problems? Ongoing Assessment Steps: Repeat the initial assessment Reassess mental status Maintain an open airway Monitor patients breathing Reassess pulse rate and quality Monitor skin color and temperature Reestablish patient priorities Ongoing Assessment Reassess and record vital signs Unstable – every 5 mins Stable – every 15 mins Repeat focused assessment Check interventions Ensure adequacy of oxygen delivery/artificial ventilation Ensure management of bleeding Ensure adequacy of other interventions QUESTIONS?

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