Lesson 04
- 1. Lesson 4 Principles of Assessment and Management
- 2. Objectives As a result of active participation in this lesson you should be able to: Identify potential threats to the safety of patients, bystanders, and emergency personnel that are common to all emergency scenes Differentiate between critical and noncritical patients Integrate analysis of scene safety, scene situation, and kinematics along with the physical findings and history to make patient care decisions
- 3. Establishing Priorities of Scene Assessment Scene assessment includes: Scene safety issues Scene situation An abbreviated form of triage Determining whether you have a multi-patient or mass casualty incident
- 4. Scene Safety What are the components for assessing scene safety Ensure safety of rescuers and patients Threatening situations may include Fire/electrical Hazardous materials/blood and other body fluids Traffic/weather conditions Hostile individuals/weapons Others? Click to play video
- 5. Scene Situation What really happened? What are the kinematics? How many patients are involved? Ages? Additional resources needed? How will patients be transported?
- 6. Personal Protective Equipment Personal protective equipment includes: Gloves Eye protection Masks Gowns Ensure proper handling/disposal of contaminated items!
- 7. Scenario A 47-year-old male is crossing a busy city street when he is struck by a sedan traveling at a speed of approximately 30 mph (48 km/hr). He is tossed onto the hood of the car and strikes the windshield before tumbling to the pavement.
- 8. Establishing Priorities of Patient Assessment (Primary Survey) First goal is to determine patient’s current condition Use an organized, systematic approach Quick and efficient performance of 5 steps Time is critical The most common basis of life-threatening injuries is a lack of adequate tissue oxygenation!
- 9. Step One: Airway Management and Cervical Spine Stabilization If airway is compromised, use manual methods to stabilize Clear airway if needed Special handling and consideration of the cervical spine is necessary at this point
- 10. Step Two: Breathing (Ventilation) Spontaneously breathing patient Estimate adequacy Assess oxygenation/concentration Evaluate rate and depth Listen to lungs Rate can be divided into five categories Apneic Slow Normal Fast Abnormally fast
- 11. Step Two: Breathing (Ventilation) Hypoxia can result from inadequate ventilation of lungs or lack of oxygen to tissue Nonbreathing patient Immediate use of BVM Maintain patent airway with adjuncts Continue to assist ventilation
- 12. Step Three: Circulation (Bleeding Control) Oxygenation of the RBCs without delivery to the tissue cells is of no benefit to patient Two components of assessment and management of circulation Perfusion Bleeding control
- 13. Step Three: Circulation (Bleeding Control) External bleeding Capillary, venous, arterial Control is a major priority DIRECT PRESSURE Elevation Pressure points Tourniquets A fisherman who was run over by a motorboat suffered severe damage to his lower extremities. His life was saved by first responders who applied tourniquets to both thighs.
- 14. Step Three: Circulation (Bleeding Control) Internal bleeding Suspect injury Three primary sources Thorax Abdomen Major fractures (pelvis most likely) Expose to inspect and palpate Management may include use of PASG
- 15. Step Four: Disability Assess cerebral oxygenation/function Hypoxia is the most clinically important cause of altered mental status AVPU scale Glasgow Coma Scale Pupillary response
- 16. Step Four: Disability AVPU Scale Alert Voice Pain Unresponsive Glasgow Coma Scale Provides good baseline for cerebral function Divided into three sections Eye opening Best verbal Intubated patients get “T” for verbal score Best motor
- 17. Step Five: Expose/Environment Expose to evaluate and identify hidden injuries Prevent hypothermia Respect the patient’s modesty
- 18. Scenario: Assessment The scene is safe and secured by police. You have one pale, conscious, alert patient laying on the sidewalk with abrasions noted to his face. You note that his right forearm is deformed as you approach and begin your assessment. He states he is in a lot of pain and is begging you to help.
- 19. Scenario: Assessment of Airway What is the patient’s airway status? What precautions should be taken while evaluating his airway? What indicators are present that he may have a cervical spine injury?
- 20. Scenario: Assessment of Breathing The patient is taking shallow breaths — between 20 and 30 per minute. He has equal, adequate chest rise with each breath. He speaks in full sentences as he complains of pain to his arm and pelvic region.
- 21. Scenario: Assessment of Breathing What is your assessment of his respiratory status at this point? What should be your next assessment and treatment considerations?
- 22. Scenario: Assessment of Circulation The patient is pale and cool to your touch. He has a weak, fast radial pulse present and his capillary refill is delayed at his fingertips. You note no obvious significant external bleeding.
- 23. Scenario: Assessment of Circulation (Bleeding Control) What is your initial impression regarding the circulatory status of your patient? What indicators are present? Do you suspect any bleeding is occurring? What should be your next assessment and treatment considerations?
- 24. Scenario: Assessment of Disability The patient continues to complain of pain and curse at the driver who struck him. He is calling out a phone number and asking that someone please call his wife. His pupils appear to be equally reactive and slightly constricted as he lays in the bright sunlight on the sidewalk.
- 25. Scenario: Assessment of Disability What is the patient’s level of consciousness? Based on the immediately available information, what is his Glasgow Coma Score? What does his pupillary response tell you about his neurological condition?
- 26. Scenario: Assessment Expose/Environment The weather is warm and clear. Your patient continues to complain of pain to his arm and pelvic region.
- 27. Scenario: Assessment Expose/Environment What areas of the body should be uncovered and evaluated? What are your concerns regarding inspection of the: Thorax Abdomen Pelvis Extremities
- 28. Scenario: Assessment Expose/Environment After exposing and inspecting the chest, abdomen, and pelvic region, you discover a large contusion and tenderness to the belly and extreme pain and instability to the pelvis. Law enforcement officers have minimized the number of onlookers, and removed unnecessary bystanders.
- 29. Resuscitation (Critical Patients) “Treat as you go” philosophy Limited scene intervention Scene time should be limited to 10 minutes when possible Effort directed at correcting life-threatening problems with primary survey and preparing for rapid transport to the closest appropriate facility
- 30. Critical Patient Criteria Inadequate or threatened airway Impaired ventilation Significant hemorrhage (external or suspected internal) Abnormal neurologic status Penetrating trauma to head, neck, torso Amputation, near amputation Trauma in presence of other significant findings
- 31. Treatment Options: Critical Trauma Patients Intubation Needle decompression PASG Option with circulatory insufficiency May be useful with bleeding control/pelvic injuries Systolic below 60
- 32. Treatment Options: Critical Trauma Patient Critical patients should be rapidly packaged and prepared for transport after primary survey and initial interventions have been completed Fluid resuscitation Lactated Ringer’s is fluid of choice Two large-bore catheters (14-16 gauge) En route procedure
- 33. Transport Decisions Closest appropriate facility Critically injured should go to a designated trauma center Receiving facility should be determined by local protocol Mode of transport-ground vs. air Evaluate patient’s needs, terrain, traffic, weather, location of receiving facility
- 34. Trauma Center Candidates Physiologic criteria Most likely to need urgent surgery Anatomic criteria Life threats based on anatomic location Mechanism of injury Life or limb threat Preexisting conditions
- 35. Scenario: Resuscitation, Treatment and Transport You are approximately 10 minutes (by ground transport) to a trauma center. Your partner has brought the necessary packaging and immobilization equipment to your side. The patient has become lethargic and now has an absence of radial pulses.
- 36. Scenario: Resuscitation, Treatment and Transport Is this a critical trauma patient? Why? How should the patient be packaged? Where should the patient be transported? What interventions should be initiated On scene? En route?
- 37. Components of the Secondary Survey Vital signs Full set AMPLE history Allergies Medications Past medical history Last meal Events preceding injury Neurological exam Calculate GCS Motor and sensory Pupillary response Head-to-toe exam Evaluate each region Observation Soft tissue injury Deformities Auscultation Noisy breathing Breath sounds Palpation Crepitus Tenderness Pulses
- 38. On-going Reassessment of Patient Frequency of reassessment Severity and types of injury Distance from receiving facility Interventions performed What should be reassessed Primary survey ET tube placement Blood pressure Circulation to injured extremities Neurological exam Pulse oximetry
- 39. Appropriate Use of Pain Management Consider analgesia for isolated extremity injuries and spinal fractures Titrate narcotics in small increments IV Overmedication can impair assessment of neurological function and abdomen Commonly used medications can cause ventilatory depression and hypotension Hypotension is more likely to develop in patients who are mildly hypovolemic
- 40. Communication and Documentation Notify receiving facility early to allow activation of resources (trauma team) Communicate pertinent information about patient, incident, findings, treatment, and response Document with a well-written narrative including patient presentation, assessment findings, treatment, response, and transport destination
- 41. Scenario: Transport, Communication, Documentation While en route to the hospital, your patient shows some improvement upon reassessment of primary survey. Your secondary survey revealed multiple abrasions to the face and hands and a deformity to the right wrist with a palpable radial pulse. V = 20, P = 110, B/P = 94/52
- 42. Scenario: Transport, Communication, Documentation What important information was collected during the secondary survey? What information should be communicated to the receiving facility? What information should be documented on the patient care report?
- 43. Managing Multiple Patients Adequate resources Establish incident command/call for help Triage patients/treat critical first Don’t overload closest hospital Inadequate resources Focus on most viable/provide comfort to those who are not Physician on scene may be helpful Be familiar with local disaster plan Use an incident command system
- 44. Summary Perform scene assessment Initiate treatment for life-threatening conditions when identified Prompt transport of critically injured to closest appropriate facility Complete assessment and definitive care of noncritical patients Communicate and document key information
- 45. QUESTIONS?
Editor's Notes
- #4: Instructor Notes: Remember that 95% of injury can be predicted by understanding the kinematics. Preplanning between partners and the use of observation and communications skills enhance scene safety and assessment. Personnel must monitor the scene for safety during the entire patient encounter.
- #5: Instructor Notes: An increasing number of EMS personnel are injured or killed each year while working motor vehicle collisions. EMS personnel must develop good habits and use all available protective gear. Ask, “What types of safety issues would you anticipate in this situation?”
- #9: Instructor Notes: The most common basis of life-threatening injuries is lack of adequate tissue oxygenation. Attention should immediately be focused on oxygenation of red blood cells and delivery of RBCs to the cells through the body.
- #10: Instructor Notes: Form a general impression and follow the 5 steps of the primary survey.
- #11: Instructor Notes: Ensure inspired oxygen concentration of 85% or higher. Apneic patients need aggressive management with a BVM. Slow rates (below 12) need assistance with a BVM and supplemental oxygen with a concentration of 85% or higher. Fast rates (between 20 and 30) should be monitored closely. Increase FiO 2 with a nonrebreather mask. Abnormally fast rates (above 30) indicate hypoxia and need assistance with a BVM and supplemental oxygen. Attempt to determine whether this is an oxygenation problem or an RBC delivery problem.
- #13: Instructor Notes: Perfusion: evaluate pulse, skin color, temperature/moisture. Peripheral pulse is a rough estimate of blood pressure
- #14: Instructor Notes: Use caution in elevating an extremity that is fractured or dislocated. The value of tourniquets has increased recently due to experience in Iraq; however, they are not to be used on every patient and are available as a judgment option in specific situations.
- #15: Instructor Notes: Early decision-making considerations should be directed toward initiation of rapid transport to an appropriate facility and warmed IV fluid replacement en route. Patients with traumatic cardiac arrests in the prehospital setting have an extremely low likelihood of survival. Less than 4% of trauma patients who require CPR in the field survive to discharge, and almost all of these have significant neurological deficits upon discharge and never return to prearrest activity or function. Such unsuccessful attempts at resuscitation may divert resources away from patients who are viable and have a greater likelihood of survival.
- #17: Instructor Notes: GCS of 15 indicates no disability. GCS of 13 to 15 indicates minor injury. GCS of 9 to 13 indicates moderate injury. Score of 8 or less is indication for intubation. Score of 3 is lowest score and an ominous sign. GCS of 14 or less with abnormal pupil exam can indicate possible presence of life-threatening traumatic brain injury.
- #20: Instructor Notes: The airway is open and appears to be clear. Attention to the cervical spine is necessary due to the kinematics and a distracting injury.
- #22: Instructor Notes: The patient needs to be placed on high flow oxygen.
- #24: Instructor Notes: Circulation is compromised and there are indications of shock. Bleeding should be suspected in the abdomen and/or the pelvis. Attention should be directed toward maintenance of airway and oxygenation while packaging the patient and preparing for transport.
- #26: Instructor Notes: The patient is alert and has a GCS of 15 at this point. Pupil response is difficulty to appreciate outdoors in bright light. Effort should be made to reevaluate the pupils when the patient is in a more controlled environment where the lighting can be reduced.
- #28: Instructor Notes: All areas of the body should be uncovered and inspected. Bleeding into the chest, abdomen, or pelvis could be life threatening. Extremity fractures can be distracting and may need to be splinted prior to moving the patient. After exposing and examining the patient, ensure the patient is kept warm and body heat is conserved.
- #30: Instructor Notes: Resuscitation describes treatment steps taken to correct life-threatening problems as identified in the primary survey. There should be limited scene intervention and effort should be directed at packaging and transporting the critical patient to the closest appropriate facility. Scene time should be limited to 10 minutes or less.
- #31: Instructor Notes: Impaired ventilations include abnormally fast or slow rates, SpO 2 less than 95% even with supplemental oxygen, dyspnea, open pneumothorax, flail chest, or a suspected pneumothorax. Abnormal neurological status includes a GCS of less than 13, seizure activity, or sensory motor deficit. Significant findings include a history of serious medical condition, greater than 55 years old, hypothermia, burns, or pregnancy.
- #32: Instructor Notes: PASG is considered an option in the presence of circulatory insufficiency caused by trauma. They also may be used for hemorrhage control with pelvic fractures, bleeding from major solid organ injuries, and when the systolic is below 60 mm Hg.
- #37: Instructor Notes: Definitive care in the field includes packaging, spinal immobilization, splinting musculoskeletal injuries, and dressing wounds. Other definitive medical treatment could include defibrillation and IV glucose.