Ch. 5 - Assessment - EMALB

When you arrive at the scene of an emergency, after ensuring the safety of yourself and others, you must quickly determine whether the patient has any life-threatening injuries or conditions by conducting a primary assessment. This includes assessing the patient’s level of responsiveness and his or her airway, breathing, and circulation. Once the primary assessment is complete, you can begin your secondary assessment, which includes interviewing the patient (or bystanders), assessing and documenting vital signs, and conducting a thorough physical exam. Having a clear plan of action will help you to respond effectively in any emergency situation. The important questions are “What are my priorities?” and “What interventions may be necessary?” The general steps in this section will provide answers to these questions (Figure 5–1).

These steps, conducted in this order, help to ensure your safety and that of the patient and bystanders. They will also increase the patient’s chance of a positive outcome.

Transcript

1. Ch 5 – Pg 79
2. Why Follow An Assessment Model? • Having a clear plan of action will help you to respond effectively • “What are my priorities?” • “What interventions may be necessary?” • These steps, conducted in this order, will increase the chance of a positive outcome Ch 5 – Pg 79-80
3. This assessment model may be modified depending on the situation. For example, a responsive patient may complain of an ankle injury. In this case, a full head-to- toe assessment is probably unnecessary, unless you have reason to suspect that additional injuries or conditions may be present Ch 5 – Pg 80
4. Scene Survey Ch 5 – Pg 80 and EMALB SOPU Steps of the Scene Survey / Rescue Scene Evaluation Hazards • Are there any hazards at the scene? Environment • Where is the emergency located? • How many environmental factors affect the flow of the call? • What is my overall impression with the scene and/or patient? MOI • What happened? (How far did the patient fall? How fast was the car going?) Patients (Number Of) • How many people have been injured? PPE • What PPE should be worn? o Gloves? o Goggles? o Mask? o Gown? Additional Resources • Who else has been dispatched? • Who else do I need with me on this call? o Police? o ALS? o Fire? o SAR? General Impression • What do I see upon approach? • What does the patient look like? o Do I see any massive hemorrhage that requires immediate care? • What is my initial “game plan”?
5. Once You Reach the Patient – Moving a Patient You should avoid moving a patient unless the situation makes it necessary, including: • Moving a patient away from dangerous materials or situations • Moving a patient with minor injuries to reach someone who may have a life-threatening condition • Moving a patient to provide appropriate care • See Ch 19 about how to move patients If the scene is unsafe to enter and the patient is able to do so, ask the patient to move to a safe location. Ch 5 – Pg 81
6. Primary Assessment A rapid systematic check to identify conditions that pose an immediate threat to life. • Assessing LOC • Is there potential for a Delicate Spine? • Simultaneously assessing ABC’s • Performing RBS • Other SOAP BB Ch 5 – Pg 82 and EMALB SOPU
7. Level of Consciousness (LOC) Introduce yourself and obtain consent Ch 5 – Pg 83
8. Delicate Spine • Is spinal motion restriction required based on the MOI? • Is there any evidence of trauma to the head/neck/spine? • How does the conscious patient answer, “Did you fall or hit your head or back?” Ch 5 – Pg 83 and EMALB SOPU
9. Airway Conscious: • Is the patient talking? Unconscious: • Open with a head-tilt/chin-lift or jaw thrust • Is it clear? • Do I need to suction or roll to clear fluids? • Does the patient need an oropharyngeal airway (OPA) / nasopharyngeal airway (NPA)? Ch 5 – Pg 84 and EMALB SOPU
10. Breathing • Assess rate and quality • Perform a simultaneous ABC check if the patient is unconscious (up to 10 seconds) • Assist ventilations if inadequate respirations • Ventilate if respiratory arrest Ch 5 – Pg 84-85 and EMALB SOPU
11. Circulation Conscious = radial pulse Unconscious = carotid pulse Baby = brachial pulse • Perform a simultaneous ABC check if the patient is unconscious (up to 10 seconds) • CPR / AED if the patient is in cardiac arrest Ch 5 – Pg 85-86 and EMALB SOPU
12. Rapid Body Survey (RBS) • Expose and examine injuries. Perform distal circulation, motor, sensory check (CMS) • Look for medical alerts • Control major bleeds (direct pressure / tourniquet) • Cover open chest wounds • Manually stabilize fractures, then check distal CMS. Realign pulseless limbs (if needed) and apply ice if appropriate • Initiate cooling of burns Do not put your hands anywhere you cannot see! Ch 5 – Pg 88 and EMALB SOPU
13. Circulation, Motor, Sensory Check (CMS) Circulation, motor, sensory check (CMS): Part of the head-to-toe and rapid body survey examination, the goal of the CMS is to assess the circulation, motor, and sensory function at the end of each limb. Circulation can be determined by assessing the dorsalis pedis pulse, the posterior tibialis pulse, or capillary refill. • In conscious patients, motor and sensory checks can include asking the patient to wiggle their toes, push against your hands, identify which toe you are touching, etc. • In unconscious patients, you might apply pain to the patient’s toes and watch for them to withdraw from the pain stimuli. • Another key aspect of the CMS is comparing the findings on each side of the patient to identify any deficits that are isolated to one side of the body or to one limb. EMALB SOPU
14. Other SOAP BB Skin Oxygen Airway Pt Position Bandages Blanket EMALB SOPU
15. Skin Check the patient’s skin for … • Colour: • Normal, red, pink, pale, bluish/cyanotic, etc. • In patients with darker skin, cyanosis may appear ashen- grey, yellow-brown, or greyish-green • Temperature • Hot, warm, cool, cold • Moisture • Dry, clammy, sweaty Ch 5 – Pg 95 and EMALB SOPU
16. Oxygen Apply the pulse oximeter and assess the patient’s presentation • Room Air Saturation: reading taken before administering supplemental O2 • Is oxygen needed? • Nasal cannula? • Simple face mask? • Non-rebreather face mask? Ch 5 – Pg 86-88 and EMALB SOPU
17. Airway Adjunct Does the patient need an airway adjunct inserted? EMALB SOPU
18. Patient Position Is your patient in the best position? • Patients in shock or who are lightheaded should be laid supine • Short-of-breath patients often benefit from being positioned in an upright position • Unconscious non-trauma patients are usually best positioned 3/4 prone, etc. Ch 5 – Pg 89-90 and EMALB SOPU
19. Bandaging Are there any major bleeds or wounds that need to be bandaged? EMALB SOPU
20. Blanket Does the patient need a blanket? EMALB SOPU
21. Transport Decision Once the scene survey and primary survey have been completed, enough information has usually been gathered to make an accurate transport decision. A stable patient with an isolated ankle fracture will usually benefit from a more detailed survey performed on-scene — from the administration of pain management if the provider is licensed to do so, to proper splinting — prior to being moved to the stretcher. An unconscious head injury patient, on the other hand, requires urgent transport to definitive care. After the primary survey, this patient should be packaged and loaded immediately if the provider is transport capable, with all further assessments and treatments performed in the back of the ambulance enroute to the hospital. EMALB SOPU
22. Transport Decision Rapid Transport Category (RTC): • Life-threatening conditions • If working as a team, one responder can make preparations for transport while the other continues care • Examples on Pg 89 • VS q 5min Non-Rapid Transport Category (Non-RTC): • Stable conditions • If the patient’s condition deteriorates, you must re- evaluate • If delaying transport could have a negative effect on the patient’s condition, transport immediately • VS q 15min Ch 5 – Pg 89 and EMALB SOPU
23. Primary Assessment - Recap • LOC • Delicate Spine • ABC’s • RBS • SOAP BB Transport Decision (RTC/Non-RTC) Ch. 5 and EMALB SOPU
24. Secondary Assessment This is usually done on-scene if the patient is stable, and enroute if the patient is unstable (and if the provider is working in a transport-capable capacity). Can reveal injuries or conditions that may become life-threatening. • History / Interview • Vital Signs • Head-To-Toe Examination Ch 5 – Pg 91 and EMALB SOPU
25. Patient History Listen carefully but also watch for signs of injury or illness Ch 5 – Pg 91-92 and EMALB SOPU
26. Vital Signs (VS) • Detailed physiological information • The first set is considered the baseline VS • Every 5min for unstable patients • Every 15min for stable patients Ch 5 – Pg 92
27. Vital Signs Ch 5 – Pg 92
28. Vital Signs - LOC Ch 5 – Pg 83
29. Vital Signs - LOC EMALB
30. Vital Signs – Blood Pressure Blood Pressure (BP) • The force exerted by the blood against the blood vessel walls • Created by the pumping action of the heart, in two phases: • Contracting (systole) • Refilling (diastole) Methods Used to Assess BP • Palpation: • Only a blood pressure cuff • Only measures systolic pressure • Auscultation: • Blood pressure cuff and stethoscope • Measures systolic and diastolic pressures Ch 5 – Pg 96-99
31. Vital Signs – Heart Rate Heart Rate (HR) • If the heartbeat changes, so does the pulse • Rate, rhythm, and quality • A well-conditioned athlete may have a pulse of 50bpm or lower • Count for 15sec Ch 5 – Pg 94
32. Vital Signs – Heart Rate Heart Rate (HR) • A pulse may be hard to find: take your time • If a patient is breathing, their heart is also beating • Loss of circulation to an area can cause a loss of pulse • If you cannot find the pulse in one location, check it in another Ch 5 – Pg 95
33. Vital Signs – Breathing Rate Breathing Rate • A healthy person breathes regularly, quietly, and effortlessly • Rate, rhythm and volume • Try to assess breathing without the patient’s knowledge • Count for 15sec Ch 5 – Pg 94
34. Vital Signs – SpO2 SpO2 • Apply pulse oximeter to support patient assessment • Decide whether the patient requires supplemental O2 based on S&S, C/C and SpO2 Ch 5 – Pg 86-88
35. Vital Signs – Skin Check the patient’s skin for … • Colour: • Normal, red, pink, pale, bluish/cyanotic, etc. • In patients with darker skin, cyanosis may appear ashen- grey, yellow-brown, or greyish-green • Temperature • Hot, warm, cool, cold • Moisture • Dry, clammy, sweaty Ch 5 – Pg 95 and EMALB SOPU
36. Vital Signs – Pupils Pupils • Look closely at size, whether they react to light and are equal size • Check by shading each eye and then allowing light to enter, or by shining a light into each eye Ch 5 – Pg 96-97
37. Vital Signs – BGL Quantifying a patient’s blood glucose level (BGL) can provide important information about a patient’s condition. This is especially true in patients suffering from diabetes. People with diabetes check their BGL regularly, often using a portable device called a glucometer. This test is done by piercing the skin with a sterile lancet, and then placing a drop of blood on a test strip that is inserted into the glucometer. Because this procedure requires you to break the patient’s skin to obtain the blood sample, it is considered an invasive diagnostic technique. EMALB SOPU
38. Vital Signs – BGL Interpreting the Glucometry Reading • BGL are measured in millimoles per litre (mmol/), and a normal BGL ranges from 4-8mmol/L • Hypoglycemia: less than 4mmol/L • Hyperglycemia: greater than 8mmol/L • Although the result may vary depending upon the patient and testing device used, it is generally accepted that the normal range before meals is 4-6mmol/L, and for the 2hrs after meals it is 5-8mmol/L Professional responders should remember that a glucometer is just one assessment tool. Responders should use this reading, along with the patient’s history and other information gathered during the assessment, to determine whether to treat the situation as a diabetic emergency. EMALB SOPU
39. Head-to-Toe (H2T) • To gather additional information about injuries or conditions • May not be immediately life- threatening, but they could become so • Look for medical identification products • Balance is necessary: • Ensure that you are palpating effectively • Handle gently to avoid aggravating any existing injuries • Look for abnormalities: • Discolouration • Deformity • Bleeding • Etc. Ch 5 – Pg 10-101
40. H2T - Head Physical • Facial asymmetry • Bruises • Deformity • Pain • Fluid leaks • Loose teeth Neurological Questions • Headache? • Dizziness? • Blurred vision? • Numbness/tingling? Ch 5 – Pg 101 and EMALB SOPU
41. H2T – Neck & Chest Neck • Bruises • Deformity • Pain • Tracheal midline • No jugular vein distention (JVD) Chest Physical: • Bruises • Deformity • Pain • Equal expansion • Auscultate lungs (4 spots // 2 on each side, top and bottom) Cardiac/Respiratory Questions: • Recent or current SOB? • Recent cough? • Sputum present? • Recent or current chest pain or heart palpitations • Recent decline in exercise tolerance? Ch 5 – Pg 101 and EMALB SOPU
42. H2T- Abdomen • Nausea or vomiting? • Recent changes with urination or bowel movements? • Last menstrual period? • Any chance of pregnancy? • Recent dietary changes or weight loss? Physical Check 4 quadrants for: • Bruises • Rigidity • Guarding • Tenderness or pain GI / GU / Repro Questions Ch 5 – Pg 101 – EMALB SOPU
43. H2T – Back and Pelvis Back and Pelvis: • Bruises • Deformity • Pain Pelvis in Particular: • Instability Ch 5 – Pg 102 and EMLB SOPU
44. H2T – Upper and Lower Extremities Ch 5 – Pg 102-103 and EMALB SOPU • Bruises • Deformity • Pain • Distal CMS
45. Ongoing Assessment • Monitor the patient’s ABC’s and VS’s • RTC/Unstable: VS q 5min • None-RTC/Stable: VS q 15min • Continue to provide appropriate protocols and treatments • Keep the patient calm and comfortable • Re-inspect any injuries, bandages, etc. periodically • If any life-threatening emergencies develop, stop whatever you are doing and provide appropriate interventions immediately Ch 5 – Pg 103 and EMALB SOPU
46. Documentation • Completed immediately or as soon as possible • Patient care cannot be delayed to fill out paperwork • Can simplify the transfer of care • Protect you from legal action Ch 5 – Pg 103