Patient Assessment in the field

Patient Assessment in The Field : 

1 Patient Assessment in The Field EMS Professions Temple College

Patient Assessment : 

2 Patient Assessment Problem-oriented evaluation to identify potentially life-threatening injury or disease Followed by clinical decision-making to determine course of action

Components : 

3 Components Dispatch Information Scene Size-Up MOI or Nature of Illness Safety Considerations General Impression Initial Assessment Focused History Physical Exam: Detailed, Focused & Ongoing

Dispatch Information : 

4 Dispatch Information May Provide: Mechanism Hazards No. of patients Special resources required Example: “Respond to a car vs. train with car fire. Multiple victims.”

Size-Up : 

5 Size-Up Begins with dispatch info Create a mental image of the scene Update the image as new info is available Finalize the image on arrival

Visual Size-Up on Approach : 

6 Visual Size-Up on Approach What do you see? Hazards Mechanism Est. No. of patients Special Needs Radio Size-Up What is involved? Mechanism Severity Actions taken & resources needed What is your size-up of this incident?

Scene Assessment : 

7 Scene Assessment Who is the patient? More than one = triage Special resources or actions needed Extrication/Rescue Haz Mat Additional transport & manpower What really happened? “Tell me a story”

General Impression of the Scene : 

8 General Impression of the Scene MOI or Nature of Illness The Environment Location & Position of Patient(s) General Appearance & Behavior Obvious Injuries or Illness Patient’s Activity & Awareness

Scene Size-Up Practice : 

9 Scene Size-Up Practice #1 #1 #2

Safety Considerations : 

10 Safety Considerations Safety What types of specific hazards might you encounter in these situations & how can you minimize your risk of injury/illness? Violent acts MVC Ill person in a building Group Discussions

General Impression : 

11 General Impression Sick or Not Sick Is there an obvious emergent problem? Is there a potentially life-threatening condition? Does the patient need immediate interventions? What is your overall summation of the patient’s condition?

Initial Assessment(Primary Survey / ABCDEs) : 

12 Initial Assessment(Primary Survey / ABCDEs) Cervical Spine (if indicated) Manual immobilization in neutral position Airway Obvious Difficulty or abnormal sounds Clear & Position as needed Breathing Est Rate, Pattern, Effort & Symmetry Lung sounds - present or absent Ventilate, Oxygen, Decompression, Occlusion

Initial Assessment(Primary Survey / ABCDEs) : 

13 Initial Assessment(Primary Survey / ABCDEs) Circulation Central & Peripheral pulses Amplitude, Regularity, Est Rate  ID Cause Skin color, moisture & temp Severe hemorrhage  Control Disability/Defibrillation Mental Status - LOC Posturing Obvious sensory or motor deficits Cardiac arrest - The Hunt for VF!

Initial Assessment(Primary Survey / ABCDEs) : 

14 Initial Assessment(Primary Survey / ABCDEs) Exposure Remove clothing as needed Prevent from overexposure to environment Determine Priority Treat Life-Threatening problems immediately; Load & Go OR Slightly Delayed Direct Baseline Vital Signs on scene or en route

Initial Assessment(Primary Survey / ABCDEs) : 

15 Initial Assessment(Primary Survey / ABCDEs) Branching Points Rapid Trauma Assessment Or Detailed Physical Exam Or Focused Physical Exam

The Rapid Trauma Assessment : 

16 The Rapid Trauma Assessment Objective: Identify whether the patient needs to be transported now and why Rapid Head to Toe What specifics structures or findings are you interested in assessing in the rapid trauma assessment? Group Discussions: 1) Head to chest, 2) Abdomen to Pelvis and back, 3) Extremities & Others

Patient Priority : 

17 Patient Priority What are examples of patients with a high priority requiring immediate transport? Why are they a high priority?

Detailed vs Focused Physical Exam : 

18 Detailed vs Focused Physical Exam What determines the need for the detailed vs the focused physical exam? What is included in the focused physical exam? Which systems and structures? What is included in the detailed physical exam? Group Discussions: What additional examinations or tests would you do in the detailed that were not done in the rapid trauma assessment?

Preparation & Reassess : 

19 Preparation & Reassess Preparation for Immediate Transport Backboard, C-Collar, CID, 10 pt. Straps MAST & Splints applied if appropriate Cover and protect from environment Secure all if heli transport Reassess Reassess all interventions & vital signs Early notification to receiving facility

History of the Present Illness - Sample History : 

20 History of the Present Illness - Sample History SAMPLE History Symptoms - Current symptoms Allergies - specifics, focus on meds Medications - current prescribed medications and OTC meds Past medical History - significant, pertinent Last oral intake - potential surgical candidates Events preceding the incident

History of the Present Illness - Current Health Status : 

21 History of the Present Illness - Current Health Status Current Health Status Current Medications and OTC meds Risk factors for disease Family history Alcohol and/or substance abuse Immunizations Occupation or environmental factors

History of the Present Illness - OPQRST : 

22 History of the Present Illness - OPQRST Onset - What was occurring at onset? Contributing factors Provocation/Palliation - What makes it worse or better? Quality - Describe specifically. Prompt with example choices Region/Radiation - Exactly where is the pain? Does it radiate? Where? Severity - How bad? Rate on a scale of 10. Time - Time of onset. Duration of pain/symptoms. Associated Symptoms & Pertinent Negatives

History of the Present Illness : 

23 History of the Present Illness Gathering history is like charting a map Identify pertinent negatives to rule out possibilities Continue looking for evidence supporting a specific diagnosis or limited differential dx.

Additional Diagnostics : 

24 Additional Diagnostics Blood glucose level Pulse oximetry ECG Diagnostic (12 Lead) ECG Cincinnati Prehospital Stroke Scale Future Cardiac Enzymes, Predictive instruments, Abdominal Ultrasound

Neurologic System Exam : 

25 Neurologic System Exam LOC, Pulse, Motor and Sensory are the basics Cranial Nerves Pupillary response to light (III) Ocular movement (III, IV, VI) Clench teeth (V) Show teeth; Raise eyebrows (VII) Open mouth and stick out tongue (XII) Gag Reflex (IX, X) Shrug shoulders (XI) Symmetry, Pain response, Point discrimination

Develop a plan : 

26 Develop a plan Likely Diagnosis Appropriate Therapies What if? Plan for the worst Stay two steps ahead MD Consult if needed Transport appropriately