Accidental

order of the steps

1. SS

2. Bystander

3. CC

4. MOI

5. Vitals

6. Expose

7. ROM

8. Palptae

9. OPQRST

10. Treat

11. Retrend

12. Sample

ALS cut offs

• significant MOI

• Debilitating pain (find out by asking if you can go about day)

• Unable to treat or stabilize

Scene Size up

1. Scene safety/BSI

2. # of PT

3. # of Bystander

4. Obvious life threats

5. Pertinent weather/enviromental concerns

6. ALS co dispatched?

7. Bags: primary, trauma, fannies

8. General impression

*See if there is anything around that could indictation MOI for pt

Bystander Investigation

• SAMPLE

• Did anything abnormal happen before fall? Dizzy? etc

• Get general timeline + MOI questions

• HH/LOC?

Chief complaint

• What’s going on?

• HH/LOC? if yes, neuro

MOI investigation types

6 categories

1. fall (5)

2. MVA or Bike accident (3)

3. Musculoskeletal injury (4)

4. Laceration (5)

5. Abrasion (1)

6. Puncture (2)

If significant MOI: call als

fall

1. What height fall? Catch self?

2. What hit ground first?

3. What surface land on?

4. Dizzy before fall?

5. Blood thinners

Musculoskeletal injury

1. hear snap/crack/pop?

2. Tried to bear weight?

3. Numbness or tingling?

4. Injured this area before?

MVA or bike accident

1. how fast were u going?

2. wore seatbelt/helment?

3. vehicle condition

Laceration

1. What caused it?

2. Any rust or dirty on object? dirty touch meat?

3. Last tetanus booster shot? >5 years ago recommend to get another

4. actively bleeding?

5. how many towels gone thru

Abrasion

1. How much skin was removed

Puncture

1. How large is the object causing the puncture?

2. Is obj or some of obj still inside?

Vitals

1. Skin

2. HR

3. SpO2

4. BP

5. RR

Expose

1. Compare injured to uninjured

2. Look for DCAPBTLSIC

3. If swelling? how quick was the onset?

ROM

1. Ask pt to move injured and uninjured side to compare

2. Comparing prior range of motion in that limb, not to the other limb

Palpate

• Start distally and ask where it hurts most

• palpate and be like “does that hurt” “does that hurt” “does that hurt”

• Ask PT to point to where it hurts the most

• check for point tenderness, ask if they've tried to use their limb

OPQRST

if debilitating pain: call ALS

Onset

Provocation

Quality

Radiation

Severity

Time

• O: should be covered in prior portion of investigation, how long ago did this happen 

• P: does anything make it better or worse 

• Q: ask them to describe pain and also investigate in they are experiencing point tenderness or if the pain is more diffuse

• R: does the pain radiate anywhere else beyond where the injury is

• S: scale of 1 to 10 → this is where you can ask/ investigate whether the pain is debilitating 

  • Debilitating generally considered 8/10 or greater BUT what’s more important is asking whether the patient could go about their normal day with this pain. If no, clayton. 

  • Note about Debilitating pain

    • If the pt has debilitating pain but adamantly refuses hospital, you can have them transported to urgent care

    • Although debilitating pain is self-defined, there are points where a pt will say they have debilitating pain when they are not exhibiting symptoms of debilitating pain

• T: changing over time 

Break

1. Immediate, extreme swelling

2. Heard crack or snap

3. Obvious deformity

4. Discoloration

5. Numbness or tingling distally

6. Point tenderness (localized pain) on palpation

7. Sharper pain

Sprain

1. Slower onset of swelling

2. Discoloration

3. Heard pop or no noise

4. Generalized pain, decreased ROM

5. Delocalized pain

Treat!

4 types of treatment

1. wrap

2. splint + wrap

3. laceration/abrasino

4. puncture

what do you do before you treat?

PMS

• pulse

• motor

• sensation

if pulse covered, check cap refill <2 seconds

wrap

for sprain

1. slow onset swelling

2. generalized tenderness

3. limited ROM

4. pop or no sound

splint + wrap

for break

1. fast onset swelling

2. point tenderness

3. snap/crack

4. very limited ROM

for laceration/abrasion

Clean -> bandage -> wrap

for puncture:

leave object in and wrap around or pack with gauze

what do you do after treat?

PMS

• pulse

• motor

• sensation

if pulse covered, check cap refill <2 seconds

Treatment details

• Know how to both wrap and splint any part of the body (check background EMS info for videos on this). Also know how to sling and swathe. 

• Make sure you ask the patient how it feels once you’re done- is it too tight? Does it feel stable? Is it comfortable? 

• Also remember to recheck PMS 

  • If a bandage, splint, or wrap is covering the pulse, get cap refill instead. 

• If swelling, give the patient an ice pack. 

• If lower extremity injury, consider giving crutches. 

  • Only can be given to WashU students

  • Will have a $30 fee on their student account which will go away as long as they return crutches to the front desk of Habif within 30 days. 

  • Have to sign crutch form

  • Teach pt how to use crutches

Retrend

1. vitals

2. opqrst

SAMPLE

1. Signs/symptoms

2. Allergies AND age

3. Medication

   1. break up otc and perscription meds

   2. ask rec/drugs/alc

4. Past Pertinent Medical History

5. Last oral intake

6. Event leading up to call

Consider

Orthos

(only necessary if the patient is or has been recently dizzy or nauseous.

• If someone just trips and twists their ankle and has no other symptoms, no need for orthos

• if lots of blood lost- this can make some people woozy and we don’t want them to stand up and pass out).

Orthostatic vitals (anytime after second set)

• Consider orthostatic vitals here if releasing to self

  • Stand pt up for two minutes

  • Take BP, pulse, ask how they feel

  • Fail orthos if:

    • Pulse rises by 30

    • Systolic BP falls by 20

    • Pt cannot stand unassisted

Disposition, call als for

• Open fracture

• Extreme/ debilitating pain

  • Pt can’t go about normal day

• Inability to properly stabilize or splint the injury

  • This includes a dislocation, especially one where circulation is cut off

• Suspected Femur or Hip/Pelvic fracture

• Pt fell or hit their head while on blood thinners

Disposition

• Can have WUPD/friend give a ride to urgent care or habif if needed 

• Release to self if the patient can walk

  • Patients must be able to walk to RTS. It’s OK if they need crutches to walk; you can still release them. 

• Urgent care vs release to self is mostly dependent on what the patient wants. 

  • If you splint, should highly encourage them to go to urgent care/ habif 

  • If you only have to wrap, still encourage them to get it checked out if pain persists 

Advise pt to

• Rest the joint as needed and use the joint as tolerated

•  Ice for 3 hours - 20 min on and 20 min off

  • Can provide them with an ice pack

• Use compression to reduce inflammation and swelling 

  • Rewrap or redress if necessary

• Elevate the injury if possible (if extremity)

• Seek additional care

• Return Crutches

• See a dr or go to urgent care if the pain worsens or they want to get it checked out or if its a break they need to do the the er to check if bone is set right