Chapter 10 - 14 Study

patient assessment process

scene size up

primary assessment

rapid exam

history taking

secondary assessment

reassessment

scene size up - step 1

ensure scene safety

determine MOI/NOI

take standard precautions (PPE)

determine number of patients (triage)

consider additional/specialized resources

primary assessment - step 2

form a general impression

scan for signs of uncontrolled external bleeding (XABCDE)

assess level of consciousness (AVPU) / Orientation

assess the Airway: identify and treat life threats

assess Breathing: identify and treat life threats

assess Circulation: identify and treat life threats

assess Disability

assess Exposure

determine priority of patient care and transport

form a general impression

rapid identification of potentially life-threatening problems

note age, sex, race, level of distress, overall appearance

uncontrolled external bleeding

takes priority over other assessments

should be controlled before assessment proceeds

assess level of consciousness (LOC)

AVPU

Awake and Alert

responsive to Verbal stimuli

responsive to Pain

Unresponsive

assessing orientation

Person

Place

Time

Event

determine A+Ox4 or altered mental status

identify and treat life threats

begin cpr if patient in cardiac arrest

address life threat posed by exsanguinating hemorrhage if necessary

assess the airway

look for signs of airway obstruction

responsive patients - talking/crying = open airway. cant speak or cry = severe airway obstruction

unresponsive - jaw-thrust/head tilt - chin lift. use airway adjunct as necessarya

assessing breathing

ensure breathing is present and adequate

not breathing/inadequate - positive pressure ventilations

assessing circulation

assess mental status, pulse, skin condition

assessing pulse (circulation)

ensure its present

no pulse - CPR

difficult to feel/irregular - problems with circulation

assessing skin condition (circulation)

color, temp, moisture, capillary refill

assessing skin color (circulation)

pale, white, ashen, gray - poor peripheral circulation

blue - insufficient oxygen/air exchange

flushed/red - high BP, fever, heatstroke, sunburn

yellow - jaundice

assessing skin temp (circulation)

hot - fever, sunburn, hyperthermia

cool - early shock, mild hypothermia, inadequate perfusion

cold - profound shock, hypothermia, frostbite

skin moisture (circulation)

dry - normal

early shock - moist, clammy, damp

shock - wet/diaphoretic

capillary refill (circulation)

2 seconds - normal

> 2 seconds - poor peripheral circulation

assessing diability

assess pupils - PERRL

GCS score

PERRL

Pupils (are present)

Equal in size

Round in shape

Reactive to Light

gcs score

rapid exam - step 3

head to toe exam to find additional injuries

DCAP-BTLS

DCAP-BTLS

Deformity - misshapen body part

Contusions - bruising

Abrasions - damage to surface of skin

Punctures - small penetration through skin

Burns - redness, blisters

Tenderness - pain when area is palpated

Lacerations - deep cut in skin

Swelling - raised or enlarged tissue

rapid scan procedure

head, pupils

neck (jvd, deviation of trachea, spinal step off, vertebra not aligned)

chest (chest wall movement, crepitus, emphysema, equal rise and fall)

abdomen (ridgidity, distention)

pelvis (tenderness, instability if no pain)

extremities (distal pulses, motor/sensory function)

back/buttocks (stabilization)

priority of patient care and transport

determine if injuries require immediate transport

high priority: unresponsive, difficulty breathing, uncontrolled bleeding, altered LOC, severe chest pain, pale skin/poor perfusion, complicated childbirth, severe pain

some patients may benefit from remaining on scene and receiving continuing care

History taking - step 4

investigate chief complaint - history of present illness

SAMPLE history

pertinent negatives

what to document (history taking)

date

age

sex

race

past medical history

current health status: diet, medications, drug use, environment

investigate chief complaint (history taking)

most serious thing patient is concerned with

OPQRST

OPQRST (history taking)

Onset

Provocation/palliation

Quality

Region/radiation

Severity

Timing

Onset - OPQRST

What were you doing when the symptoms began?

Provocation/palliation - OPQRST

Does anything make the symptoms better or worse? How are you most comfortable?

Quality - OPQRST

What does the symptom feel like? Is it sharp, dull, crushing, tearing? Does it come in waves? Ask the patient to describe the symptom.

Region/radiation - OPQRST

Where do you feel the symptom? Does it move anywhere?

Severity - OPQRST

On a scale of 0 to 10, with 0 being “nothing at all” and 10 being “the worst you can imagine,” how would you rate your symptom?

Timing - OPQRST

How long have you had the symptom? When did it start?

identify pertinent negatives (history taking)

signs and symptoms patients do not have

helpful in identifying patients problem

SAMPLE history (history taking)

Signs and symptoms

Allergies

Medications

Pertinent past medical history

Last oral intake

Events leading up to the injury or illness

Signs and symptoms - SAMPLE

What signs and symptoms occurred at the onset of the incident?

Allergies - SAMPLE

Is the patient allergic to any medication, food, or other substance? What reactions did the patient have to any of them? If the patient has no known allergies, you should note this on the run report as “No known allergies.”

Medications - SAMPLE

What medication is the patient prescribed? What dosage is prescribed? How often does the patient take the medication? What prescription, over-the-counter, and herbal medications has the patient taken in the last 12 hours? Are there medications the patient has been prescribed but is not taking? Does the patient take recreational drugs?

Pertinent past medical history - SAMPLE

Does the patient have any history of medical, surgical, or trauma occurrences? Is there important family history that should be known?

Last oral intake - SAMPLE

When and what did the patient last eat or drink? In women of childbearing age, the “L” in SAMPLE also represents last menstrual period.

Events leading up to the injury or illness

What are the key events that led up to this incident? What occurred between the onset of the incident and your arrival? What was the patient doing when this illness started?

secondary assessment - step 5

identify hidden injuries or identify causes that may not have been identified during the 60- to 90-second exam that took place during the primary assessment.

more in depth head to toe examination

obtain vitals

vitals (secondary assessment)

blood pressure

heart rate

respiratory rate

skin condition

level of consciousness

focused assessment

generally performed on patients who have sustained nonsignificant MOIs or on responsive medical patients

focus your attention on the body part or systems affected by the priority problem or problems.

breathing - secondary assessment

listen to breath sounds

Respiratory rate

Rhythm: regular or irregular

Quality of breathing

Depth of breathing

snoring

upper airway obstruction

stridor

upper airway obstruction

heard during inspiration

wheezing

lower airway obstruction

heard during expiration

crackles

lower airway fluid

heard during inspiration and expiration

rhonchi

lower airway mucus or fluid

most prominent on expiration

head to toe exam - (secondary assessment)

• Head & Face: Check scalp, pupils, eyes, ears for drainage or blood (Battle's sign), nose, and mouth.

• Neck: Inspect for jugular vein distension (JVD), tracheal deviation, and palpate the cervical spine.

• Chest: Observe chest rise and fall, palpate ribs, and auscultate breath and heart sounds.

• Abdomen & Pelvis: Palpate abdomen for guarding, rigidity, or tenderness; gently compress pelvis for stability.

• Extremities: Check for Pulse, Motor, and Sensation (PMS) and look for deformities or edema.

• Back: Log-roll the patient to inspect the posterior spine and back

reassessment - step 6

Repeat the primary assessment

Reassess vital signs

Reassess the chief complaint

Recheck interventions

Identify and treat changes in the patient’s condition

Reassess the patient

• Unstable patients: every 5 minutes

• Stable patients: every 15 minutes

external respiration

pulmonary respiration

process of breathing fresh air into respiratory system and exchanging oxygen and carbon dioxide between alveoli and blood in pulmonary capillaries

internal respiration

exchange of oxygen and carbon dioxide between the systemic circulatory system and cells of the body

aerobic metabolism vs anaerobic metabolism

aerobic = with oxygen. cells convert glucose to energy

anaerobic = without oxygen. cells do not completely convert glucose to energy. lactic acid and other toxins accumulate

signs of adequate breathing

normal rate: 12-20/min

regular pattern

clear equal lung sounds on both sides

regular and equal chest rise and fall

signs of inadequate breathing

<12 or >20 /min

shallow depth

labored

tripod position

irregular rhythm

unequal/inadequate chest expansion

diminished breath sounds

reduced flow

skin pulling

assessment and care of patient with apnea

cheyne stokes - patient breathes with increase rate and depth followed by period of apnea

ataxic respirations - irregular, ineffective respiration without identifiable pattern

kussmaul pattern - deep, rapid respiration seen with metabolic acidosis

airway management, supplemental oxygen, ventilatory support

oropharyngeal airway indications

unresponsive patient without gag reflex

any apneic patient being ventilated with bag-mask device

oropharyngeal airway contraindications

conscious patient

patient with gag reflex

oropharyngeal airway mneasurement

measure from patients earlobe or angle of jaw to corner of mouth

nasopharyngeal airway indications

semiconscious or unconscious patient with gag reflex

patient who otherwise will not tolerate oropharyngeal airway

nasopharyngeal airway contraindications

severe head injury

history of fractured nasal bone

nasopharyngeal airway measurement

tip of patients nose to earlobe

nonrebreathing mask

significantly hypoxemic patients who are otherwise breathing adequately

10-15L/min

90% oxygen

ensure reservoir bag is full

nasal cannulas

patients with mild hypoxemia

1-6L/min

24%-44% oxygen

partial rebreathing mask

used when you want to increase patients CO2

80%-90% oxygen

venturi mask

24%-40%

used for fine tuning

tracheostomy mask

covers tracheostomy hole

use regular mask if not available

humidification

use for long term oxygen therapy

bag mask device

15L/min

100% oxygen

patients who need high concentration of oxygen and are ventilating inadequately

respiratory arrest, cardiopulmonary arrest, respiratory failure

bag mask squeeze rate

adults: every 6 seconds

children: every 2-3 seconds

perform over the course of 1 second to avoid gastric distention

adequate artificial ventilation

visible chest rise and fall

appropriate rate

heart rate returns to normal range

color improves

oxygen sat increases

inadequate artificial ventilation

minimal or no chest rise/fall

too fast or too slow

heart rate not returning to normal range

remains cyanotic, mottled, deteriorates

oxygen sat does not increase

continuous positive airway pressure (CPAP)

increases pressure in the lungs

opens collapsed alveoli

prevents further alveolar collapse (atelectasis)

pushes more oxygen across the alveolar membrane

forces interstitial fluid back into the pulmonary circulation.

cpap indications

alert and able to follow commands

Patient is displaying obvious signs of moderate to severe respiratory distress from an underlying pathology, such as pulmonary edema or obstructive pulmonary disease

Respiratory distress occurs after a submersion incident

Patient is breathing so rapidly that it affects overall minute volume.

Pulse oximetry reading is less than 90%.

cpap contraindications

Patient is in respiratory arrest or has agonal respirations.

Patient is hypoventilating (slow respiratory rate and/or reduced tidal volume).

Patient cannot speak.

Patient is unresponsive or otherwise unable to follow verbal commands.

Patient cannot protect his or her own airway.

Patient has hypotension (systolic blood pressure less than 90 mm Hg).

Signs and symptoms of a pneumothorax or chest trauma are present.

Patient has a tracheostomy.

Active gastrointestinal bleeding, nausea, or vomiting is present.

Patient has experienced facial trauma.

Patient is in cardiogenic shock.

Patient cannot sit upright.

System mask and strap cannot be properly fit.

mild airway obstruction

as long as patient can talk, breathe, or cough forcefully, do not interfere

severe airway obstruction

adults - 5 back pats, 5 abdominal thrusts

infants - 5 chest pats, 5 back pats

if becomes unconscious, begin CPR

BEMAGIC

B - perform Bag mask preoxygenation

E - Evaluate for airway difficulties

M - Manipulate the patient

A - Attempt first pass intubation

GI - use supraglottic airway if unable to intubate

C - Confirm successful intubation

What are the types of shock by cause?

• Pump failure: cardiogenic, obstructive • Poor vessel function: distributive (septic, neurogenic, anaphylactic, psychogenic) • Low volume: hypovolemic

What is cardiogenic shock?

• Heart (pump) failure • Heart can’t keep up cardiac output • Cardio = heart

What is obstructive shock?

• A blockage stops blood distribution • Tension pneumothorax • Cardiac tamponade • Pulmonary embolism

What is distributive shock?

• Widespread vessel dilation • Blood pools, perfusion drops • Septic, neurogenic, anaphylactic, psychogenic

What is septic shock?

• Severe infection (usually bacterial) • Bacteria release toxins

What is neurogenic shock?

• Spinal cord injury (upper cervical) • Vessels lose their tone below the injury

What is anaphylactic shock?

• Severe allergic reaction • To a substance the person is sensitized to • Injection, sting, ingestion, inhalation

What is psychogenic shock?

• Sudden nervous system reaction • Temporary vasodilation • Causes fainting (syncope)

What is hypovolemic shock?

• Too little fluid in the circulation • Hemorrhagic: bleeding • Nonhemorrhagic: vomiting, diarrhea, burns, dehydration

Cardiogenic shock: how does low cardiac output develop?

• Cardiac output = volume pumped per minute • Contractility: strength of contraction • Preload: blood returning to the heart • Afterload: resistance the heart pumps against • Low preload, poor contractility, or high afterload

Cardiogenic shock: how does it cause pulmonary edema?

• Weak heart: blood backs up into the lungs • Fluid leaks into the alveoli • Oxygen can’t diffuse: tachypnea, crackles

Obstructive shock: how does cardiac tamponade cause shock?

• Blood or fluid fills the pericardial sac • Squeezes the heart • Ventricles can’t refill: output falls

Obstructive shock: how does tension pneumothorax cause shock?

• Air leaks into the chest; lung collapses • Pressure shifts the mediastinum • Vena cava compressed: less blood returns, BP drops

Obstructive shock: how does pulmonary embolism cause shock?

• Clot blocks the pulmonary arteries • Blood backs up in the right ventricle • Left heart gets no blood

Septic shock: how does it develop?

• Toxins damage vessel walls • Vessels leak plasma and dilate • Low volume plus a bigger container • Fluid may collect in the alveoli

Neurogenic shock: how does it develop?

• Spinal injury blocks sympathetic signals • Vessels below the injury dilate • Blood pools; 6 L can’t fill the space • No blood loss needed

Neurogenic shock: why is the skin warm and why is hypothermia a risk?

• No vasoconstriction: skin stays warm • Temperature control is lost • Body temperature falls to match the environment

Anaphylactic shock: how does it develop?

• Person is sensitized to a substance • Re-exposure causes vasodilation • Increased vessel permeability • Bronchoconstriction