patient care Flashcards
Patient Assessment
Two primary components
1. Information gathering:
MOI for trauma patients
NOI for medical patients
Ascertain the Hx of the events leading up to EMS activation, gather a SAMPLE Hx, etc
2. Physical examination
ABC or CAB, followed by appropriate examination medical or trauma
Patient Assessment fundamental components
Identify problems- done during primary and secondary survey
Set priorities- determine immediate threats to life/limb (during primary and RTA/RMA)
Develop a care plan- how will you intervene
Execute the plan- perform your interventions and reassess, ALWAYS REASSESS
elements of patient assessment
Gather information
Primary source of information is usually the patient
Other sources include the patient’s family, friends or eyewitnesses to the emergency event
Be observant, it may be necessary to gather information from the scene itself
Primary Survey C-EMCA-P
- Confirm the call information with dispatch
- Environmental hazard check
- Mechanism of injury
- Casualty numbers
- Additional resources required
- Personal protection required
Primary Survey
LOA - Level Of Awareness (AVPU)
Manual C-spine Control (as required)
Airway or Circulation
Breathing or Airway
Circulation or Breathing
Critical Injuries And Gross Bleed Check
Critical Interventions
Primary Survey General impression
The Paramedic will immediately form a “general impression” of the patient. This is also referred to as the Look Test
What do you see?
Focuses on identification and management of life-threatening problems
Medical
Is my patient sick?
If so, how sick are they?
Trauma
Is my patient hurt?
If so, how badly hurt are they?
General impression signs of distress
Altered mental status
Anxiousness
Laboured breathing
Difficulty speaking
Diaphoresis
Poor colour
Obvious pain
Obvious deformity, guarding or splinting
Gross external hemorrhage
Mental Status and Neurological Function
Mental status
One of the prime indicators of how sick the patient really is
Are there changes in the state of consciousness? (do they present with AMS or is this normal for patient?)
Establish a baseline as soon as you encounter a patient.
The Chief complaint
The “Chief Complaint” is determined at the outset of patient contact. It often comes prior to the Primary Survey, as you approach the patient. Or it can be elicited very quickly as you begin to communicate about why the patient called for an ambulance.
C-spine
Evaluate
First for the MOI- is there reason to suspect this pt requires SMR
Altered mental status?
Presence of pain
Distracting injury?
THE BASIC ABCDE’S
AIRWAY
- Open the airway
- Clear the airway
- Insert an oral/nasal airway prn
BREATHING
- Assess breathing
- BVM Ventilations prn
- Supplemental oxygen prn
CIRCULATION
- Assess pulses
- CPR prn (if pt is unconscious CAB)
DISABILITY
-pupillary response
-neuro deficits
EXPOSE- inspect the patient, cut away clothing prn
Airway Status
Focuses primarily on two questions:
1. Is the airway open and patent?
how is the pt positioned? foreign body?
2. Is it likely to remain so?
Are there Sonorous sounds?
Are there Gurgling or bubbling sounds ?
Work from Simple to Complex
Easiest problem to solve is position- requires no special equipment
Possibility of spine injury drives the decision of which technique to use to open the airway.
Head tilt-chin lift or jaw thrust
If Obstruction is present or suspected utilize BLS procedures to clear the obstruction.
BASIC AIRWAY what to do to open
Open And Clear The Airway:
Chin lift and/or modified jaw thrust maneuver.
Visualize the oro-pharynx
Suction and/or remove foreign bodies.
Insert an oral airway if the patient has a decreased LOC and NO gag reflex.
Insert a nasal airway if the patient has a decreased LOC and a gag reflex.
V-Vac
Suction only as far
as you can see…
Measure from
corner of mouth to
tragus
Adult setting=380mmHg
No more than 10 sec
intervals
oropharyngeal airway
An oropharyngeal airway holds back the tongue. Insert an oral airway if the patient has a decreased LOC and NO gag reflex.
Nasopharyngeal Airway
A nasopharyngeal airway runs behind the tongue. Insert a nasal airway if the patient has a decreased LOC and a gag reflex. Note that one (1), nasal airway is sufficient. Two (2) nasal airways can be inserted
King LT Airway
The King LT airway comes in three (3) different sizes for use in adults.
The choice of which size to use is based on the estimated height of the patient. Each size is differentiated by the colour of the tip:
. YELLOW – 4 to 5 feet (122-155 cm)
#4. RED – 5 to 6 feet (155-180 cm)
#5. PURPLE – Over 6 feet (> 180 cm)
Supraglottic Airway Directive indications
Indications
Need for ventilatory assistance or airway control
AND Other airway management is ineffective
patient must be in cardiac arrest
maximum 2 attempts
Supraglottic Airway Directive contraindications
Inability to clear the airway
Stridor
Active vomiting
Airway edema
Caustic ingestion
Breathing minute volume
Respiratory rate multiplied by the tidal volume
Resp Rate x tidal volume
Amount of air actually moved in to and out of the lungs each minute
Basic breathing, assess for adequacy
Look – for rise and fall of the chest. Listen – for the sound of moving air. Feel – for breath on your hand or cheek. Determine whether the patient is breathing, and then whether
the patient is breathing adequately. Determine the approximate rate, rhythm and quality
Basic breathing inadquate level and what to do
8-10 rpm = assist ventilations>
28 rpm with a decreased LOC = assist ventilations.
Claps
Look for CLAPS to ascertain injuries to the thorax and the lungs
C-ontusions
L-acerations
A-brasions
P-enetrations
S-ubcutaneous Emphysema
TICS-D
Look for TICS-D to ascertain injuries to the ribs, sternum and clavicles
T-enderness
I-nstability
C-repitus
S-welling
D-eformity
Circulation Pulse
Provides a rapid check of the patient’s cardiovascular status,
Information about the rate, strength, and regularity of heartbeat
Note the force and rhythm of the pulse- compare central & peripheral
Circulation Skin Colour
Skin colour, temperature, and condition
Collectively provide insight into the patient’s overall perfusion
Use the back of your hand to assess the warmth and moisture of the patient’s skin.
Colour of the skin reflects the status of the circulation immediately underlying the skin.
Normal skin is moderately warm and dry.
Adequate Circulation rate rhytm quality
Rate - normal = 60 – 100 bpm
- too fast = > 160 bpm
- too slow = < 50 bpm
Rhythm - regular
- irregular
Quality - strong
- weak
Capillary Refill
Blanch the skin and wait for the colour to return
< than 2 seconds = normal
> than 2 seconds = delayed
RAPID TRAUMA ASSESSMENT
Typically done between the Primary Survey (initial assessment) and the Secondary Survey (focused physical examination) of a trauma patient
It is an organized, systematic and rapid head to toe exam used to identify any potential threats to life/limb that may not have been apparent during the initial primary survey
RAPID TRAUMA ASSESSMENT Indications
There was a significant mechanism of injury (ex. a high-speed car accident) OR
The patient has analtered mental status OR
The paramedic suspects that the patient hasmulti-system trauma
CRITICAL INJURIES CHECK
The Critical Injuries Check is a rapid “Neck-to-Knees” assessment for gross bleeding as well as findings more specific to their location: RTA
Head – AMS, CLAPS/TICS-D,
Neck – JVD, tracheal deviation, CLAPS/TICS-D.
Chest – auscultation, CLAPS/TICS-D.
Abdomen – observe and palpate all four (4) quadrants for tenderness, distension, rigidity, penetrations.
Pelvis – palpate and compress for TICS-D.
Femurs – palpate for CLAPS/TICS-D
CRITICAL INTERVENTIONS
Critical Interventions are procedures that MUST be completed prior to transport, even with a critical patient:
Oro/nasal airway (decreased LOC).
100% oxygen +/- positive pressure ventilations (hypoxia).
Chest compressions (VSA).
Defibrillation (Cardiac Arrest Protocol –Trauma/Medical).
Hemorrhage control (gross bleed).
Cervical collar (suspected spinal injury).
Spinal board + head immobilization (suspected spinal injury).
Occlusive dressing - open neck wound (4-sided)
- open abdominal wound (4-sided)
- open chest wound (3-sided)
DEFIBRILLATION
It is important to apply the monitor/defibrillator without delay to any patient who is suspected to be in cardiac arrest.
For all other patients, the monitor should be applied as a “bridge” device between the Primary Survey and the Secondary Survey.
Therefore, if you do NOT believe it may be necessary to immediately defibrillate your patient, the cardiac monitor should be applied AFTER the Critical Injuries Check, and AFTER any Critical Interventions.
Defibrillate which rhythms
Ventricular fibrillation
Pulseless Ventricular Tachycardia
MARCH
Massive Haemorrhage
Airway
Respirations
Circulation
Head Injury/Hypothermia
its a framework forprioritized trauma care to adress in order
Massive Hemorrhage
M- bleeding controlis priority in trauma patients
Not all bleeding control is a priority. Bleeding could easily refer to a spurting, lacerated artery or trickling blood from a skin tear or a scrape
the term “massive hemorrhage” gives a clear picture; immediate, active, life-threatening bleeding that will kill a patient if not stopped.
Massive Hemorrhage adressed by
Massive hemorrhage can be addressed by (D’s):
Detect: find the source of the bleeding.
Direct pressure: hold pressure on the source of the bleeding until the clot forms.
Devices: if necessary, use equipment such as tourniquets, hemostatic gauze and pressure bandages to supplement direct pressure.
Don’t dilute: use the concept of permissive hypotension to avoid thinning the blood or popping established clots.
March Airway
AIRWAY CONTROL
A –airway management is still a key elementfor severe traumatic injuries.
March Respiratory Support
must ensure proper respiratory support. The pt who is not breathing or breathing inadequately must have assisted ventilations provided. Care must be taken to provide only enough volume to ensure adequate chest rise and fall. Aggressive or “over-bagging” may worsen a developing pneumothorax or increase intrathoracic pressure, decreasing venous return
March Circulation
C- refers to shock. After massive hemorrhage, airway and breathing have been addressed, the patients circulatory status needs to be optimized
Basic methods for circulation improvement, such as laying the patient flat, maintaining body temperature (prevent coagulopathy) and careful fluid resuscitation may be required
March Hypothermia
Hypothermia is a critical factor in trauma. It is a key part of the trauma triad of death, which includes Hypothermia, Acidosis- (which disrupts the blood’s ability to properly carry oxygen), and Coagulopathy (reduced ability to clot). The trauma triad can begin with any one of these elements, each of them feeding the other
March Head Injury
Head injury care is virtually all about making sure the primary injury (the initial impact) does not progress into a secondary injury (injury caused or made worse by inadequate EMS care).
Care for patients with severe head injuries must avoid the H bombs
March Hypoxia
even a brief drop in oxygen saturation can cause permanent secondary brain injury.
March Hyperventillation
hyperventilation will blow off too much CO2, causing cerebral vasoconstriction, decreasing perfusion to the brain.
March Hypotension
as ICP increases, the blood pressure required to perfuse the brain also increases. The rule of thumb is to avoid systolic blood pressure below 90 mm/Hg to avoid states of decreased perfusion
March Hypoglycemia
an injured brain deprived of much needed sugar will have a worse outcome
SS VItal Signs
- Pulse -Respirations -Blood Pressure
-O2 Sat. -Skin -Pupils
-GCS -Blood Glucose -ETCO2
SS Head to toe exam
Head Neck Chest
Abdomen Pelvis Back
Extremities
SS Incident and Medical History
SAMPLE – To illicit a patient history and a history of events.
OPQRST – To illicit a description of the pain and the patient’s response to treatment.
SS Respiration
Rate, Rhythm, Volume (tidal volume-full, shallow, labored)
Look, listen and feel
Can include SPO2 here (refer to BLS-PCS O2 therapy standard)
measures percentage of hemoglobin saturation.
if in doubt treat the patient, not the monitor (false readings)
SS Heart Rate
Rate, Rhythm, Volume
Are pulses present? if so compare peripheral to central
Is it fast, slow, regular, irregular?
Full, bounding, weak, thread?
If not performed, can include skin Colour, Temp, Condition here
SS Blood Pressure
Recorded as Systolic over diastolic
It is the measurement of force exerted against walls of blood vessels
BP=CO x PVR
Systolic pressure created by LV during contraction
Diastolic pressure produced during LV relaxation
SS Pupils
Assess for size, equality and reactivity
Alterations in any of these may indicate injury or illness such as intracranial bleed (pressure on occulomotor nerve), toxicological ingestion/OD, hypoxia
Cardiac/ECG Monitoring
Another tool used for patient assessment to observe and monitor the heart rhythm
Can be used to determine the electrical rate-which should be compared to mechanical rate or palpable pulse.
Monitor for changes in patient’s rhythm which may be unstable or life threatening, such as Vtach
Always treat the patient, not the monitor (PEA)
Standard monitoring performed using limb leads
Leads I, II, III
Together these make up Einthoven’s Triangle
Eithovens Triangle
Right arm, Left arm, Left leg
Lead Placement
Limb lead placement
white (RA) right upper chest/shoulder
black (LA) left upper chest/shoulder
red (LL) left lower ABD
green (RL) right lower ABD (ground)
OPQRST
Onset- what was patient doing during onset of symptoms
Provoking Factors- what makes pain worse/better
Quality- What is quality of pain? how does pt describe it? (dull sharp burning crushing tearing constant intermittent)
region/radiation
severity
time
SAMPLE
SIgns and Symptoms
Allergies
Medications
Past pertinent medical history
Last oral Intake
Events prior to condition
Reassessment
With any change in patient status or condition or if you have rendered any treatment you must repeat your assessment
Start at the top…LOA/LOC, ABC or CAB depending on patient presentation
Repeat vital signs
Reassess the treatment you have provided, ie. OPA, BVM, hemorrhage control, symptom relief
Observe trends in the patient’s current condition. Do they remain unchanged, is the patient improving or deteriorating?
Advanced ABCD’S
AIRWAY- Gain control of the airway by inserting a KingLT. (or ETT)
BREATHING- Confirm ETT or KingLT placement by auscultating for breath sounds and with Capnography (ETCO2).
CIRCULATION- Obtain intravenous access.
- Give rhythm appropriate medication.
DIFFERENTIAL DIAGNOSES - What are the possible problems or reasons that may have caused the patient’s condition?
Advanced Breathing
Confirm ETT placement
and effective breath sounds.
You will have to use the Easy-Cap or Capnography as part of your protocol for confirming proper ETT placement.
Advanced Circulation drugs
Obtain intravenous access in order to deliver an IV fluid bolus or appropriate IV medication.
This usually involves the immediate administration of medication or IV therapy that is appropriate to the patient’s chief complaint, or the provisional diagnosis.
In some cases, chiefly where the patient is found to be in critical condition (i.e. VSA), no further investigation or deliberation is required for the administration of drugs such as Epinephrine or Atropine, or for an IV fluid bolus.
In other cases, more investigation is required before the administration of certain drugs. Such as a full set of vital signs and an incident and medical history before the administration of D50%W or Nitroglycerin.
In still other cases, more deliberation is required via Base Hospital Contact, before the administration of drugs such as Adenosine or Dopamine. In these cases it is also wise to obtain a complete set of vital signs as well as an incident and medical history, as it could be crucial to the decision making process.
Advanced differential Diagnosis
“the distinguishing between two or more diseases with similar symptoms by systematically comparing the signs and symptoms.
Differential diagnosis is best performed by understanding the dimensions of human pathophysiology before you are faced with the patient. Then by approaching the patient with an open mind, allowing your judgment to be guided solely by a thorough physical examination and by obtaining accurate signs and symptoms. Any conclusions must never be final, but rather open to further developments as they evolve. This entire process can be aided greatly by field experience and continued medical education.
Advanced Differential Diagnosis When in doubt
When in doubt, the philosophy of “find a symptom, treat a symptom” will at least allow for FORWARD MOMENTUM.
Not breathing adequately … Ventilate!
Shortness of breath and wheezing … Give Salbutomol!
The medical patient Survey
C – EMCA – P
Level Of Consciousness - (AVPU)
Airway - Open the airway / Insert an oral/nasal airway
Breathing - BVM Ventilations / Supplemental O2
Circulation - Pulse checks / CPR
Defibrillation - “Shock” VF / “Shock” Pulseless VT
Advanced Airway - Intubate the patient
Advanced Breathing - Confirm ETT placement
Advanced Circulation - Obtain intravenous access
Differential Diagnosis - Reasons for the patient’s condition?
Secondary Survey - Vitals / SAMPLE / OPQRST / 12-LEAD
SRP Protocol – ASA / Nitro. / Epi. /Glucagon / Ventolin
Load And Go - Notify ER - Stroke / Acute Trauma / STEMI
Reassessment - Vitals / Further SRP (Repeat SRP Drug Doses)
The trauma Patients Survey
C – EMCA – P
Level Of Consciousness - (AVPU)
Manual c-spine
Airway - Open the airway / Insert an oral/nasal airway
Breathing - BVM Ventilations / Supplemental O2
Circulation - Pulse checks / CPR
Defibrillation - “Shock” VF / “Shock” Pulseless VT (X 1 ONLY)
Advanced Airway - Intubate the patient
Advanced Breathing - Confirm ETT placement
Differential Diagnosis - Reasons for the patient’s condition?
Critical Injuries Check - Neck-to-Knees / Gross Bleed
Critical Interventions - Occlusive Dressing / Chest Needle
Load And Go - Notify ER (Trauma Pre-Alert)
Secondary Survey - Vitals / SAMPLE / Head-to-Toe
Advanced Circulation - Obtain IV access (large bore x 2)
Reassessment - Vitals / Further Treatment (Splinting/Dressing)
OPEN HEAD INJURY
CLAPS / TICS-D
- Basal Skull Fracture:
- rhinorrhea
- ottorrhea
- battle sign
- racoon eyes
CLOSED HEAD INJURY
Widening pulse pressure
- Bradycardia (X)
- Ipsilateral dilation (III)
- Ataxic respirations
- Decorticate positioning
- Decerebrate positioning
CLOSED PNEUMOTHORAX
CLAPS / TICS-D
- A/E Affected side
OPEN PNEUMOTHORAX
CLAPS / TICS-D
- Open Wound
- A/E Affected side
TENSION PNEUMOTHORAX
CLAPS / TICS-D
- Absent A/E Affected side
- A/E Unaffected side
- Mediastinal shift
- Tracheal Deviation
HEMOMOTHORAX
CLAPS / TICS-D
- A/E Affected side
- Hypotension
- S + S of Shock
CARDIAC TAMPONADE
CLAPS / TICS-D
- Sternal Trauma
- Hypotension
- JVD
- Muffled Heart Sounds
BLUNT ABDOMINAL TRAUMA
CLAPS
- Pain
- Distension
- Rigidity
- Guarding
- Doughyness
PENETRATING ABDOMINAL TRAUMA
CLAPS
- Pain
- Distension
- Rigidity
- Guarding
- Evisceration
HEMORRHAGIC SHOCK
Tachycardia - Tachypnea - Pale, Cool, Clammy - Narrowing Pulse Pressure (Hypotension) - Decreasing LOC
FRACTURED PELVIS
CLAPS
- TICS-D
- Pain
- Instability
- Crepitus
HEMORRHAGIC SHOCK
Tachycardia
- Tachypnea
- Pale, Cool, Clammy
- Hypotension
- Decreasing LOC
NEUROVASCULAR ASSESSMENT
Pain
- Pallor
- Pulselessness
- Parasthesia
- Paralysis
NEUROVASCULAR DEFICIT
Manipulate x 1
- Reassess
- Splint As Found
- Load And Go
CRITICAL INJURY
Bilateral Fractured Femurs
- Load And Go
HEMORRHAGE CONTROL
Direct Pressure
- Elevate Limb
- Rest Patient
- Pulse Point Pressure
- Tourniquet (BP Cuff)
HEMORRHAGIC SHOCK
Tachycardia
- Tachypnea
- Pale, Cool, Clammy
- Hypotension
- Decreasing LOC
