lesson 04

Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

Lesson 4Lesson 4

Principles of Assessment and Principles of Assessment and ManagementManagement

Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 2

ObjectivesObjectives

As a result of active participation in this As a result of active participation in this lesson you should be able to:lesson you should be able to: Identify potential threats to the safety of patients, Identify potential threats to the safety of patients,

bystanders, and emergency personnel that are bystanders, and emergency personnel that are common to all emergency scenescommon to all emergency scenes

Differentiate between critical and noncritical Differentiate between critical and noncritical patientspatients

Integrate analysis of scene safety, scene situation, Integrate analysis of scene safety, scene situation, and kinematics along with the physical findings and kinematics along with the physical findings and history to make patient care decisionsand history to make patient care decisions


Establishing Priorities Establishing Priorities of Scene Assessmentof Scene Assessment

Scene assessment includes:Scene assessment includes: Scene safety issuesScene safety issues Scene situationScene situation An abbreviated form of triageAn abbreviated form of triage Determining whether you have a multi-patient or Determining whether you have a multi-patient or

mass casualty incident mass casualty incident


Scene SafetyScene Safety

What are the components What are the components for assessing scene safetyfor assessing scene safety Ensure safety of rescuers Ensure safety of rescuers

and patientsand patients Threatening situations may Threatening situations may

includeinclude• Fire/electricalFire/electrical

• Hazardous materials/blood Hazardous materials/blood and other body fluidsand other body fluids

• Traffic/weather conditionsTraffic/weather conditions

• Hostile individuals/weaponsHostile individuals/weapons Others?Others?

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Scene SituationScene Situation

What really happened?What really happened? What are the kinematics?What are the kinematics? How many patients are involved? Ages?How many patients are involved? Ages? Additional resources needed?Additional resources needed? How will patients be transported?How will patients be transported?


Personal Protective EquipmentPersonal Protective Equipment

Personal protective equipment includes:Personal protective equipment includes: GlovesGloves Eye protectionEye protection MasksMasks Gowns Gowns

Ensure proper handling/disposal of contaminated items!


ScenarioScenario

A 47-year-old male is crossing A 47-year-old male is crossing a busy city street when he is a busy city street when he is struck by a sedan traveling at struck by a sedan traveling at a speed of approximately 30 a speed of approximately 30 mph (48 km/hr). He is tossed mph (48 km/hr). He is tossed onto the hood of the car and onto the hood of the car and strikes the windshield before strikes the windshield before tumbling to the pavement.tumbling to the pavement.


Establishing Priorities of Patient Establishing Priorities of Patient Assessment (Primary Survey)Assessment (Primary Survey)

First goal is to determine patient’s current First goal is to determine patient’s current conditioncondition Use an organized, systematic approachUse an organized, systematic approach Quick and efficient performance of 5 stepsQuick and efficient performance of 5 steps Time is criticalTime is critical

The most common basis of life-threatening injuries

is a lack of adequate tissue oxygenation!


Step One: Airway Management and Step One: Airway Management and Cervical Spine StabilizationCervical Spine Stabilization

If airway is compromised, use manual If airway is compromised, use manual methods to stabilizemethods to stabilize

Clear airway if neededClear airway if needed Special handling and consideration of the Special handling and consideration of the

cervical spine is necessary at this pointcervical spine is necessary at this point


Step Two: Breathing (Ventilation)Step Two: Breathing (Ventilation)

Spontaneously breathing patientSpontaneously breathing patient Estimate adequacyEstimate adequacy Assess oxygenation/concentrationAssess oxygenation/concentration Evaluate rate and depthEvaluate rate and depth Listen to lungsListen to lungs

Rate can be divided into five categoriesRate can be divided into five categories ApneicApneic SlowSlow NormalNormal FastFast Abnormally fastAbnormally fast


Step Two: Breathing (Ventilation)Step Two: Breathing (Ventilation)

Hypoxia can result from Hypoxia can result from inadequate ventilation inadequate ventilation of lungs or lack of of lungs or lack of oxygen to tissueoxygen to tissue Nonbreathing patientNonbreathing patient

• Immediate use of Immediate use of BVMBVM

• Maintain patent Maintain patent airway with adjunctsairway with adjuncts

• Continue to assist Continue to assist ventilationventilation


Step Three: Circulation Step Three: Circulation (Bleeding Control)(Bleeding Control)

Oxygenation of the RBCs without delivery to Oxygenation of the RBCs without delivery to the tissue cells is of no benefit to patientthe tissue cells is of no benefit to patient

Two components of assessment and Two components of assessment and management of circulationmanagement of circulation PerfusionPerfusion Bleeding controlBleeding control


Step Three: CirculationStep Three: Circulation(Bleeding Control)(Bleeding Control)

External bleedingExternal bleeding Capillary, venous, arterialCapillary, venous, arterial Control is a major priorityControl is a major priority

• DIRECT PRESSUREDIRECT PRESSURE

• ElevationElevation

• Pressure pointsPressure points

• TourniquetsTourniquetsA fisherman who was run over by a motorboat suffered severe damage to his lower extremities. His life was saved by first responders who applied tourniquets to both thighs.


Step Three: CirculationStep Three: Circulation(Bleeding Control)(Bleeding Control)

Internal bleedingInternal bleeding Suspect injurySuspect injury Three primary sourcesThree primary sources

ThoraxThorax AbdomenAbdomen Major fractures (pelvis most likely)Major fractures (pelvis most likely)

Expose to inspect and palpateExpose to inspect and palpate Management may include use of PASGManagement may include use of PASG


Step Four: DisabilityStep Four: Disability

Assess cerebral Assess cerebral oxygenation/functionoxygenation/function

Hypoxia is the most Hypoxia is the most clinically important cause clinically important cause of altered mental statusof altered mental status

AVPU scaleAVPU scale Glasgow Coma ScaleGlasgow Coma Scale Pupillary responsePupillary response


Step Four: DisabilityStep Four: Disability

AVPU ScaleAVPU Scale AlertAlert VoiceVoice PainPain UnresponsiveUnresponsive

Glasgow Coma ScaleGlasgow Coma Scale Provides good baseline Provides good baseline

for cerebral functionfor cerebral function Divided into three Divided into three

sectionssections

• Eye openingEye opening

• Best verbalBest verbal Intubated patients get Intubated patients get

“T” for verbal score“T” for verbal score

• Best motorBest motor


Step Five: Expose/EnvironmentStep Five: Expose/Environment

Expose to evaluate and identify hidden injuriesExpose to evaluate and identify hidden injuries Prevent hypothermiaPrevent hypothermia Respect the patient’s Respect the patient’s

modestymodesty


Scenario: AssessmentScenario: Assessment

The scene is safe and secured by police. You The scene is safe and secured by police. You have one pale, conscious, alert patient laying have one pale, conscious, alert patient laying on the sidewalk with abrasions noted to his on the sidewalk with abrasions noted to his face. You note that his right forearm is face. You note that his right forearm is deformed as you approach and begin your deformed as you approach and begin your assessment. He states he is in a lot of pain and assessment. He states he is in a lot of pain and is begging you to help.is begging you to help.


Scenario:Scenario: Assessment of Airway Assessment of Airway

What is the patient’s airway status?What is the patient’s airway status? What precautions should be taken while What precautions should be taken while

evaluating his airway?evaluating his airway? What indicators are What indicators are

present that he may present that he may have a cervical have a cervical spine injury?spine injury?


Scenario: Scenario: Assessment of Breathing Assessment of Breathing

The patient is taking shallow breathsThe patient is taking shallow breaths—— between between 20 and 30 per minute. He has equal, adequate 20 and 30 per minute. He has equal, adequate chest rise with each breath. He speaks in full chest rise with each breath. He speaks in full sentences as he complains of pain to his arm and sentences as he complains of pain to his arm and pelvic region.pelvic region.


Scenario:Scenario:Assessment of BreathingAssessment of Breathing

What is your assessment of his respiratory What is your assessment of his respiratory status at this point?status at this point?

What should be your next assessment and What should be your next assessment and treatment considerations?treatment considerations?


Scenario:Scenario:Assessment of CirculationAssessment of Circulation

The patient is pale and cool to your touch. He The patient is pale and cool to your touch. He has a weak, fast radial pulse present and his has a weak, fast radial pulse present and his capillary refill is delayed at his fingertips. You capillary refill is delayed at his fingertips. You note no obvious significant external bleeding. note no obvious significant external bleeding.


Scenario:Scenario:Assessment of Circulation Assessment of Circulation

(Bleeding Control)(Bleeding Control) What is your initial impression regarding the What is your initial impression regarding the

circulatory status of your patient?circulatory status of your patient? What indicators are present?What indicators are present? Do you suspect any bleeding is occurring?Do you suspect any bleeding is occurring? What should be your next assessment and What should be your next assessment and

treatment considerations?treatment considerations?


Scenario: Scenario: Assessment of DisabilityAssessment of Disability

The patient continues to complain of pain and The patient continues to complain of pain and curse at the driver who struck him. He is calling curse at the driver who struck him. He is calling out a phone number and asking that someone out a phone number and asking that someone please call his wife. His pupils appear to be please call his wife. His pupils appear to be equally reactive and slightly constricted as he equally reactive and slightly constricted as he lays in the bright sunlight on the sidewalk.lays in the bright sunlight on the sidewalk.


Scenario:Scenario:Assessment of DisabilityAssessment of Disability

What is the patient’s level What is the patient’s level of consciousness?of consciousness?

Based on the immediately Based on the immediately available information, what available information, what is his Glasgow Coma Score?is his Glasgow Coma Score?

What does his pupillary What does his pupillary response tell you about his response tell you about his neurological condition?neurological condition?


Scenario:Scenario:Assessment Expose/EnvironmentAssessment Expose/Environment

The weather is warm and clear. Your patient The weather is warm and clear. Your patient continues to complain of pain to his arm and continues to complain of pain to his arm and pelvic region. pelvic region.



What areas of the body should be uncovered What areas of the body should be uncovered and evaluated?and evaluated?

What are your concerns regarding inspection of What are your concerns regarding inspection of the:the: ThoraxThorax AbdomenAbdomen PelvisPelvis ExtremitiesExtremities



After exposing and inspecting the chest, abdomen, After exposing and inspecting the chest, abdomen, and pelvic region, you discover a large contusion and pelvic region, you discover a large contusion and tenderness to the belly and extreme pain and and tenderness to the belly and extreme pain and instability to the pelvis. Law enforcement officers instability to the pelvis. Law enforcement officers have minimized the number of onlookers, and have minimized the number of onlookers, and removed unnecessary bystanders.removed unnecessary bystanders.


ResuscitationResuscitation(Critical Patients)(Critical Patients)

““Treat as you go” philosophyTreat as you go” philosophy Limited scene interventionLimited scene intervention Scene time should be limited to 10 minutes Scene time should be limited to 10 minutes

when possiblewhen possible Effort directed at correcting life-threatening Effort directed at correcting life-threatening

problems with primary survey and preparing problems with primary survey and preparing for rapid transport to the closest appropriate for rapid transport to the closest appropriate facilityfacility


Critical Patient CriteriaCritical Patient Criteria

Inadequate or threatened airwayInadequate or threatened airway Impaired ventilationImpaired ventilation Significant hemorrhage (external or Significant hemorrhage (external or

suspected internal)suspected internal) Abnormal neurologic statusAbnormal neurologic status Penetrating trauma to head, neck, torsoPenetrating trauma to head, neck, torso Amputation, near amputationAmputation, near amputation Trauma in presence of other significant Trauma in presence of other significant

findingsfindings


Treatment Options:Treatment Options:Critical Trauma PatientsCritical Trauma Patients

IntubationIntubation Needle decompressionNeedle decompression PASGPASG

Option with circulatory insufficiencyOption with circulatory insufficiency May be useful with bleeding control/pelvic injuriesMay be useful with bleeding control/pelvic injuries Systolic below 60Systolic below 60


Treatment Options:Treatment Options:Critical Trauma PatientCritical Trauma Patient

Critical patients should be rapidly packaged Critical patients should be rapidly packaged and prepared for transport after primary and prepared for transport after primary survey and initial interventions have been survey and initial interventions have been completedcompleted

Fluid resuscitationFluid resuscitation Lactated Ringer’s is fluid of choiceLactated Ringer’s is fluid of choice Two large-bore catheters (14-16 gauge)Two large-bore catheters (14-16 gauge) En route procedureEn route procedure


Transport DecisionsTransport Decisions

Closest appropriate facilityClosest appropriate facility Critically injured should go to a designated trauma Critically injured should go to a designated trauma

centercenter Receiving facility should be determined by local Receiving facility should be determined by local

protocolprotocol Mode of transport-ground vs. airMode of transport-ground vs. air

Evaluate patient’s needs, terrain, traffic, weather, Evaluate patient’s needs, terrain, traffic, weather, location of receiving facilitylocation of receiving facility


Trauma Center CandidatesTrauma Center Candidates

Physiologic criteriaPhysiologic criteria Most likely to need Most likely to need

urgent surgeryurgent surgery Anatomic criteriaAnatomic criteria

Life threats based on Life threats based on anatomic location anatomic location

Mechanism of injuryMechanism of injury Life or limb threatLife or limb threat

Preexisting conditionsPreexisting conditions


Scenario:Scenario:Resuscitation, Treatment Resuscitation, Treatment

and Transportand TransportYou are approximately 10 You are approximately 10 minutes (by ground transport) minutes (by ground transport) to a trauma center. Your partner to a trauma center. Your partner has brought the necessary has brought the necessary packaging and immobilization packaging and immobilization equipment to your side. The equipment to your side. The patient has become lethargic patient has become lethargic and now has an absence and now has an absence of radial pulses.of radial pulses.


Scenario:Scenario:Resuscitation, Treatment Resuscitation, Treatment

and Transportand Transport Is this a critical trauma patient?Is this a critical trauma patient? Why?Why? How should the patient be packaged?How should the patient be packaged? Where should the patient be transported?Where should the patient be transported? What interventions should be initiatedWhat interventions should be initiated

On scene?On scene? En route?En route?


Components of the Components of the Secondary SurveySecondary Survey

Vital signsVital signs Full setFull set

AMPLE historyAMPLE history AllergiesAllergies MedicationsMedications Past medical historyPast medical history Last mealLast meal Events preceding injuryEvents preceding injury

Neurological examNeurological exam Calculate GCSCalculate GCS Motor and sensoryMotor and sensory Pupillary responsePupillary response

Head-to-toe examHead-to-toe exam Evaluate each regionEvaluate each region

• ObservationObservation Soft tissue injurySoft tissue injury DeformitiesDeformities

• AuscultationAuscultation Noisy breathingNoisy breathing Breath soundsBreath sounds

• PalpationPalpation CrepitusCrepitus TendernessTenderness PulsesPulses


On-going On-going Reassessment of PatientReassessment of Patient

Frequency of reassessmentFrequency of reassessment Severity and types of injurySeverity and types of injury Distance from receiving facilityDistance from receiving facility Interventions performedInterventions performed

What should be reassessedWhat should be reassessed Primary surveyPrimary survey ET tube placementET tube placement Blood pressureBlood pressure Circulation to injured extremitiesCirculation to injured extremities Neurological examNeurological exam Pulse oximetryPulse oximetry


Appropriate Use of Pain Appropriate Use of Pain ManagementManagement

Consider analgesia for isolated extremity injuries Consider analgesia for isolated extremity injuries and spinal fracturesand spinal fractures

Titrate narcotics in small increments IVTitrate narcotics in small increments IV Overmedication can impair assessment of Overmedication can impair assessment of

neurological function and abdomenneurological function and abdomen Commonly used medications can cause Commonly used medications can cause

ventilatory depression and hypotensionventilatory depression and hypotension Hypotension is more likely to develop in Hypotension is more likely to develop in

patients who are mildly hypovolemicpatients who are mildly hypovolemic


Communication and Communication and DocumentationDocumentation

Notify receiving facility early to allow activation Notify receiving facility early to allow activation of resources (trauma team)of resources (trauma team)

Communicate pertinent information about Communicate pertinent information about patient, incident, findings, treatment, and patient, incident, findings, treatment, and responseresponse

Document with a well-written narrative Document with a well-written narrative including patient presentation, assessment including patient presentation, assessment findings, treatment, response, and findings, treatment, response, and

transport destinationtransport destination


Scenario:Scenario:Transport, Communication, Transport, Communication,

DocumentationDocumentation

While en route to the hospital, your patient While en route to the hospital, your patient shows some improvement upon shows some improvement upon reassessment of primary survey. Your reassessment of primary survey. Your secondary survey revealed multiple abrasions secondary survey revealed multiple abrasions to the face and hands and a deformity to the to the face and hands and a deformity to the right wrist with a palpable radial pulse. V = 20, right wrist with a palpable radial pulse. V = 20, P = 110, B/P = 94/52P = 110, B/P = 94/52


Scenario:Scenario:Transport, Communication, Transport, Communication,

DocumentationDocumentation What important information was collected What important information was collected

during the secondary survey?during the secondary survey? What information should be communicated to What information should be communicated to

the receiving facility?the receiving facility? What information should be documented on What information should be documented on

the patient care report?the patient care report?


Managing Multiple PatientsManaging Multiple Patients

Adequate resourcesAdequate resources Establish incident command/call for helpEstablish incident command/call for help Triage patients/treat critical firstTriage patients/treat critical first Don’t overload closest hospitalDon’t overload closest hospital

Inadequate resourcesInadequate resources Focus on most viable/provide comfort to those Focus on most viable/provide comfort to those

who are notwho are not Physician on scene may be helpfulPhysician on scene may be helpful Be familiar with local disaster planBe familiar with local disaster plan Use an incident command systemUse an incident command system


SummarySummary

Perform scene assessmentPerform scene assessment Initiate treatment for life-threatening conditions Initiate treatment for life-threatening conditions

when identifiedwhen identified Prompt transport of critically injured to closest Prompt transport of critically injured to closest

appropriate facilityappropriate facility Complete assessment and definitive care of Complete assessment and definitive care of

noncritical patientsnoncritical patients Communicate and document key Communicate and document key

informationinformation


QUESTIONS?QUESTIONS?

lesson 04

Education