Module6

PatientAssessment

PatientAssessment
MechanismofInjury(MOI)trauma
InorderforECPtobeabletoprovidebestpossibletreatment,youneedtohaveunderstandingofinjuriesaresustained bylookatMOI. Youarerequiredtosearchforcluesandbevigilant E.g.MVAs Steeringwheelthatisbuckledorbent o Thoracictrauma/fractures,neck,spinal,headtrauma/fractures/injuries Frontwindshielddamagedwithatargetlookingshatter/crack/brokenwherewindshieldisdamaged o Head,neck,spinal,thoracictrauma/fractures Dashboardisdamagedorcrumbled o Legandpelvicfractures Kineticforce: Whenacarisdrivingat120km/p/handhasaheadoncollisionwithabrickwall,thecarcollideswiththewallat approximately240km/p/h

Natureofillness(NOI)medical
Youarerequiredtosearchforcluesandbevigilantforcluesonhowtheincidenthappened/occurred. Pt.homegeneralappearanceoflivingquarterscanprovidemanyclues. Rundownmessyapartmentwithliquorbottlesscatteredeverywherecouldgiveanindicationofthetypeofpt.youare abouttotreat.

PrimarySurvey
Primarysurveyconsistsof o BSIandthen o HHH ABC(consciouspt.)alternatively o HHH CAB(unconsciouspt.) Primarysurveymostimportantstartingpointinprehospitalpt.assessmentinemergencycare Evenasyouwalkingtowardspt.andscenecriticalassessmentofABC/CABwilldeterminept.outcome Beforeprimarysurveytherearevitalstepstobetakenbeforept.canbetouchedortreated o ThatisBodySubstanceIsolation

1.1

BodySubstanceIsolation(BSI)
PracticeregardingALLbodilyfluidsasbeingpotentiallyinfectious AlwaysuseBSItoprotectyourself&partnerfromexposuretoinfectiousdisease/s Variouswaystoprotectyourselffromexposuretoinfectiousdisease/s o Masks o Glovesandeyeprotection o Handwashing o Disposalofusedsupplies NEVERleavemedicalequipment/dressing/bandagesoranythingusedwhiletreatingthe pt.behind!!!!!!

OnceBSItakencareofprimarysurveycanbegin Primarysurveyincludesrapidassessmentofpt.levelofconsciousness

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Module6

PatientAssessment

Inalmosteverysituationfollowingstepsareexcellentguidelinestofollow: H Hazards Isthescenesafetoapproachthept. H Help Sendforhelpifneeded e.g.firebrigade H Hello A Airway Ispt.airwayclearandfreeofdebris? B Breathing Ispt.breathing? C Circulation Doespt.havepulse? Andorobviousbleeding? Afterprimarysurveyiscompleteandalllifethreateninginjuriestakencareof o Proceedtofindingoutpt.history Primarysurveymustbecontinuouslyassessedonsamept. o IfABCnotreassessedcontinuouslypt.conditionmaydeterioratewithoutyoubeingawareofit. SPEAKtoyourpt.NONSTOP o GSCcaneasilybecompletedifpt.isspeaking o Ifpt.stopsspeakingyouareimmediatelyawarethatthept.hasdeteriorated.

Secondarysurvey

Integralpartofthept.overallapproach Secondarysurveyhassequenceandmannerfollowthis

GENERALAPPEARANCE
Myprovideclueinprovidingadiagnosese.g.coldandclammy Foetalpositioncouldmeantheyareguardinganacuteabdomen Traumapatientsmaylieinvariouspositionsdependingoninjuriessustained Pt.inpainmaybecryingorhavevariousfacialexpressions Anxiouspt.maylookscaredandwaryofsurroundings Bepreparedforsignsofrestlessness o Mayindicatept.becominghypoxicorhasinternalbleeding o Restlessnessinpt.mustneverbeoverlookedcanoftenindicateserious/potentiallyserious condition. Lookforareasofbloodsoakedclothing Ordeformed/unnaturalpositionedextremities Alwaysobservethecolour,temperatureandabnormalities Thiswillgiveyouagoodideaofthept.perfusion Brightredskincouldbeindicationof: o carbonmonoxidepoisoning(gasheater,attemptedsuicidebyexhaustfumes) o allergicrash o dilationofbloodvessels Paleskin o oftenassociatedwithpt.inshockornormallypt.asbeingcoldandclammy Bluishtingedskin o canbeindicationofhypoxia/hypothermia Yellowskin o Usuallyindicationofjaundicebestseeninwhitesofeyes o Jaundicemostoftenduetoliverdiseasee.g.hepatitis Hivesandurticarialindicationofallergicreaction

PT.POSITIONING

BEHAVIOUR

OBVIOUSWOUNDSANDDEFORMITIES

SKIN

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Module6 2.1 Pt.History

SAMPLE SignsandSymptoms Allergies Medication Pastmedicalhistory

PatientAssessment

Lastmeal Eventsleadinguptothe event

Signsissomethingyousee Symptomsiswhatthept.tellsyou Askareyouallergictoanythinglikemedicationlikeaspirinorfoodlikepeanuts Areyouonchronicmedicationortakingmedicationforanythinglikefluorheart problems Thisquestionneedstoincludethept.aswellasthept.family (pt.maynothavepastheartproblemsbutpt.parentsorfamilymayhaveheart problems) Whenwasthelasttimethept.ateorhadsomethingtoeat Whatwasthept.doingbeforethepainstarted

2.2

ChiefComplaint
Thisismainsymptomthatcausespt.tocallforassistancee.g.difficultybreathing Alwaysbealerttomoreseriousunderlyingconditionseventhough Pt.mightbecomplainingaboutspecificwounde.g.pedestrianinvolvedinMVAmaycomplainofinjuredarm Physicallyexaminationmayrevealinternalabdominalbleedpossiblerupturedspleen

2.2.1

HistoryofChiefComplaint

Obtainfullaspossiblehistoryfrompt. Asktheflowingquestions:OPQRST Onset Whendidthepainstart/begin? Provokes Whatprovokesthepain? E.g.wasthept.exercising? Quality Whatisthequalityofpain? Crushing/stabling/feelslikesomeoneissittingontheirchest Radiation/Radiating Isthepainradiating? i.e.tothejaw,arms,abdomen,back Severity Howseveristhepain? Scaleof110?10beingtheworsethept.haseverfelt Time Howlonghasthepainlasted? 1hour Andisthepainconstantordoesitcomeandgoandforhowlong

VITALSIGNS
AtthispointvitalsMUSTbetaken Signssomethingyoucansee,hear,feel Pt.maynotbeawareoftheme.g.rate/rhythm/strengthofpulse Pulse Respiration Airentry Haemoglucosetest(HGT) Bloodpressure Pupils Glasgowcomascale Revisedtraumascore Skincolourandtemperature Capillaryrefill

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Module6 2.3 Pulse

PatientAssessment

Palpatedwhereanarteryliesclosetosurfaceskine.g.radialartery Whenevaluatingpulse:(thingstoconsider) Rate Numberofbeatsperminute Rhythm Regularityofbeats Volume/strength Force/amplitudeofeachbeat Normalpulseratesperminute: Adults 60 100bpm Children 80 100bpm Toddlers 100 120bpm Newborns 120 140bpm Extremelyfitadultcanhavepulserateaslowas4060bpm(unfitpersonhasfasterpulse) Pulserateonlytelluslittle Pulseratewithrhythmandstrengthcouldtelluslots E.g.pt.pulserate120bpmregularbutweak Couldindicatept.thatisinshock E.g.pt.pulserate120bpmregularbutstrong Couldindicatehealthpt.afterexercising WhendescribingpulseALWAYSincluderhythm,rateandstrength/volume Pulsecanbelocatedinmanyareasofthebody:

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Module6 2.4 Respiration

PatientAssessment

WhendescribingrespirationrateALWAYSincluderhythm,rateanddepthandANYabnormalsounds/smellsif present Normalrespirationrate: Adult 1220bpm Child 1530bpm Infant 2550bpm Groupsofchildren Ages Normalrespiratoryrates Newbornsandinfants Upto6monthsold 3060breaths/min Infants 6to12monthsold 2430breaths/min Toddlersandchildren 1to5yearsold 2030breaths/min Children 6to12years 1220breaths/min Cheynestokesrespiration o Usuallyasignofseverebraininjury o Breathinggetsdeeperanddeeperthenstopsforsometimeandthecyclethenrepeats Depthsofbreathsmaybeaffectedbymanyfactors o Pt.ribfracturespt.willfinditdifficulttobreathandthereforedecreasebreathinginordertolessen pain o Overdoseofnarcoticdrugs(respirationdepressants)mayhaveshallowbreathing Abnormalbreathingsounds o Snoringobstructedairway o StridorhighpitchedsqueakingnoiseheardonINhalationcausedbynarrowingofairway Usuallyaroundlarynx o Gurglingindicatedcollectionoffluidsinupperairway Totallungcapacity o 6000ml:ForceddeepbreatheVolumeofairinlungafteraforcefulinspiration Tidalvolume o 500ml:Normalbreathingvolumeofairinspire/expireduringeachrespiratorycycle o Normalbreathing1220breathesperminute) Deadairspace o 150ml:Airremaininginpassages Minutevolume o Amountofairthatmovesinandoutofthelungsperminute o TidalVolumexrespiratoryrate(1220bpm)=minutevolume o VT or tidal volume is the amount of air the lungs breathe in one breath, o VE or minute volume is the number of breaths o RR (respiratory rate or f=frequency) breathed in one minute times the tidal volume. o Thus VT x RR = VE. 350ml x 12 breaths per minute = 4,2 L/min.

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Module6

PatientAssessment

2.4.1.1

Signsofabnormalbreathing

Slowerthe8breaths/minORfasterthan24breaths/min Musclesretractions Pale/cyanoticskin(bluishcolouredskin) Cool,damp(clammy)skin Shallow/irregularrespirations Pursedlips Nasalflaring

2.5

Airentry
Airentryisdeterminedbyauscultatingboththeleftandrightsidesofthethoraciccavity Auscultatingthethoraxwithastethoscope Itisusedtodetermineequalityofbreathsoundsonbothsidesofthechest o Unequalairentrymaysuggestpneumothorax

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Module6
Auscultation: Sound Expansion Effort Normal Present&equal Adequate&equal Unlaboured/normal

PatientAssessment

Abnormal Diminished/unequal/absent Inadequate/unequal Laboured/increasedeffort/usesaccessorymuscles/flailribfractures/ subcutaneousemphysema

2.6

BloodPressure

Twocomponentstobloodpressuremeasurements: Systolic(contractionoftheheart) Diastolic(relaxationoftheheart) BloodPressure=CardiacOutputxPeripheralresistance Cardiacoutput=StrokevolumexHeartrate Bloodpressureisrecorded:systolicoverdiastolice.g.120/80 Normalbloodpressures: Systolic: 100140mmHG Diastolic: 6590mmHG Malept.Adult Age+100=SystolicBP 40+100=140 DiastolicBP=2/3ofsystolicBP 90 100 Femalept.Adult Age+90=SystolicBP 30+90=120 DiastolicBP=2/3ofsystolicBP 80 Bloodpressurecanbeestimatedbyfindingdifferentpulses: Pedalpulse: 90mmHG Radialpulse: 80mmHG Femoralpulse: 70mmHG Carotidpulse: 60mmHG RMB: BPonlyofmanyvitalsignsandmustnotbeusedinisolation e.g.pt.thathaslostlotsofbloodmayhavenormalBP o thisduetoresponseofvasoconstrictionbyvesselsandincreaseinheartrateandoutputtomaintain pressure o Bythetimethept.BPfallspt.isalreadyinseverhypovolaemicshock

2.7

Pupils

Remember:PEARL Pupilsequalandreactivetolight +Normalsizepupil4mm Stateofpupilsmaybeindicatorofcerebralperfusionandoxygenationofbrain Twomainparameters: Sizeofpupils Reactionofpupilstolight Innormalhealthypersonpupilsareequalsizeandshape

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Module6

PatientAssessment

Sizeofpupilisusuallydeterminedbyamountoflightenteringtheeye Brightlightcausespupiltoconstrict Darknesscausespupilstodilate Whenbraindeprivedofoxygenpupilsdilate Useofdrugsmayaffectpupils Pt.whohavedilatedpupilsbutarealertandresponsiveDONThaveproblemwithoxygenationtobrain Drugmayhavecausedpapillaryresponse Rateofreactiontolightmaygivecluestostatesofbrain Pupilsslowtoreactusuallymeanthebrainorportionofthebrainishypoxic

2.8

Glasgowcomascale(valueoutof15)

Derivedfromvariousresponsestostimuli: Responsesare: o Openingofeyes o Useofspeech o Abilitytomove /15 VisualResponse 1 Eyesdontopen 2 Paincauseseyestoopen 3 Voicescauseeyestoopen 4 Spontaneous 5 6 Lowestscoreis3

VerbalAbility None Incomprehensiblewords/sounds Inappropriatewords Minimal/confused Orientated

MotorSkills Nomovement Abnormalextensiontopain Abnormalflexiontopain Withdrawsfrompain Localizespain Movesoncommand

2.9 RevisedTraumaScore /12 GCS SystolicBP Resp.Rate 4 1315 >90 1029 3 912 7689 >29 2 68 5075 69 1 45 149 15 0 3 0 0 Lowestscoreis3 2.10 Capillaryrefill
2secondstorefill Pressnailbedreleaseanddeterminetimeittakesfornailbedtoreturntoinitialcolour.

2.11 Haemoglucosetest(HGT)
Haemoglucosetestdonebyassessingbloodsugarlevelofpt. Normalbloodsugarlevel3.56.7(or7.4)mmol/L

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Module6 2.12 HeadtoToe

Head

PatientAssessment

Slidehandsfromneckupwardstofeelposteriorscalp.Beextremelycarefulintraumapt.NOTtomove head DONOTpresshardondeformitiesmaypushfragmentsofbrokenboneintobrain Feelfordeformities,swellingandblood Ears Lookforeardamage BloodandCSF(cerebraspinalfluid)maybeoozingfromearsMaybeindicationofskullfracture Battlesigns(bruisingovermastoidprocessMaybeindicationofskullfracture Nose Lookforswelling,deformityorbruising BloodandCSF(cerebraspinalfluid)drainingfromnoseMaybeindicationofskullfracture Eyes Checkexternaltraumaeyesandeyelids Raccooneyes(bruisingaroundtheeyes)Maysometimesbeindicationofskullfracture Mouth 1stfeeljawforsignsoffractures Openmouthcheckthereisnoforeignmatterwithine.g.brokenteeth/dentures,vomits,bloodetc. Neck DONOTmoveneckintraumapt. Gentlyexamineneckforwounds,bruises,palpateforsubcutaneousemphysema Examinetracheadeviatedormidline Examineposteriorandanterioraspectsofneckforswellinganddeformities. Completionofneckexaminationimmobilizeneckwithneckbrace Chest Fullyexposept.chestwhennecessary. berespectfulandallowpt.tokeep theirdignity Examinechestforstability,unity,bruisingandwounds Auscultatechestforunequalbreathsoundsoranyabnormalbreathsoundse.g.wheezing,rales Lookoutformedicalertbracelet Abdomen Ensureabdomenisexposed Lookforbruising,lacerations,boweleviscerations Palpateabdomenfortenderness,rigidityorguarding Pelvis Locatecrestsofilium(hips)andgentlyexertpressure Instabilityorpainfromthiscompressionmayindicatedfractureofthepelvis Genitalia Shouldnotnormallybedoneunlessobvioussignsofinjuryi.e.bloodsoakingthroughclothing, impalementofobject Alwaysbesensitiveandcautiouswhenexposinggenitaliaallowpt.maintaindignityprovideprivacy Verylegalproblemsmaybecausedbythistypeofexamination Extremities Exposelegsandarmsifinjuryisexpected Examineforbleeding,deformity,bruising,abnormalitiesorabnormalpositioningoflimbs Testpt.sensationresponsetotouchBADINSKIREFLEXnormalmovementtoescurlabnormal movementtoespullupandawayfortouch. Medicalpt.lookforswellingsacraloedemaandpericardialoedemaandpoorcirculation(pulse) Lookoutformedicalertbracelet Completionofexamininglegsexaminearmsinthesamemanor.

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Module6

PatientAssessment

Triage
TriageisaFrenchwordmeaningsorting Definedascategorizingandsortingofpt.accordingtodegree/severityofinjuries/illness Assessmentofinjuriesisconductedbrieflyestablishing o Typeofinjuriessustained o Howsevereinjuriesare o Whoistoreceivepriorityinprimarycare o Andtransportationtomedicalfacility DuringthisassessmentABCprincipleisapplied o Screaming,hystericalpt.usuallyNOThighestpriority Pt.isconsciousandhasopenairway o Silentpt.usuallyhavedepressedlevelofconsciousness Possibleairwayobstruction Possiblebreathingdifficulty Possiblehaemorrhageresultinginshock ECPresponsiblefortriageMUSTovercomedesiretostopandtreatindividualpt.ECPmustcompleteABC ECPshouldcontinuecategorizingeachpt. Toenablearrivingteamtoquicklyidentifypt.needsofimmediatetreatment

3.1.1

Prioritizationofpts.
ECPresponsiblefortriagemustensureallpt.arecloselymonitoredtriagingpt.maychange Attentionmustbedirectedtopriority1(/highestpriority)beforetreatmentisadministeredtoprioritytwopt.(/ lowerprioritypt.) CallcentremustbeupdatedofALLeventsoncontinuousbasisandanyfurtherassistancerequired TriageMUSTbeperformedrepeatedly(doesnotconsistofoneassessment)

3.1.1.1

Priority1

Highestpriority Lifethreateningemergencies Pt.indangerofasphyxia/hypoxia Obstructedairway Apnea Suckingchestwounds Tensionpneumothorax Pt.inshock/impendingshock Majorexternal/internalbleeding Burnsovermorethan20%ofbodysurface Cardiactamponade

3.1.1.2

Priority2

Secondpriority Pt.seriouslyinjured VisceralinjuriesWITHOUTshock Burnslessthan20% o Includingface/hands/feet/genitalia Spinalcordinjuries Compoundfractures/dislocations

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Module6 3.1.1.3 Priority3

PatientAssessment

Thirdpriority Pt.withmoderatetolightinjuries SofttissueinjuriesWITHOUTshock MusculoskeletalinjuriesWITHOUTshock/WITHOUTlossofpulse/WITHOUTlossinsensation Minorinjuriesoftheeyes Burnsofotherlocationslessthan20%

3.1.1.4

Priority4

Thesearedeadpt. Priority4pt.shouldbeleftwheretheyarefoundandcovered SAPSwilltakeoverresponsibilityforremovalofthesevictims

4
4.1

Pt.Effectiveinteraction/communication
Effectiveinteractionwithpatients
Makeandkeepeyecontact Usept.propername(ifyouforgetpt.nameusesir/maam) Tellpt.truth Uselanguagept.canunderstand Becarefulofwhatyousayaboutpt.toothers Beawareofownbodylanguage Speakslowly,clearly,distinctly(always) Ifpt.hearingimpaired,speakclearlyandfacept.whenspeaking Allowtimeforpt.toanswerquestions Actincalm,confidentmanner

4.2

Communicatingwithelderlypt.
Determinept.functionage DONOTassumeelderlypt.senile/confused Allowpt.ampletimetorespond Watchforconfusion,anxiety,impairedhearing/vision ALWAYSexplainwhatisbeingdone

4.3

Communicatingwithchildren
Childrenareawareofwhatsgoingon Allowpeople/objectsthatprovidecomforttoremainclose Explainprocedurestochildrentruthfully Positionyourselfontheirlevel

4.4

Communicatingwithhearingimpairedpt.
Alwaysassumept.hasNORMALintelligence Makesureyouhavepaperandpen Facept.andspeakslowly,clearlyanddistinctly NEVERshout Learnsimplephrasesusedinsignlanguage

4.5

Communicatingwithvisuallyimpairedpt.
Askpt.iftheycanseeatall Explainallprocedurestruthfullyasbeingperformed Ifguidedogpresenttransportguidedogalso.

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Module6 4.6

PatientAssessment

Languagebarriers
Useshort,simplequestionsandanswers Pointstospecificpartsofbodyasyouaskquestions LearncommonwordsandphrasesnonEnglishlanguageareas

4.7

Mentallydisturbedpt.
Interactionwithmentallydisturbedcanbedifficultatbestoftimes Shouldbekeptinmindabnormalbehaviourmaybepartandparcelofmedicaldiseases,reactiontosevere stress,drugabuse NOTeverypt.hasspecificmental(psychiatric)disorder. Pt.withhypoglycaemiaoralcoholingestionmayappearmentallydisturbed

Disruptivebehaviouranddrugabuse

Overview Drugdefinedassubstancecanproducephysical/mentaleffectonthebody Everydrugcanhaveundesirablesideeffectorreaction Somereactionsarelifethreateningandrequireemergencytreatment Sometimesdrugsmisusedandcauseseriousreactions Mostdrugsabusedaredoneformoodalteringeffects Includesalcohol Generalmisuseofdrugsistermedassubstanceabuse

5.1

Drugs

Drugdefinedassubstancecanproducephysical/mentaleffectonthebody Drugabuseisworldwide Variesfrom Simpleminoroverdosesofmedicallyprescribeddrugs o Inhalationofintoxicatingchemicals o Tomajornarcoticusage CocainepowerfulCNSstimulant HeroinCNSdepressantdoeshavemoodelevatingeffects LSDOneofmostimportantanddangeroushallucinogenicdrug o Alterspt.awarenessofthemselvescancausefatalsituationswhenpt.believestheycanleapoff buildingsandfly.

5.2

Alcohol
AlcoholpowerfulCNSdepressant Chronicalcoholicsmaybesuicidal Drunkenpt.mayshowaggression,inappropriatebehaviour,falleasily/becombative Pt.whoabusesalcoholanddrugsusuallyhaveunderlyingpersonalitydisorder o Pt.shouldalwaysbeapproachedincaringandunderstandingmanner Ifpt.becomestooaggressivecallforassistanceSAPS

6
6.1

Deathandterminalillness
SIDS(SuddenInfantsDeathSyndrome)
ThousandsofbabiesdiefromSIDSeveryyear Usuallyoccursduringsleepinapparentlyhealthybaby:24monthold Alsoknownascotdeath Almostcertainlyencounteranguished,severelydistressedpts. Alwaysmakeefforttorevivebabywithbasiclifesupportunlessbabyiscoldandstiff

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Module6

PatientAssessment

Transporttohospitalevenifbabyseemsdeadtoyou o Besuretoexaminebaby o SignsofchildabuseDONOTmakethisobvioustotheparents EvidenceofchildabuseMUSTbereportedtodoctoratreceivinghospital

6.2

Suddendeath
Oftenpt.willnothavebeenpreviouslyill/indangerdeathwillbeagreatshocktoeveryone Anydoubtsifthept.isdeadfullresuscitationshouldbecarriedout. o Whenpersonobviouslydeadsupportshouldbegiventothefamilyandfriends Keepfamilyinformedofwhatyouaredoing Closerelativesandfriendsshouldbeallowedtoseethebodyifdesired o BUTanymutilatedareasshouldbecovered NEVERraisefalsehopespossibleresponsetoresuscitationifdeathisinevitable Ifpossible,donotresuscitatept.whenfamilyaround;askfamilytoleavetheroom

6.3

Terminalillness
Terminallyillpt.usuallyknow/stronglysuspecttheyareabouttodie Maybelittletodoforterminallyillpt.otherthantomakethemcomfortable Determineifpt.andfamilyareawarethatdeathisapproaching Pt.shouldNOTdiealone!!

7
7.1

Abuse
Childabuse
Childabusemaytakemanyforms o Beatings o Burns o Rape o Evenattemptedmurder Anyonemaybeavictimofabuseseenmostoftenamongfamilymembers Victims/pts.Ofabusemaydemonstrateanger/rage/withdrawal Victimmaysaylittle,appearnottocare,maynotwantanyonenearthem Ifchildabuseitsuspectedmakeeveryefforttogetchildtohospitalfordoctorsexamination o RMBtoexpressyourfeelingstodoctoravoidconfrontingparentswithsuspiciouns

7.2

Adultabuse
Commonlyknownaswifebeating/husbandbeating(abuseofhusbandsalsorecognised) Maybepossibleattimestoquietlydiscussproblemwithvictimalonewhowilloftenrefusehelp HoweverissuemustNOTbeforcedbestcourseofaction o Attempttopersuadept.tobetakentohospital

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