1 Patient Assessment Condell Medical Center EMS System July 2011 CE Site Code #107200E-1211 Sharon Hopkins, RN, BSN, EMT-P

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Patient AssessmentPatient Assessment

Condell Medical Center EMS SystemCondell Medical Center EMS SystemJuly 2011 CEJuly 2011 CE

Site Code #107200E-1211Site Code #107200E-1211

Sharon Hopkins, RN, BSN, EMT-PSharon Hopkins, RN, BSN, EMT-P

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ObjectivesObjectives

Upon successful completion of this Upon successful completion of this module, the EMS provider will be able to:module, the EMS provider will be able to:

1. Define mechanism of injury.1. Define mechanism of injury. 2. Define nature of illness.2. Define nature of illness. 3. Define general impression.3. Define general impression. 4. Discuss purpose of a general impression.4. Discuss purpose of a general impression. 5. Discuss In-field Spine Clearance components. 5. Discuss In-field Spine Clearance components.

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Objectives Cont’dObjectives Cont’d

6. Describe assessment of the patient’s circulation6. Describe assessment of the patient’s circulation status during the initial assessment.status during the initial assessment. 7. Describe normal and abnormal findings of7. Describe normal and abnormal findings of assessment of skin color, temperature, andassessment of skin color, temperature, and condition.condition. 8. Describe the physical examination of the patient8. Describe the physical examination of the patient with a medical complaint.with a medical complaint. 9. Describe components of the on-going physical9. Describe components of the on-going physical examination.examination.

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Objectives Cont’dObjectives Cont’d

10.Describe purpose of trending of the patient’s10.Describe purpose of trending of the patient’s

physical assessment.physical assessment. 11.Actively participate in a patient11.Actively participate in a patient

assessment when given a scenario.assessment when given a scenario. 12. Demonstrate placing the HARE traction12. Demonstrate placing the HARE traction

splint working in a group.splint working in a group. 13. Demonstrate placing the KED device in a13. Demonstrate placing the KED device in a

group.group. 14.Successfully complete the post quiz with a14.Successfully complete the post quiz with a

score of 80% or better.score of 80% or better.

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Mechanism of InjuryMechanism of Injury

What exactly is this?What exactly is this? Officially “the combined strength, direction, Officially “the combined strength, direction,

and nature of forces that injured your patient”and nature of forces that injured your patient”

Basically – this is what causes an injury; what Basically – this is what causes an injury; what happened to your patient happened to your patient

Determined by information received by Determined by information received by dispatch (how call came in) and confirmed by dispatch (how call came in) and confirmed by your observational and interview skills once your observational and interview skills once on the sceneon the scene

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Nature of Illness ComplaintNature of Illness Complaint

This is the medical complaint your patient This is the medical complaint your patient has called EMS forhas called EMS for Not always readily apparentNot always readily apparent May even differ from the chief complaintMay even differ from the chief complaint

• The true nature of illness may not be what The true nature of illness may not be what the patient initially thought was the problemthe patient initially thought was the problem

Example: Called for difficulty breathingExample: Called for difficulty breathing Patient thought it was allergiesPatient thought it was allergies

Patient eventually diagnosed withPatient eventually diagnosed with pneumoniapneumonia

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General ImpressionGeneral Impression An impression of what you think is wrong An impression of what you think is wrong

with the patientwith the patient Formed during the initial impressionFormed during the initial impression

Based on your observations of Based on your observations of Patient’s appearancePatient’s appearancePatient’s environmentPatient’s environmentPatient’s chief complaintPatient’s chief complaint

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General ImpressionGeneral Impression

Becomes a working diagnosis based on:Becomes a working diagnosis based on: Your experienceYour experience History obtained of present and past illnessesHistory obtained of present and past illnesses Data obtainedData obtained

Vital signsVital signsBreath soundsBreath soundsEKG monitor; 12 lead EKGEKG monitor; 12 lead EKGGlucose levelGlucose level

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Benefit of Forming General Benefit of Forming General ImpressionImpression

Drives the choice of protocol followedDrives the choice of protocol followed Used to guide your treatment optionsUsed to guide your treatment options May be changed as the call unfoldsMay be changed as the call unfolds

May change as you gather more dataMay change as you gather more data May change based on patient response to May change based on patient response to

treatment initiatedtreatment initiated May involve the use of more than one May involve the use of more than one

SOP based on the complaintSOP based on the complaint

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Scenario for Group Discussion: Scenario for Group Discussion: What is this general impression?What is this general impression?

You are called to the scene for difficulty You are called to the scene for difficulty breathingbreathing

Upon arrival you observe the patient to be Upon arrival you observe the patient to be sitting upright in obvious distresssitting upright in obvious distress

You hear audible noisy breathingYou hear audible noisy breathing The patient is pale, diaphoretic, and The patient is pale, diaphoretic, and

tachycardictachycardic You auscultate bilateral cracklesYou auscultate bilateral crackles What’s your initial general impression?What’s your initial general impression?

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Are you thinking acute pulmonary edema?Are you thinking acute pulmonary edema?

As you begin to assess the patient, more As you begin to assess the patient, more information comes forthinformation comes forth The patient has had chest pain 7/10 for the The patient has had chest pain 7/10 for the

last 5 hourslast 5 hours The chest pain is non-radiating, feels like a The chest pain is non-radiating, feels like a

vise grip on their chestvise grip on their chest They have taken multiple doses of their NTGThey have taken multiple doses of their NTG

Now what is your general impression?Now what is your general impression?

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The general impression now The general impression now includes a possible acute MI includes a possible acute MI complicated with complicated with

acute pulmonary edemaacute pulmonary edema

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Scene Size-upScene Size-up First part of any patient assessment First part of any patient assessment

processprocess Begins as you arrive at the sceneBegins as you arrive at the scene

Remember to consider information conveyed, Remember to consider information conveyed, including possible prior knowledge of callerincluding possible prior knowledge of caller

Can start some formulation of ideas before Can start some formulation of ideas before actually pulling up to the curbactually pulling up to the curb

Scene safety is a priorityScene safety is a priority Includes determination of mechanism of Includes determination of mechanism of

injury or nature of illnessinjury or nature of illness Number of patients; need for equipmentNumber of patients; need for equipment

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Spinal Motion RestrictionSpinal Motion Restriction

C-spine control should be considered on C-spine control should be considered on all traumatic and some medical callsall traumatic and some medical calls Evaluate the patientEvaluate the patient

Mechanism of injuryMechanism of injurySigns and symptomsSigns and symptomsReliabilityReliability

Document equipment used to restrict Document equipment used to restrict spinal motion if this is care providedspinal motion if this is care provided

Document findings if the need for spinal Document findings if the need for spinal control/motion restriction is not requiredcontrol/motion restriction is not required

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In-field Spinal ClearanceIn-field Spinal Clearance Risky mechanisms of injuryRisky mechanisms of injury

High velocity MVC High velocity MVC >> 40mph 40mph Unrestrained occupant in MVCUnrestrained occupant in MVC Passenger compartment intrusion >12Passenger compartment intrusion >12″″ Ejection from vehicleEjection from vehicle Rollover MVCRollover MVC Motorcycle collision >20 mphMotorcycle collision >20 mph Death in same vehicleDeath in same vehicle Pedestrian struck by vehiclePedestrian struck by vehicle Falls > 2 time patient heightFalls > 2 time patient height Diving injuryDiving injury

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In-field Spinal ClearanceIn-field Spinal Clearance

Signs and/or symptomsSigns and/or symptoms Pain in neck or spinePain in neck or spine Tenderness/deformity of neck or spine upon Tenderness/deformity of neck or spine upon

palpationpalpation Paralysis or abnormal motor examParalysis or abnormal motor exam Abnormal response to painful stimuliAbnormal response to painful stimuli

Any little complaint of numbness or tingling Any little complaint of numbness or tingling to distal extremities or a single digit is to distal extremities or a single digit is included as an abnormal responseincluded as an abnormal response Remember dermatomes from May 2011 CE? Remember dermatomes from May 2011 CE?

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In-field Spinal ClearanceIn-field Spinal Clearance

Patient reliabilityPatient reliability Signs of intoxicationSigns of intoxication Abnormal mental statusAbnormal mental status Communication difficultyCommunication difficulty

• Includes non-English speaking patientsIncludes non-English speaking patients Abnormal stress reactionAbnormal stress reaction

Being added to revised SOP’sBeing added to revised SOP’s Distracting injuriesDistracting injuries

• Amazing how the mind can focus on one thing and Amazing how the mind can focus on one thing and ignore other problemsignore other problems

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When in doubt, immobilizeWhen in doubt, immobilize

When appropriate and supported with When appropriate and supported with assessment, immobilization not necessaryassessment, immobilization not necessary

Either way...Either way...

DOCUMENTDOCUMENT

DOCUMENT DOCUMENT

DOCUMENTDOCUMENT

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Patient CirculationPatient Circulation

What is the perfusion status of the patient?What is the perfusion status of the patient? Is their circulation sufficient to support Is their circulation sufficient to support

perfusion to the brain (mental status) and perfusion to the brain (mental status) and generate a blood pressure (can you feel a generate a blood pressure (can you feel a radial pulse)?radial pulse)? Altered mental status first sign of altered Altered mental status first sign of altered

perfusionperfusion Hypotension a late sign of altered Hypotension a late sign of altered

perfusionperfusion

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CirculationCirculation

Does the patient have a pulse?Does the patient have a pulse? Rate?Rate?

• Only 3 options: normal, too slow, or too fastOnly 3 options: normal, too slow, or too fast Quality?Quality? Palpated distally?Palpated distally?

• Takes higher blood pressure to generate a Takes higher blood pressure to generate a distal pulse (ie: radial)distal pulse (ie: radial)

Does the patient have signs of shock?Does the patient have signs of shock? Does the patient have life threatening Does the patient have life threatening

bleeding?bleeding?

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First Patient ContactFirst Patient Contact

Can learn a lot from “hello”Can learn a lot from “hello” Walk up to patient and say hello and Walk up to patient and say hello and

introduce yourselfintroduce yourself As you do this, take their hand (feeling their As you do this, take their hand (feeling their

pulse)pulse)• Do their eyes focus?Do their eyes focus?• Are their eyes glazed over?Are their eyes glazed over?• Do you have a pulse?Do you have a pulse?• What’s the general information of the What’s the general information of the

pulse– pulse– Rate? Regularity? Quality?Rate? Regularity? Quality?

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Circulation StatusCirculation Status

The eyes are very sensitive to blood flowThe eyes are very sensitive to blood flow Eyes will reflect when circulation is decreasedEyes will reflect when circulation is decreased

Need adequate perfusion to the brain to Need adequate perfusion to the brain to maintain normal mentationmaintain normal mentation

Need a blood pressure of at least 60 Need a blood pressure of at least 60 systolic to feel the distal radial pulsesystolic to feel the distal radial pulse

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Relatively Stable PatientRelatively Stable Patient

If the patient can talk (make sense)…If the patient can talk (make sense)… If the patient has a radial pulse…If the patient has a radial pulse…

They are considered relatively stable They are considered relatively stable even though they may have signs and even though they may have signs and symptomssymptoms

Hence the phrase “relatively” stableHence the phrase “relatively” stable

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Assessing the SkinAssessing the Skin

Reflects patient circulationReflects patient circulation ColorColor TemperatureTemperature ConditionCondition

Skin not a priority organ and a decrease in Skin not a priority organ and a decrease in circulation noted with reflexive circulation noted with reflexive vasoconstriction and therefore paleness vasoconstriction and therefore paleness during times of poorer circulationduring times of poorer circulation

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Skin ColorSkin Color Areas to assess in the Areas to assess in the adultadult

Nail bedsNail bedsInside of cheekInside of cheekInside of lower lidsInside of lower lids

Capillaries are close to the surface of Capillaries are close to the surface of the skin in these areas so quickly reflect the skin in these areas so quickly reflect changes in circulationchanges in circulation

• Accurate even in dark complexionsAccurate even in dark complexions Normal color is pinkNormal color is pink

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Skin ColorSkin Color

Areas to assess in Areas to assess in pediatricspediatricsPalms of the handsPalms of the handsSoles of the feetSoles of the feet

In darker complexions evaluate lips and In darker complexions evaluate lips and nail bedsnail beds

Normal color is pinkNormal color is pink

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Skin ColorSkin ColorSkin ColorSkin Color SignificanceSignificance

PinkPink Normal (inner eye, lips, Normal (inner eye, lips, nail beds)nail beds)

PalePale Vasoconstriction, blood Vasoconstriction, blood loss, shock, distressloss, shock, distress

CyanoticCyanotic HypoxiaHypoxia

Flushed/redFlushed/red Exposure to heat, Exposure to heat, excitementexcitement

JaundicedJaundiced Abnormality of liverAbnormality of liver

Mottled/blotchyMottled/blotchy Poor circulationPoor circulation

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Assessing TemperatureAssessing Temperature

Body constantly generating and losing Body constantly generating and losing heatheat

Body functions in a narrow temperature Body functions in a narrow temperature rangerange

EMS most concerned with cases of the EMS most concerned with cases of the extremeextreme HypothermiaHypothermia HyperthermiaHyperthermia

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Measuring TemperatureMeasuring Temperature Palpating the skin measures surface Palpating the skin measures surface

temperaturetemperature Usually evaluated in subjective termsUsually evaluated in subjective terms

• Normal/Hot/Warm/Cool/ColdNormal/Hot/Warm/Cool/Cold

Core temperature reflects level of heat inside Core temperature reflects level of heat inside trunk around organstrunk around organs Normal oral temperature around 98.6Normal oral temperature around 98.600FF Normal rectal temperature 1 degree higherNormal rectal temperature 1 degree higher Normal axillary temperature 1 degree lowerNormal axillary temperature 1 degree lower

Tympanic thermometers very commonTympanic thermometers very common Beware: wide margin of errorBeware: wide margin of error

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Assessing Skin ConditionAssessing Skin Condition

Subjective evaluationSubjective evaluation NormalNormal DryDry MoistMoist DiaphoreticDiaphoretic

Can reflect recent activity level of patientCan reflect recent activity level of patient Can reflect under/over dressingCan reflect under/over dressing

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Skin ConditionSkin Condition

Skin ConditionSkin Condition Possible CausesPossible Causes

Cool, clammyCool, clammy Signs of shock, anxietySigns of shock, anxiety

Cold, moistCold, moist Body is losing heatBody is losing heat

Cold, dryCold, dry Exposure to coldExposure to cold

Hot, dryHot, dry High fever; heat exposureHigh fever; heat exposure

Hot, moistHot, moist High fever; heat exposureHigh fever; heat exposure

Goose pimples Goose pimples with shiveringwith shivering

Chills, communicable disease, Chills, communicable disease, fear, exposure to cold/painfear, exposure to cold/pain

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What’s Important???What’s Important???

Watching the trends!!!Watching the trends!!!

What is staying the same?What is staying the same? What is changing?What is changing?

• What does it mean when there is What does it mean when there is a change?a change?

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Physical ExaminationPhysical Examination

Used to evaluate/investigate areas that Used to evaluate/investigate areas that are/may be involved in the patient’s are/may be involved in the patient’s complaintcomplaint

Practice and experience dictate your Practice and experience dictate your comfort and capability when performing a comfort and capability when performing a physical examphysical exam Learn to pick up on intuitive information as Learn to pick up on intuitive information as

well as objective informationwell as objective information

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Steps of Physical AssessmentSteps of Physical Assessment

Inspection – visual process always done firstInspection – visual process always done first PalpationPalpation

Palpate painful areas lastPalpate painful areas last Use light touch with finger tips and warmed handsUse light touch with finger tips and warmed hands

AuscultationAuscultation Most commonly of breath soundsMost commonly of breath sounds Warm stethoscope firstWarm stethoscope first Listen directly over skin; not over clothingListen directly over skin; not over clothing

PercussionPercussion Rarely done in the field; needs a quiet environmentRarely done in the field; needs a quiet environment Requires practice to be a benefitRequires practice to be a benefit

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History of Present Illness/InjuryHistory of Present Illness/Injury

O – onset (what were you doing)?O – onset (what were you doing)? P – what makes it better/worse?P – what makes it better/worse?

Palliation/provocationPalliation/provocation Q – describe it in your own wordsQ – describe it in your own words R – does it radiate/spread anywhere?R – does it radiate/spread anywhere? S – what is the discomfort on a scale ofS – what is the discomfort on a scale of 0-10?0-10? T – what time did this start?T – what time did this start?

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On-going Physical AssessmentOn-going Physical Assessment

The most important aspect is watching for The most important aspect is watching for changes/trendschanges/trends

One set of vital signs, one time for One set of vital signs, one time for palpation, one time for anything related to palpation, one time for anything related to the patient and you have nothing for the patient and you have nothing for comparisoncomparison On-going means to repeat what has already On-going means to repeat what has already

been donebeen done If abnormalities are found, be same person If abnormalities are found, be same person

doing the reassessing doing the reassessing

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Patient Assessment DiscussionPatient Assessment Discussion Divide the participants up into smaller groups Divide the participants up into smaller groups Assign each group a scenarioAssign each group a scenario The groups should decide on an approach for The groups should decide on an approach for

assessing their patientassessing their patient Discuss general impressionDiscuss general impression Discuss treatmentDiscuss treatment Discuss what to documentDiscuss what to document Answer the “Critical Thinking” questionsAnswer the “Critical Thinking” questions Smaller group to report their discussion to the Smaller group to report their discussion to the

larger grouplarger group

You may use your SOP’s as reference tool You may use your SOP’s as reference tool

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Case Scenario #1Case Scenario #1

Dispatched for a 67 year-old male with Dispatched for a 67 year-old male with complaints of difficulty breathingcomplaints of difficulty breathing Sudden onset after smoking a cigaretteSudden onset after smoking a cigarette

Awake, oriented, obeys commandsAwake, oriented, obeys commands Tripod position; pursed lip breathingTripod position; pursed lip breathing

Radial pulse rapid and regularRadial pulse rapid and regular Skin cool, dusky, diaphoreticSkin cool, dusky, diaphoretic Hx: Emphysema, hypertension, “water in the Hx: Emphysema, hypertension, “water in the

lungs”lungs” On home OOn home O2 2 last 5 years last 5 years

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Case Scenario #1 cont’dCase Scenario #1 cont’d

Allergies: environmentalAllergies: environmental Meds: Lasix, digoxin, Aldactone, theophylline, Meds: Lasix, digoxin, Aldactone, theophylline,

Alupent inhalerAlupent inhaler VS: 158/88; P – 120; R – 20; SpOVS: 158/88; P – 120; R – 20; SpO22 85% 85%

Breath sounds: Breath sounds: Bilateral wheezingBilateral wheezing

Talking in 1-2 word sentencesTalking in 1-2 word sentences Using accessory musclesUsing accessory muscles JVD and pedal edema present and chronicJVD and pedal edema present and chronic

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Case Scenario #1Case Scenario #1 What is the rhythm strip?What is the rhythm strip?

Sinus tachycardia with PVC’sSinus tachycardia with PVC’s ST elevation noted so needs 12 lead ST elevation noted so needs 12 lead

• Check if there are 2 or more contiguous leads with Check if there are 2 or more contiguous leads with ST elevation present (there is none)ST elevation present (there is none)

Note: PVC’s fairly common in the COPD populationNote: PVC’s fairly common in the COPD population

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Case Scenario #1Case Scenario #1Small Group DiscussionSmall Group Discussion

What is your impression?What is your impression?

What is your treatment?What is your treatment?

How do you monitor effectiveness of How do you monitor effectiveness of treatment?treatment?

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Case Scenario #1Case Scenario #1 ImpressionImpression

Exacerbation of COPDExacerbation of COPD Possible left heart failurePossible left heart failure

TreatmentTreatment Increase oxygen deliveryIncrease oxygen delivery Administer Albuterol nebulizer treatment for wheezingAdminister Albuterol nebulizer treatment for wheezing Obtain 12 lead EKGObtain 12 lead EKG

• Note ST segment elevation on Lead II – is there Note ST segment elevation on Lead II – is there more? (only present in Lead II)more? (only present in Lead II)

ReassessmentReassessment Respiratory statusRespiratory status EKG monitor (unchanged)EKG monitor (unchanged)

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Case Scenario #1Case Scenario #1Critical Thinking QuestionsCritical Thinking Questions

1. What is the significance of the tripod position, 1. What is the significance of the tripod position, speaking in 1-2 word sentences, and use of speaking in 1-2 word sentences, and use of accessory muscles?accessory muscles?

2. What is the relationship with emphysema and 2. What is the relationship with emphysema and “water in the lungs”?“water in the lungs”?

3. What action can be taken regarding the home 3. What action can be taken regarding the home oxygen tank?oxygen tank?

4. Based on the patient’s medications, what 4. Based on the patient’s medications, what electrolyte may be a factor?electrolyte may be a factor?

5. How do you assess the degree of respiratory 5. How do you assess the degree of respiratory distress?distress?

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Dispatched for a 76 year-old male due to a Dispatched for a 76 year-old male due to a fall at homefall at home

Upon arrival your patient is sitting upright Upon arrival your patient is sitting upright on the couch, watching you approachon the couch, watching you approach

Awake, verbally responsive, oriented x3Awake, verbally responsive, oriented x3 Radial pulse irregularRadial pulse irregular Skin normal, drySkin normal, dry Hx: After a nap patient tried to get up but Hx: After a nap patient tried to get up but

fell; Pt states “I can’t get up right”fell; Pt states “I can’t get up right”

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Hx: Relatively healthy; total hip Hx: Relatively healthy; total hip replacement 2 years ago, hypertensionreplacement 2 years ago, hypertension

Allergies: noneAllergies: none Meds: Hydrodiuril, digoxin, CoumadinMeds: Hydrodiuril, digoxin, Coumadin VS: 146/82; P – 78; R – 16; SpOVS: 146/82; P – 78; R – 16; SpO22 98% 98% Does not move left leg on command, left Does not move left leg on command, left

arm moves weakly and no grasp on leftarm moves weakly and no grasp on left Blood glucose 89Blood glucose 89 Abrasion to left elbow and knee from fallAbrasion to left elbow and knee from fall Denies hitting his headDenies hitting his head

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What is the rhythm?What is the rhythm?

Atrial fibrillationAtrial fibrillation

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Acute strokeAcute stroke Most likely ischemic (a clot) due to risk factor of atrial Most likely ischemic (a clot) due to risk factor of atrial

fibrillationfibrillation Need to also assess for injuries from the fallNeed to also assess for injuries from the fall

TreatmentTreatment IV-OIV-O22-monitor-monitor Assess with Cincinnati Stroke ScaleAssess with Cincinnati Stroke Scale Expedited transport; Activating “Stroke Alert” at Expedited transport; Activating “Stroke Alert” at

receiving hospitalreceiving hospital

ReassessmentReassessment Monitor B/P, watch for mental status changesMonitor B/P, watch for mental status changes

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1.1. What is the significance of atrial What is the significance of atrial fibrillation related to strokes?fibrillation related to strokes?

2.2. What side of the brain has the stroke What side of the brain has the stroke affected?affected?

3.3. Why isn’t the patient’s speech affected?Why isn’t the patient’s speech affected?4.4. How does hypertension predispose to How does hypertension predispose to

stroke?stroke?5.5. What is the most important questions to What is the most important questions to

ask?ask?

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Dispatched for a 3 year-old for possible Dispatched for a 3 year-old for possible allergic reactionallergic reaction

Upon arrival you hear fussy cryingUpon arrival you hear fussy crying Patient on mother’s lap squirming, trying to Patient on mother’s lap squirming, trying to

scratch selfscratch self Watching your approachWatching your approach Patient is covered with hivesPatient is covered with hives Itching started 1 hour ago and 30 minutes Itching started 1 hour ago and 30 minutes

ago broke out in hivesago broke out in hives

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Hx: Current ear infection; history of being treated Hx: Current ear infection; history of being treated in the past for multiple ear infectionsin the past for multiple ear infections

Allergies: noneAllergies: none Meds: Ampicillin, Flintstone vitaminsMeds: Ampicillin, Flintstone vitamins VS: P – 188 regular; R – 40 non-laboredVS: P – 188 regular; R – 40 non-labored Lungs clearLungs clear Weight: 30 poundsWeight: 30 pounds Mother had called pediatrician who directed her Mother had called pediatrician who directed her

to call 911to call 911

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ImpressionImpression Simple allergic reaction (no airway Simple allergic reaction (no airway

involvement) most likely due to repeat involvement) most likely due to repeat exposure to the antibioticexposure to the antibiotic

TreatmentTreatment Benadryl 1 mg/kg IVP slowly over 2 minutes Benadryl 1 mg/kg IVP slowly over 2 minutes

or IM (max 25 mg)or IM (max 25 mg) ReassessmentReassessment

Monitor breath sounds, vital signsMonitor breath sounds, vital signs Monitor subjective complaintsMonitor subjective complaints

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1.1. What causes this patient’s condition?What causes this patient’s condition?

2.2. Is the pulse rate (188) okay for this Is the pulse rate (188) okay for this patient in this condition?patient in this condition?

3.3. Why is the patient having a reaction now Why is the patient having a reaction now if they have taken this antibiotic multiple if they have taken this antibiotic multiple times before?times before?

4.4. What would wheezing indicate?What would wheezing indicate?

5.5. What are the differences in treatment for What are the differences in treatment for various levels of allergic reactions?various levels of allergic reactions?

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You respond to a local business for a You respond to a local business for a 56 year-old female having a “heart attack”56 year-old female having a “heart attack”

Patient is awake, oriented, palePatient is awake, oriented, pale Radial pulse present, regular, slightly Radial pulse present, regular, slightly

elevatedelevated Hx: Was at desk working and developed Hx: Was at desk working and developed

pain between shoulder blades, chest pain between shoulder blades, chest discomfort and slight shortness of breath discomfort and slight shortness of breath for past one hour. Discomfort rated 7/10for past one hour. Discomfort rated 7/10

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Hx: Hypertension, diet controlled diabetes, Hx: Hypertension, diet controlled diabetes, and GERDand GERD

Allergies: morphineAllergies: morphine Meds: Toprol, Hydrochlorothiazide, and Meds: Toprol, Hydrochlorothiazide, and

prilosecprilosec VS: 118/78; P – 92; R-18; SpOVS: 118/78; P – 92; R-18; SpO22 99% 99%

Lung sounds are clearLung sounds are clear Blood glucose: 89Blood glucose: 89

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What is the rhythm?What is the rhythm?

Sinus rhythmSinus rhythm

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Case Scenario #4Case Scenario #4 Is there any ST elevation present?Is there any ST elevation present?

ST elevation V2 – V5ST elevation V2 – V5

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What complication do you monitor for with What complication do you monitor for with ST elevation in this location?ST elevation in this location? V1 through V6 view the anterior, septal, and V1 through V6 view the anterior, septal, and

lateral walls of the left ventriclelateral walls of the left ventricle Supplied by the left anterior descending artery Supplied by the left anterior descending artery

(LAD)(LAD) Occlusion of the LAD (the “widow maker”) Occlusion of the LAD (the “widow maker”)

leads to left ventricular damage and therefore leads to left ventricular damage and therefore cardiogenic shock and deathcardiogenic shock and death• Also watch for heart blocksAlso watch for heart blocks

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ImpressionImpression Acute MI (ST elevation V2-V5)Acute MI (ST elevation V2-V5) Vital signs currently stableVital signs currently stable

TreatmentTreatment IV-OIV-O22-monitor-monitor Aspirin, NTG, morphine if necessaryAspirin, NTG, morphine if necessary

ReassessmentReassessment Monitor pain level, EKG monitor, vital signsMonitor pain level, EKG monitor, vital signs Watch for drop in B/P after nitroglycerinWatch for drop in B/P after nitroglycerin

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1.1. What is the typical presentation of complaints for What is the typical presentation of complaints for men, women, elderly, and diabetics?men, women, elderly, and diabetics?

2.2. Why was there no ST elevation on the Lead II?Why was there no ST elevation on the Lead II?

3.3. If the patient had a transplanted heart, are there If the patient had a transplanted heart, are there any traditional cardiac drugs not effective?any traditional cardiac drugs not effective?

4.4. What does aspirin do for the patient What does aspirin do for the patient experiencing an acute MI?experiencing an acute MI?

5.5. What information needs to be conveyed to the What information needs to be conveyed to the hospital for them to activate a cardiac alert?hospital for them to activate a cardiac alert?

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You have been dispatched for a 68 year-You have been dispatched for a 68 year-old female with complaints of chest painold female with complaints of chest pain

Upon arrival the patient is sitting on the Upon arrival the patient is sitting on the floor next to her washing machinefloor next to her washing machine

Awake, oriented, pale and slightly Awake, oriented, pale and slightly diaphoretic, very dizzydiaphoretic, very dizzy

Radial pulse rapid, regularRadial pulse rapid, regular Hx: Doing laundry and suddenly couldn’t Hx: Doing laundry and suddenly couldn’t

catch her breath and felt her heart racingcatch her breath and felt her heart racing

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Hx: Arthritis, osteoporosisHx: Arthritis, osteoporosis Allergies: Iodine, hay fever, pollen, catsAllergies: Iodine, hay fever, pollen, cats Meds: Multivitamins, BonivaMeds: Multivitamins, Boniva VS: 102/64; P- 196; R – 22; SpOVS: 102/64; P- 196; R – 22; SpO22 95% 95%

Lungs: clear, breaths shallowLungs: clear, breaths shallow This feeling has happened once before This feeling has happened once before

years ago and thinks it went away on its years ago and thinks it went away on its ownown

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What is the rhythm strip?What is the rhythm strip?

SVT (narrow QRS complex)SVT (narrow QRS complex)

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SVTSVT Patient relatively stable Patient relatively stable

• Evaluated mental status and B/PEvaluated mental status and B/P TreatmentTreatment

IV established in antecubital area, preferably rightIV established in antecubital area, preferably right Administer med as rapidly as possible followed Administer med as rapidly as possible followed

immediately with saline flushimmediately with saline flush• Pre-warn the patient that most patients say they Pre-warn the patient that most patients say they

feel “funny” for a few minutesfeel “funny” for a few minutes ReassessmentReassessment

Vital signs, cardiac monitorVital signs, cardiac monitor

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Case Scenario #5Case Scenario #5 What is the significance of the rhythms What is the significance of the rhythms

related to administering Adenosine?related to administering Adenosine?#1 During med administration

#2 Following medication administration

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1.1. What is the criteria for SVT?What is the criteria for SVT?2.2. Describe how to perform the valsalva Describe how to perform the valsalva

maneuver and what response is maneuver and what response is expected.expected.

3.3. Describe how to administer Adenosine.Describe how to administer Adenosine.4.4. What side effects are common with What side effects are common with

Adenosine?Adenosine?5.5. When can the 2When can the 2ndnd dose of Adenosine be dose of Adenosine be

administered?administered?

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Return DemonstrationReturn Demonstration

A large volume of calls are of a BLS natureA large volume of calls are of a BLS nature Low volume use of equipment means more Low volume use of equipment means more

practice time required to retain competency of practice time required to retain competency of skillsskills

Work in small groups using one person as the Work in small groups using one person as the “patient”“patient” Apply the HARE traction deviceApply the HARE traction device Apply the KEDApply the KED

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HARE Traction/Sager SplintHARE Traction/Sager Splint

Used to splint a suspected fractured femurUsed to splint a suspected fractured femur Reduces muscle spasm which reduces Reduces muscle spasm which reduces

painpain Prevents bone ends from moving and Prevents bone ends from moving and

damaging close lying tissuedamaging close lying tissue Takes a minimum of 2 people to applyTakes a minimum of 2 people to apply

Easier if 3 people are availableEasier if 3 people are available• 1 to hold traction1 to hold traction• 1-2 to measure/place/secure device1-2 to measure/place/secure device

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HARE TractionHARE Traction

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Sager SplintSager Splint

7474

HARE Traction/Sager SplintHARE Traction/Sager Splint Pearls Pearls

Never apply a strap over the kneeNever apply a strap over the knee Always assess distal PMS/CMS/SMV Always assess distal PMS/CMS/SMV

before and after splinting before and after splinting Most often need to extend the backboard Most often need to extend the backboard

off the cart to have a solid surface for the off the cart to have a solid surface for the foot stand to rest onfoot stand to rest on

7575

KED DeviceKED Device

Used to immobilize a seated patient with Used to immobilize a seated patient with possible spinal injuries onto the standard possible spinal injuries onto the standard back board back board

Takes 3 people to place the device onTakes 3 people to place the device on Is time consumingIs time consuming Used just to move a seated patient to a Used just to move a seated patient to a

standard back boardstandard back board Not useful when rapid extrication is requiredNot useful when rapid extrication is required Manual c-spine control must be constantly Manual c-spine control must be constantly

maintainedmaintained

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KED DeviceKED Device

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KED Device PearlsKED Device Pearls

Maintain manual control of the c-spine at Maintain manual control of the c-spine at all times until secured to a long back boardall times until secured to a long back board

When applying the chin strap, allow for the When applying the chin strap, allow for the possibility of vomitingpossibility of vomiting

Apply thigh straps lastApply thigh straps last Do not lift the patient by the strapsDo not lift the patient by the straps

The patient is rotated on their buttocks and The patient is rotated on their buttocks and then tilted to the supine position onto the long then tilted to the supine position onto the long boardboard

7878

BibliographyBibliography

Bledsoe, B., Porter, R., Cherry, R. Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Paramedic Care Principles & Practice.Principles & Practice. Brady. 2009. Brady. 2009.

Dalton, A., Walker, R. A. Mosby’s Paramedic Refresher Dalton, A., Walker, R. A. Mosby’s Paramedic Refresher and Review – A Case Studies Approach. 2and Review – A Case Studies Approach. 2ndnd Edition. Edition. Mosby. 1999.Mosby. 1999.

Limmer, D., O’Keefe, M. Limmer, D., O’Keefe, M. Emergency CareEmergency Care, 12, 12thth Edition. Edition. Brady. 2012Brady. 2012

Phalen, T., Aehlert, B. The 12 Lead ECG in Acute Phalen, T., Aehlert, B. The 12 Lead ECG in Acute Coronary Syndromes. 2Coronary Syndromes. 2ndnd Edition. Elsevier Mosby. 2006. Edition. Elsevier Mosby. 2006.

Documents

1 Patient Assessment Condell Medical Center EMS System July 2011 CE Site Code #107200E-1211 Sharon Hopkins, RN, BSN, EMT-P