Document

Report
“BASICS” OF BASIC
SCENE ASSESSMENT
Amy Gutman MD ~ EMS Medical Director
[email protected]
OBJECTIVES
• Systematic method of scene
& patient assessment
• Look at cool photos…see
how your eyes & gut lead to
assessment & management
strategies
BACK TO BASICS
• The majority of patients
seen daily require
competent performance of
basic interventions
• Although it’s not “sexy”,
the most basic AND most
difficult skill is patient
assessment
NREMT EMT SKILL
REQUIREMENTS
Assessment
• Scene size-up, initial assessment,
reducE patient anxiety
• Focused history for trauma,
medical, geriatric, pediatric &
special population patients
• Detailed physical exams & ongoing
assessment
• Communication & documentation
Operational
• Ambulance operations
• Infection control procedures
• Scene safety, access, extrication
& hazardous materials
emergencies
• Multiple casualty incidents,
START triage & weapons of mass
destruction
ASSESSMENT STARTS WITH
DISPATCH
• Emergency dispatch designed so crew receives information to
appropriately manage the scene
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Trauma vs medical
Life-threatening conditions
Multiple patients / vehicles
Special hazards (Fire, haz mat, water, weather, traffic)
Requires special personnel or equipment
Reported violence
Pre-arrival instructions
SIZING UP THE SCENE
• Scene safe?
– Police / Haz Mat required?
• Establish “Danger Zone”, Access
& Egress
• Medical, Trauma, Both?
– A family all with "flu“
– MVC with unconscious pt w/o
obvious injury?
• MVC
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PDOF & speed of vehicles
Restraints
Position in Car
Other injuries
MOTOR VEHICLE COLLISIONS
• PDOF Patterns
– Frontal
– Lateral
– Rear
– Rotational
– Rollover
PDOF?
FRONT END COLLISION INJURY PATTERN
PDOF?
“T BONE” PELVIC FRACTURE
PDOF?
Rollover
UNRESTRAINED PATIENT W/ ROLLOVER
TUNNEL VISION
• Avoid urge to rush
• Tunnel vision may cause
you to overlook safety
precautions & require rescue
yourself
• Ask Yourself:
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PPD?
MOI? / Nature of illness?
Number & type of patients ?
Need for additional help ?
Triage & Incident Command ?
onto scene
WARNING SIGNS
• Fighting or loud voices
• Weapons used / visible
• Signs of drug use
• Unusual silence
• Knowledge of prior violence
• Panic
– Remember your inner voice
SCENE CONTROL
• Establish control immediately,
access & egress
• Key is the confidence with
which you interact with patient,
family & prehospital personnel
• Work with police to establish
control / preserve evidence
• Know when the scene is “out-ofcontrol”
– Too many confounders
– Too many patients
SPECIAL
CIRCUMSTANCES
• Recognize early to rapidly
request additional
resources
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Toxins
Crash scenes
Crime scenes
MCI
Water / Weather
MASS CASUALTY / DISASTERS
• Any event overwhelming available
resources
• MCIs often trigger a health crisis
• Disasters often compounded by
poor planning, disjointed
communications costing time,
resources, & lives
MCIs
• Early recognition of personnel &
equipment needs
– 1st on scene calls “Code Black”
– Most experienced on scene is IC
• Triage maximizes outcomes by effective
resource allocation & patient sorting
• Know local / regional resources for
appropriate back-up
PROVIDERS’ ROLES
• Data collection
– Rapid assessment
• Data analysis
– Differential diagnoses
• Data application
– Treatment plan
CLINICAL DECISION MAKING:
GUTMAN’S PORNOGRAPHY PRINCIPLE
SICK
NOT SICK
SICK
NOT SICK
LIKELY TO BE SICK
DATA COLLECTION: CRITICAL THINKING
• 911 call to transfer of care
• Constantly evolving
• “Unconsciously Conscious”
thought process
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“Fundamental” knowledge
Data organization
Comparison to similar situations
Construction of data-driven plan
DATA?
DATA ANALYSIS
• Use what you “see” & what you
“know”
• Differential Diagnoses:
– Absolutely “No”
– Possibly
– Absolutely “Yes”
• Decide what is going to kill patient
first & start intervening
• You will never fix what you do not
consider
WHEN DATA DOESN’T MAKE SENSE,
ASK A DIFFERENT QUESTION
ASSESSMENT?
ASSESSMENT?
INITIAL ASSESSMENT: AVPU
• Begins with 1st impression
• Evaluate patient, environment,
appearance & activity
• If patient has AMS
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Glucose
Narcan
Oxygen
Head Trauma / CVA
Cardiac
ABCDE PET PEEVES
• Missed respiratory distress
• Missed injuries
• Fully dressed patients
• Abnormal vitals with no explanation
• Uncorrected symptomatic
hypotension
DON’T MISS THE FATA INJURY
HPI: SAMPLE
• Ideally obtained from patient
• Bystander “Rule of Indirect Uselessness”
– Runs of “Tachylawdys” & “Paroxysmal Sweet Jesuses”
• Assessments must be situational, systematic & performed
the same way every time
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Signs & Symptoms
Allergies
Medications
Pertinent PMH / PSH
Last Meal
Events leading to CC
WTF INJURIES?
HPI: OPQRST
• If the patient is conscious with a
specific complaint, limit exam to
that area
• If unresponsive or a vague
complaint, assessment must be
broader
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Onset
Provocation
Quality
Radiation
Severity
Time
SUBTLE FOCAL INJURIES
BLS vs ALS
• If the patient is mentating, they are circulating
• ALS?
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Gut response
Unresponsive or altered mental status
Airway compromise or respiratory distress
Inadequate perfusion / Shock
Cardiac arrest / Chest Pain
Uncontrolled bleeding
• Better to over-triage than under-triage
DETAILED PHYSICAL EXAMINATION
• Not Appropriate:
– Critical injuries
– Multiple Injuries
– Short transports
• Appropriate:
– Long Transports
– Prolonged Extrications
– Awaiting Aeromedical
Evacuation
ASSESSMENT: HEENT
• Scalp:
Inspect & palpate
• Facial Bones:
Palpate & evaluate for asymmetry
• Ears:
Drainage
• Eyes:
Discoloration, foreign bodies,
Pupil size & reactivity
• Nose:
Drainage or bleeding
• Mouth:
Loose / missing teeth, swollen / cut tongue,
Foreign bodies
• Neck:
JVD, trachea alignment
ASSESSMENT: THORAX & ABDOMEN
• Chest:
– Breath sound presence /
quality, paradoxical motion,
crepitus
• Abdomen:
– Firm / soft, masses,
pulsations, tenderness
• Pelvis:
– Stability, crepitus
DON’T MISS THE SECOND INJURY
ASSESSMENT: EXTREMITIES & NEURO
• Extremities:
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Injury / deformity
Pulses
Movement
Sensation
Instability
• Neurological:
– GCS / AVPU
– Deficits
• Time
• Type
SERIAL ASSESSMENTS
• Assessment is a continuous
process throughout entire
patient encounter
• Reassess every time you deliver
or change an intervention
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Repeat & record vital signs
Repeat focused exam prn
O2 delivery adequate?
Bleeding controlled?
Splint too tight?
PCR DOCUMENTATION
• Leave a copy for ED (yes…some of us read it)
• Complete, legible documentation keeps you out of trouble
more than good patient care
– Never written, never done
• Errors occur
– When they do, document what happened & what steps were taken
to correct it
– Never attempt to cover up errors
• Narrative must have pertinent positives & negatives
DOCUMENTATION PET PEEVES
• I can’t figure out what happened
• Too much / not enough info
• Illegible anything
• Made-up acronyms
– “DMF”
– “TSTL”
• Concrete statements
– “Entry wound”
• Sloppy charting = sloppy care
SUMMARY: DON’T OVERLOOK THE OBVIOUS
• Is the scene safe?
• Is the patient sick?
• What does your gut say?
• Standard: A, B, C, D, E, but
Don’t forget the “F, G, H” ~
• “F_ _king Get to
the Hospital”!
Thanks For Your Attention!
[email protected]

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