Download July 2010 CE with video clip

Formulating a Pre-hospital
General Impression
July 2010 CE
Condell Medical Center EMS System
Prepared by: FF/PMD Michael Mounts
Lake Forest Fire Department
Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P
Objectives
Upon successful completion of this module, the
EMS provider will be able to:
 Review critical thinking concepts.
 Identify a patient with a medical emergency.
 Identify a patient with a cardiac emergency.
 Identify a patient with a CVA.
 Identify a patient with traumatic injuries.
 Identify a pediatric patient with a medical
emergency.
Objectives cont.




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Identify a geriatric patient with a medical
emergency.
Review documentation components for
discussed conditions.
Demonstrate treatment during patient
scenario.
Demonstrate use of cardiac equipment.
Demonstrate use of bandaging techniques.
Critical Thinking Review (June CE)

EMS personnel must be knowledgeable in
the specific components, stages, and
sequences associated with the critical
thinking process.
Concept formation
 Data interpretation
 Application of principle
 Evaluation
 Reflection on action

Concept Formation

Multiple elements gathered to form a
general impression

The “what” of the patient story
 Scene assessment
 Chief complaint
 Pt history & affect
 Initial assessment
 Physical exam
 Diagnostic test
Data Interpretation

Information gathering
“Working phase” of patient care
 Quality of interpretation depends on
knowledge of A & P and experience
 Obtaining a complete “picture”
 Success greatly affected by attitude and
patient interaction

Application of Principle

Patient care after impression and working
diagnosis/general impression

Treatments & Interventions
 Based on SOP or Medical Control
Evaluation
Ongoing assessment
 Effectiveness of interventions
 Revision of impression
 Review of protocol or orders
 Revision of treatments and/or interventions

Reflection on Action

After the event or incident

Critique
 Provides EMS with avenue to add or
modify experience related to future calls
Thinking Under Pressure

Mental checklist
Stop and think
 Scan the situation
 Decide and act
 Maintain clear and concise control
 Regularly and continually evaluate the patient
 Not reassessment… think constant
assessment!

Thinking Under Pressure cont.

Plenty of information can be ascertained in a
very short amount of time
 Once on scene, you start assessing long
before you are told anything
 Utilize all of your senses during size-up

The following video slide illustrates this point…

Check volume level please
Click anywhere on video picture to play…
Thinking Under Pressure cont.

In about 8 seconds, he was able to get basic
visual info on 5 people


Oh and 4 rolls of paper, too
Practice and experience will help you hone
these skills
Always Remember…

Initial Assessment
 Airway/c-spine immobilization
 Breathing
 Circulation
 Deficit/disability
 If cardiac complaint think “D” for
defibrillation and apply cardiac
monitor
Don’t forget ABC’s !!!
Patient Scenarios


Time to put ideas to work
Step by step verbal and practical application of
skills
 Have crews review the following cases as if
they were on the call
 Use as much equipment as possible to care for
the patient
 Use the time to discuss your department’s
particular equipment (ie: monitor) and how it
works including trouble shooting
Scenario #1

Called for checkup of 45 year-old male that
was driving erratically. Police have pt. sitting
on roadside. Pt. is alert and oriented x2 and
has slight ETOH odor. Pt stated had 2 beers a
couple hours ago during a buffet dinner.

Impression?
Scenario #1 cont.

Vitals:


History:


BP: 158/86, P-76, R- 24, SpO2 97%, Wt 130 kg
HTN (hypertension), Asthma, gastric bypass
Pt. states he feels nauseous and has to
“pee real bad again”
Same impression?
 What else do you want to know?

Scenario #1 cont.

Blood sugar is 376

Possible new onset, or worsening, of diabetes
Large food intake
 Polyuria (excessive urination)
 Nausea
 Rapid respirations
 Acetone odor

Scenario #1 Summary
Some signs are very similar to intoxication
 Not always “just another drunk guy”
 Hyperglycemic Protocol (pg. 28)
 If glucose reading >200
 Fluid challenges - 200ml

Hyperglycemia

So, why are fluids necessary?
 Patient becomes dehydrated
 Large glucose molecule “stuck” in
vascular space
• Glucose drags fluid out of cells to
dilute the high solute concentration
• “Where glucose goes so does water”
• Cells become dehydrated
•  urination to rid body of excess
glucose  eliminates excess fluid
Hyperglycemia

Signs and symptoms of dehydration
 Warm and dry skin; dry mouth
 Tachycardia & weakness
 Hypotension (fluid level down!)
 Restless (unconscious with high levels)
 Fruity breath - build up of ketone byproducts from alternative fat metabolism
(fat used for energy instead of glucose)
 Deep, rapid respirations (blowing off
excess acid by-products)
Region X SOP –
Hyperglycemia/Ketoacidosis

Blood glucose determinant >200 and
warm, flushed skin and
deep, rapid respirations
 IV fluid challenges 200 ml
 May repeat IV fluid challenge
200 ml x 2
 Transport
DKA and Hyperkalemia




Patient in DKA prone to hyperkalemia due to shift
in potassium from inside cell to vascular space
Potassium critical for normal function of muscles,
heart, & nerves
Major electrolytes for transmission of electrical
signals throughout the nervous system of the body
Increased levels result in abnormal heart rhythms,
slowing of the heart rate, weakening of the pulse,
and suppression of all cardiac activity
EKG Effects of
Hyperkalemia:
Tall peaked T
waves
Documentation Keys
Results of blood glucose levels taken
 Amounts of fluid administered (in ml)
 Cardiac monitor interpretation
 Mounted 6 second strip
 Copies with EMS “pink” and ED chart

Scenario #2

Called for a 56 year old female that
fell during a syncopal episode. Pt
states she has had similar events in
the past, but this one is different.
She denies any alcohol intake and
has eaten normally. She also states
that she feels slightly out of breath.

Impression?
Scenario #2 cont.

Vitals:


History:


BP: 116/68, P-70, R-12, SpO2 96%, Wt 65 kg
Diabetes (diet controlled), runs every day
Pt. states she can be “a klutz”
Same impression?
 What else do you want to know?

Scenario #2 cont.

Pt. states she is starting to feel a little dizzy

Would you do ECG monitoring?
 What rhythm is this?
• Normal sinus rhythm
Scenario #2 cont.

Would you obtain a 12-lead?
 If so…
 What’s going on?
ST elevation V1 –V4 (anterior-septal wall)
12-Lead EKG Format/Pattern
Lead I
Lateral wall
aVR
not evaluated
V1
Septum
V4
Anterior wall
Lead II
Inferior
wall
aVL
Lateral wall
V2
Septum
V5
Lateral wall
Lead III
Inferior
wall
aVF
Inferior wall
V3
Anterior
V6
Lateral wall
Most Frequent Complications
Related to MI Locations




Lateral wall – I, aVL, V5, V6
 Heart block
Inferior wall – II, III, aVF
 Hypotension (hold that NTG – call Medical
Control for permission to administer)
Septal wall – V1 – V2
 Heart block
Anterior wall – V3 – V4 (The “widowmaker”)
 Lethal dysrhythmias, cardiogenic shock
Scenario #2 Summary
 Remember
categories for vague
cardiac symptoms
Females
 Long standing diabetics
 Elderly
 Watch out for the “triple threat”


This patient only contained the first two
 ACS

Protocol (pg. 12)
I.V., Monitor (12-lead), O2, ASA, Nitro
Region X SOP - ACS

Stable – alert, warm & dry, B/P >100
 Aspirin 325 mg
 Withhold if reliable and taken within past 24
hours
 If consistently takes aspirin and takes 1
baby per day, contact Medical Control for
guidance
• May not add additional doses
– Drug level is already established
Region X SOP – ACS cont

Nitroglycerin
 For pain control and to reduce the workload
of the heart
 Screen for use of Viagra type drugs within
past 24 hours
 May repeat a dose in 5 minutes
 After 2 doses, consider advancing to
Morphine
• Medical Control may have you continue
to alternate Nitro with Morphine
Region X SOP – ACS cont

Morphine
 Used as pain reliever
 Also dilates blood vessels decreasing
blood flow volume returning to the heart
 Watch for hypotension
 2 mg IVP slowly over 2 minutes
 May repeat every 2 minutes up to a
total dose of 10 mg
Documentation Keys
Full assessment following OPQRST process
 Onset, provocation/palliation, quality,
radiation, severity, time
 Obtain and record B/P before administering
Nitroglycerin
 When obtaining a 12 lead EKG, document
findings related to ST elevation
 If present, state in which leads viewed

Scenario #3
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Called for a 5 year-old with trouble breathing
in a school lunchroom.
Onset happened during her meal just after gym
class.
Pt A&O x3 and in moderate to severe distress.
Teacher tells you this happens from time to
time.
Impression?
Pediatric Assessment Triangle
 Assess
from the doorway
 Appearance
 Work of breathing
 Circulation
Scenario #3 cont.

Vitals:



BP: 88/56, P-112, R-28, SpO2 91%, Wt 40 lbs
Hx:
 Asthma, seasonal allergies, & some food
allergies
Patient states she traded part of a sandwich with
her friend.
Same impression?
 What else do you want to know?

Scenario #3 cont.

What did she eat?


Sandwich was peanut butter & jelly
Peanut allergy?

Many kids have this now
 Most know about it due to history of severe
reaction, but be prepared
 Can go into anaphylaxis very quickly
Anaphylaxis
Key difference between allergic reaction
and anaphylaxis is:
 HYPOTENSION
 Both patients can look “bad” and both can
have wheezing
 Note: Need a 1st exposure for the body to
develop antibodies to antigens to be able to
react to subsequent exposures

Scenario #3 Summary

Peds Allergic reaction (pg. 70)
 Stable with airway involvement
 Epi 1:1000 SQ 0.01 mg/kg
 Benadryl 1 mg/kg IVP slowly
 Albuterol 2.5mg/3 ml nebulized
 Again, be prepared for worsening
Medications
Benadryl – antihistamine
 Stops further release of histamines
 Epinephrine – sympathomimetic
 Stimulates vasoconstriction to support
blood pressure; bronchodilates to ease
breathing
 Albuterol – bronchodilator
 To ease breathing by dilating bronchioles

Documentation Keys
SpO2 room air and after oxygen initiated
 Pertinent negatives
 Effort of breathing
 Use of accessory muscles
 Positioning (ie: tripoding)
 Ability to speaking full sentences

Scenario #4

You are called to the scene for an unknown
medical emergency. The scene is secure. Your
patient is a 54 year-old male who is having
trouble communicating. Patient’s speech is clear,
but responses are not to anything you are saying to
him.

Impression?
Scenario #4 cont.



Vitals:
 BP: 188/96, P-76, R-12, SpO2 98%, Wt 184 lbs
Hx:
 HTN, diabetic, depression, & alcoholism
Pt. appears to be “favoring” right side and still
having trouble following direction.
Same impression?
 What else do you want to know?

Scenario #4 cont.
Attempt to do Cincinnati Stroke Scale Test
 Mild right side arm drift noted
 Determine time of onset
 Treat for CVA (pg. 26)


Is comprehension problem an issue or
symptom?

Yes, positive for Receptive Aphasia
 i.e. Wernicke’s Aphasia
Scenario #4 cont.



Wernicke’s Area
 Controls speech comprehension
Brocca’s Area
 Controls speech production
Both on left side of brain


If either of the above speech
areas are noted to be affected,
see if right sided weakness
is also present
Speech and motor problems will be
reflected on opposite sides of the
body
Cincinnati Stroke Scale or FAST
F – look for facial drooping
 Have patient smile large enough to see
teeth
 A – check for arm drift
 Patient holds hands out in front for 10
seconds with eyes closed, palms up
 S – check for slurred speech
 T – teach patients to call 911 – time is
essential

Scenario #4 Summary



With someone having trouble understanding,
you may have to treat as a language barrier
Person with trouble speaking will look and act
visibly frustrated with themselves. They can
hear and comprehend the strange things they
are saying.
Using hand signals or other forms of
communication may come in handy
Region X SOP- Stroke/Brain Attack





Determine time of onset
Obtain blood glucose level
Perform Cincinnati Stroke Scale
Alert Medical control early
If rapid neurological deterioration ventilate with
BVM
 Adult once every 3 seconds (20/minute)
 Child once every 2 seconds (30/minute)
 Infants once every 1.7 seconds (35/minute)
Documentation Keys
Time of onset of signs and/or symptoms
 Results of Cincinnati Stroke Scale
 Right, left or no facial droop
 Right, left, or no arm drift
 Clear speech or not
 Notification made to receiving hospital

Scenario #5

Called for a 89 year-old female
with chest pain. Patient stated
she had pain going on for about
an hour and “just got scared”.
Pt seems very anxious and
states she does want to go to the
hospital and doesn’t want to
die.

Impression?
Scenario #5 cont.




Vitals:
 BP: 186/102, P-102, R-16, SpO2 100%, Wt 55kg
Hx:
 HTN, asthma, & anxiety
Pt. states her pain was a 10/10 and substernal.
Pt. also states she has a long history of heart and
lung issues.
Same impression?
 What else do you want to know?

Scenario #5 cont.

ECG monitor


Lead II shows…
Sinus rhythm with junctional bigeminy
Scenario #5 cont.

12-lead – no ST elevation noted (look at sinus beats)
Scenario #5 Summary

Could be cardiac or anxiety

Treat as ACS to be safe (pg. 12)


I.V., Monitor (12-lead), O2, ASA, Nitro
Some elderly patients are very lonely and
scared to ask for help
EMS must gain and keep their trust
 Don’t be quick to judge or treat as lesser illness
and/or injury

Documentation Keys
If St elevation is noted or not on 12 lead
EKG
 If St elevation is noted, in which leads
 Detailed assessment covering OPQRST
prompts
Onset
Provocation
Quality
Radiation
Severity
Time

Scenario #6

Your 34 year-old patient received a GSW to the
right upper abdomen. They are conscious and
alert; bleeding is minimal. Patient in moderate
amount of pain.

Impression?
 Do you know you’re A & P?
Category trauma?

Scenario #6 cont.




Vitals:
 BP: 90/62, P- 120, R- 28, SpO2 94%, Wt 85kg
History:
 Denies any past history or medications
Pt. denies any trouble breathing, but says it hurts
when he breaths in deep. No other injuries noted.
Pt is Category I trauma
Same impression?
 What else do you want to know?

Scenario #6 cont.

Make sure the scene is secured. Consider need
for spinal immobilization. During assessment,
consider thoracic injury in addition to
abdominal injury depending on the angle of
GSW.

Examine for an exit wound
 Check the back and the axilla
 Look for signs & symptoms of possible pneumo
Prepare for the worst – assume the patient will
deteriorate before ED arrival

Scenario #6 cont.




Repeat VS: B/P 80/; HR 140; R 32
Remains conscious and in pain
Cover the wound and watch for evisceration
Fluid resuscitation – keep B/P at low levels;
the higher the B/P the faster the patient bleeds
out
Scenario #6 cont. - Transfer Mode

Where does this pt. need to
be transported to?


Highest level Trauma
Center within 25 minutes
How should they be
transported?
 Ground or Aero?
 Whichever you deem
necessary in the field
Documentation Key Reminders

Remember…

If you don’t write it, it didn’t happen!
Include pertinent negatives
 Make sure to use the proper abbreviations



See Condell approved list
 Available from your Medical Officer
Fill out the proper doses on meds

Use ml not cc
Documentation Keys cont.

Trauma
 Include results of inspection, auscultation,
palpation
Mechanism of injury
 Deformity
 Assessment of the general area (ie: contusions,
bleeding, swelling/distention, pain, powder
marks)
 Location of entrance and exit wounds
 Size of wound(s)
 If distance & angle from weapon known

Remember why we’re here…
Questions?
Bibliography
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Mosby’s Paramedic Textbook – Second Edition
Movie clip: “Metro”. 1997.
Various photos via BING search engine
Wikipedia – Brain photo & info
Previous Condell CE’s – some patient info and treatments