Download Principles of Assessment for EMS by: Bob & Kirsten Elling

Principles of Patient Assessment
in EMS
Assessment Approach to the
Infant & Child
Introduction
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Key to assessing children is to understand
the physiological, psychological and
sociological changes that occur throughout
development.
The EMS Provider must be able to modify
the exam to the age of the patient.
Pediatrics are classified into 7 age groups.
Age Groups
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Newborn – birth to the first few hours
Neonate – birth to 1 month
Infancy – birth to 1 year
Toddler – 1 to 3 years
Preschooler – 3 to 5 years
School age – 6 to 12 years
Adolescent (teenager) – 13 to 18 years
The Focused History
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Obtain the OPQRST and SAMPLE
information
For younger patients look to the parent or
caregiver for information
When no parent or caregiver is present
the EMS Provider may treat an emergency
as necessary under the “implied consent.”
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
The OPQRST History
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O – Is this a new problem or has a
preexisting condition worsened?
P – What was the patient doing at the
time of onset?
Q – What does the pain feel like?
R – Has the parent/caregiver performed
any interventions?
S – Is this condition improving or not?
T – When did the symptoms begin?
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
The SAMPLE History
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S – What prompted you to call EMS?
A – Does the child have any allergies?
M – What medication is the child taking?
P – Has this ever happened before?
L – When did the child last eat?
E – Did the problem occur suddenly or has
it been getting worse?
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Pediatric Vital Signs
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Important to use proper size equipment.
Use pediatric reference charts, pocket
guides, or length based tapes.
Older than 12 have VS similar to normal
adult ranges.
Temperature is important in children.
Less than 3 months fever is a serious
symptom.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Pediatric Vital Signs (continued)
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Young children have an immature thermal
control mechanism.
Infants/ small children are unable to
shiver.
Rapid and wide fluctuations can occur (i.e.
febrile seizures).
Rectal temperature readings are preferred
in children < 5 years old.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Heart Rate
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Infants – obtain by auscultating apical
heart beat, or palpate brachial or femoral
pulses.
Sinus arrhythmia is normal in children.
Older child – palpate the radial pulse.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Respiratory Rate
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Infants/small children - watch the
abdomen for respiratory movement.
Older child – observe/palpate the chest
the same as an adult.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Blood Pressure
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May be difficult to obtain on small children
due to uncooperativeness and fear.
An exact BP reading on most children is
not necessary.
Skin color, temperature and condition
(CTC) is a reliable indicator of circulation.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Capillary Refill
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A reliable indicator of a child’s circulatory
condition.
Refill time greater than 2 seconds is
delayed.
Assess refill on the bottom of the foot of
an infant.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Body Weight
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Important factor in emergency care (i.e.
medication/fluid administration).
Ask parent/caregiver about the weight.
Estimate weight in Kg. By multiplying the
child’s age by 2 and adding 8.
(child’s age x 2) +8=weight in Kg.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
The Physical Exam
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Modify the PE to the age of the patient.
Include an assessment of the child’s
environment and interactions with family
or caregivers.
Consider the anatomical, cognitive, and
emotional differences for each age group.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Approach to the Newborn
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The newborn assessment is performed
immediately after birth.
Respiratory effort, heart rate and skin
color for perfusion are evaluated using the
APGAR scoring system at 1 and 5 minutes
after birth.
Listen for breath sounds in the mid-axillary
area.
Palpate the pulse at the umbilical stump or
apically on the chest.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
APGAR Scoring System
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Appearance – color of the skin from blue
to pink
Pulse – absence to over 100 bpm
Grimace – no response to cries
Activity – limp to extremely active
Respirations – absent to good crying
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Approach to the Neonate and
Infant
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Keeping the child and the parents calm is
a key factor for an accurate assessment
and preventing the child from agitating
the current condition or injury.
The EMS provider’s facial expressions and
body language communicates a lot.
Anatomical significances include:
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Larger head size in proportion to the body
Fontanels can be used as an aid to assessing
for dehydration/shock or rising ICP
Approach to the Neonate and
Infant (continued)
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Anterior closes by 12 to 18 months, posterior
closes by 4 to 6 months
Tongue is very large
Small trachea is more anterior than an adult’s
airway (increased risk for FBAO)
Smallest diameter of the airway is the cricoid
Obligate nose breathers until 6 months (nasal
secretions create obstruction)
Belly breathers due to immature respiratory
muscles
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Approach to the Toddler
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Primary concerns are similar to those of
infant.
Establish rapport with parent/caregiver
and involve them in care as much as
possible.
General appearance is a reliable indication
of how ill/injured the child is.
Perform the PE in a toe-to-head fashion in
an effort to reduce anxiety/fear.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Approach to the Toddler
Smile, talk gently, warm hands prior
to touching. Use distractions.
 Demonstrate procedures on a toy or
parent or yourself first.
 Save unpleasant/invasive procedures
for last.
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Approach to the Preschooler
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The child should have mastered basics of
language and be able to tell what hurts.
Cognitive/social competency is dependent
on home environment and level of
distress. The child may be comfortable
independent or cling to the parent.
This group takes things you say very
literally.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Approach to the Preschooler
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Gaining the child’s trust is important.
Explain steps and do not lie.
Tell the child what to do instead of asking
them.
The child will often be comforted by a toy
or having a parent nearby.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Approach to the School-Age Child
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There is increased modesty, independence
and self esteem.
Important not to feel different from other
children.
Involve the child in history taking and
verify information with parent or caregiver.
Allow the child to make minor choices in
order to increase the sense of control.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Approach to the Teenager
(Adolescent)
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Approach is the same as an adult.
Preserve modesty. If possible
interview/examine without a parent
nearby.
Take them seriously, especially with
suicide “threats.”
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Trauma Emergencies
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Leading cause of death in children.
Most common causes include:
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MVCs
Abuse and falls
Auto-pedestrian incidents
Bicycle injuries and firearms
Burns and drowning
Many causes are preventable (i.e. wearing
seat belts, wearing helmets).
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Trauma Emergencies (continued)
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EMS providers can play a key role in
education on prevention (setting the
example).
Suicide is a major cause of death and is
still increasing.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Trauma Emergencies (continued)
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In history taking be alert for clues of
suicidal intentions and risk factors such as:
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Dramatic personality changes
Self destructive behavior
Withdrawal from family or friends
Expressing signs of depression, hopelessness
or excessive guilt
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Abuse and Neglect
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Can be physical, sexual or emotional.
Incidence of > 3 million cases a year
(grossly under reported).
EMS providers may be the first to
recognize signs in the home environment
and observe key family interactions.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Abuse and Neglect
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Environmental conditions may
include:
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Evidence of alcohol or substance abuse
A MOI that does not fit the scene
Family members giving different accounts of
the incident
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Medical Emergencies
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Respiratory distress is the leading medical
complaint in children.
Common causes of respiratory distress in
children include:
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Asthma and Bronchiolitis
Croup and Epiglottitis
Pneumonia and FBAO
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Medical Emergencies
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Indications of respiratory distress include:
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AMS
Poor skin CTC
Changes in respiratory effort and respiratory
sounds
Nasal flaring and use of accessory muscles
Stridor or grunting
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Asthma
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Reversible airway disease prominent in 3
to 12 year age group.
History of allergies helps to differentiate
from croup, epiglottitis and FBAO.
Early indications include:
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Wheezing and dyspnea
Difficulty exhaling and tachypnea
Accessory muscle use
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Asthma
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Late indications include:
 Physical exhaustion and a quiet chest
 Tachypnea and respiratory failure
A slow heart rate and decreased MS in the
face of an asthma attack is an imminent
sign of respiratory arrest.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Bronchiolitis
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A viral infection of the bronchioles that
causes swelling of the lower airways.
Symptoms similar to asthma including:
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Tachypnea
Retractions
Cyanosis
History of recent or current respiratory
infection.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Croup
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A viral infection or other infection (i.e. ear
infection).
The infection in the upper airway causes
swelling of the vocal cords, trachea, and
the tissue under the epiglottis creating a
partial airway obstruction.
Child has a mild or severe “seal-like”
barking cough.
Common in the 3 month to 3 year age
group.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Epiglottitis
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A rare, potentially life-threatening
infection, which causes severe
inflammation/swelling of the epiglottis.
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Potential for complete airway obstruction
Can occur at any age (most common 3 to 6)
History of mild flu-like symptoms
Rapid onset of respiratory distress, difficulty
swallowing, drooling, and little or no cough
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Pneumonia/FBAO
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Pneumonia is caused by a viral or bacterial
infection and associated with recent
respiratory infection.
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Signs and symptoms include: fever,
tachypnea, rales, consolidation in one or more
lobes, and a cough
Foreign bodies – should be suspected
when respiratory distress is sudden or
wheezing or stridor is present (common in
1 to 3 yr. olds).
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Additional Medical Emergencies
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Seizures – can occur at any age.
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Febrile seizure is most common and caused
by a rapid increase in body temperature
Other causes include: infection, epilepsy,
poisoning, ICP, electrolyte disturbances,
tumors, and idiopathic (unknown causes)
Dehydration – is a significant problem for
pediatrics.
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Diarrhea is the leading cause
Other causes include: fever, loss of appetite,
DKA, severe burns, persistent vomiting
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Additional Medical Emergencies
(continued)
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Rotavirus is a virus that nearly all children
get by age 2.
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Symptoms include vomiting and diarrhea,
lasting 24 hours to several days
Signs include: extreme sleepiness, decreased
urine output, sunken eyes, poor skin turgor
and dry mucus membranes
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Additional Medical Emergencies
(continued)
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Hypothermia – caused by exposure,
ingestion of drugs/alcohol, metabolic
disorders, prolonged infection (sepsis) and
brain disorders.
Hyperthermia – caused by exposure, toxic
doses of medications, viral or bacterial
infections.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Additional Medical Emergencies
(continued)
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Hypoglycemia – caused by too much
insulin, increased stress (i.e.: exercise or
fever).
Hyperglycemia – caused by too little or
missed insulin dosing, new onset diabetes
mellitus. Abdominal pain is a common
symptom associated with DKA.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Additional Medical Emergencies
(continued)
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Shock – common causes include:
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Dehydration and DKA
Sepsis and burns
Poisoning and anaphylaxis
Adrenal insufficiency or meningoccemia
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Additional Medical Emergencies
(continued)
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Ataxia – due to poisoning, infection or
tumor.
Delirium or coma – due to infection
(meningitis or encephalitis), Reye’s
syndrome, DKA, hypoglycemia, hepatic
failure, substance abuse or head trauma.
Apnea – caused by congestion from:
colds, seizures, dysrhythmias, SIDS, or
acute life-threatening events (ALTE).
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Additional Medical Emergencies
(continued)
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Congenital heart defects – defects of the
heart or diseases of the heart that occur
en utero and are present at birth.
 More than 35 types with causes
unknown
 Signs/symptoms may appear days or
years after birth and can range from
cyanosis to heart failure
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
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Special Needs and Technology Assisted
Children
Better technology has produced a steadily
growing population.
EMS provider needs to have a basic
knowledge of such technology:
 Oxygen devices, ventilators and apnea
monitors.
Special needs may include chronic illness,
physical disabilities, cognitive mental
disability and forms of technology used to
assist the child.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Special Needs and Technology Assisted
Children (continued)
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Devices may include:
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Prosthetics and tracheostomies
Other ostomies and vascular access devices
Feeding tubes and suction
Medication and feeding pumps
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
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Special Needs and Technology Assisted
Children (continued)
Family/caregivers are usually very
knowledgeable about the patient and
devices.
Emergencies seen in the home-care
patient include:
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Infections and sepsis
Respiratory and cardiac failure
Defective or not operating equipment
Be prepared to spend extra time obtaining
a history and performing a PE.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Technology Assisted Children: Airway
Devices
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Possible problems:
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Improperly placed or obstructed
Oxygen run out or power failures
Pressures are either too high or low
Signs and symptoms of problems:
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Dyspnea
Decreased breath sounds
Decreased tidal volumes
Decreased peak flow/ SpO-2
Respiratory failure/arrest
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
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Technology Assisted: Vascular Access
Devices
Possible problems:
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Infections or clotting
Dislodgement or extravasation
Hemorrhage or equipment failure
Embolism or obstruction
Signs and symptoms of problems:
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Infection at the site
Hemorrhage
Hemodynamic compromise
Embolism
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Technology Assisted: Ostomies and Feeding
Tubes
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Possible problems:
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Improper positioning
Urinary tract infections
Urinary retention
Urosepsis
Signs and symptoms of problems:
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Signs of aspiration
Abdominal pain/distention
Decreased bowel sounds
Distended bladder
Dysuria
Change in urine output
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Conclusion
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The key to assessment is to modify your
approach to fit the child’s developmental
age.
Include the parents/caregivers when
appropriate.
Use proper sized equipment.
Include the child’s weight and body
temperature routinely.
© 2003 Delmar Learning, a Division of Thomson Learning, Inc.
Conclusion
Be prepared to spend more time
obtaining a FH and PE for a special
needs child or one with assisted
technology devices.
 Become familiar with such technology
and possible problems which could
result in a call for EMS.
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© 2003 Delmar Learning, a Division of Thomson Learning, Inc.