Formulating a Pre-hospital General Impression

1. 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

2. 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.

3. Objectives cont. • 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.

4. 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

5. 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

6. 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

7. Application of Principle • Patient care after impression and working diagnosis/general impression • Treatments & Interventions • Based on SOP or Medical Control

8. Evaluation • Ongoing assessment • Effectiveness of interventions • Revision of impression • Review of protocol or orders • Revision of treatments and/or interventions

9. Reflection on Action • After the event or incident • Critique • Provides EMS with avenue to add or modify experience related to future calls

10. 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!

11. 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

12. Click anywhere on video picture to play…

13. 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

14. 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 !!!

15. 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

16. 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?

17. Scenario #1 cont. • Vitals: • BP: 158/86, P-76, R- 24, SpO2 97%, Wt 130 kg • History: • 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?

18. 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

19. 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

20. 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

21. 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 by-products from alternative fat metabolism (fat used for energy instead of glucose) • Deep, rapid respirations (blowing off excess acid by-products)

22. 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

23. 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

24. EKG Effects of Hyperkalemia: Tall peaked T waves

25. 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

26. 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?

27. Scenario #2 cont. • Vitals: • BP: 116/68, P-70, R-12, SpO2 96%, Wt 65 kg • History: • Diabetes (diet controlled), runs every day • Pt. states she can be “a klutz” • Same impression? • What else do you want to know?

28. 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

29. Scenario #2 cont. • Would you obtain a 12-lead? • If so… • What’s going on? ST elevation V1 –V4 (anterior-septal wall)

30. 12-Lead EKG Format/Pattern

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. Scenario #3 • 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?

38. Pediatric Assessment Triangle • Assess from the doorway • Appearance • Work of breathing • Circulation

39. 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?

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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?

46. 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?

47. 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

48. 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

49. 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

50. 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