Principles of Patient Assessment in EMS

Principles of Patient Assessment in EMS By: Bob Elling, MPA, EMT-P & Kirsten Elling, BS, EMT-P

Objectives • List the most common neurological emergencies EMS providers encounter. • Describe why the duration of symptoms is helpful in making a field impression of a neurological event. • List some of the reasons why getting a focused history may be difficult in a patient with a neurological problem. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Objectives (continued) • Give examples of clues the EMS provider should look for in the SAMPLE history of a patient with a neurological problem. • List the six components of the neurological examination. • Describe the functions of the twelve pairs of cranial nerves. • Describe how to assess the cranial nerves. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Objectives (continued) • Describe two ways to assess a patient’s coordination. • List the diagnostic tools that are useful in performing a neurological examination. • Describe the two prehospital ministroke tests developed to help in the assessment of a suspected stroke patient. • Explain how the mnemonic AEIOU-TIPS is used in the assessment of the patient with AMS. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Objectives (continued) • Describe the three types of seizures. • List the two most common causes of headache. • Describe the four general categories of head injury. • Describe the three phases of brain herniation syndrome. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Introduction • The nervous system is the most complex of all body systems. • The components of the nervous system can be easily assessed and tested to form a reasonable field impression. • The most common neurological emergencies include: stroke, AMS, seizure, headache, and traumatic brain injury. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

The Neurological Patient • Duration of onset is a helpful feature in making a field impression • Vascular pathologies tend to be acute in onset (i.e. seconds to minutes) • Some vascular causes may provide a warning sign, such as a TIA, prior to a CVA © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

The Neurological Patient • Changes occurring over 2 to 3 days may be caused by dehydration, CNS infection, subdural hematoma, medications, or other toxic metabolic conditions. • Degenerative or chronic neurologic diseases progressively worsen over weeks to years. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

The Focused History • Obtaining the FH of a patient experiencing a neurological emergency can be challenging. • The patient may have difficulty communicating. • Unable to form words, speak clearly or say what he or she is thinking • Whenever possible verify information with family, caretakers, coworkers or MDs. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

OPQRST History • O – What were the circumstances when this event began? • P – Is there anything making the condition worse or better? • Q – What is the quality of neurologic symptoms (i.e. severe headache, or acute parathesia)? • R – Is there any progression of symptoms. Have you attempted anything to improve the condition? • S – Is this similar to prior episodes? Rate on the scale of 1-10. • T – How long has this event been going on? © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

SAMPLE History • S – Consider the associated symptoms with a neurologic complaint: • Headache • Memory loss • Confusion • Motor disturbance • Neck or back pain • Paralysis • Parathesia • Paresis • Speech disturbances • Weakness • Loss of bladder or bowel control © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

SAMPLE History (continued) • A – Any allergies to medications? • M – What changes have there been to the patient’s medication schedule recently? • P – Any history of a condition that could cause a neurologic condition (i.e. hypertension)? • L – What was the last oral intake? • E – What may have precipitated the incident (i.e. medication non-compliance)? © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Physical Exam • The neurological exam evaluates 6 components: • Mental status (MS) • Cranial nerves • Motor response • Sensory response • Coordination • Reflexes © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Physical Exam • Assessing for symmetry is a key objective: • Asymmetry is abnormal till proven otherwise • In some people asymmetry is normal. Always ask “Is this normal for you?” © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Mental Status • A reliable indicator of nervous system dysfunction is the finding of subtle changes. • In the IA use AVPU for the mini-neurological exam followed by the GCS. • AVPU is quick and easy to perform and provides a gross estimation of the neurological status. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Mental Status (continued) • GCS is easy to perform and provides a more quantitative measure of dysfunction. • There is a pediatric version of the GCS (the modified coma score for infants). • Evaluation of MS includes the patient’s affect, behavior, cognition and memory. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Mental Status (continued) • Recall, short, and long term memory are tested by asking questions such as: • Recall – instruct the patient to remember the name of an object and then ask the name of the object at 5 minute intervals. • Short – What day of the week is it? When did you eat last? • Long – What is your date of birth? Social security number? Address? © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Cranial Nerves: Pupils • Normally equally round and 3-5 mm in size. A difference of > 1 mm is abnormal. • Aniscoria means unequal pupils and may indicate a CNS disease or traumatic injury. • Pupils should constrict to light sources. • Light in one pupil should constrict both (consensual light reflex CN-3). • Assess visual acuity by asking the patient to read your name tag. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Cranial Nerves: Pupils (continued) • Accomodation is the ability of the eyes to focus on various distances. • Normally the eyes move apart (diverge) to a parallel position (conjugate gaze) as they focus on a distant object. As an object comes closer to the face the eyes should converge and pupils constrict. • Ask the patient to focus on a distant object and then on your finger in front of their face (CNS 2 & 3). • Assess the field of vision by checking the patient’s peripheral vision (CN 2). © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Cranial Nerves: Pupils (continued) • Assess EOMs to measure brainstem integrity (pons and midbrain). • Assess the 6 cardinal positions of gaze. • The inability to move one or both eyes indicates a neurological deficit (CN 3, 4, 6). • Paralysis of a lateral gaze is an early sign of rising ICP • Paralysis of the upward gaze may indicate an orbit fracture. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Cranial Nerves: Pupils (continued) • Nystagmus is a fine motor twitching of eyeball during extreme lateral gaze. It is normal but in other positions it may be due to ETOH, MS, inner ear problem or brain lesion. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Cranial Nerves: Pupils/Face (continued) • PERRLA – pupils equally round, reactive to light and accomodating. • Assess facial movement/sensation by asking the patient to smile, show their teeth, frown and raise the brows. Touch the forehead, cheeks and chin. • Unilateral drooping is abnormal and associated with paralysis as in a CVA (CN 7). © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Cranial Nerves: Face • Assess the palate by asking the patient to say “aah,” the soft palate should rise in the middle and the uvula midline (CN 10). • Ask the patient to stick out the tongue. Midline position is normal (CN 12). • Assess for an intact gag reflex (CN 9 and 10). © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Cranial Nerves: Face (continued) • Note any abnormal speech (i.e. aphasia, dsyphasia, dysarthria) or difficulty swallowing (dysphagia), chewing or drooling. • Assess CN 5 by asking the patient to move the jaw from side-to-side while you place resistance with your hands. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Cranial Nerves: Face (continued) • A sudden hearing loss is a significant finding involving CN 8. • Assess CN 6 by testing strength any symmetry of shoulder shrug. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Motor Response • Assess equality of muscle strength, tone, and symmetry in both upper and lower extremities. • When pain or injury are present do not test the affected extremity. • Test upper extremities for grip strength and pronator drift. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Motor Response • Test lower extremities by asking patient to push and pull their feet against resistance. • Note any unilateral weakness. • When appropriate have the patient take a few steps to assess balance and gait. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Sensory Response • This component of the neurological exam is useful in a patient who is conscious or has a suspected spinal cord injury (SCI). • Dermatomes are the areas on the surface of the body that are innervated by affected nerve fibers from one spinal route. • Assessing dermatomes is helpful to estimate a rough correlation to the level of spine injury. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Sensory Response (continued) • For a patient with suspected SCI, with loss of sensation or paralysis, begin at the head and work down to find the line of demarcation for loss of sensation. • For a non-SCI patient assess for destination between sharp and dull touch on the skin of the face and extremities. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Sensory Response (continued) • Ask the patient to close the eyes while you alternate between sharp and dull touch. • In the unconscious patient assess for deep pain response. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Coordination and Reflexes • Cerebellar function is concerned with the control of muscular contractions of the extremities. • Assess function by testing a patient’s balance, fine motor movements, and coordination. • When appropriate observe a patient’s gait. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Coordination and Reflexes (continued) • Examples of abnormal gait: • Ataxia – wobbly and unsteady • Festination – uneven & hurried (Parkinsons) • Spastic hemiparesis – unilateral weakness and foot dragging • Steppage – steps appear to be walking up stairs while on even surface © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Coordination and Reflexes (continued) • Assess fine movements by asking the patient to touch the nose with a finger while the eyes are closed. • Assess reflexes on patients who are unconscious, unresponsive, or with a possible SCI. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Coordination and Reflexes (continued) • The level of reflex response from good to bad: • Purposeful withdrawal from pain • Absent gag reflex • Flexion (decorticate posturing) • Extension (decerebrate posturing) • No response © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Coordination and Reflexes (continued) • Assess motor response in the lower extremities by testing the plantar (Babinski) reflex: • Using a capped pen draw a light stroke up the lateral side of the sole of the foot and across the ball. • The normal response is plantar flexion of the toes and foot. • The abnormal response is dorsi-flexion of the big toe and fanning of all the toes. • In children (<18 months) a positive Babinski is normal. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Diagnostic Tools • The use of diagnostic tools in the neurological exam includes: • Glucometer or dexistrips • Thermometer • ECG monitor • SpO-2 • EtCO-2 © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Neurologic Emergencies • Cerebrovascular Accident (CVA) • CVA is an acute loss of blood flow to the brain. • Transient ischemic attack (TIA) is an acute temporary loss of blood flow to the brain. • AHA recognizes 2 prehospital mini stroke tests to help in the assessment of a suspected stroke patient: • The Cincinnati Prehospital Stroke Scale • The Los Angles Prehospital Stroke Screen (LAPSS) © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Altered Mental Status: AEIOU-TIPS • Can range from a subtle confusion or agitation to unconsciousness and coma. • Try to exclude hypoxia, hypoglycemia and trauma first. • Obtain VS as well as temperature and blood glucose (especially in the young and elderly). © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Seizure • Is this the first or is there a history? • Is there a history of recent head trauma, illness or infection? • Is the patient compliant with meds? • Is this seizure different from previous seizures? • Consider variable causes for each age group? • Be prepared for another seizure. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Seizure (continued) • Three phases: preictal, ictal, and postictal. • After the seizure most patients will feel exhausted and initially confused with progressive improvement over several minutes. • Types of seizure include: • Partial • Generalized • Absence © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Seizure (continued) • Partial seizures: • Occur in a specific area of the brain • Affect only specific area of the body • Often present with an aura © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Seizure (continued) • Generalized seizures: • Involve the entire brain and may include an aura • Classified as: complete motor seizure, absence seizure, and atonic seizure • Postictal confusion, fatigue, or headache • Loss of consciousness. Convulsive activity – tongue biting, incontinence © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Seizure (continued) • Absence seizures: • Formerly called petit mal • Common in children • Daydreaming with convulsive activity • Usually no aura or postictal activity period © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Headache • Common neurological complaint. • Associated symptom of other medical conditions. • Most caused by: tension, muscle-contraction, and sinusitis. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Headache • Other causes include: • Vascular (including migraine) • Cluster • Meningitis • Temporal arteritis • Subarachnoid bleed or increased ICP • Glaucoma or eyestrain • Systemic problems (i.e. anemia, uremia, brain tumor, infection) © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Headache (continued) • Is it acute, recurrent, or chronic. • Types and Severity: • Tension – due to stress and anxiety • Sinus – begin in am and worsen throughout the day. Pressure increases with coughing and sneezing • Migraine – severe and throbbing followed by dull pain. Light sensitive, nausea, vomiting and sometimes an aura. May last hours to days • Cluster – severe, stabbing and burning pain recurring in patterns © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Headache (continued) • Location of pain – does not always indicate the cause. • There are conditions that present with associated findings: • Headache and hypertension – subarachnoid hemorrhage • Headache and fever – meningitis, encephalitis, brain abcsess. • Obtain as much info on associated findings to report to the ED. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Principles of Patient Assessment in EMS