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Goal Directed Patient Assessment. Dan Batsie dbatsie@apems.org. How is an EMT different than a taxi driver?. Goals of the EMT. Go home Identify resuscitation Identify/intervene in immediate life threats Identify ongoing (subtle) life threats Symptom relief Customer service.

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goal directed patient assessment

Goal Directed Patient Assessment

Dan Batsie

dbatsie@apems.org

goals of the emt
Goals of the EMT
  • Go home
  • Identify resuscitation
  • Identify/intervene in immediate life threats
  • Identify ongoing (subtle) life threats
  • Symptom relief
  • Customer service
bottom up approach1
Bottom Up Approach
  • Final diagnosis
  • Ancillary testing
  • Differential diagnosis
  • Diagnostic testing
  • Comprehensive physical examination
  • Comprehensive history
slide11

Symptoms

  • Allergies
  • Medications
  • Past medical history
  • Last meal
  • Events
slide14

What’s wrong with the patient?

What does the patient need?

slide19

Specific respiratory conditions—definition, causes, assessment findings and symptoms, complications, and specific prehospitalmanagement and transport decisions

A. Asthma

B. Pulmonary Edema

C. Chronic Obstructive Pulmonary Disease

D. Pneumonia

E. Spontaneous Pneumothorax

F. Pulmonary Embolism

G. Epiglottis

H. Pertussis

I. Cystic Fibrosis

J. Environmental/Industrial Exposure/ Toxic Gasses

K. Viral Respiratory Infections

slide20

Asthma

Pulmonary edema

COPD

Pneumonia

Spontaneous pneumo.

PE

Epiglottitis

Cystic fibrosis

Pertussis

Respiratory infections

Toxins

slide21
Although there are many pathologies to consider, the emergent needs of the patient are relatively few.
slide22
Interventions

Medications

O2

Epi auto-injector

Albuterol

Charcoal

Aspirin

Nitronox

Glucose

NTG

  • Restraints
  • CPR
  • Defibrillation
  • Hemorrhage control
  • Foreign body airway/suction
  • NPA/OPA
  • BIAD
  • PPV
  • CPAP
  • Supplemental O2
  • Splinting/immobilization
  • Cool/warm
  • Childbirth
  • Transport
  • Request ALS
  • PASG
  • Wound care/bandaging
top down approach what does the patient need
Top Down Approach(What does the patient need?)
  • Safety
  • Identify the need for resuscitation/correction of a primary assessment problem
  • Identify the need for other immediate action
  • Identify life threatening conditions
  • Symptom relief
  • Customer service
slide26

Primary Assessment

  • Airway
  • Breathing
  • Circulation
  • Disability
slide27

Primary Assessment

  • Circulation
  • Airway
  • Breathing
  • Disability
slide28

Primary Assessment

Circulation

Airway

Breathing

Disability

Circulation

slide29

Disability

Breathing

Circulation

Airway

History

Secondary Assess.

Interventions

Diagnostic

tests

Phys. Exam

primary assessment
Primary Assessment

ID Resuscitation

Prevent Hypoxia

Prevent Hypoperfusion

Goals

slide33

Massive hemorrhage

Airway

Respiration

Circulation

Hypothermia/Headinjury

EXsanguinating hemorrhage

Airway

Breathing

Circulation

Disability

slide34

Airway

X

A

B

C

D

  • Is it open?
  • Will it stay open?
slide36

Initial Assessment Revisited

Breathing

Is it adequate?

breathing adequacy
Breathing Adequacy
  • Oxygenation
  • Ventilation
identify respiratory failure
Identify Respiratory Failure

Bad signs

Super bad signs

Tiring

Rate changes

Respiratory pattern changes

Lethargy, somnolence

Silent chest

  • Hypoxia despite O2
  • Hypercapnia
  • Poor tidal volume
  • Anxiety/Combativeness
slide43

Airway

  • Breathing
  • Circulation
  • Disability
  • Expose
  • Fit into CUPS
  • Get Vitals
  • History/Head to Toe
slide44

Safety

  • Resuscitation
  • Correction of a primary assessment problem
  • Identification of life threatening condition
  • Symptom relief
  • Customer service
  • Scene Survey
  • Primary Assessment
    • ABCD
  • Secondary Assessment
    • History
      • OPQRST, SAMPLE
    • Physical
      • Diagnostic testing
  • Reassess
slide45

Secondary Assessment

  • Not important if interventions are necessary or ongoing
  • May not be an achievable goal.
eastern maine medical center average door to balloon time 2011
Eastern Maine Medical Center Average Door to Balloon Time 2011:
  • Self transported - 70.56 min.
  • EMS Transported with activation - 40.29 min.
  • ED Bypass- 16 min.
  • EMS transported without activation - 77.69 min.
slide57

Specific respiratory conditions—definition, causes, assessment findings and symptoms, complications, and specific prehospitalmanagement and transport decisions

A. Asthma

B. Pulmonary Edema

C. Chronic Obstructive Pulmonary Disease

D. Pneumonia

E. Spontaneous Pneumothorax

F. Pulmonary Embolism

G. Epiglottis

H. Pertussis

I. Cystic Fibrosis

J. Environmental/Industrial Exposure/ Toxic Gasses

K. Viral Respiratory Infections

slide59

Specific respiratory conditions—definition, causes, assessment findings and symptoms, complications, and specific prehospitalmanagement and transport decisions

A. Asthma

B. Pulmonary Edema

C. Chronic Obstructive Pulmonary Disease

D. Pneumonia

E. Spontaneous Pneumothorax

F. Pulmonary Embolism

G. Epiglottis

H. Pertussis

I. Cystic Fibrosis

J. Environmental/Industrial Exposure/ Toxic Gasses

K. Viral Respiratory Infections

slide61

Asthma

Pulmonary edema

COPD

Pneumonia

Spontaneous pneumo.

PE

Epiglottitis

Cystic fibrosis

Pertussis

Respiratory infections

Toxins

slide62

Ask questions to get answers

  • Use history to make decisions
  • One question leads to the next
  • Questions are used to narrow your focus
slide68

Is there a wheeze?

How long has this been going on?

How fast were you going?

Have you ever had a seizure before?

When was the last time you were normal?

Do you still have your appendix?

Any hives?

When did this start?

Do you have asthma?

Did you just eat a greasy meal?

Have you been coughing?

Have you had a fever?

Do you have CHF?

Ripping or tearing pain?

What exactly did you take and how much?

How big was the knife?

Do you have any pain?

Are you a diabetic?

Are you a smoker?

Are you able to speak?

Have you ever had kidney stones?

Is anyone else sick in the house?

Have you urinated/moved your bowels recently?

Do you feel the urge to push?

Do you still have your appendix?

Do you take an ED medication?

Has this ever happened before?

Are you allergic to…

How far did you fall?

Do you have a history of alcohol abuse?

Any recent injuries/illness?

Are you sexually active?

Were you trying to hurt yourself?

Can you describe the pain?

slide71

General Impression

Primary Assessment

History

Field Diagnosis

History

Physical Exam

Better Diagnosis

symptom relief
Symptom relief?
  • Can be done without diagnosis
  • Not always an ALS procedure
cool air and dypsnea
Cool Air and Dypsnea
  • Stimulation of mechanoreceptors mediated through the trigeminal nerve on the face may alter afferent feedback and modify the perception of dyspnea.
  • Shown to reduce dyspnea in normal volunteers in response to hypercapnia and inspiratory resistive loads

Schwartzstein, R. et al. Cold facial stimulation reduces breathlessness induced in normal subjects. Am. Rev. Respir. Dir. 13658-61 1987

questions
Questions?

Dan Batsie

dbatsie@apems.org

slide86

Safety

  • Resuscitation
  • Correction of a primary assessment problem
  • Other immediate action
  • Identification of life threatening condition
  • Symptom relief
  • Customer service
  • Scene Survey
  • Primary Assessment
    • ABCD
  • Secondary Assessment
    • History
      • OPQRST, SAMPLE
    • Physical
      • Diagnostic testing
  • Reassess
slide90

Primary Assessment

Airway

Breathing

Circulation

Disability

CPR

Airway

PPV

Hemorrhage control

Seal chest wounds

Transport

slide92

What’s wrong? (symptoms/events)

  • Has this ever happened before? (PMHx)
  • Allergies
  • Medications
  • Last meal
  • Symptoms
  • Allergies
  • Medications
  • Past medical history
  • Last meal
  • Events