Goal Directed Patient Assessment

1. Goal Directed Patient Assessment Dan Batsie dbatsie@apems.org

2. How is an EMT different than a taxi driver?

4. Goals of the EMT • Go home • Identify resuscitation • Identify/intervene in immediate life threats • Identify ongoing (subtle) life threats • Symptom relief • Customer service

8. Dr Reuben Strayer

9. Bottom Up Approach

10. Bottom Up Approach • Final diagnosis • Ancillary testing • Differential diagnosis • Diagnostic testing • Comprehensive physical examination • Comprehensive history

11. Symptoms • Allergies • Medications • Past medical history • Last meal • Events

14. What’s wrong with the patient? What does the patient need?

19. 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

20. Asthma Pulmonary edema COPD Pneumonia Spontaneous pneumo. PE Epiglottitis Cystic fibrosis Pertussis Respiratory infections Toxins

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

22. 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

23. Simple ≠ Dumb

24. 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

26. Primary Assessment • Airway • Breathing • Circulation • Disability

27. Primary Assessment • Circulation • Airway • Breathing • Disability

28. Primary Assessment Circulation Airway Breathing Disability Circulation

29. Disability Breathing Circulation Airway History Secondary Assess. Interventions Diagnostic tests Phys. Exam

30. What are the goals of our assessment?Primary Assessment

31. Is it safe?

32. Primary Assessment ID Resuscitation Prevent Hypoxia Prevent Hypoperfusion Goals

33. Massive hemorrhage Airway Respiration Circulation Hypothermia/Headinjury EXsanguinating hemorrhage Airway Breathing Circulation Disability

34. Airway X A B C D • Is it open? • Will it stay open?

35. Prevent Hypoxia

36. Initial Assessment Revisited Breathing Is it adequate?

37. <8 >20

38. Breathing Adequacy • Oxygenation • Ventilation

39. 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

40. Are the perfusing?

41. Prevent Hypoperfusion

42. Do we need to leave right now?

43. Airway • Breathing • Circulation • Disability • Expose • Fit into CUPS • Get Vitals • History/Head to Toe

44. 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

45. Secondary Assessment • Not important if interventions are necessary or ongoing • May not be an achievable goal.

46. Assessment is more than just identifying interventions

47. N Engl J Med, Vol. 345, No. 19

48. Every 10 minute increase in the time to reperfusion therapy increases mortality by 1%

49. Missed AMI doubles mortality

50. 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.