Principles of Patient Assessment in EMS

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

2. Chapter 18 – The Assessment Approach for the Pregnant Patient © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

3. Objectives • Describe the normal A&P changes that occur during the first, second and third trimesters of pregnancy. • Explain why the pregnant patient is at increased risk for vomiting and possible aspiration. • Describe the condition “anemia of pregnancy” and its significance in a patient who is hemorrhaging. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

4. Objectives (continued) • Explain the importance of prenatal care and list some of the potential problems that can develop with inadequate or no prenatal care. • Discuss the OPQRST history and SAMPLE history specific to the pregnant patient. • List additional focused information to obtain specific to the current pregnancy, as well as any prior pregnancies. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

5. Objectives (continued) • Explain why positioning becomes an important consideration for the woman in late 2nd and 3rd trimesters. • Explain the condition supine hypotension and describe how to correct the condition. • List the gestational ages at which fetal movement can be felt by the mother and by the examiner. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

6. Objectives (continued) • Describe fetal assessment including: measurement of the fundus, fetal heart rate and palpation of uterine contractions. • List the possible causes of fetal distress. • List six complications associated with pregnancy and describe the characteristics of each. • Differentiate signs of active labor from imminent delivery. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

7. Introduction • Assessing the pregnant patient is focused on the patient’s chief complaint. • Normal anatomical and physiological changes during pregnancy will modify the assessment process. • Assessment may involve 2 or more patients. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

8. Normal A&P Changes of Pregnancy • Normal gestation is 38-42 weeks. • Pregnancy is broken into 3 – 3 month segments (trimesters). • At 12 weeks the fundus (top of uterus) can be palpated above the symphysis pubis. • Displaces the urinary bladder. • Excessive fatigue and SOB is common throughout pregnancy. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

9. Normal A&P Changes (continued) • Release of progesterone causes: • Relaxation of the GI tract and other smooth muscles • Slowed peristalsis • Nausea/vomiting (increasing the risk of aspiration) © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

10. Normal A&P Changes (continued) • Circulating blood volume increases by nearly 50% by full term. • Hemoglobin does not increase proportionately creating a mismatch called “anemia of pregnancy” • During hemorrhagic shock normal signs/symptoms will not be apparent until 30-35% blood loss • The fetus becomes stressed due to hypoxia before signs and sypmtoms of shock are apparent © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

11. Normal A&P Changes (continued) • Enlarging uterus displaces main internal organs: • Diaphragm displaced upward decreasing functional tidal volume • Esophgeal sphincter displaced resulting in reflux • Low back pain is common in late pregnancy • BP decreases slightly in 2nd trimester and returns to normal in the 3rd trimester • Hypertension during pregnancy is always dangerous and requires evaluation • Heart rate increases 10-20 bpm throughout pregnancy © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

12. The Focused History • The most common EMS calls are for traumatic injury, pain, or vaginal bleeding. • Pregnant patient’s are not immune from any other causes of abdominal pain (i.e. appendicitis, gallbladder, or kidney stones). • Obtain OPQRST and SAMPLE Hx, as well as specific information about the current pregnancy and any previous pregnancies. • Identify any possible risk factors for complications in pregnancy. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

13. The OPQRST History • O – When did the pain, bleeding, labor or traumatic injury or other complaint begin? • P – What was the patient doing at the onset and are there any complications of pregnancy? • Q – Describe the pain and compare to previous episodes. • R – Any radiation from the point of origin? Did she do anything for relief? • S – Rate the pain on the 1 to 10 scale. • T – When did it begin? Any life-threats and imminent delivery indications? © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

14. The SAMPLE History • S – amenorrhea, nausea, vomiting, breast tenderness, back pain, abdominal pain, cramping, vaginal discharge, urinary or bowel problems, abnormal weight gain, generalized edema, etc. • A – Any increased sensitivity to environmental allergens? • M – Any drugs during the pregnancy? • P – Is there a prior pregnancy history or high risk situations? • L – When was the last menstrual period and last oral intake? • E – What events lead to EMS being called (i.e. ruptured waters, labor pain, trauma, hemorrhage)? © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

15. The Physical Exam • Perform the Initial Assessment (MS-ABCs) as with any other patient. • The depth of the PE is focused on the patient’s chief complaint. • For the female in late 2nd or in 3rd trimester positioning is an important factor for comfort and circulation. • Let the patient assume the position of comfort • Immobilized patient’s need to be tilted to avoid supine hypotension © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

16. The Vital Signs • Keep in mind normal vs changes in each trimester. • Assess skin CTC, note presence of generalized edema. • Respiratory rate – unusually normal or slightly increased. • Heart rate – increases 10 – 20 bpm throughout the pregnancy. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

17. The Vital Signs • BP – decreases (10 to 15 mmHg) during 2nd trimester, returns to normal in 3rd. • BP varies with positioning (supine hypotension) • New onset hypertension is abnormal and dangerous > 140/90 may indicate preeclampsia and eclampsia © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

18. The Skin • Changes in skin color are normal due to increased estrogen levels. • Chloasoma or “mask of pregnancy” – mild darkening of the face • Linea nigra – darkened midline from umbilicus to public bone • Areolar, armpits, perineum and inner thigh may also darken © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

19. Changes Assessed During Visualization • Postural changes: • Lordoses • Kyphosis • Protruding abdomen • Widened rib cage, flaring of the lower ribs. • When imminent delivery is suspected examine external vagina for the presence of crowning, prolapsed cord, or the progression of labor. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

20. Changes Assessed During Palpation • Neck – enlarged thyroid gland is normal. • Thorax – costal angle may be wider than normal. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

21. Changes Assessed During Palpation • Abdomen – note any tenderness, guarding and the fundal height. • > 12 weeks fundus can be palpated above symphysis pubis • At 20 weeks at the level of the umbilicus • At 36 weeks it has reached the ribs or costal margin • When contractions are reported measure duration and time between the start of one until the start of another. Perform a fetal assessment © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

22. Changes Assessed During Auscultation • Abnormal heart sounds develop during pregnancy in some women. • S-1 may be louder than normal. • S-3 may be heard. • A systolic murmur may be heard. • Fetal heart tones may be heard > 12 weeks gestation. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

23. Fetal Assessment • Includes: • Measuring fundal height and fetal heart rate • Fetal movement and contractions (when present) • Assess during active labor for signs of distress. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

24. Fetal Assessment • Fundal height: • In supine position, place the zero mark of the measuring tape at the top of the symphysis pubis. Measure in the midline up and over the abdomen to the top of the fundus, note the mark (1cm = approx. 1 wk gestation) • A smaller/larger uterus, than expected, is an abnormal finding • 12 wks at the symphysis pubis, 16 wks between pubis and umbilicus, 36 wks at coastal margin • > 24 wks is age where the fetus is survivable outside the womb © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

25. Fetal Heart Rate • Fetal heart tones (FHT) may be heard 12 to 14 wks with a Doppler or handheld ultrasound or by a Fetoscope by 20 wks. • Normal FHT range is 110 to 160. • Brief rate changes are normal during fetal movement, sleep and contractions. • Locating the FHT may be difficult. Most often other tasks take priority. • Place the mother supine for listening: • Place the microphone on the abdomen and move in slow circles until the FHT are heard © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

26. Fetal Heart Rate (continued) • Count for a minute. Repeat as you repeat the maternal vital signs. • Early pregnancy listen in the midline between the symphysis pubis and the umbilicus. • Late pregnancy listen in the right or left upper quadrant. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

27. Fetal Movement/Contractions • Mother feels movement in the 2nd trimester. • May feel movement during auscultation (especially in the 3rd trimester). • Ask the mother when last movement was felt. • Assess contractions or movement by placing one hand on the top of the fundus. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

28. Fetal Movement/Contractions • A contraction is felt as a muscle tensing. • Measure duration and time of onset of one to another. • True labor is persistent regular contraction. • False labor (Braxton-Hicks) is irregular and inconsistent. • Preterm labor is true labor prior to 38 wks gestation. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

29. Pregnancy Associated Complications • Most OB/GYN emergent complaints are of pain, bleeding or both. • Complications are not common. The goal is to rapidly identify life-threatening conditions: • Eclampsia • Ectopic pregnancy • Determine if delivery is imminent © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

30. Ectopic Pregnancy • When pregnancy is unknown or in 1st trimester and the c/c is lower abdominal pain with/without bleeding suspect ectopic pregnancy. • In 1st trimester, ectopic or miscarriage may be life-threatening conditions when unrecognized and untreated. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

31. Ectopic Pregnancy • The c/c is usually lower abdominal pain, vaginal bleeding or both. • Uncontrolled vaginal bleeding can lead to hypovolemia, shock or death for both the mother and fetus. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

32. Spontaneous Abortion (miscarriage) • A loss of pregnancy < 20 wks gestation. • Occurs in 20 to 30 % of all pregnancies. • c/c is vaginal bleeding with or without abdominal pain. Often there is passing of fetal tissue (blood clot). © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

33. Diabetes • In 2nd trimester hormones trigger a release of increased insulin. • New onset or gestational diabetes typically begins in 2nd or 3rd trimester and subsides after delivery. • Diabetes requires carefully monitoring due to increased risk of birth defects, hypertension, eclampsia and an oversized fetus. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

34. Hypertension • BP (>140/90) is always abnormal during pregnancy. • Can progress to stroke, acute pulmonary embolism, renal failure, preeclampsia, eclampsia, or death. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

35. Hypertension • Signs and Symptoms of pregnancy induced HTN include: • Increase of 30 mm Hg systolic or 15 mmHg diastolic above baseline • Abnormal weight gain • Headaches and visual disturbances • Abdominal pain and generalized edema • Decreased urine output (oliguria) • Protein in the urine on clinical analysis © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

36. Preeclampsia and Eclampsia • Leading cause of maternal/fetal morbidity and mortality. • Signs and symptoms are the same as pregnancy-induced HTN. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

37. Preeclampsia and Eclampsia • More severe symptoms include: • Severe headaches • Blurred vision and diplopia • Nausea and vomiting • RUQ or epigastric pain • Anuria and hematuria • Oliguria, dizziness, confusion • Fetal distress and abruptio placentae • Without rapid treatment may progress to eclampsia (seizures, coma and death). © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

38. Abruptio Placentae / Placenta Previa • Abruptio • A sudden separation of the placenta from the uterine wall • S & S vary with the extent of the detachment • Severe abdominal pain with or without bleeding, but (+) signs of shock • Previa • Abnormal implantation of the placenta in a lower uterine site • S & S include signs of shock and vaginal bleeding without abdominal pain © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

39. Prehospital Delivery • Active labor typically progresses slowly in the female who has never given birth and rapidly in the female who has. • Assessment includes: • Palpate / measure the contractions • Establish Hx of fundus (gestational age) • Inspect external genitalia for presenting fetus • Ask about ruptured membranes © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

40. Prehospital Delivery • Determine if birth is imminent: • Urge to move bowels • Mother says it is time • Crowning © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

41. Conclusion • Approach to the pregnant patient is directed by the c/c, which is typically pain bleeding or both. • Obtain acute details in the FH. • When pregnancy is unknown, or in 1st trimester, all abdominal pain in lower abdomen with/ without bleeding is a possible ectopic pregnancy. (manage as a life-threat!) © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

42. Conclusion • Consider preexisting conditions (i.e. HTN or diabetes). • Consider other causes of abdominal pain (i.e. appendicitis or reflux). • Include the patient’s priorities and concerns. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.