EMT Lecture - Trauma Patient Assessment

Patient Assessment in EMT Training

Introduction to Patient Assessment

• The importance of patient assessment is emphasized for EMTs, who are expected to assess every patient they encounter, similar to assessing students.

• Acknowledges the diversity of EMT training across different instructors and schools, highlighting the need for standardized assessment practices.

Types of Patients

• Distinction between trauma patients (those injured by external forces) and medical patients (those who are ill).

• Focus on serious trauma cases; examples include severe injuries from accidents or violence rather than minor injuries like cuts.

Mechanisms of Injury

• Serious mechanisms of injury will be the focus throughout the course, including vehicle accidents and falls.

• Clarification that minor traumas will not be covered in depth during this training but may still occur in real EMS work.

Standardized Assessment Protocol

• Emphasis on a uniform approach to patient assessment across New York State, regardless of where an EMT is trained.

• Importance of performing assessments consistently to ensure effective communication and collaboration among EMTs from different backgrounds.

Learning Objectives

• The goal for the session is to understand the theory behind trauma assessments and their procedural order.

• Introduction to scene size-up as a critical first step in patient assessment, focusing on safety protocols like BSI (Body Substance Isolation).

Scene Size-Up Process

• Start with BSI and scene safety; understanding potential hazards before engaging with patients is crucial.

• Assessing the mechanism of injury involves determining how many patients are involved at a scene—critical for resource allocation.

Resource Management

• Importance of accounting for all individuals involved in incidents such as motor vehicle accidents before beginning treatment.

Emergency Medical Response Overview

Role of EMTs in Emergency Situations

• EMTs may need to temporarily handle tasks outside their primary responsibilities, such as diverting traffic or coordinating with utility companies like Con Edison for electrical issues.

• The importance of involving specialized services is emphasized; EMTs should not engage in tasks like electrical wiring, which are beyond their training.

Understanding Spinal Motion Restriction (SMR)

• The term "spinal stabilization" has been updated to "spinal motion restriction" (SMR), highlighting the evolving terminology in emergency medical care.

• SMR is crucial and often tested knowledge; it’s important for students to recognize this change and its implications in practice.

Primary Assessment Protocol

• The primary assessment aims to locate and treat life-threatening injuries. This process is critical and should be prioritized over other assessments.

• General impression involves quickly assessing the patient's gender, position, appearance, and any visible injuries upon arrival at the scene.

Chief Complaint Identification

• The chief complaint is defined by the patient’s own words regarding why they called for an ambulance. It should remain unaltered into medical jargon.

• In cases where a patient is unresponsive, EMTs must deduce the chief complaint based on observed conditions rather than verbal communication.

Level of Consciousness (LOC)

• LOC can refer to both "level of consciousness" and "loss of consciousness," creating potential confusion. Clarity in usage is essential for effective communication among medical professionals.

• Understanding how to assess LOC accurately impacts patient evaluation; it’s vital that EMT personnel are trained on these distinctions.

Evaluation Techniques

• Different methods exist for evaluating patients' conditions; while GCS (Glasgow Coma Scale) remains prevalent in some areas, alternative systems may be more effective depending on regional practices.

GCS Assessment and Patient Responsiveness

Understanding GCS (Glasgow Coma Scale)

• The initial Glasgow Coma Scale (GCS) of the patient was 3, indicating severe unresponsiveness. It has now improved to 14, showing significant recovery.

• GCS ranges from 3 to 15; a higher score indicates better responsiveness. The speaker emphasizes that understanding these numbers is crucial for assessing patient alertness.

• To achieve a high GCS score, patients must respond correctly to specific questions about their identity and location.

Assessing Alertness

• Effective questioning involves asking about personal details like name, current location, and time of year. These questions help gauge cognitive function.

• It's important to tailor questions based on the patient's background; not all patients will know the exact date but can identify seasons or holidays.

Evaluating Responses

• A response does not always mean correct answers; it’s essential to assess if the patient is genuinely alert or just producing words without comprehension.

• Verbal responses should be meaningful; nonsensical answers do not indicate true alertness. The focus should be on coherent communication.

Defining Unresponsiveness

• True unresponsiveness means no reaction to verbal or physical stimuli. This state is critical in determining the severity of a patient's condition.

• Patients may appear responsive by speaking but still lack genuine awareness or coherence in their responses.

Techniques for Assessing Responsiveness

• Physical stimuli can also indicate responsiveness; actions such as moving away from pain show some level of awareness even if verbal communication fails.

• Consistent assessment requires asking three key questions: who they are, where they are, and what season it is—aiming for clarity in responses.

Handling Unresponsive Patients

• EMT training often lacks emphasis on effective techniques for eliciting responses from patients. Proper methods include gentle physical stimulation like sternal rub instead of painful pinching.

• Recognizing true unresponsiveness involves checking for any reaction at all—no flinching or grimacing indicates deep unconsciousness.

Implications of Unresponsiveness

• While being unresponsive can signify serious conditions, it doesn't inherently imply a negative outcome unless accompanied by other critical signs like lack of breathing or pulse.

Understanding Unresponsiveness in Patients

The Importance of Airway Management

• Discusses the critical issue of unresponsiveness in patients, emphasizing that it is a significant problem that needs to be addressed immediately.

• Highlights the physiological aspect of unresponsiveness, noting that loss of muscle control can lead to airway obstruction due to the tongue blocking airflow.

Key Interventions for Unresponsive Patients

• Stresses the necessity of maintaining an open airway; suggests techniques like head tilt-chin lift and using an oropharyngeal airway (OPA) if needed.

• Introduces a debated concept in medicine regarding pulse palpation and blood pressure correlation, specifically mentioning radial pulses indicating systolic blood pressure levels.

Blood Pressure Assessment via Pulse Palpation

• Explains the relationship between different types of pulses (radial, femoral, carotid) and their corresponding systolic blood pressure thresholds: 80 mmHg for radial, 70 mmHg for femoral, and 60 mmHg for carotid.

• Clarifies that "mmHg" refers to millimeters of mercury used in measuring blood pressures but notes this detail won't be tested.

Transport Decisions in Emergency Situations

• Discusses changes in patient status classifications from "cup statuses" to more simplified categories affecting transport decisions.

• Emphasizes making informed transport decisions based on patient assessment—whether to load and go or stay and play with the patient.

Criteria for Serious Trauma Assessment

• Outlines criteria for serious trauma assessments such as falls from over 20 feet being considered significant due to potential spinal injuries.

• Concludes primary assessment discussions by linking them directly with transport decision-making processes.

Rapid Scan Protocol Overview

Understanding Rapid Scans

• Introduces rapid scans as part of emergency assessments despite not being mandated by New York state regulations.

• Describes rapid scans as comprehensive evaluations covering head, neck, chest, abdomen, pelvis, extremities, and posterior areas.

Learning Objectives for Rapid Scans

• Encourages familiarity with acronyms related to rapid scan protocols which will be crucial during examinations.

Understanding Patient Assessment Techniques

Easy Questions and Initial Assessments

• The speaker emphasizes the importance of recognizing straightforward questions in patient assessments, indicating that some knowledge should be instinctive.

• Discussion on pupil response: constricted pupils can indicate opioid use, while dilated pupils may suggest cocaine or crack cocaine usage.

• The significance of unequal pupils is highlighted as a potential indicator of head injury or trauma.

Secondary Assessment Importance

• Transitioning from primary to secondary assessment is crucial; secondary assessments can reveal non-life-threatening injuries that may change the treatment approach.

• A brief overview of trauma centers and their role in patient care is provided, emphasizing the need for familiarity with these facilities.

Historical Context and Methodology

• The speaker shares personal experiences from refresher classes dating back to 2006, noting that many students struggle with trial patient assessment steps despite passing EMT school.

• A structured method for practical assessments is introduced, designed to help students succeed in state exams and real-life scenarios.

Practical Examination Differences

• Key differences between real-life situations and state exams are discussed; real-life involves multiple responders working simultaneously, whereas state exams require linear communication of actions.

• Students must articulate every action during state exams while managing an imaginary partner's role effectively.

Rules of Engagement for Assessments

• Clear rules are established regarding the order of operations during assessments; skipping steps can lead to automatic failure.

Emergency Medical Response Procedures

Assessing a Dead Patient

• Discussion begins on the protocol for handling a deceased patient, questioning the necessity of certain procedures.

• Emphasizes that CPR is mandatory for patients who are not alive, highlighting the importance of identifying life threats without physical contact.

Life Threat Assessment

• The speaker stresses the need to check for a carotid pulse and breathing as part of the life threat assessment process.

• Introduces spinal motion restriction (SMR), previously known as spinal immobilization, explaining how to perform it with an imaginary partner.

Gathering Information

• Discusses gathering information about the patient's chief complaint and age while considering additional resources needed during emergencies.

• Encourages flexibility in order of operations during assessments, noting that students often prefer to address specific tasks first.

Airway Management Techniques

• Outlines three critical steps in airway management: clear, open, and maintain. Each step is essential for effective emergency response.

• Describes two methods for clearing an airway: suctioning or using a finger sweep. Importance placed on knowing when to use each method based on airway contents.

Practical Application in Trauma Cases

• Highlights the significance of understanding what may obstruct an airway (e.g., blood or vomit), guiding responders on how to proceed effectively.

• Advises against mixing protocols in real-life scenarios; emphasizes that while exams may be linear, actual responses are simultaneous and require adaptability.

Maintaining Airway Patency

• Reiterates maintaining airway patency through OPA (oropharyngeal airway) and MPA (nasopharyngeal airway), stressing familiarity with both techniques.

Understanding Breathing and Circulation in Emergency Care

The Importance of Breathing

• The discussion begins with the emphasis on keeping options open regarding airway management, highlighting that breathing is fundamentally about getting air from outside to inside the body.

• The speaker introduces a mnemonic related to "El Paso" to remember the steps involved in assessing breathing, indicating a focus on practical learning methods.

• Emphasis is placed on exposing the patient’s chest to assess for injuries such as flail chest or sucking chest wounds, which are critical indicators of respiratory distress.

Assessment Techniques

• Key assessment techniques include palpation of the ribs to check for integrity and auscultation using a stethoscope to listen for abnormal sounds, which can indicate serious conditions like pneumothorax.

• The importance of sealing and stabilizing open chest wounds is discussed, along with identifying potential sources of bleeding or impaled objects.

Decision-Making in Oxygen Delivery

• Before administering oxygen, EMTs must evaluate whether the patient's breathing is adequate. Two devices are mentioned: non-rebreather masks for adequate breathing and bag-valve masks (BVM) for inadequate breathing.

• A critical threshold is established: if respiratory rates fall below eight breaths per minute, it indicates inadequate breathing requiring immediate intervention.

Personal Philosophy vs. Protocol

• The speaker expresses personal disagreement with standard protocols but acknowledges that they must adhere to state mandates regarding respiratory assessments and interventions.

Transitioning to Circulation Assessment

• Following the discussion on breathing, attention shifts towards circulation assessment. The acronym "PBS" is introduced as part of this evaluation process.

• An anecdote illustrates communication challenges within medical terminology when discussing patient symptoms; clarity in language is emphasized during assessments.

Pulse Assessment Insights

• The presence of pulses becomes a focal point; specifically, checking radial pulses due to their reliability in assessing shock states.

• Reassessing pulse after initial checks raises questions about new information gained from repeated evaluations during emergency situations.

Understanding Radial Pulse and Trauma Assessment

Importance of Checking Radial Pulses

• The speaker emphasizes the significance of checking both radial pulses simultaneously during trauma assessments to ensure accurate readings.

• A single radial pulse check may not provide a complete picture, especially in severe cases like falls from heights where injuries could affect blood flow.

Assessing for Major Hemorrhage

• The discussion shifts to identifying major hemorrhages, focusing on significant bleeding rather than minor cuts or dried blood.

• Emphasis is placed on examining the patient thoroughly after removing clothing to identify any hidden major bleeding.

Evaluating Circulation and Condition

• The acronym CTC (Color, Temperature, Condition) is introduced as a method for assessing circulation during trauma evaluations.

• Key indicators include skin color changes (e.g., cyanosis, pallor), temperature variations (hot/cold), and overall condition (clammy/dry).

Five-Step Program for Patient Assessment

Step 1: Sample History

• The first step involves gathering a sample history from the patient or their companions if they are unresponsive.

Step 2: Secondary Assessment

• This step entails conducting an in-depth head-to-toe examination to identify any additional injuries or conditions that require attention.

Step 3: Vital Signs Monitoring

• Vital signs such as pulse rate, blood pressure, and respiratory rate are crucial for determining necessary interventions based on findings from the secondary assessment.

Step 4: Treatment Interventions

• Based on the secondary assessment results, appropriate treatment measures should be taken for non-life-threatening issues identified during evaluation.

Step 5: Ongoing Assessment

Patient Assessment and Management Techniques

Focused Exams and Initial Assessments

• For stable patients, assessments are done every 15 minutes; for unstable patients, every 5 minutes.

• A focused exam targets the specific problem identified during assessment, ensuring thorough checks on relevant areas.

• The initial assessment (or primary assessment) includes three critical components: circulation, breathing, and maintaining patient life.

Vital Signs and Treatment Continuity

• Vital signs should be repeated every five minutes to monitor patient status effectively.

• Continuous evaluation of specific body systems is crucial, especially in cases like a sucking chest wound where breathing must be monitored closely.

Changes in Spinal Motion Restriction Protocol

• In 2015, New York State abolished the use of backboards for transporting trauma patients due to associated risks.

• Although backboards remain available on ambulances, their purpose has shifted from immobilization to spinal motion restriction.

Risks Associated with Traditional Immobilization

• Previous practices of immobilizing patients on backboards were found to cause discomfort and potential harm over extended periods.

• Increased risk of aspiration occurs when a patient vomits while supine on a backboard without the ability to move.

Nexus Criteria for Spinal Assessment

• The Nexus criteria provide a simplified approach for assessing spinal injuries using an easy mnemonic acronym.

• Key indicators include mental status changes (AMS), intoxication effects, neurological deficits, distracting injuries, and spinal tenderness during palpation.

Historical Context of Patient Handling

• Historically, upon arrival at an emergency scene with suspected head or neck injuries, immediate immobilization was standard practice.

Backboard Protocol Changes in Emergency Medical Services

Overview of Backboard Use

• The use of backboards for patient transport has been abolished in New York State as of 2015. They can only be used to move a patient from the scene to a stretcher, after which they must be removed.

Cervical Collar Application

• EMTs are trained on the discretion involved in using cervical collars. The decision is based on the patient's condition and presentation.

Case Study: Construction Zone Incident

• A case was presented where an unresponsive patient was found lying in a construction zone with no clear cause of injury. EMTs had to assess whether to apply a cervical collar based on their observations.

Assessment Protocol for Spinal Injuries

• Prior to 2015, protocols included using backboards and other equipment like scoop stretchers for suspected spinal injuries. Current practices require careful assessment before deciding on immobilization methods.

Mental Status Evaluation

• Evaluating mental status is crucial; if a patient is unresponsive, it raises concerns about potential neurological deficits or intoxication that could affect treatment decisions.

Physical Examination and Decision Making

• During physical examination, if spinal tenderness is noted, the cervical collar should remain in place until further evaluation can confirm stability or injury severity.

Criteria for Cervical Collar Removal

Spinal Motion Restriction Techniques

Patient Handling and Transport

• Emphasizes the importance of preventing patient movement during transport; suggests using a soft stretcher and securing patients to avoid transfers.

• Discusses the concept of "standing take down," previously taught in EMT training, which is no longer practiced. Highlights the shift towards safer methods for handling patients.

Spinal Immobilization Devices

• Introduces a spinal immobilization device known as "cab d," used for seated patients. Notes that it was once part of state testing but is not commonly used today.

• Stresses the need for knowledge about spinal immobilization devices despite their reduced usage, indicating potential exam questions on this topic.

Pediatric Considerations

• Highlights special considerations when treating pediatric patients, particularly regarding padding due to their larger heads relative to body size.