Chapter 24 Poisoning and Overdose

Introduction to Emergency Medical Care1

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonAdvance Preparation Prepare video clips and media graphics. Invite programmed patients. Prepare assessment equipment for psychomotor sessions. Prepare standardized skill sheets for demonstration and psychomotor sessions. Invite assistant instructors to assist with psychomotor sessions1OBJECTIVES11.1Define key terms introduced in this chapter. Slides 1112, 14, 1921, 2811.2Explain the purpose of the primary assessment. Slides 1113continued

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe Dickinson2MULTIMEDIASlide 31Prehospital Patient VideoSlide 32Initial Assessment Procedures Video Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonThese videos appear later in the presentation; you may want to preview them prior to class to ensure they load and play properly. Click on the links above in slideshow view to go directly to the slides.7OBJECTIVES11.4Given several scenarios, do the following: form a general impression, determine the chief complaint, determine the patients mental status, assess the airway, assess breathing, assess circulation, determine the patients priority for transport. Slides 1829continued

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe Dickinson4OBJECTIVES11.5Recognize findings in the primary assessment that require immediate intervention. Slides 22, 27continued

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe Dickinson5OBJECTIVES11.6Differentiate the approach to the primary assessment based on the following: mechanism of injury/nature of the illness and level of responsiveness, patients age (adult, child, or infant). Slides 3435

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonDeciding on the approach to the primary assessmentManual stabilization of the head and neckThe general impressionAssessment of mental status using the AVPU scaleThe ABCs as part of the assessment processHow to make a priority decision

CORE CONCEPTS Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe Dickinson8TopicsPrimary AssessmentPatient Characteristics and Primary Assessment Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonPlanning Your Time: Plan 50 minutes for this chapter. Primary Assessment (30 minutes) Patient Characteristics and Primary Assessment (20 minutes)

Note: The total teaching time recommended is only a guideline. 9Approach to the Primary AssessmentFocus on life threatsAirway (A), breathing (B), circulation (C)May vary depending onPatients conditionOn the scene resourcesOthercontinued

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonPoint to Emphasize: Use warning signs in the general impression to help identify critical patients.

Talking Points: The order in which interventions are performed depends on the patients specific condition and the number and priority of the urgent conditions that you are presented with. Remember: Multiple EMTs can accomplish multiple priorities simultaneously.

11Approach to the Primary AssessmentOrder of A-B-C depends on initial impression of patientSequence will varyA-B-C if patient has signs of lifeC-A-B if patient appears lifeless, no pulse Immediate interventions may be needed

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonTalking Points: Interventions will be performed based upon the initial impression and the immediate needs of the patient. Compressions may come first in a lifeless patient. Airway might come first in a patient with a suspected airway threat. Bleeding control might come first in a patient with an exsanguinating hemorrhage.

12Primary Assessment StepsForming a general impressionAssessing mental status Assessing airwayAssessing breathingAssessing circulationDetermining patient priority

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonTalking Points: Life-threatening conditions discovered during the primary assessment require immediate interventions.

13General ImpressionAssesses environment, patients chief complaint, and appearanceHelps determine patient severityHelps set priorities for care and transportcontinued

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonPoint to Emphasize: The chief complaint is the reason that EMS was called, usually in the patients own words.

Talking Points: Although the EMT cannot rely completely on the patients environment to rule out trauma, when combined with the chief complaint, environmental clues become extremely useful.

14General ImpressionLook Test: feeling from environmental observations as well as first look at patientcontinued

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe Dickinson15General ImpressionFindings that indicate critical patientAltered mental statusAnxietyPale, sweaty skinObvious trauma to head, chest, abdomen, pelvisSpecific positions indicating distresscontinued

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonTalking Points: Specific positions indicating distress include tripod position and Levines sign. The presence of any of these signs usually indicates a serious patient, but absence of these signs does not guarantee that the patient is stable.

Discussion Topic: Describe findings in the general impression that might indicate a critical patient.

16General ImpressionPatients appearing lifeless Resuscitate by beginning CPR compressions Prepare AED as soon as possible

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonTalking Points: Appearance of lifelessness includes no movement or apparent evidence of breathing or only gasping breathing.

Knowledge Application: Present pictures and/or video clips of patients to the class. Ask students to describe their general impression.17Forming a General ImpressionLookPatients age, sex, and position Listen Moaning, snoring, or gurgling respirations SmellFumes, urine, feces, vomitus, or decay

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonTalking Points: After you gain some practice assessing and managing patients, you may develop a sixth sense that clues you in to the severity of a patients condition. This is part of clinical judgment, or judgment based on experience in observing and treating patients.

Discussion Topic: Describe findings in the general impression that might indicate a critical patient.

18Chief ComplaintPatients description of why EMS was calledMay be specificabdominal painMay be vaguenot feeling good

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe Dickinson19Assess Mental Status: AVPUAlertDocument orientation to person, place, and timeVerbal responsePainful responseUnresponsive

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonPoint to Emphasize: Determining mental status is an important element of the primary assessment.

Talking Points: Patients who can speak clearly can almost always tell you their name (orientation to person). A few patients are oriented to person, but cannot tell you where they are (orientation to place). Some patients are oriented to person and place but cannot tell you the time, day, or date (orientation to time).

Discussion Topic: What criteria are necessary for a patient to be deemed alert and oriented?

Knowledge Application: Have students work in small groups. Use a programmed patient to present various mental status levels. Discuss the use of the AVPU scale.

Critical Thinking: How might a patient with Alzheimers disease affect your ability to assess mental status?20Assess ABCsOrder of primary assessment will vary depending on patients conditionAirwayBreathingCirculation

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonPoint to Emphasize: Assessment of airway, breathing, and circulation will allow for rapid identification of life threats.

Talking Points: If the patient can speak, airway is open. Investigate airway further in unresponsive patients.21AirwayIf airway is not open or is endangered, take measures to open

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe Dickinson22BreathingSituations calling for breathing assistanceRespiratory arrestNot alert, inadequate breathingSome alertness, inadequate breathingAdequate breathing, but signs suggesting respiratory distress or hypoxia

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonTalking Points: Inadequate breathing can be caused by insufficient minute volume because of decreased rate or depth or both.

Discussion Topic: In primary assessment of breathing, what four general situations call for immediate respiratory assistance?23CirculationAssess pulseAssess skinAssess bleeding

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonTalking Points: Note that if the patient has appeared lifeless, CPR will have begun.24CirculationThree results of assessing pulseWithin normal limitsUnusually slowUnusually fastcontinued

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonTalking Points: During primary assessment, pulse check is performed rapidly. It is not necessary to take the pulse for a full 30 seconds and obtain an exact rate. Any result other than within normal limits is cause for concern.

Discussion Topic: Describe the three possible results of a pulse check performed in the primary assessment.

25CirculationAssessing skinGood circulation: warm, pink, dry skinShock: pale, clammy (cool and moist) skin

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonTalking Points: With dark-skinned patient, check color of lips or nail beds, which should be pink if circulation is good.26Immediate InterventionTreat any life-threatening ABC problem as soon as discovered!

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonPoint to Emphasize: Any life threats found while evaluating the ABCs must be treated immediately.

Knowledge Application: Have students use a standardized skill sheet to write out the steps that they would take and the questions that they would ask to accomplish the listed elements of the primary assessment.27Determining Patient PriorityStableVital signs in normal rangePotentially unstablePotential for deterioration can indicate potentially unstable categoryUnstableThreat to ABCs rules out stability

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonTalking Points: A threat to the ABCs can be either actual or imminent. A patients priority can change as the patients condition changes.

Discussion Topic: Describe findings in the primary assessment that might lead you to categorize a patient as unstable.

28Need for Priority TransportInitiate priority transport if a life-threatening problem cannot be controlled or threatens to recurContinue assessment and care en route

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonClass Activity: Assign primary assessments as homework. Ask each student to complete five primary assessments, using a standardized skill sheet, for the next session.29Think About ItWhy must you continue to re-evaluate the primary assessment?

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonTalking Points: Although the primary assessment occurs immediately, it is a part of your ongoing assessment. Re-evaluation of the primary assessment identifies life threats that may appear after the primary assessment and identifies problems that have deteriorated and now pose a life threat.30Prehospital Patient VideoClick here to view a video on the subject of assessment of the prehospital patient.Back to Directory

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonVideo ClipPrehospital Patient Why is patient assessment so important? What are the steps of assessment? List three life-saving management techniques used by an EMT. How can the dynamics of an emergency scene influence a patients assessment? What role does the mechanism of injury play in the assessment of a trauma patient?

31Patient CharacteristicsPatient characteristics determine the form of assessmentMedical or traumatic problem?Altered mental status?Child or adult?

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonPoints to Emphasize: Patient assessment may need to be adjusted based on the patients characteristics. Mental status, nature of illness, and severity of injury all impact the assessment technique. General impression and evaluation of mental status vary greatly between conscious patients and unconscious patients. EMTs must consider spinal immobilization during the primary assessment of a trauma patient.

Discussion Topics: Describe how your assessment might differ between a conscious patient and an unconscious patient. Describe the additional steps necessary when assessing a trauma patient.

Class Activity: In a class discussion, ask students to brainstorm types of patients for whom they might need to adjust the assessment technique.

Knowledge Application: Have students work in small groups. Present each group with a different patient and ask group members to describe the assessment technique that they would use. Have each group present its plan to the class; discuss differences.34

Pediatric NoteAdjust assessment to social and physiological norms of children

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonPoint to Emphasize: EMTs must adapt the expectations of the primary assessment based upon the age of the patient.

Discussion Topics: Describe how the assessment of a 4-year-old patient might differ from that of an 84-year-old patient.

Knowledge Application: Use programmed patients to present assessment scenarios that require adaptive thinking. Discuss the specific strategies used.

35Think About ItHow might normal findings in a primary assessment differ for a child compared with an adult?

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonTalking Points: Many physiologic differences alter findings of a pediatric primary assessment. Respiratory and heart rates are faster. Capillary refill is a useful tool and the same quantities of bleeding might be life threatening in a child, but not in an adult.36Steps of Primary AssessmentDespite patient characteristics, follow primary assessment steps systematicallyGeneral impressionMental statusABCsPriority for transport

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonPoint to Emphasize: Although the application of the primary assessment may vary based on patient type, it is exceptionally important to be systematic and to include all the essential components.

Discussion Topic: Discuss the key elements of a primary assessment that must be accomplished regardless of the patients condition.

Knowledge Application: Take a field trip. Visit a day care center or nursing home to experience actual patients and the difficulties that they present to assessment.

Critical Thinking: You are conducting your primary assessment when the scene suddenly becomes unsafe. How might this dynamic scene change affect your primary assessment?37Chapter Review Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonChapter ReviewPrimary assessment is a systematic approach to quickly find and treat immediate threats to life.General impression, although subjective, can provide extremely useful information regarding urgency of a patients condition.Determination of mental status follows the AVPU approach.continued

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe Dickinson39Chapter ReviewEvaluating airway, breathing, and circulation quickly but thoroughly will reveal immediate threats to life that must be treated before further assessment.Patients priority describes how urgent patients need to be transported is and how to conduct the rest of the assessment.

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe Dickinson40RememberDetermine if a problem is medical or traumatic in nature.Determine if a patient is responsive or unresponsive; an adult, child, or infant.Rapidly identify the need for immediate airway intervention.continued

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe Dickinson41RememberDetermine if the patients condition is stable enough to allow further assessment and treatment at the scene.

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe Dickinson42Questions to ConsiderWhat factors will you take into account in forming a general impression of a patient?How should you assess a patients mental status with regard to the AVPU levels of responsiveness?continued

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonTalking Points: The general impression combines environmental findings and initial patient findings. Important elements include chief complaint, environmental clues such as mechanism of injury, and level of distress of the patient.

AVPU is an acronym that stands for 4 categories of mental statusalert, verbal, painful stimuli, and unresponsive. 43Questions to ConsiderHow should you assess airway, breathing, and circulation during the primary assessment?What is meant by the term priority decision?

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonTalking Points: Airway and breathing are first assessed by talking to the patient. If patient can speak, then at least at some level the airway and breathing are intact. If no airway is present, steps must be taken to provide one. Breathing is assessed by ensuring adequacy of breathing and recognizing respiratory arrest or respiratory failure. Circulation is assessed by evaluating pulses, skin, and gross bleeding.

Priority decision is the determination of the need for either immediate intervention or transport (or both). This decision is completed after assessing ABCs and is directly related to recognizing life threats.44Critical ThinkingA middle-aged male is lying on the street after being hit by a car. He appears unresponsive as you approach. You notice that he is bleeding from a laceration on his forearm and making gurgling sounds from his airway.continued

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe Dickinson45Critical ThinkingIf you are alone, what factors do you consider in deciding what to do first? Why?

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonTalking Points: Gurgling sounds in the airway require immediate suctioning unless the bleeding is life threatening. In general, the airway is the more important concern except in the case of exsanguinating hemorrhage.46Please visit Resource Central on www.bradybooks.com to view additional resources for this text.

Copyright 2012 by Pearson Education, Inc.All rights reserved.Emergency Care, Twelfth EditionLimmer OKeefe DickinsonPlease visit our web site at www.bradybooks.com and click on the mykit links to access content for this text. Under Instructor Resources, you will find curriculum information, lesson plans, PowerPoint slides, TestGen, and an electronic version of this instructors edition. Under Student Resources, you will find quizzes, critical thinking scenarios, weblinks, animations, and videos related to this chapterand much more.47