module 3 - patient assessment

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ECRN:

Assessment Based Management; Thoracic & Abdominal Trauma; Neurological Considerations

Condell Medical Center EMS System

2006

Site Code: #10-7214-E-1206Revised by Sharon Hopkins, RN, BSN

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ObjectivesUpon successful completion of this module, the ECRN

should be able to:

1. Understand the factors that affect patient assessment and decision making capabilities.

2. Describe the steps of patient assessment based on ITLS guidelines.

3. Identify mechanisms of injury that can lead to thoracic and abdominal traumatic injuries.

4. Understand EMS interventions appropriate for thoracic and abdominal injuries.

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Objectives cont’d

5. Describe a variety of degenerative neurological diseases.

6. Review case scenarios.

7. Successfully complete the quiz with a score of 80% or better.

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ASSESSMENT BASED MANAGEMENT

Involves the use of:critical thinking skillsproblem solving abilitiesclinical decision making

Includes avoiding: tunnel vision (can create distractions)patient labeling or jumping to conclusions based on

preconceived ideas“the drunk”; “the frequent flyer”; “the whiner”

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Goals of Our Profession

Provide competent,

compassionate care

for each and every

patient interaction

You need a strong knowledge base and excellent assessment skills to care for patients

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Factors Affecting Assessment and Decision-Making

Attitude needs to be non-judgmental May “short circuit" information gathering

leading to insufficient information gathering May leap to conclusions before gathering a

thorough assessment Garbage in = garbage out Patients depend on us for medical

assessment/ management and not determination of social standing or "likability"

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Uncooperative PatientsPerception of intoxication - drugs or alcoholIn all uncooperative, restless, belligerent

patients consider other possible causeshypoxiahypovolemiahypoglycemiahead injury

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Patient compliance influenced by:Patient confidence in the medical

teamPrior experiences of the patient and

their familyCultural and ethnic barriers

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Distracting injuriescan divert attention from more serious

problems

Need to resist the temptation of forming an initial diagnosis too early

Gut instincts may lead to snap judgements

Systematic approach to patient carehelps prioritize & avoid being swayed by

the wrong impression

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Distractors in the environmentScene chaosViolent & dangerous situationsCrowds of bystandersHigh noise levelsCrowds of responders

enough help is crucial but they must be used wisely

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General Approach to Patient Assessment in The

Field & The EDSize-up the situation Identify need for body substance isolation (BSI)

gloves, gown, mask, eye protection as needed

Evaluate scene safetyhazards to yourself, the team, the patient

Identify mechanism of injury or nature of illnesscan help determine severity of situation

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Patient AssessmentInitial assessmentTo identify life-threatening conditionsMental status (AVPU)

A - awake, not necessarily orientedV - responding to verbal stimulationP - responding only after touch or lite pain appliedU - unresponsive (absolutely no response)

Airway assessmentBreathing assessmentCirculation status

pulses present?obvious bleeding to be controlled?

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Initial assessment cont’d

Forming a general impressionWhat do you think is going on? These answers drive the care you want

to start providing.Which protocol will you follow?

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Patient AssessmentFocused history and physical exam performed based on chief complaint and information gathered so far trauma patient with significant mechanism of injury or altered

mental statusneeds rapid head-to-toe

trauma patient with isolated injury (ie: ankle sprain)

focus on body systems related to complaintmedical patient (responsive) - focus exam on c/o medical patient (unresponsive)

needs rapid assessment with head-to-toe exam when patient input not available

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Patient AssessmentVital signsCMC ED policy: take and record vital signs minimally every 2 hours or

more often as needed

SAMPLE history - reminds you to obtain:symptomsallergiesmedicationspertinent past medical history last oral intake food or liquids including waterevents leading up to the incident

Check for medic alert bracelet, necklace

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Blood PressureA measurement of the force of blood against the walls of the blood vessels

Reassessment over time gives most accurate reflection of patient state

Changes in B/P can be very significant

Is last vital sign to change in decompensation

Cuff should cover 2/3rds of the upper arm

Cuff should not be placed over clothing

Arm should be maintained at heart level

Obese arm? Wrap cuff around forearm; place stethoscope over radial pulse area

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Tips, Tricks & Pearls on Blood Pressure & Pulses

B/P by palpation can only determine a systolic readingAs cuff is deflated, palpate over the radially area until the pulse

returnsRecord as “90/systolic”

Guidelines suggest that palpated pulses equate with systolic blood pressurescarotid pulse felt means B/P at least 60/systolic radial pulse felt means B/P at least 80/systolic

No peripheral pulse? Think circulatory collapse

B/P should always be attempted & documented

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Patient AssessmentDetailed physical exama more detailed & slower head-to-toe exam than the initial

one performedclinical experience and patient condition often dictate how & if

a detailed exam is done in the field & if there is time before ED arrival

Ongoing Assessment - always doneused to detect trends, determine changes in patient

condition, and assess effectiveness of interventionsmental status, ABC’s, vital signs (pulse, respirations, B/P,

SaO2, pain level), EKG

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Assessment TechniquesInspectionobservation; looking beyond the obvious

Palpationuse your sense of touch to gather informationpads of fingers more sensitive than tips for touchback of hand is better for sense of temperature

Percussion - not often done in the field

Auscultation listening for sounds (lungs, heart, intestines) for lung sounds, note abnormal sounds, location, timing during

inspiration or expiration

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Accurate Decision MakingRelies on:Patient history obtainedPhysical, hands-on exam performedRecognizing a pattern

comparing information gathered with what you already know (existing knowledge base)

Impression or field diagnosis made the first diagnosis is based on the most probable cause of the

patient’s complaint based on the information gathered during the assessment

used to formulate a plan of action based on the patient’s condition and the environment

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Use of Protocols & SOP’sProtocol - policies and procedures of all components of the EMS system

Standard operating procedures (SOP’s) - preauthorized treatment procedures

Exercise judgement when following protocol and SOP’sknow which protocol/SOP to chooseknow when and how to follow protocol/SOP’s recognize when you must deviate from the stated

protocol/SOP - allergies, abnormal vital signs (ie: hypotension)

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SOP’s/Protocols & The ECRN

An ECRN, by the restriction of their license, cannot give a medical order; the ECRN is only authorized to give an order if it is printed in the SOP/protocol

The ECRN must consult with the ED MD to give an order to EMS that is not listed in the SOP (ie: lidocaine drip after bolus given for stable ventricular tachycardia)

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Difficulty Establishing An Airway In The Field

If EMS cannot establish an airway on any patient in the field, EMS is to transport the patient to the closest Comprehensive Emergency Department even if they are on by-pass

A Comprehensive Emergency Department is one that is open 24 hours, 7 days a week and has a physician on duty as well as other support services

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CommunicationHospital reports are best when they:Are given in less than one minuteAre clear and conciseAvoid use of unfamiliar or unclear medical or technical

terms including “10” codesFollow a basic format Include both pertinent findings and pertinent negatives

(findings that would be expected but are not present)Conclude with specific actions, requests, or questions

related to the plan

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Transmission of Patient Information

Provider identified by name and vehicle number

Age, sex, and approximate weight of patient

Level of consciousness

Chief complaint and degree of distress

Vital signs, EKG, pulse oximetry, blood glucose if obtained

If indicated, lung sounds, pupils, skin condition and color, GCS, pain assessment

Treatment rendered and patient response

Patient history

ETA and destination

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Calling Report on Trauma Patients

Important for EMS to include information the hospital can use to categorize the trauma level for this patient as well as determine which members of the trauma team that need to be activatedmechanism of injurydestruction to vehicle/surroundings injuries noted or suspectedvital signs, GCS

Restlessness: first think hypoxia & shock

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THORACIC TRAUMA

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Anatomy & Physiology of the Thorax

Thoracic cage responsible for moving air in and out

Place where carbon dioxide and oxygen exchange takes place to support metabolism

Includes thoracic skeleton, diaphragm, and supporting musculature

Location of major organs and vesselsheart, aorta, trachea, lungs, mediastinum

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Thoracic TraumaClassifying thoracic injuries

Blunt trauma - closed injury from kinetic energy transmitted through tissue

blastsdecelerationcompression/crush

Penetrating trauma - open wound; direct or indirect trauma transmitted via kinetic energy dart

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Blunt Trauma From Blast Injuries

Blast injury - explosion caused by dust, fumes, natural gas, explosive compounds

Confined space blast/shock wave pressure wave & debris cannot dissipate as

far & so maintains higher energy level longerdanger of structural collapse & flying debrisextremely deadly overpressures created

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Thoracic InjuriesThoracic cage - ribs & sternal fx, flail segment

Cardiovascular - contusion, tamponade

Pleural and pulmonary- contusions, pneumo’s

Mediastinal - pneumomediastinum

Diaphragm - tear, laceration, rupture

Esophageal - laceration

Penetrating cardiac trauma - laceration aorta, vena cava, pulmonary arteries/veins

Spinal cord injuries

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Flail ChestDefinition3 or more adjacent ribs broken in 2 or more places

Most common mechanism of injury - blunt trauma falls, MVC, industrial injuries, assaults

Risks to the patient reduces tidal volume (air moving in and out) increases respiratory effortusually accompanied by pulmonary and possibly

cardiac contusions

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Flail ChestSigns and symptomsparadoxical motion of the chest wall

asymmetrical chest wall movement; flail segment moves in opposite direction from the rest of the chest

increased respiratory effort and ratedecreased pulse oximetry readings increased amount of pain to the chest wall

Treatmentsupport respiratory effort - supplemental O2 via nonrebreather mask; BVM as

neededsupport fractured section manually - no taping of the chest or sandbags/IV’s

placed on chestEKG monitoring

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Sucking Chest WoundDefinitionopen wound of the chest with air passage into the pleural space

Risks to the patientcollapse of the lung on the affected sideuninjured lung unable to fully expandchange in intrathoracic pressures negatively affect venous

return to the heart if the chest wall opening is at least 2/3 the diameter of the

trachea (normally the size of the patient’s little finger), air will move in & out thru the chest wall defect & not thru the trachea

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Sucking Chest WoundSigns and symptomsopen wound to the thorax & frothy blood noted around

the chest wall defectgurgling sound heard near the chest woundsevere dyspneapossible hypovolemia - associated injury & hemorrhage increased pulse rate & respiratory rate; decreased blood

pressureevidence of air hunger if, with each breath, more air

enters thru the chest wall defect than thru the trachea

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Sucking Chest WoundTreatment Immediately seal the chest wound (gloved hand to

start with if necessary); eventually with occlusive dressing taped on 3 sides

Open pneumothorax now converted to closed pneumothorax - watch for increased respiratory distress leading to tension pneumothorax

if needed, burp dressing by lifting one corner during exhalation

O2 via nonrebreather maskMonitor vital signs, pulse ox, EKG

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Tension PneumothoraxDefinitionAn open or simple pneumothorax that

generates and maintains a greater pressure than atmospheric pressure within the thorax via a created one-way valve

Risks to the patientAir is trapped in the pleural space and puts

pressure on the affected lung, the structures in the mediastinum, the opposite lung

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Tension Pneumothorax

(rare & late sign not often appreciated)

decreased B/P

Low pulse ox, narrowed pulse pressure

(JVD)

Dyspnea, SOB

PEA

tachycardia

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Needle DecompressionTreatmentProvide supplemental oxygenation (nonrebreather

mask) or BVM Initially perform needle decompression

identify site: 2nd intercostal space in midclavicular line; above the rib

prep the siteprepare a flutter valve on a 3 large gauged needle insert 3 needle largest gauge available (12-14g) straight

into the chest wall over the top of a ribcan take the plug off the catheter end and attach a syringeupon feeling a “pop” or noting air return in syringe, advance

catheter & remove needle; secure catheter

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Needle Decompression

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HemothoraxDefinitionan accumulation of blood in the pleural space due

to internal hemorrhagemore of a blood loss problem than an airway issueeach side of the thorax may hold up to 3000 ml of

blood

Risks to the patienthypovolemic shock reduction of tidal volume & efficiency of ventilations

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Hemothorax Signs & Symptoms

decreased blood pressure

History blunt or penetrating trauma

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HemothoraxTreatmentsupport the patient with supplemental oxygenation

(nonrebreather mask) and potentially BVM IV access for fluid resuscitation

20 ml/kg normal saline (Routine Trauma Care Protocol) carefully administer fluids to avoid worsening the edema

and congestion of pulmonary contusions

Note:Hemothorax is primarily a blood loss problem more

than a respiratory one

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Cardiac TamponadeDefinitionA restriction to cardiac filling caused by blood or fluid in the

pericardial sac

Most common mechanism of injurypenetrating trauma (could be medical problem)

Risks to the patientaccumulating blood exerts pressure on the heartpressure limits cardiac filling restricting venous return to the

heartcardiac output is diminished

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Cardiac Tamponade

Muffled heart tones

agitation(JVD)

Diaphoretic, ashen or cyanotic

PEA

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Cardiac TamponadeTreatmentkeep high index of suspicion field care limited to supportive oxygenation

(nonrebreather mask or BVM),IV fluids, and rapid transport

definitive care must be provided in-hospitalremoval of some of the accumulated fluid

from the pericardial sac in the ED and then patient needs to go to the OR

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ABDOMINAL TRAUMA

A high degree of suspicion must be exercised based on mechanism of injury and kinematics.

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Abdominal Anatomy and Physiology

Boundariessuperiorly the diaphragm inferiorly the pelvisposteriorly the vertebral column, posterior

& inferior ribs, back muscles laterally the flank musclesanteriorly the abdominal muscles

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Abdominal Anatomy and Physiology

The 3 abdominal spaces peritoneal space

organs or portions of organs covered by abdominal (peritoneal) lining

retroperitoneal spaceorgans posterior to the peritoneal lining

pelvic spaceorgans contained within the pelvis

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Abdominal QuadrantsRUQgallbladder, right kidney, most of the liver, some

small bowel, portion of ascending & transverse colon, small portion of pancreas

LUQstomach, spleen, left kidney, most of pancreas,

portion of liver, small bowel, transverse & descending colon

RLQappendix, portions urinary bladder, small bowel,

ascending colon, rectum, female genitalia

LLQ - sigmoid colon, portion urinary bladder, small bowel, descending colon, rectum, female genitalia

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Blunt Abdominal TraumaProduces least visible signs of injury

Responsible for 40% of splenic injuries

Responsible for 20% or liver injuries

Bowel and kidneys next most frequently injured organs

Injuries must be anticipated by evaluating mechanism of injury with force & direction of impact

Maintain high index of suspicion based on mechanism of injury

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Blunt Mechanisms

Compression forces

Shear forces

Deceleration forces

Motor vehicle crashes

Motorcycle collisions

Pedestrian injuries

Falls

Assault

Blast injuries

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Penetrating Abdominal Trauma

Low velocity - injury limited to the direct areaKnife, ice pik

Medium velocityHandgun & shotgun wounds

High velocityHigh power hunting riflesMilitary weapons

Ballistics - study of projectiles in motion

Trajectory - path a projectile follows

Distance traveled a consideration

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Evisceration of the bowel caused by a knife wound

Cover eviscerated area with sterile, moistened dressing

Minimize patient movement, coughing

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Hollow Organ InjuryHollow organsStomach, small bowel, large bowel, rectum, urinary bladder,

gallbladder, pregnant uterus

Anticipated injuriesMay rupture due to forces especially if the organ is full and

distendedCan cause hemorrhage and spillage of the contents into the

peritoneal, retroperitoneal or pelvic spacesContents spilled may have high bacterial counts, contain

irritating chemicals, have high acid counts, or contain digestive enzymes

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Solid Organ Injury

Solid organsspleen, liver, pancreas, kidneys

Anticipated injuriesProne to contuse resulting in organ damage; bleeding often

minimal if organ intact and contained within the organ but could be severe

If organ torn or lacerated may cause life-threatening hemorrhage

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Patient AssessmentMaintain high index of suspicion

Serious trauma to the abdomen is often a surgical problem and requires prompt and rapid transport with frequent reassessment

Identify additional causative forces of injuryseatbelt worn above the iliac crestno seatbelt restraint used, steering wheel

deformity type of weapon used in penetrating trauma

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Patient Assessment For Abdominal Trauma

Early signs of serious or continuing internal hemorrhage diminishing level of consciousness increasing anxiety or restlessness thirst increasing pulse rate decreasing pulse pressure - systolic and diastolic

numbers moving closer together increasing capillary refill time (>2 seconds) increasing abdominal distention, bruising

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Abdominal AssessmentInspectionRedness, ecchymosis, contusions, open wounds, distentionMay hold up to 1.5 L of blood before distended

PalpationGently palpate each quadrant individually with tips of fingersQuadrants with pain or injury are palpated lastDistention, tenderness, crepitus, instability, guarding,

pulsations

Auscultation - Not often done in field in trauma - too much time and need for quieter environment

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Initial Abdominal Trauma Treatment

Timely, thorough assessment repeated oftenCritical findings: rigid or distended abdomen or

guarding; presence of shock; shock out of proportion to findings (maybe haven’t found all the sources of bleeding yet)

Supportive oxygenation (nonrebreather mask)

IV access

EKG monitoring

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Neurological Emergencies

The human body’s ability to maintain a state of homeostasis results primarily from the nervous system’s regulatory and coordinating activities

A disruption in the nervous system affects the functioning of the body and can be in a variety of forms from simple to severe

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Headache

Common ailmentDescribed as a symptom rather than a disorderCan accompany many disordersCan be brought on by emotional eventsRecurring headaches may be an early sign of a more serious diseaseMost are caused by vasodilatation in tissues surrounding the brain

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HeadacheImmediate attention is needed if:Severe and sudden in onsetOther neurological impairments such as visual

disturbances, confusion, motor dysfunction or sensory loss also occur

Accompanied by fever or stiff neck

Patient states “the worse headache in my life”

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Types of HeadacheMigraineUsually one sided and accompanied by nauseaPersonal or environmental triggersDietary substances or medication triggers

Cluster Unilateral intense pain over and behind the eyeLasts about an hour and occur in clusters (bunches)

TensionProlonged overwork or stressUsually occipital region

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HeadacheTreatment in general Medications based on individual history, symptoms and

needsAnalgesics may or may not be effectiveMild diuretics may be effective at timesDark environmentRestDetermine trigger and use avoidance

Accurate diagnosis necessary in case of more severe problem!

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Neoplasms - Tumor Any abnormal growth of cells

May be benign or malignant

Cell multiplication is fast and uncontrolled

Classified by origin

Treatment - depends on type, location & age of tumorObservationChemotherapyRadiation therapySurgical removal

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Malignant Neoplasms

Cancerous tumorEmbryonic or poorly differentiated

cellsGrow in a disorganized mannerNecrosis and ulceration is common sign Invasion of surrounding tissue for nutritional

needsMetastatic in nature (i.e.: Initiates growth of like

tumors in other areas)

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Benign Neoplasms

Usually not dangerous to life unless they occur in a vital organ

Slow growth

Do not invade tissue for nutrition

Usually encapsulated

Do not form secondary tumors in other organs

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Assessment of Neoplasms

Some are painful yet some have no pain at all

External presentation Irregular borders Rough texture Brown/black in color

Capsule formation under the skin

Ulceration of overlying skin

Dependant on the organ or organ system affected

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Neoplasm

When to be concerned:Change in bowel or bladder habitsA sore throat that does not healUnusual bleeding or dischargeThickening on breast or other soft tissue Indigestion or difficulty swallowingObvious change in a wart or moleNagging cough or hoarseness

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Neoplasm Treatment

Chemotherapy Intravenous pharmacological therapy to

slow growth or kill tumorsCytotoxic to all cells of the body even

though target is cancerous cellsCan cause lethargy, hair loss, unsteady

gait, weakness and nausea

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Neoplasm Treatment

Radiation therapy Ionizing radiationDose of particulate or electromagnetic

radiation to a specific area of the organ or body

Can come from outside the body or inside the body (implanted radiotherapy)

More effective and less harmful than when first introduced

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Neoplasm Treatment

Surgical interventionDependant on type and amount of tissue

involvement with the tumorCan be radical or preciseCan be used in conjunction with other

therapy methodsCan cause self esteem issues

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Neoplasms Prevention strategies to include in patient teaching:Self breast examsMammogramsPAP smearsYearly physical examsSelf testicular examsProstate screening

PSADigital inspection

Seek medical evaluation early after abnormal finding

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Bell’s PalsySeventh cranial nerve inflammation or trauma

Temporary weakness or paralysis in facial muscles

Can reoccur

Good to complete recovery with nerve regeneration

Conditions that compromise the immune system increase odds of disease Lyme disease, herpes viruses, mumps and HIV infections

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Degenerative Neurological Disorders

Muscular fatigue usually attributed to interruption in the ability of the axon to communicate with the muscular endplate for various reasons

Symptoms can be mild to severe depending on manifestation and advancement of the disease process; can come and go; can be localized or systemic

Chronic conditions can be debilitating and affect quality of life

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Pathophysiology is variable and dependant on the specific diseaseSome are caused by an autoimmune type response to a toxic invaderExample: Multiple sclerosis

Some are the muscle’s inability to use the proteins provided by the body as fuelExample: Muscular dystrophy

Some are actual nerve tissue breakdown Example: Parkinson’s disease

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Partial facial paralysisExample: Bell’s Palsy

Degeneration of the cell bodies in the gray matter of the anterior spinal cord, brain stem and pyramidal tractExample: Amyotrophic Lateral Sclerosis (ALS)

Contraction of muscles or muscle groups that can contribute to convulsive disordersExample: Myoclonus

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An abnormal closing of the protective bony casement for the spinal cord. Nervous meninges may or may not be exposedExample: Spina bifida

Non-inflammatory lesions that affect the peripheral nervous systemExample: Peripheral neuropathy

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General disease manifestationsWeaknessGeneral body achesPartial paralysis that comes and goesParasthesia - pins & needles sensationPeripheral sensory impairmentRespiratory insufficiency (chronic stages) Immunosuppression - more vulnerable to

contract communicable diseasesMultiple medication interactions

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Pharmacological interventions range from anti-inflammatory drugs to experimental protein altering medicationsMedication usage depends on the organ system involved and the severity of symptomEnvironmental changes (living in a cool area) can help some diseasesDecreased exercise or production of muscular heat can decrease symptoms

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Caring for the patient in crisis must include maintaining ABC’sEndotracheal intubation or bagging the patient through an in-place tracheostomy may be necessarySupportive care for hypotensionPatients may need total lift assistance to move

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Muscular DystrophyInherited through DNA degeneration of muscle fibersEarly recognition in children who are slow to sit and walkCalf muscles become bulky as wasted muscle turns to fatPulmonary infections and heart failure are frequent causes of death

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Multiple SclerosisMyelin in the brain and spinal cord are destroyed. Autoimmune system sees myelin as foreign material.

Experience numbness to paralysis

Damage to white matter causes fatigue, vertigo, unsteady gait, slurred speech, pain

Some disable at onset; others degenerative over many years

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Structure of the Neuron and Multiple Sclerosis

The myelin sheath is a membranous extension of specialized cells called oligodendrocytes. These form an insulating substance. Non-myelinated axons (not insulated) conduct impulses very slowly

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Parkinson’s DiseaseDegeneration of nerve cell in basal ganglia in the brainLack of dopamine inhibits basal ganglia from modifying nerve pathways that control muscle contractionTremors, joint rigidityLeading cause of neuro disability in those over 60 years old

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Lou Gehrig’s Disease - ALS

Progressive motor neuron diseaseTypesSpinal muscular atrophyBulbar palsyPrimary lateral sclerosisPseudobulbar palsy

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Amyotrophic Lateral

Sclerosis (ALS)

Upper motor neurons affected in the central nervous

system; lower motor neurons affected in the

peripheral muscles

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Amyotrophic Lateral Sclerosis (ALS)

More common men over 50 Weakness, quivering (fasciculations)Unable to speak, swallow, move, breath on own Intellect and awareness maintainedBecome ventilator dependentAspiration pneumonia constant threatStarvation, failure to thrive

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Trigeminal NeuralgiaTrigeminal nerve – 5th cranial nerve with opthalmic, maxillary and mandibular functionsAffects skin of upper eye, side of nose, half of scalpAffects mucous membranes of nose, forehead, upper lipAffects lower teeth and tongue

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Peripheral NeuropathyAxon or myelin sheath in peripheral nervous system damaged/irritated causing blockage of electrical signals

Can affect:muscle activitysensation reflexes internal organ function

Can be caused locally - trauma, compression (tight casts, tourniquet use), carpal tunnel, infections

Can be demyelination or degeneration of peripheral nerves - diabetes, Guillain-Barre syndrome

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Myoclonus

Temporary, involuntary rapid, uncontrolled muscular contractions (jerking) or twitching of a group of muscles

Generally considered a symptom more than a diagnosis

Can occur at rest or during movement

Can distort normal movement and interfere with the ability to eat, walk, and talk

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Spina BifidaDefect of neural tube closure

Portion of vertebra fails to develop leaving a portion of the spinal cord unprotected

Lower back most affected

Nerve damage is permanent

Long term effectsphysical & mobility limitations loss of bowel & bladder control most have some form of a learning disability

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Spina Bifida

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Degenerative Neurological Diseases

Make treating the chief complaint a priorityDo not overlook the underlying history but do not

allow it to cloud judgement for a more serious issue

Management PlanHistory

Acute or chronic complaint for today?General health?Previous medical conditions?Medications?

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ManagementOxygenPosition of comfortVenous accessPharmacological interventions

Check for hypoglycemia in setting of altered level of consciousness

Antihistamine - benadryl for dystonic reactions (impairment of muscle tone (peculiar posturing & difficulty speaking) after exposure usually to certain meds)

Psychological support

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Treatment concerns:mobility often limitedcommunication often difficult - hearing, speech

unclear respiratory compromise - especially

exacerbations of underlying problemsanxiety - coping with debilitating disease

difficult on patient and family & stress and anxiety levels can run high

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Case Study #132 year old male unrestrained in head-on MVC at 55 mph

Awake & oriented, increased respiratory rate, weak & rapid radial pulse

Major complaint is pain to the left side of the chest with evident redness, crepitation felt on palpation

Vital signs: B/P 102/50; P - 108; R - 24 pulse ox 94%; EKG - sinus tachycardia

Breath sounds - decreased left side

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Case Study #1General impression (what are possibilities)? Cardiac contusions Lung contusions Pneumothorax

The patient is becoming more restless with increased anxiety; pulse ox dropping to 84%; respiratory rate climbing to 38 and now shallow with increasing dyspnea

What’s going on now?

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Case Study #1Reassess ABC’sAirway still openBreathing getting more difficultBreath sounds absent on the leftPulse more rapid and thready and barely palpable

radially

Impression:Tension pneumothorax

Treatment: Initially needle decompression

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Case Study #1Landmarks for needle decompression? 2nd intercostal space in the midclavicular line Be above the rib (avoid vessels & nerves that run under

the rib)

Equipment used in the field Largest gauge & longest needle available

12-14 G and 3 inches long Flutter valve prepared Skin prepped Needle must be secured in place

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Case Study #255 year old extremely obese female unrestrained rear seat passenger of taxi cab involved in 60 mph MVC

Patient is agitated, complaining of pain all over (was thrown around back of cab)

Patient is pale, slightly diaphoretic (apologizes because she says she is always somewhat sweaty), unable to feel radial pulse “because of fat wrists”

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Case Study #2If unable to take a blood pressure in the upper arm, what are alternatives?

Place the cuff around the forearm and place the stethoscope over the radial pulse area.

Not acceptable to not attempt any kind of blood pressure.

Why is this patient so restless?

Don’t be fooled by the obvious and don’t dismiss her concerns to her “weight”

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Case Study #2What can cause restlessness?

Hypoxia

Hypovolemia

Internal injury

Hypoglycemia

Pain

Anxiety; being scared

Being uncomfortable (pain, positioning, full bladder)

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Acknowledgement

NIMSCA contribution for packet by:Kathy Wexelberg RN, Advocate ChristMarlene Blacklaw, RN, Advocate ChristLonnie Polhemus, EMT-P, Silver Cross

Additions made by:Sharon Hopkins, RN, BSN,

Condell Medical CenterRegion X SOP’s, Effective March 2005

module 3 - patient assessment

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