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Lesson 04
- 1. Lesson 4 Principles of Assessment and Management
Editor's Notes
- Instructor Notes: Remember that 95% of injury can be predicted by understanding the kinematics. Preplanning between partners and the use of observation and communications skills enhance scene safety and assessment. Personnel must monitor the scene for safety during the entire patient encounter.
- Instructor Notes: An increasing number of EMS personnel are injured or killed each year while working motor vehicle collisions. EMS personnel must develop good habits and use all available protective gear. Ask, “What types of safety issues would you anticipate in this situation?”
- Instructor Notes: The most common basis of life-threatening injuries is lack of adequate tissue oxygenation. Attention should immediately be focused on oxygenation of red blood cells and delivery of RBCs to the cells through the body.
- Instructor Notes: Form a general impression and follow the 5 steps of the primary survey.
- Instructor Notes: Ensure inspired oxygen concentration of 85% or higher. Apneic patients need aggressive management with a BVM. Slow rates (below 12) need assistance with a BVM and supplemental oxygen with a concentration of 85% or higher. Fast rates (between 20 and 30) should be monitored closely. Increase FiO 2 with a nonrebreather mask. Abnormally fast rates (above 30) indicate hypoxia and need assistance with a BVM and supplemental oxygen. Attempt to determine whether this is an oxygenation problem or an RBC delivery problem.
- Instructor Notes: Perfusion: evaluate pulse, skin color, temperature/moisture. Peripheral pulse is a rough estimate of blood pressure
- Instructor Notes: Use caution in elevating an extremity that is fractured or dislocated. The value of tourniquets has increased recently due to experience in Iraq; however, they are not to be used on every patient and are available as a judgment option in specific situations.
- Instructor Notes: Early decision-making considerations should be directed toward initiation of rapid transport to an appropriate facility and warmed IV fluid replacement en route. Patients with traumatic cardiac arrests in the prehospital setting have an extremely low likelihood of survival. Less than 4% of trauma patients who require CPR in the field survive to discharge, and almost all of these have significant neurological deficits upon discharge and never return to prearrest activity or function. Such unsuccessful attempts at resuscitation may divert resources away from patients who are viable and have a greater likelihood of survival.
- Instructor Notes: GCS of 15 indicates no disability. GCS of 13 to 15 indicates minor injury. GCS of 9 to 13 indicates moderate injury. Score of 8 or less is indication for intubation. Score of 3 is lowest score and an ominous sign. GCS of 14 or less with abnormal pupil exam can indicate possible presence of life-threatening traumatic brain injury.
- Instructor Notes: The airway is open and appears to be clear. Attention to the cervical spine is necessary due to the kinematics and a distracting injury.
- Instructor Notes: The patient needs to be placed on high flow oxygen.
- Instructor Notes: Circulation is compromised and there are indications of shock. Bleeding should be suspected in the abdomen and/or the pelvis. Attention should be directed toward maintenance of airway and oxygenation while packaging the patient and preparing for transport.
- Instructor Notes: The patient is alert and has a GCS of 15 at this point. Pupil response is difficulty to appreciate outdoors in bright light. Effort should be made to reevaluate the pupils when the patient is in a more controlled environment where the lighting can be reduced.
- Instructor Notes: All areas of the body should be uncovered and inspected. Bleeding into the chest, abdomen, or pelvis could be life threatening. Extremity fractures can be distracting and may need to be splinted prior to moving the patient. After exposing and examining the patient, ensure the patient is kept warm and body heat is conserved.
- Instructor Notes: Resuscitation describes treatment steps taken to correct life-threatening problems as identified in the primary survey. There should be limited scene intervention and effort should be directed at packaging and transporting the critical patient to the closest appropriate facility. Scene time should be limited to 10 minutes or less.
- Instructor Notes: Impaired ventilations include abnormally fast or slow rates, SpO 2 less than 95% even with supplemental oxygen, dyspnea, open pneumothorax, flail chest, or a suspected pneumothorax. Abnormal neurological status includes a GCS of less than 13, seizure activity, or sensory motor deficit. Significant findings include a history of serious medical condition, greater than 55 years old, hypothermia, burns, or pregnancy.
- Instructor Notes: PASG is considered an option in the presence of circulatory insufficiency caused by trauma. They also may be used for hemorrhage control with pelvic fractures, bleeding from major solid organ injuries, and when the systolic is below 60 mm Hg.
- Instructor Notes: Definitive care in the field includes packaging, spinal immobilization, splinting musculoskeletal injuries, and dressing wounds. Other definitive medical treatment could include defibrillation and IV glucose.