Copyright 2004 Mosby Inc All rights reserved

Case History You respond to a 28 -year-old male who has been struck by a car. You take the appropriate BSI precautions and ensure that the scene is safe and begin to assess the patient. Slide 2 Copyright © 2004, Mosby Inc. All rights reserved.

Initial Assessment Means of assessing patient condition and priorities of care Slide 3 Copyright

General Impression of the Patient The general impression is formed to determine priority of care and is based on the EMTs immediate assessment of the environment and the patient's chief complaint. • • • Determine if the patient is ill or injured. Reconsider mechanism of injury. Patient data Ø Age, sex, race • Identify and treat life-threatening conditions. Slide 4 Copyright © 2004, Mosby Inc. All rights reserved.

Initial Assessment Components • Life-threatening conditions so treatment can be given immediately • Lifesaving treatments Ø Opening/maintaining Ø Ø Ø the airway Positive-pressure ventilations Supplemental oxygen Automated external defibrillation Cardiopulmonary resuscitation Bleeding control Slide 5 Copyright © 2004, Mosby Inc. All rights reserved.

Mental Status • Quickly assessed during initial assessment • AVPU mnemonic ØAlert Ø Responds to Verbal stimuli Ø Responds to Pain ØUnresponsive Slide 6 Copyright © 2004, Mosby Inc. All rights reserved.

Assess the Airway • Use the appropriate technique. Ø Head tilt/chin lift for medical

Assess the Airway • Use the appropriate technique. Ø Jaw thrust for trauma patients

Assess the Airway • Note abnormal sounds. • Snoring Ø Denotes obstruction by the tongue Ø Oropharyngeal or nasopharyngeal airway to maintain patency • Gurgling Ø Suction may be needed to clear fluids. Slide 9 Copyright © 2004, Mosby Inc. All rights reserved.

Assess the Airway • Stridor or inability to speak Ø May denote airway obstruction » Heimlich or other maneuvers may be needed. Ø Patient may be having severe allergic reaction. » Positive-pressure ventilation, epinephrine, and rapid transport may be needed. Slide 10 Copyright © 2004, Mosby Inc. All rights reserved.

Assess the Airway • In unresponsive patients Ø Maintain an open airway. Ø Oropharyngeal or nasopharyngeal airway may be needed for continued airway control. Slide 11 Copyright © 2004, Mosby Inc. All rights reserved.

Assess the Airway • In unresponsive patients Ø Suction may be needed to clear

Assess the Infant’s or Child’s Airway • Place head in a sniffing or neutral position. • Be careful not to hyperextend the neck. • Slightly extend the head and neck of the child (1 to 8 years old) if no trauma is present. Slide 13 Copyright © 2004, Mosby Inc. All rights reserved.

Infants and Children • Look carefully for signs of Ø Nasal flaring Ø Seesaw breathing (alternate use of chest and abdominal muscles during breathing) Ø Retractions of the chest wall when assessing for inadequate breathing • When needed, provide positive-pressure ventilation. Slide 14 Copyright © 2004, Mosby Inc. All rights reserved.

Assess Breathing • Look, listen, and feel method Ø Look for chest and abdominal movements, accessory muscle use, and retractions. Ø Listen for air movement and abnormal sounds of breathing. Ø Feel for warm air from the lips and mouth. Slide 15 Copyright © 2004, Mosby Inc. All rights reserved.

Adequate Breathing • Rhythm Ø Regular Ø Irregular • Quality Ø Breath sounds — present and equal Ø Chest expansion — adequate and equal Ø Minimum effort of breathing • Depth (tidal volume) – visible chest rise Slide 16 Copyright © 2004, Mosby Inc. All rights reserved.

Adequate Breathing Rate • Adult: 12 -20/minute • Child: 15 -30/minute • Infant: 25

Review of Definitions • Respiratory distress Ø Any patient who experiences difficulty breathing and increased work of breathing as evidenced by dyspnea, accessory muscle use, retractions, increased respiratory rate, cyanosis, and other signs • Respiratory failure Ø A state when the respiratory system can no longer support life Ø Failure of the respiratory system to adequately remove carbon dioxide and deliver oxygen Ø Evidenced by multiple signs » Altered mental state, decreased breath sounds, very rapid or slow respiratory rate, minimal chest rise, cyanosis • Respiratory arrest Ø Complete cessation of breathing Slide 18 Copyright © 2004, Mosby Inc. All rights reserved.

Respiratory Distress • Shortness of breath • Agitation or restlessness • Active accessory muscle use • Retractions • Cyanotic skin • Increased pulse rate • Increased respiratory rate Slide 19 Copyright © 2004, Mosby Inc. All rights reserved.

Noisy Breathing • • • Crowing Audible wheezing Gurgling Snoring Stridor Ø A harsh

Respiratory Failure Inadequate Breathing • Depressed mental state (e. g. , responsive to voice, responsive to pain, or unresponsive) • Rate – very fast or very slow • Rhythm — irregular • Quality Ø Breath sounds — diminished or absent Ø Chest expansion — unequal or inadequate • Depth (tidal volume) — inadequate/shallow • Cyanotic skin color Slide 21 Copyright © 2004, Mosby Inc. All rights reserved.

Management of Respiratory Distress • High-concentration supplemental oxygen • Airway adjuncts • Assisted ventilations,

Assess the Circulation • Pulse check Ø Radial pulse in children and adults Ø Brachial pulse in infants Ø Carotid pulse in unresponsive adults and children when unable to feel a pulse in the arm Slide 23 Copyright © 2004, Mosby Inc. All rights reserved.

Assess the Circulation • Other signs of circulation Ø Normal breathing Ø Movement Ø

Assess Circulation and Perfusion • Assess for color, temperature, and condition (moisture). Ø Skin Ø Nail bed Ø Conjunctivae and mucous membranes • Note cyanosis. • Signs of hypoperfusion — pale, cool, clammy skin Slide 25 Copyright © 2004, Mosby Inc. All rights reserved.

Assess Capillary Refill • Assessment for perfusion in infants and children • Note a delay of more than 2 seconds. • Check for normal color to return. Slide 26 Copyright © 2004, Mosby Inc. All rights reserved.

Transport and ALS Backup • Consider need for rapid transport and ALS backup for patients with Ø Poor general impression Ø Unresponsive with no gag or cough Ø Responsive but not following commands Ø Difficulty breathing Slide 27 Copyright © 2004, Mosby Inc. All rights reserved.

Transport and ALS Backup • Consider need for rapid transport and ALS backup for patients with Ø Shock or hypoperfusion Ø Complicated childbirth Ø Chest pain with low blood pressure (< 100 mm Hg systolic) Ø Uncontrolled bleeding Ø Severe pain Slide 28 Copyright © 2004, Mosby Inc. All rights reserved.

Summary • • Form a general impression. Identify life-threatening conditions. Note level of responsiveness. Evaluate Ø Airway Ø Breathing Ø Circulation • • Provide lifesaving treatments. Rapidly transport critical patients. Slide 29 Copyright © 2004, Mosby Inc. All rights reserved.