Patient Assessment Surveys Patient Assessment Surveys An Outline of the Approach to Patients An...

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Patient AssessmentSurveys

An Outline of theApproach to Patients

Raymond L. Fowler, M.D., FACEPRaymond L. Fowler, M.D., FACEP

Associate Professor of Emergency MedicineAssociate Professor of Emergency Medicineandand

Co-Chair of the Section onCo-Chair of the Section onEMS, Disaster Medicine, and Homeland SecurityEMS, Disaster Medicine, and Homeland Security

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Chief of Medical OperationsChief of Medical OperationsThe Dallas Metropolitan BioTel SystemThe Dallas Metropolitan BioTel System

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Associate Professor of Emergency MedicineAssociate Professor of Emergency Medicineandand

Co-Chair of the Section onCo-Chair of the Section onEMS, Disaster Medicine, and Homeland SecurityEMS, Disaster Medicine, and Homeland Security

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Chief of Medical OperationsChief of Medical OperationsThe Dallas Metropolitan BioTel SystemThe Dallas Metropolitan BioTel System

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www.rayfowler.comwww.rayfowler.comwww.rayfowler.comwww.rayfowler.com

www.utsw.wswww.utsw.wswww.utsw.wswww.utsw.ws

An immediate responseis requiredto problems foundin the primary andsecondary survey

For example,an obstructed

airway can bringdeath in a matter

of a coupleof minutes

For example,an obstructed

airway can bringdeath in a matter

of a coupleof minutes

As we assess patients,we must quickly determine

fundamental parametersof their respiratory

and circulatory status.

As we assess patients,we must quickly determine

fundamental parametersof their respiratory

and circulatory status.

The medical and ethical performance

of medical professionalshas never been

more important thanit is today

The medical and ethical performance

of medical professionalshas never been

more important thanit is today

Part of excellenceis performing

superior medicalhistories and

physical exams

Part of excellenceis performing

superior medicalhistories and

physical exams

Approaching thePatient

“See what you see!”“See what you see!”

““People look, but theyPeople look, but theydon’t see”don’t see”

……A. Fowler, Jr.A. Fowler, Jr.

““People look, but theyPeople look, but theydon’t see”don’t see”

……A. Fowler, Jr.A. Fowler, Jr.

Alertness? Level of distress?Noises?Respirations?The pulse rate?Skin?Obvious things (bleeding)

The “art” of medicineis missing from

so many practitioners…

…are they not looking,or have they lost interest?

The “art” of medicineis missing from

so many practitioners…

…are they not looking,or have they lost interest?

History Taking:This seems to be a “lost black art” for

so many medical providers

What happened?When?LOC?

Major system symptoms?Co-morbid conditions?

Above all: RISK???Above all: RISK???

History Taking:This seems to be a “lost black art” for

so many medical providers

What happened?When?LOC?

Major system symptoms?Co-morbid conditions?

Above all: RISK???Above all: RISK???

Critical CareEvaluation and Management

The Essence of what Makes a Medical Provider

“Safe” Around Patients

The Essence of what Makes a Medical Provider

“Safe” Around Patients

Basic Physiologyof Emergency Medicine

Relates to thePrimary Survey Findings

LOC/ABCLOC/ABC

Scene Survey/Mechanism/# pts.Scene Survey/Mechanism/# pts.

LOC/Airway/CspineLOC/Airway/Cspine

Respiratory Rate and LaborRespiratory Rate and Labor

Pulses R & Q, N & WSkin CMT/CRT/External Bleeding

Neck appearance, JVD, TracheaNeck appearance, JVD, Trachea

Chest appearance, BS, HTChest appearance, BS, HT

Quick survey of abdomen, pelvis,extremities, and back

The Primary SurveyThe Primary Survey

Abbreviations:

R & Q – Rate and Quality

N & W – Neck and Wrist

CMT – Color, Moisture, Temperature

CRT – Capillary Refill Time

JVD – Jugular Venous Distension

BS – Breath Sounds

HT – Heart Tones

Abbreviations:

R & Q – Rate and Quality

N & W – Neck and Wrist

CMT – Color, Moisture, Temperature

CRT – Capillary Refill Time

JVD – Jugular Venous Distension

BS – Breath Sounds

HT – Heart Tones

Scene Survey/Mechanism/# pts.

LOC/Airway/Cspine

Respiratory Rate and Labor

Neck appearance, JVD, Trachea

Chest appearance, BS, HT

Quick survey of abdomen, pelvis,and extremities

Scene Survey/Mechanism/# pts.

LOC/Airway/Cspine

Respiratory Rate and Labor

Neck appearance, JVD, Trachea

Chest appearance, BS, HT

Quick survey of abdomen, pelvis,and extremities Reveals threats to

Basic PhysiologyReveals threats toBasic Physiology

. . .the vital elements of the Primary Survey. . .the vital elements of the Primary Survey

The Order of the SurveyThe Order of the Survey

…flows in an orderly way from head to toe…flows in an orderly way from head to toe

HeadHead

NeckNeck

Upper ExtremitiesUpper Extremities

ChestChest

AbdomenAbdomen

PelvisPelvis

Lower ExtremitiesLower Extremities

The Secondary SurveyThe Secondary Survey

LOCLOC

AirwayAirway

BreathingBreathing

CirculationCirculation

Any other pertinent positive or negative

found in the primary or

secondary surveys

Any other pertinent positive or negative

found in the primary or

secondary surveys

The Third SurveyThe Third Survey

For example, if wheezing was found

and treated in theprimary survey,is the wheezing

still there?

If external bleedingwas found and a

dressing put on it,is the bleedingstill stopped?

For example, if wheezing was found

and treated in theprimary survey,is the wheezing

still there?

If external bleedingwas found and a

dressing put on it,is the bleedingstill stopped?

The Concept of ConsciousnessThe Concept of Consciousness

…as revealed throughthe specific findings of

the Primary and the GCS

…as revealed throughthe specific findings of

the Primary and the GCS

LOCLOC

The Coma ScaleThe Coma Scale

EVM 456EVM 456

The Coma ScaleThe Coma Scale

Eyes 4 elementsVerbal 5 elementsMotor 6 elements

•A moment to moment issue•Transits three body sites•Monitored acoustically, visually, and by changes in basic physiology•Made of “non-collapsible” material

AirwayAirway

The Negative Space ConceptThe Negative Space Concept

•Normal breathing sucks air into the chest

•Positive pressure ventilation decreases cardiac output

•Protected by bone

•Normal breathing sucks air into the chest

•Positive pressure ventilation decreases cardiac output

•Protected by bone

BreathingBreathing

Central Pumping ConceptCentral Pumping Concept

•Bone protected•Negative venous return: “Straw”•Cardiac Output tied strictly

to venous return•Alterations in return affect output

•Bone protected•Negative venous return: “Straw”•Cardiac Output tied strictly

to venous return•Alterations in return affect output

CirculationCirculation

UnderstandingCapnography

Oxygen -> lungs -> alveoli -> blood

muscles + organs

Oxygen

Oxygen +Glucose

energy

breath

Physiology Physiology

The negative pressure inside thethorax “pulls” blood back from the positive pressure areas.

Positive pressurePositive pressure

Negative pressureNegative pressure

Maintaining the “negativity” of thepressure inside of the thorax isone of the most vital areasof understandingresuscitation

Negative pressureNegative pressure

Positive Pressurein the Thorax

decreasesVenous Return!!

Positive Pressurein the Thorax

decreasesVenous Return!!

Need to VentilateNeed to VentilateNeed to VentilateNeed to Ventilate• CO2 Production

(O(O2 2 CConsumption onsumption & Venous Return)& Venous Return)

• Airway Dead Space

(wasted ventilation)(wasted ventilation)

• CO2 Production (O(O2 2 CConsumption onsumption & Venous Return)& Venous Return)

Speed of VentilationSpeed of VentilationSpeed of VentilationSpeed of Ventilation

Why would we bag the patient any faster

if no more oxygen is neededthan a “one hand squeeze

every eight seconds”??

Why would we bag the patient any faster

if no more oxygen is neededthan a “one hand squeeze

every eight seconds”??

…which is whatyou are breathing right now

as you are sitting therelistening to this stuff…

…which is whatyou are breathing right now

as you are sitting therelistening to this stuff…

Generally speaking:

The patient in The patient in circulatory collapsecirculatory collapsesuffers greatly fromsuffers greatly from

positive pressure ventilationpositive pressure ventilationused by rescuersused by rescuers

Generally speaking:

The patient in The patient in circulatory collapsecirculatory collapsesuffers greatly fromsuffers greatly from

positive pressure ventilationpositive pressure ventilationused by rescuersused by rescuers

Breathing thepatient too fastINCREASES

pressure inside the chest!

Breathing thepatient too fastINCREASES

pressure inside the chest!

Do NOTuse

Two-handedSqueezes

on the bags!

Do NOTuse

Two-handedSqueezes

on the bags!

……as you see here…as you see here…

don’t do this!!!don’t do this!!!

……as you see here…as you see here…

don’t do this!!!don’t do this!!!

Do YOU make ajudgment as to how fast

to bag your patientswho are critically ill?

Do YOU make ajudgment as to how fast

to bag your patientswho are critically ill?

You must…

……it is now the standardit is now the standard

You must…

……it is now the standardit is now the standard

Blood pressure =Blood pressure =

Cardiac output x Cardiac output x Peripheral resistancePeripheral resistance

What does a lowWhat does a lowblood pressure mean?blood pressure mean?

EitherEither......EitherEither......

•Loss of volumeLoss of volume•Low cardiac outputLow cardiac output•Increased vascularIncreased vascular

spacespace

•Loss of volumeLoss of volume•Low cardiac outputLow cardiac output•Increased vascularIncreased vascular

spacespace

Or a combinationOr a combinationof any of theseof any of these

Signs of ShockSigns of ShockWeak, thirsty, lightheaded

Pale, then sweatyTachycardiaTachypnea

Diminished urinary output

Weak, thirsty, lightheadedPale, then sweaty

TachycardiaTachypnea

Diminished urinary output

HypotensionAltered LOC

Cardiac arrestDeath

HypotensionAltered LOC

Cardiac arrestDeath

EarlyEarly

LateLate

Three Types of Shock

Heart: Cardiogenic, or mechanicalVolume: Low volume

Vasodilatory: High space

Three Types of Shock

Heart: Cardiogenic, or mechanicalVolume: Low volume

Vasodilatory: High space

ShockShock

CardiogenicCardiogenicRapid pulseDistended neck veinsCyanosis

Volume LossRapid pulseFlat neck veinsPale

VasodilatoryVariable pulseFlat neck veinsPale or pink

What is the problem with shock?

Oxygen deprivation to the tissuesbelow an absolute level of about 10 mmHg

at the tissue level, causing cell membrane damage,

ion depolarization, and calcium shifts with cell death.

What is the problem with shock?

Oxygen deprivation to the tissuesbelow an absolute level of about 10 mmHg

at the tissue level, causing cell membrane damage,

ion depolarization, and calcium shifts with cell death.

THUS!!!

Providing a base level of a few CC’s of oxygen per 100 cc of blood

(far less than normally carried in arterial blood – 15 to 20 cc’s/100 cc blood)

may prevent cellular injury and death

THUS!!!

Providing a base level of a few CC’s of oxygen per 100 cc of blood

(far less than normally carried in arterial blood – 15 to 20 cc’s/100 cc blood)

may prevent cellular injury and death

Synthesis

The scope and breadth of

Medicineis limited

only byyour

imagination

The scope and breadth of

Medicineis limited

only byyour

imagination

You have so muchto learn…

…and a lifetime to practice…

You have so muchto learn…

…and a lifetime to practice…

Whoever you are,wherever you work…

……only your best,only your best,every time, is enough…every time, is enough………only your best,only your best,every time, is enough…every time, is enough…

Drop a lineif you haveany questionsor comments

drray@doctorfowler.comwww.rayfowler.comwww.rayfowler.com

www.utsw.wswww.utsw.ws““the emergency medicine education website”the emergency medicine education website”

Patient Assessment Surveys Patient Assessment Surveys An Outline of the Approach to Patients An...

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