August 2012 CE
Site code # 107200E-1212
Reading the Scene
Prepared by Sharon Hopkins, RN, BSN, EMT-P
To view on the Advocate Condell website visit: www.advocatehealth.com/condell/body.cfm?id=422
Date of CE presentation: August 2012 Topic: Reading the Scene Behavioral Objectives: Upon successful completion of this module, the EMS provider will be able to:
1. Describe components of the scene assessment/size-up. 2. Describe benefits of the windshield survey. 3. Define the term mechanism of injury. 4. Describe common mechanism of injuries and potential injuries. 5. Define nature of illness. 6. Describe the index of suspicion. 7. Describe the 4 main impacts that occur in a motor vehicle collision (MVC). 8. Define the term general impression. 9. Describe the role of critical thinking or clinical judgment 10.Describe the components of the primary assessment. 11. Given a scenario, determine a general impression 12. Given a scenario, determine key questions to ask 13. Given a scenario, determine the Region X SOP to follow 14. Given a scenario, demonstrate the primary survey. 15. Successfully complete the post quiz with a score of 80% or better.
References
• Bledsoe, B., Porter, R., Cherry, R. Essentials of Paramedic Care 2nd edition Update. Brady. 2011.
• Limmer, D., O’Keefe, M. Emergency Care 12th Edition. Brady. 2012. • Region X SOP’s IDPH Approved January 6, 2012 • Walraven, G., Basic Arrhythmias 7th Edition. Brady. 2011.
Scene Size-up
• Scene safety • Take Standard Precautions
– Minimally gloves on all calls
• Determine number of patients – Is there a clue that something more is going on? – Is there a need to activate the multiple patient plan?
• Do you need additional help?
Common Mechanisms of Injury
Twisting injuries tend to affect – Hip – Femur – Knee – Tibia/fibula – Ankle – Shoulder – Elbow – ulna,/radius – Wrist
Direct blows may affect – Clavicle – Scapula – Shoulder girdle – Humerus – Knee – Hip – Femur
Index of Suspicion
• Use your “sixth sense” • Keep heightened suspicion and open mind • Be cautious of jumping to a diagnosis • Don’t be swayed by the patient’s opinion
– “I’m not really hurt” – “It’s just a chest cold”
• Anticipate the worse and hope for the best
Forced bending or extension tend to affect
– Elbow – Wrist – Fingers – Femur – Knee – Foot – Cervical
spine
Indirect blows may affect – Pelvis – Hip – Femur – Knee – Tibia/fibula – Shoulder – Humerus – Elbow – Ulna/radius
General Impression
• Your impression of the patient’s condition Based on your scene size-up with mechanism of injury or nature of the
illness (i.e.: the patient's chief complaint) Based on the patient’s appearance Meant to evolve as you gather additional data Drives your decision on how to treat the patient
Primary Assessment
Form a general impression Assess the mental status
o Include cervical spinal immobilization simultaneously if indicated Assess the airway Assess the breathing Assess the circulation Determine the transport priority
Scenario #1 Causes of seizures: Medications used to control seizure activity: Scenario #2 Scene size-up
Take Standard Precautions Is the scene safe? Number of patients? What is the MOI? Do I need help or specialized equipment?
Scenario #3 Spinal clearance
Evaluate the mechanism of injury Evaluate the signs and symptoms Evaluate the reliability of the patient
Scenario #4 Scenario #5
– Head injury from a fall • Epidural – usually see more rapid decline after a lucid period • Subdural – usually develops signs and symptoms gradually over
a period of time – Elderly have shrunken brain tissue and more room to
bleed before vital tissue is compromised
Field neurological exam Level of consciousness (i.e.: AVPU) Speech GCS Pupillary response Motor response Sensory test
Most important is to evaluate the responses over time watching for a change Cincinnati Stroke Scale
Facial droop Arm drift Speech pattern
Scenario #6
Sources of pulmonary embolism (PE) Blood clots – most common Air embolism (i.e.: during external jugular stick) Fat embolism (i.e.: from a long bone fracture) Amniotic fluid embolism (i.e.: during OB delivery) Foreign body (i.e.: sheared IV catheter tip)
Signs & Symptoms of pulmonary embolism (PE)
• Scenario #7Depends on size & location of obstruction • Usually have sudden onset severe unexplained dyspnea • Sometimes pleuritic chest pain • Unproductive cough (or hemoptysis if cough is productive) • Labored breathing, tachypnea • Tachycardia; occasionally dropping B/P • Often clear breath sounds • Confusion/agitation with hypoxia • May find warm, swollen, painful lower extremity (a clot) • Key: low oxygen saturation!!! Does not improve with oxygen.
Positioning for intubation in obese patients
BMI rough calculation = weight (lbs) x 703 height (inches)2 Scenario #7
Scenario #8
Pediatric dosing differences:
Allergic Reaction
STABLE Allergic Reaction
STABLE
WITH AIRWAY INVOVLEMENT
ANAPHYLACTIC SHOCK
Benadryl 1 mg/kg IVP or
IM (Adult max 25 mg)
Epinephrine 1:1000 – 0.01 mg/kg SQ
Maximum 0.3 mg (0.3ml) per single dose
Benadryl 1mg /kg IVP slowly or IM
(adult max 50 mg)
Albuterol 2.5 mg/3ml mixed with
Atrovent 0.5 mg/2.5 ml NEB treatment
Epinephrine 1:1000 – 0.01 mg/kg
IM. Maximum 0.3 mg (0.3ml) per
single dose
Benadryl 1 mg/kg IVP or IM
Albuterol 2.5 mg/3ml mixed with
Atrovent 0.5 mg/2.5 ml NEB
Benefit of medications used in allergic reactions/anaphylaxis – Epinephrine
• Bronchodilator to open the airways • Vasoconstrictor to prevent the blood vessels from dilating
causing a drop in cardiac output • Relatively short acting by often 1 dose is sufficient
– Benadryl • Antihistamine to stop the release of histamine that is causing
the reactions seen; last 4-6 hours
– DuoNeb – Albuterol mixed with Atrovent • Promotes bronchodilation
File: CE, EMS; CE Packets; 2012; August Reading the Scene
Pre-Quiz Paramedic And Basic Level
From August 2012 CE Material
Reading the Scene
Name_________________________________Date__________ 1. What is evaluated in the scene size-up? (Hint: There are 5 components) 2. Why is it helpful to evaluate the mechanism of injury on trauma calls? 3. What information do you use to form a general impression? 4. List the components of the primary assessment? 5. How would you control the airway for a patient in active seizures? 6. What are the 3 components to evaluate for spinal clearance?
Pre-quiz August 2012 Reading the Scene P & B
7. List at least 3 components of a field neurological assessment. 8. List the 3 components of the Cincinnati Stroke Scale. 9. List at least 3 signs or symptoms of pulmonary embolism. In PE, is the SpO2 typically (circle one): low high normal 10. What’s your BMI category? You may need to wait for the formula in the CE Formula: Normal Overweight Obese Severely obese Morbidly obese
18.5 – 24.9 25-29.9 30-34.9 35-39.1 >40
File: CE, EMS; CE Packets; Quizzes; August 2012 Reading the Scene