Patient AssessmentSurveys
Patient AssessmentSurveys
An Outline of theApproach to Patients
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
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
Copyright 2006 Ray Fowler MD, FACEPRay Fowler MD, FACEPCopyright 2006 Ray Fowler MD, FACEPRay Fowler MD, FACEP
Part of excellenceis performing
superior medicalhistories and
physical exams
Part of excellenceis performing
superior medicalhistories and
physical exams
Copyright 2006 Ray Fowler MD, FACEPRay Fowler MD, FACEPCopyright 2006 Ray Fowler MD, FACEPRay Fowler MD, FACEP
Approaching thePatient
Approaching thePatient
Copyright 2006 Ray Fowler MD, FACEPRay Fowler MD, FACEPCopyright 2006 Ray Fowler MD, FACEPRay Fowler MD, FACEP
“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.
Copyright 2006 Ray Fowler MD, FACEPRay Fowler MD, FACEPCopyright 2006 Ray Fowler MD, FACEPRay Fowler MD, FACEP
Alertness? Level of distress?Noises?Respirations?The pulse rate?Skin?Obvious things (bleeding)
Alertness? Level of distress?Noises?Respirations?The pulse rate?Skin?Obvious things (bleeding)
Copyright 2006 Ray Fowler MD, FACEPRay Fowler MD, FACEPCopyright 2006 Ray Fowler MD, FACEPRay Fowler MD, FACEP
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?
Copyright 2006 Ray Fowler MD, FACEPRay Fowler MD, FACEPCopyright 2006 Ray Fowler MD, FACEPRay Fowler MD, FACEP
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
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
Basic Physiologyof Emergency Medicine
Relates to thePrimary Survey Findings
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
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
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
Pulses R & Q, N & WSkin CMT/CRT/External Bleeding
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
Pulses R & Q, N & WSkin CMT/CRT/External Bleeding
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
11
22
33
44
55
…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
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
•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
UnderstandingCapnography
Oxygen -> lungs -> alveoli -> blood
muscles + organs
Oxygen
cells
Oxygen
Oxygen +Glucose
energy
CO2
blood
lungs
CO2
breath
CO2
Physiology Physiology
The negative pressure inside thethorax “pulls” blood back from the positive pressure areas.
The negative pressure inside thethorax “pulls” blood back from the positive pressure areas.
Positive pressurePositive pressure
Positive pressurePositive pressure
Negative pressureNegative pressure
Maintaining the “negativity” of thepressure inside of the thorax isone of the most vital areasof understandingresuscitation
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)
• Airway Dead Space
(wasted ventilation)(wasted ventilation)
Speed of VentilationSpeed of VentilationSpeed of VentilationSpeed of Ventilation
• 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)
• Airway Dead Space
(wasted ventilation)(wasted 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
Cardiac output x Cardiac output x Peripheral resistancePeripheral resistance
What does a lowWhat does a lowblood pressure mean?blood pressure mean?
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
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
CardiogenicCardiogenicRapid pulseDistended neck veinsCyanosis
Volume LossRapid pulseFlat neck veinsPale
Volume LossRapid pulseFlat neck veinsPale
VasodilatoryVariable pulseFlat neck veinsPale or pink
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
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…
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
Drop a lineif you haveany questionsor comments
www.utsw.wswww.utsw.ws““the emergency medicine education website”the emergency medicine education website”
www.utsw.wswww.utsw.ws““the emergency medicine education website”the emergency medicine education website”