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- General impression
- Mental status
- ABCs
- Establish priorities
General impression
- Manage immediate life threats:
- Check for airway compromises such as airway obstruction. Open their airway.
- Look for breathing abnormalities such as paradoxical movement a segment of the chest. Provide PPV and O2.
- Control circulation problems such as major bleeding and open wounds. Direct pressure on open wounds.
- Chief complaint: "why did you call EMS today?"
- Trauma or medical.
- C-spine for trauma patients with a high index of suspicion.
Mental status
- AVPU
- A = alert. Can talk to you normally.
- V = responds to verbal stimulus. Attempts to respond when you talk to him or her.
- P = responds to painful stimulus.
- Central stimuli
- Trapezius pinch: pinch between the neck and shoulder.
- Supraorbital pressure: press up on the upper ridge of the eye socket.
- Sternal rub: rub the center of the sternum with knuckles.
- Armpit pinch: pinch the margin of the armpit.
- Peripheral stimuli
- Nail bed pressure.
- Pinch the thumb-index finger web.
- Pinch the finger, toe, hand, or foot.
- U: unresponsive.
- Nonpurposeful movements
- Flexion posturing: aka decorticate posturing. Patient arches back and flexes arms inwards. Upper brain stem compression.
- Extension posturing: aka decerebrate posturing. Patient arches back and extends arms extends arms straight and parallel to the body. Lower brain stem compression.
- Altered mental status: Not alert, but not completely unresponsive either. Responds to either verbal or painful stimuli.
- Open and protect the airway and administer oxygen to unresponsive or altered mental status patients.
ABC
- Airway
- Alert and talking or crying patients have patent airway.
- Altered mental status or unresponsive patients cannot protect their airway. You need to open their airway.
- Snoring patients: perform head-tilt chin-lift or jaw thrust, insert airway adjuncts.
- Gurgling patients: suction.
- Crowing and stridor: administer oxygen and artificial ventilation.
- ... read more on airway techniques
- Breathing
- Is the patient breathing at all? If not, give two artificial ventilations then check for pulse.
- If breathing, is the breathing adequate (rate and volume)?
- Are there breath sounds and chest rise and fall?
- Look for signs of breathing difficulties such as retractions, use of accessory muscles, nasal flaring, hypoxia and shock signs.
- Does the pulsox vital sign read above 95%?
- Treat inadequate breathing / hypoxia with oxygen administration and artificial ventilation.
- ... read more on breathing
- Circulation
- Pulse: Is there a pulse at all? Check the carotid pulse if no radial pulse is felt.
- No breathing, no pulse = begin CPR: 5 cycles of 30/2 compressions/ventilations followed by AED.
- If you just witnessed the cardiac arrest, apply AED immediately.
- Is the pulse rate normal? Is the quality strong and regular?
- Check for possible major bleeding: are there open wounds? Control any major bleeding (spurting arterial or fast flowing venous blood).
- Assess perfusion: is the patient in shock? Shock = cool and clammy skin that appears pale, mottled or cyanotic.
- Check skin:
- Pale or mottled: onset of shock.
- Cyanotic: late sign of shock.
- Red: anaphylactic or vasogenic shock, poisoning, overdose or other medical condition.
- Yellow: jaundice, liver problems.
- Cool and clammy: shock.
- ... read more on skin vital signs
Establish priorities
- Is the patient in an unstable or stable condition?
- Unstable: significant MOI, altered mental status, high index of suspicion.
- Vehicle crash involving death of a passenger, ejection from vehicle, rollover or high speed collision.
- Vehicle striking pedestrian.
- Fall of 15 feet or 3 times patient height (For a child it's 10 feed and 2 times height).
- Trauma resulting in altered mental status.
- Penetrating injuries to the head, neck, chest or abdomen.
- Explosions and collisions.
- Seat-belt injuries.
- Stable: no significant MOI, alert and orientated, low index of suspicion.
- For unstable patients, go for the rapid trauma/medical assessment. It's a "load and go" situation. During ongoing assessment, you need to reassess unstable patients every 5 minutes.
- For stable patients, "sit and play" with a focused trauma/medical assessment. During ongoing assessment, you need to reassess stable patients every 15 minutes.
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