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 Forced bending or extension tend to affect Elbow Wrist Fingers Femur Knee Foot Cervical spine Direct blows may affect Clavicle Scapula Shoulder girdle Humerus Knee Hip Femur Indirect blows may affect Pelvis Hip Femur Knee Tibia/fibula Shoulder Humerus Elbow Ulna/radius 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
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 Scenario #1 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 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 Scenario #6 Facial droop Arm drift Speech pattern 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 Benadryl 1 mg/kg IVP or IM (Adult max 25 mg) Allergic Reaction STABLE WITH AIRWAY INVOVLEMENT 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 ANAPHYLACTIC SHOCK 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?
7. List at least 3 components of a field neurological assessment. Pre-quiz August 2012 Reading the Scene P & B 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