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Scene Size-up

What part of Patient Assessment and what takes place?
-1st part of Patient Assessment
-Taken as you are approaching the scene
-Checking/Taking:
1.Scene Safety
2.Standard Precautions
3.Noting Mechanism of Injury (MOI) or Nature of Illness (NOI)
4.# of Patients
5.Decide if additional resources are needed
Mechanism of Injury (MOI)

Types of forces?
-A force or forces that may have caused injury.

Types of forces:
-Direct:
-Twisting
-Indirect
-Forced flexion or Hyperextension
Danger Zone

The area around the wreckage of a vehicle collision or other incident within which special saftey precautions should be taken.

Establishing the Danger Zone:
>No apparent hazards = Minimum 50ft.
>Fuel spill/ Fire = Minimum 100ft and stay upwind and uphill if possible.
>Down wires = Minimum 1 full span of the down wires.
Law of Inertia
A body in motion will remain in motion unless acted upon by an outside force.

and/or

A body at rest will remain at rest unless acted on by an outside force.

(e.g. being stopped by something/ being pushed or jerked)
What are the collisions involved in a motor-vehicle crash and how many take place?
  1. Vehicle striking and object
  2. Body of patient strikes interior
  3. Organs of patient strike surfaces within the body
Head-on Collisions

What 2 injury patterns are likely and describe possible patient injuries?
1. Up-and-over Pattern: Patient follows a pathway up and over the steering wheel, commonly striking the head on the windshield causing head and neck injuries. The chest and abdomen strike the steering wheel causing chest injuries or breathing problems and internal organ injuries.

2. Down-and-under Pattern: Patient follows a pathway down and under the steering wheel, typically striking the knees on the dash, causing knee, leg, and hip injuries.
Rear-end Collisions

What possible injuries may be present?
Common causes of neck and head injuries.

(Law of inertia)
Side-impact Collisions

(aka - Broadside or T-Bone)

What possible injuries may be present?
Head tends to remain still as the body s puched laterally causing injuries to the neck. The head, chest, abdomen, pelvis, and thighs may be struck directly, causing skeletal and internal injuries.
Rollover/ Rotational impact Collisions

What possible injuries may be present?
-Potentially the most serious because of the potential for multiple impacts. 

-Expect any and all types of injury patterns.
Falls

Important factors to consider...
*Falls of greater than 15 feet or 3x the patients height are usually considered severe.
*Always assess along the path of the injury. (i.e. hitting feet with energy runing up the legs to the knees then the pelvis)
-Height of fall
-Surface the patient hit
-The part of the patient that hit the ground
-Anything that may have interupted the fall (i.e. falling onto fence then hitting the gound)
Penetrating Trauma

How are these classified?
Injury caused by an object that passes through the skin or other body tissues.

Classified by: velocity, or speed of the item that caused the injury.
>Low-velocity: those that are propelled by hand, such as knives. Usually limited to the area that was penetrated.
>Medium-velocity: Usually casued by handguns or shotguns, arrows launched from a compound bow or ballistic knife.
>High-velocity: Bullets propelled by a high-powered or assault rife.

Note: medium and high-velocity injuries can cause damage almost anywhere in the body.
Bullets cause damage in what two ways? Explain?
  1. Damage directly from the projectile: the bullet itself will damage anything in its path. Size, path and if any fragments break off determines the damage.
  2. Pressure-related damage, or cavitation: means that the velocity of the bullet as it enters the body creares a pressure wave that causes a cavity considerably greater than the size of the bullet. This cavity is temporary, but it may damage items in its path.
Blunt-Force Trauma
Injury caused by a blow that does not penetrate the skin or body tissues.

(Examples: hit by a baseball bat or thrown against a steering wheel)

Often causes seriuos injury to, even rupture of, internal organs and vessels.

Can result could be hemorrhage, or spillage of organs contents.

Identifying the MOI of the injury will help due to signs and symptoms are very little if any.
Index of Suspicion
A keen awareness that there may be injuries based on the MOI
Nature of Illness
What is medically wrong with the patient.

Information can be obtained by the:
-Patient, when conscious and oriented
-Family Members or Bystanders, when patient is not conscious and oriented
-Scene, while you are sizing up the scene 
Initial Assessment

(aka Primary Assessment or Primary Survey)

Definition and parts?
The first element in assessment of a patient; steps discovering and dealing with any lif-threatning problems.

6 Parts of the Inital Assessment:
1.Forming a General Impression
2.Chief Complaint
3.Assessing Mental Status
4.Assessing Airway
5.Assessing Breathing
6.Assessing Circulation
7.Determining the priority of the patient for treatment and transportantion.
Interventions
Actions taken to correct a patient's problems.
Genteral Impression
Impression of the patient's condition that is formed on first approching the patient, based on the patients enviroment, chief complaint (CC), and appearance.
Chief Complaint (CC)
What the patient expresses to you in his/her own words what the injury and/or illness is. The reason EMS was called. 
Mental Status

AVPU
Level of responsiveness

AVPU: a memory aid for classifying a patients level of responsiveness.

Alert - patient awake and will talk and respond to questions.
Verbal Response - patient answering to talking or shouting only.
Painful Response - low level of response, patient will only respond to painful stimuli.
Unresponsive - lowest and most serious, patient does not respond to anything.
Assessing the patients ABC's

**Any life-threatening airway, breathing, or circulation problem must be treated as soon as it is discovered.

Airway: If the patient is talking or crying as you approch, the airway is clear. If not, take appropriate measures to open it and clear it of any obstructions.

Breathing: If patient is in respiratory arrest, preform rescue breathing.
>Patient breathing rate less than 8/min. and is inadequate = provide positive pressure ventalations with 100% oxygen.
>Patient that is alert and has adequate breaths at a rate faster than 24/min. = give high-concentration oxygen by nonrebreather mask.
>Patient breathing faster than 24/min. and is inadequate = ventalate with 100% oxygen. 

Circulation: Take patients pulse, if no pulse begin CPR. To Evaluate circulation, assess:
-Pulse (Rate, Rythm, Quality)
-Skin (Color, Temp.)
-Bleeding (Treat any life threatening wounds)
**Warm, Pink and Dry skin indicates good circulation.
**Pale, Clammy, Cool and Moist indicates poor circulation.
Priority patient and transport

High-Priority Conditions
Once life-threats are under control, you will decide on patients priority. If life-treats can not come under control or recur, or if level of responsiveness declines, patient priority is high.

High-Priority Conditions:
1. Poor General Impression
2. Unresponsive
3. Responsive, but not following commands
4. Difficulty Breathing
5. Shock
6. Complicated Childbirth
7. Chest pain with systolic blood pressure less than 100
8. Uncontrolled Bleeding
9. Severe pain anywhere
What would you do for a responsive patient that is breathing greater than 24/min?

And if breathing becomes inadequate?
High-concentration oxygen by nonrebreather mask.

Provide positive pressure ventilations.
What do you check for when you assess the Circulation in ABC?
Pulse, Bleeding, Skin Color, Temperature, Condition.

(Capillary refill in infants and children under 6)
What are the steps taken if an airway is compromised (blocked) on an non-trauma unresponsive patient?
1. Open airway with head-tilt, chin-lift maneuver.

2. Consider oro or nasopharyngeal airway.

3. Suction as needed.

4. For foregin body obstruction, use abdominal thrusts or other blockage-clearing technique. 
What are you looking for when assessing Breathing in your ABC assessment?
Look for rise and fall of the chest, listen and feel for rate and depth of breathing. Look for work of breathing (use of accessory muscles, retractions)
What action would be done to check:
1. Verbal Stimulus
2. Painful Stimulus
on an infant?
1. Verbal Stimulus: Shout
2. Painful Stimulus: Flick feet
When is it acceptable not to have a patient history or inital assessment complete?
When treating a patient with a serious injury or ill because you are to busy treatingimmediate threats to life.
Vital Signs

-Outward signs of what is going on inside the body.

What you check:
1. Respiration
2. Pulse
3. Skin (Color, Temperature, Codition, any Major Bleeding)
4. Pupils
5. Blood Pressure
When taking a patients pulse, you are concern with what two factors?
Rate: the number of pulse beats per minute

and

Quality: the rhythm (regular or irregular) and force (strength: strong or weak).
Normal Pulse Rates:

Adult

Infant and Children
-Adolescent 11-14
-School age 6-10
-Preschooler 3-5
-Toddler 1-3
-Infant 6-12mo
-Infant 0-5mo
-Newborn 
Adult 60 to 100

Infant and Children
-Adolescent 11-14 > 60 to 105
-School age 6-10 > 70 to 110
-Preschooler 3-5 > 80 to 120
-Toddler 1-3 > 80 to 130  
-Infant 6-12mo > 80 to 140
-Infant 0-5mo > 90 to 140
-Newborn > 120 to 160
What are significant/ possible causes for the following pulse qualities:

-Rapid, regular, and full (strong)
-Rapid, regular, and thready (weak/thin)
-Slow
-No Pulse
-Rapid, regular, and full: Exertion, fright, fever, high blood pressure, first stage of blood loss

-Rapid, regular, and thready: shock, later stage of blood loss

-Slow: head injury, drugs, some poisons, some heart problems, lack of oxygen

-No Pulse: Cardiac arrest
Infants and Children:

A high blood pressure in an infant or child is not as great a concern as a low pulse....Why?
Because a low pulse may indicate imminent (likely to occur at any moment) cardiac arrest.
Tachycardia

Bradycardia
Tachycardia: A rapid pulse; any pulse rate above 100/min.

Bradycardia: A slow pulse; any pulse rate below 60/min.
What are possible causes and the correct intervention when the following repiratory sounds are present:

-Snoring
-Wheezing
-Gurgling
-Crowing (harsh sound when inhaling)
-Snoring: Airway blockage/ open patients airway, prompt transport

-Wheezing: Medical problem such as asthma/ assist patient in taking prescribed medications, prompt transport

-Gurgling: Fluids in airway/ suction airway, prompt transport

-Crowing (harsh sound when inhaling): Medical problem that cannot be treated on scene/ prompt transport
Skin colors and what could they mean?

-Pale
-Cyanotic
-Flushed
-Jaundiced
-Mottling
-Pale: white, pasty in color/ blood vessels have costricted (growing smaller) resulting in blood loss, shock, hypotension, emotional distress

-Cyanotic: blue-gray in color/ not enough oxygen getting into the red blood cells and tissues resulting from inadequate breathing or heart function

-Flushed: red in color/ exposure to heat, emotional excitement

-Jaundiced: yellowish tint in color/ liver abnormalities

-Mottling: uncommon but it appears blotchy on patients, especially children and elderly/ shock 
What are possible causes for the following skin conditions?

-Cool, Clammy
-Cold, Moist
-Cold, Dry
-Hot, Dry
-Hot, Moist
-Goose Bumps (accompanied by shivering, chattering teeth, blue lips, and pale skin)
-Cool, Clammy: sign of shock, anxiety
 
-Cold, Moist: body is losing heat

-Cold, Dry: exposure to cold

-Hot, Dry: high fever, heat exposure

-Hot, Moist: high fever, heat exposure

-Goose Bumps (accompanied by shivering, chattering teeth, blue lips, and pale skin): chills, communicable (contagious) diseas, exposure to cold, pain, or fear
Assessing the pupils what can possibly be the cause?

Dilate
Constrict
Unequal
Lack of reactivity
Dilate (larger than normal): fright, blood loss, drugs

Constrict (smaller than normal): drugs-narcotics,

Unequal: stroke, head injury, eye injury, artificial eye

Lack of reactivity: drugs, lack of oxygen to brain
What is the normal blood pressure?

no greater than 120 systolic

no greater than 80 diastolic
If the systolic pressure is greater than ___ and the diastolic is greater than ___, the patient has hypertension.
Greater than 140

Greater than 90

Hypertension = High Blood Pressure
Readings in blood pressure between ___ to ___ systolic and ___ to ___ diastolic can be a indicate prehypertension.
121 to 139 systolic

81 to 89 diastolic
Infants and Children:

Blood pressure
*Blood pressure is usually not taken on children under 3yrs old.

**In case of blood loss or shock, a child's blood pressure will remain within limits until near the end, than fall swiftly.
SAMPLE
S signis & symptoms
A allergies
M medicaions
P pertinent past history
L last oral intake
E evennts leading to injury or illness 
Pulse Oximeter Reading
Measures the level of oxygen circulation through a patients blood vessels.

96 to 100% = Normal
91 to 95% = Hypoxia
86 to 90% = Significant Hypoxia
85% and less = Severe Hypoxia
Focused History and Physical Exam

(aka Secondary Assessment or Secondary survey.)
the steps of patient assessment that follows the initial assessment.
DCAP-BTLS
D deformities
C contusions/crepitaion
A abrasions
P punctures/penetration

B burns
T tenderness
L lacerations
S swelling
Paradoxical Motion
Movement of a part of the chest in the opposite direction to the rest of the chest during respiration. Usually occurs when a segment of the ribs has boken at two ends and is "floating" free of the rest of the ribs. (sometimes known as flail chest)
Colostomy or  Ileostomy
a surgical opening in the wall of the abdomen with a bag in place to collect excertions from the digestive system.
Priapism
persistent erection of the penis that may result from spinal injury and some medical problems.
OPQRST
O onset - What were you doing when this started?

P provokes - Can you think of anything that may have triggered this pain?

Q quality - Can you discrible the pain to me?

R radiation - Where exactly does the pain? Does it seem to spread anywhere or does it stay right there?

S severity - How bad is the pain from a scale of 0 to 10?

T time - When dd the pain start? Has it changed at all since it started?
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