patient care

Question 1

Patient Assessment

Answer 1

Two primary components
1. Information gathering:
MOI for trauma patients
NOI for medical patients
Ascertain the Hx of the events leading up to EMS activation, gather a SAMPLE Hx, etc
2. Physical examination
ABC or CAB, followed by appropriate examination medical or trauma

Question 2

Patient Assessment fundamental components

Answer 2

Identify problems- done during primary and secondary survey
Set priorities- determine immediate threats to life/limb (during primary and RTA/RMA)
Develop a care plan- how will you intervene
Execute the plan- perform your interventions and reassess, ALWAYS REASSESS

Question 3

elements of patient assessment

Answer 3

Gather information
Primary source of information is usually the patient
Other sources include the patient’s family, friends or eyewitnesses to the emergency event
Be observant, it may be necessary to gather information from the scene itself

Question 4

Primary Survey C-EMCA-P

Answer 4

• Confirm the call information with dispatch
  - Environmental hazard check
  - Mechanism of injury
  - Casualty numbers
  - Additional resources required
  - Personal protection required

Question 5

Primary Survey

Answer 5

LOA - Level Of Awareness (AVPU)
Manual C-spine Control (as required)
Airway or Circulation
Breathing or Airway
Circulation or Breathing
Critical Injuries And Gross Bleed Check
Critical Interventions

Question 6

Primary Survey General impression

Answer 6

The Paramedic will immediately form a “general impression” of the patient. This is also referred to as the Look Test
What do you see?

Focuses on identification and management of life-threatening problems
Medical
Is my patient sick?
If so, how sick are they?
Trauma
Is my patient hurt?
If so, how badly hurt are they?

Question 7

General impression signs of distress

Answer 7

Altered mental status
Anxiousness
Laboured breathing
Difficulty speaking
Diaphoresis
Poor colour
Obvious pain
Obvious deformity, guarding or splinting
Gross external hemorrhage

Question 8

Mental Status and Neurological Function

Answer 8

Mental status
One of the prime indicators of how sick the patient really is
Are there changes in the state of consciousness? (do they present with AMS or is this normal for patient?)
Establish a baseline as soon as you encounter a patient.

Question 9

The Chief complaint

Answer 9

The “Chief Complaint” is determined at the outset of patient contact. It often comes prior to the Primary Survey, as you approach the patient. Or it can be elicited very quickly as you begin to communicate about why the patient called for an ambulance.

Question 10

C-spine

Answer 10

Evaluate
First for the MOI- is there reason to suspect this pt requires SMR
Altered mental status?
Presence of pain
Distracting injury?

Question 11

THE BASIC ABCDE’S

Answer 11

AIRWAY
- Open the airway
- Clear the airway
- Insert an oral/nasal airway prn

BREATHING
- Assess breathing
- BVM Ventilations prn
- Supplemental oxygen prn

CIRCULATION
- Assess pulses
- CPR prn (if pt is unconscious CAB)

DISABILITY
-pupillary response
-neuro deficits

EXPOSE- inspect the patient, cut away clothing prn

Question 12

Airway Status

Answer 12

Focuses primarily on two questions:
1. Is the airway open and patent?
how is the pt positioned? foreign body?
2. Is it likely to remain so?
Are there Sonorous sounds?
Are there Gurgling or bubbling sounds ?
Work from Simple to Complex
Easiest problem to solve is position- requires no special equipment
Possibility of spine injury drives the decision of which technique to use to open the airway.
Head tilt-chin lift or jaw thrust
If Obstruction is present or suspected utilize BLS procedures to clear the obstruction.

Question 13

BASIC AIRWAY what to do to open

Answer 13

Open And Clear The Airway:

Chin lift and/or modified jaw thrust maneuver.
Visualize the oro-pharynx
Suction and/or remove foreign bodies.
Insert an oral airway if the patient has a decreased LOC and NO gag reflex.
Insert a nasal airway if the patient has a decreased LOC and a gag reflex.

Question 14

V-Vac

Answer 14

Suction only as far
as you can see…
Measure from
corner of mouth to
tragus
Adult setting=380mmHg
No more than 10 sec
intervals

Question 15

oropharyngeal airway

Answer 15

An oropharyngeal airway holds back the tongue. Insert an oral airway if the patient has a decreased LOC and NO gag reflex.

Question 16

Nasopharyngeal Airway

Answer 16

A nasopharyngeal airway runs behind the tongue. Insert a nasal airway if the patient has a decreased LOC and a gag reflex. Note that one (1), nasal airway is sufficient. Two (2) nasal airways can be inserted

Question 17

King LT Airway

Answer 17

The King LT airway comes in three (3) different sizes for use in adults.
The choice of which size to use is based on the estimated height of the patient. Each size is differentiated by the colour of the tip:
. YELLOW – 4 to 5 feet (122-155 cm)
#4. RED – 5 to 6 feet (155-180 cm)
#5. PURPLE – Over 6 feet (> 180 cm)

Question 18

Supraglottic Airway Directive indications

Answer 18

Indications
Need for ventilatory assistance or airway control
AND Other airway management is ineffective
patient must be in cardiac arrest
maximum 2 attempts

Question 19

Supraglottic Airway Directive contraindications

Answer 19

Inability to clear the airway
Stridor
Active vomiting
Airway edema
Caustic ingestion

Question 20

Breathing minute volume

Answer 20

Respiratory rate multiplied by the tidal volume
 Resp Rate x tidal volume
 Amount of air actually moved in to and out of the lungs each minute

Question 21

Basic breathing, assess for adequacy

Answer 21

 Look – for rise and fall of the chest. Listen – for the sound of moving air. Feel – for breath on your hand or cheek. Determine whether the patient is breathing, and then whether
the patient is breathing adequately. Determine the approximate rate, rhythm and quality

Question 22

Basic breathing inadquate level and what to do

Answer 22

8-10 rpm = assist ventilations>
28 rpm with a decreased LOC = assist ventilations.

Question 23

Claps

Answer 23

Look for CLAPS to ascertain injuries to the thorax and the lungs
C-ontusions
L-acerations
A-brasions
P-enetrations
S-ubcutaneous Emphysema

Question 24

TICS-D

Answer 24

Look for TICS-D to ascertain injuries to the ribs, sternum and clavicles
T-enderness
I-nstability
C-repitus
S-welling
D-eformity

Question 25

Circulation Pulse

Answer 25

Provides a rapid check of the patient’s cardiovascular status, Information about the rate, strength, and regularity of heartbeat Note the force and rhythm of the pulse- compare central & peripheral

Question 26

Circulation Skin Colour

Answer 26

Skin colour, temperature, and condition Collectively provide insight into the patient’s overall perfusion Use the back of your hand to assess the warmth and moisture of the patient’s skin. Colour of the skin reflects the status of the circulation immediately underlying the skin. Normal skin is moderately warm and dry.

Question 27

Adequate Circulation rate rhytm quality

Answer 27

Rate - normal = 60 – 100 bpm - too fast = > 160 bpm - too slow = < 50 bpm Rhythm - regular - irregular Quality - strong - weak

Question 28

Capillary Refill

Answer 28

Blanch the skin and wait for the colour to return < than 2 seconds = normal > than 2 seconds = delayed

Question 29

RAPID TRAUMA ASSESSMENT

Answer 29

Typically done between the Primary Survey (initial assessment) and the Secondary Survey (focused physical examination) of a trauma patient It is an organized, systematic and rapid head to toe exam used to identify any potential threats to life/limb that may not have been apparent during the initial primary survey

Question 30

RAPID TRAUMA ASSESSMENT Indications

Answer 30

There was a significant mechanism of injury (ex. a high-speed car accident) OR The patient has an altered mental status OR The paramedic suspects that the patient has multi-system trauma

Question 30

CRITICAL INJURIES CHECK

Answer 30

The Critical Injuries Check is a rapid “Neck-to-Knees” assessment for gross bleeding as well as findings more specific to their location: RTA Head – AMS, CLAPS/TICS-D, Neck – JVD, tracheal deviation, CLAPS/TICS-D. Chest – auscultation, CLAPS/TICS-D. Abdomen – observe and palpate all four (4) quadrants for tenderness, distension, rigidity, penetrations. Pelvis – palpate and compress for TICS-D. Femurs – palpate for CLAPS/TICS-D

Question 31

CRITICAL INTERVENTIONS

Answer 31

Critical Interventions are procedures that MUST be completed prior to transport, even with a critical patient: Oro/nasal airway (decreased LOC). 100% oxygen +/- positive pressure ventilations (hypoxia). Chest compressions (VSA). Defibrillation (Cardiac Arrest Protocol –Trauma/Medical). Hemorrhage control (gross bleed). Cervical collar (suspected spinal injury). Spinal board + head immobilization (suspected spinal injury). Occlusive dressing - open neck wound (4-sided) - open abdominal wound (4-sided) - open chest wound (3-sided)

Question 32

DEFIBRILLATION

Answer 32

It is important to apply the monitor/defibrillator without delay to any patient who is suspected to be in cardiac arrest. For all other patients, the monitor should be applied as a “bridge” device between the Primary Survey and the Secondary Survey. Therefore, if you do NOT believe it may be necessary to immediately defibrillate your patient, the cardiac monitor should be applied AFTER the Critical Injuries Check, and AFTER any Critical Interventions.

Question 33

Defibrillate which rhythms

Answer 33

Ventricular fibrillation Pulseless Ventricular Tachycardia

Question 34

MARCH

Answer 34

Massive Haemorrhage Airway Respirations Circulation Head Injury/Hypothermia its a framework for prioritized trauma care to adress in order

Question 35

Massive Hemorrhage

Answer 35

M- bleeding control is priority in trauma patients Not all bleeding control is a priority. Bleeding could easily refer to a spurting, lacerated artery or trickling blood from a skin tear or a scrape the term “massive hemorrhage” gives a clear picture; immediate, active, life-threatening bleeding that will kill a patient if not stopped.

Question 36

Massive Hemorrhage adressed by

Answer 36

Massive hemorrhage can be addressed by (D’s): Detect: find the source of the bleeding. Direct pressure: hold pressure on the source of the bleeding until the clot forms. Devices: if necessary, use equipment such as tourniquets, hemostatic gauze and pressure bandages to supplement direct pressure. Don't dilute: use the concept of permissive hypotension to avoid thinning the blood or popping established clots.

Question 37

March Airway

Answer 37

AIRWAY CONTROL A –airway management is still a key element for severe traumatic injuries.

Question 38

March Respiratory Support

Answer 38

must ensure proper respiratory support. The pt who is not breathing or breathing inadequately must have assisted ventilations provided. Care must be taken to provide only enough volume to ensure adequate chest rise and fall. Aggressive or “over-bagging” may worsen a developing pneumothorax or increase intrathoracic pressure, decreasing venous return

Question 38

March Circulation

Answer 38

C- refers to shock. After massive hemorrhage, airway and breathing have been addressed, the patients circulatory status needs to be optimized Basic methods for circulation improvement, such as laying the patient flat, maintaining body temperature (prevent coagulopathy) and careful fluid resuscitation may be required

Question 39

March Hypothermia

Answer 39

Hypothermia is a critical factor in trauma. It is a key part of the trauma triad of death, which includes Hypothermia, Acidosis- (which disrupts the blood’s ability to properly carry oxygen), and Coagulopathy (reduced ability to clot). The trauma triad can begin with any one of these elements, each of them feeding the other

Question 40

March Head Injury

Answer 40

Head injury care is virtually all about making sure the primary injury (the initial impact) does not progress into a secondary injury (injury caused or made worse by inadequate EMS care). Care for patients with severe head injuries must avoid the H bombs

Question 41

March Hypoxia

Answer 41

even a brief drop in oxygen saturation can cause permanent secondary brain injury.

Question 42

March Hyperventillation

Answer 42

hyperventilation will blow off too much CO2, causing cerebral vasoconstriction, decreasing perfusion to the brain.

Question 43

March Hypotension

Answer 43

as ICP increases, the blood pressure required to perfuse the brain also increases. The rule of thumb is to avoid systolic blood pressure below 90 mm/Hg to avoid states of decreased perfusion

Question 44

March Hypoglycemia

Answer 44

an injured brain deprived of much needed sugar will have a worse outcome

Question 45

SS VItal Signs

Answer 45

- Pulse -Respirations -Blood Pressure -O2 Sat. -Skin -Pupils -GCS -Blood Glucose -ETCO2

Question 46

SS Head to toe exam

Answer 46

Head  Neck  Chest  Abdomen  Pelvis  Back  Extremities

Question 47

SS Incident and Medical History

Answer 47

SAMPLE – To illicit a patient history and a history of events.  OPQRST – To illicit a description of the pain and the patient’s response to treatment.

Question 48

SS Respiration

Answer 48

Rate, Rhythm, Volume (tidal volume-full, shallow, labored) Look, listen and feel Can include SPO2 here (refer to BLS-PCS O2 therapy standard) measures percentage of hemoglobin saturation. if in doubt treat the patient, not the monitor (false readings)

Question 49

SS Heart Rate

Answer 49

Rate, Rhythm, Volume Are pulses present? if so compare peripheral to central Is it fast, slow, regular, irregular? Full, bounding, weak, thread? If not performed, can include skin Colour, Temp, Condition here

Question 50

SS Blood Pressure

Answer 50

Recorded as Systolic over diastolic It is the measurement of force exerted against walls of blood vessels BP=CO x PVR Systolic pressure created by LV during contraction Diastolic pressure produced during LV relaxation

Question 51

SS Pupils

Answer 51

Assess for size, equality and reactivity Alterations in any of these may indicate injury or illness such as intracranial bleed (pressure on occulomotor nerve), toxicological ingestion/OD, hypoxia

Question 52

Cardiac/ECG Monitoring

Answer 52

Another tool used for patient assessment to observe and monitor the heart rhythm Can be used to determine the electrical rate-which should be compared to mechanical rate or palpable pulse. Monitor for changes in patient’s rhythm which may be unstable or life threatening, such as Vtach Always treat the patient, not the monitor (PEA) Standard monitoring performed using limb leads Leads I, II, III Together these make up Einthoven’s Triangle

Question 53

Eithovens Triangle

Answer 53

Right arm, Left arm, Left leg

Question 54

Lead Placement

Answer 54

Limb lead placement white (RA) right upper chest/shoulder black (LA) left upper chest/shoulder red (LL) left lower ABD green (RL) right lower ABD (ground)

Question 55

OPQRST

Answer 55

Onset- what was patient doing during onset of symptoms Provoking Factors- what makes pain worse/better Quality- What is quality of pain? how does pt describe it? (dull sharp burning crushing tearing constant intermittent) region/radiation severity time

Question 56

SAMPLE

Answer 56

SIgns and Symptoms Allergies Medications Past pertinent medical history Last oral Intake Events prior to condition

Question 57

Reassessment

Answer 57

With any change in patient status or condition or if you have rendered any treatment you must repeat your assessment Start at the top…LOA/LOC, ABC or CAB depending on patient presentation Repeat vital signs Reassess the treatment you have provided, ie. OPA, BVM, hemorrhage control, symptom relief Observe trends in the patient’s current condition. Do they remain unchanged, is the patient improving or deteriorating?

Question 58

Advanced ABCD'S

Answer 58

AIRWAY- Gain control of the airway by inserting a KingLT. (or ETT) BREATHING- Confirm ETT or KingLT placement by auscultating for breath sounds and with Capnography (ETCO2). CIRCULATION- Obtain intravenous access. - Give rhythm appropriate medication. DIFFERENTIAL DIAGNOSES - What are the possible problems or reasons that may have caused the patient’s condition?

Question 59

Advanced Breathing

Answer 59

Confirm ETT placement and effective breath sounds. You will have to use the Easy-Cap or Capnography as part of your protocol for confirming proper ETT placement.

Question 60

Advanced Circulation drugs

Answer 60

Obtain intravenous access in order to deliver an IV fluid bolus or appropriate IV medication. This usually involves the immediate administration of medication or IV therapy that is appropriate to the patient’s chief complaint, or the provisional diagnosis. In some cases, chiefly where the patient is found to be in critical condition (i.e. VSA), no further investigation or deliberation is required for the administration of drugs such as Epinephrine or Atropine, or for an IV fluid bolus. In other cases, more investigation is required before the administration of certain drugs. Such as a full set of vital signs and an incident and medical history before the administration of D50%W or Nitroglycerin. In still other cases, more deliberation is required via Base Hospital Contact, before the administration of drugs such as Adenosine or Dopamine. In these cases it is also wise to obtain a complete set of vital signs as well as an incident and medical history, as it could be crucial to the decision making process.

Question 61

Advanced differential Diagnosis

Answer 61

“the distinguishing between two or more diseases with similar symptoms by systematically comparing the signs and symptoms. Differential diagnosis is best performed by understanding the dimensions of human pathophysiology before you are faced with the patient. Then by approaching the patient with an open mind, allowing your judgment to be guided solely by a thorough physical examination and by obtaining accurate signs and symptoms. Any conclusions must never be final, but rather open to further developments as they evolve. This entire process can be aided greatly by field experience and continued medical education.

Question 62

Advanced Differential Diagnosis When in doubt

Answer 62

When in doubt, the philosophy of “find a symptom, treat a symptom” will at least allow for FORWARD MOMENTUM. Not breathing adequately … Ventilate! Shortness of breath and wheezing … Give Salbutomol!

Question 63

The medical patient Survey

Answer 63

C – EMCA – P Level Of Consciousness - (AVPU) Airway - Open the airway / Insert an oral/nasal airway Breathing - BVM Ventilations / Supplemental O2 Circulation - Pulse checks / CPR Defibrillation - “Shock” VF / “Shock” Pulseless VT Advanced Airway - Intubate the patient Advanced Breathing - Confirm ETT placement Advanced Circulation - Obtain intravenous access Differential Diagnosis - Reasons for the patient’s condition? Secondary Survey - Vitals / SAMPLE / OPQRST / 12-LEAD SRP Protocol – ASA / Nitro. / Epi. /Glucagon / Ventolin Load And Go - Notify ER - Stroke / Acute Trauma / STEMI Reassessment - Vitals / Further SRP (Repeat SRP Drug Doses)

Question 64

The trauma Patients Survey

Answer 64

C – EMCA – P Level Of Consciousness - (AVPU) Manual c-spine Airway - Open the airway / Insert an oral/nasal airway Breathing - BVM Ventilations / Supplemental O2 Circulation - Pulse checks / CPR Defibrillation - “Shock” VF / “Shock” Pulseless VT (X 1 ONLY) Advanced Airway - Intubate the patient Advanced Breathing - Confirm ETT placement Differential Diagnosis - Reasons for the patient’s condition? Critical Injuries Check - Neck-to-Knees / Gross Bleed Critical Interventions - Occlusive Dressing / Chest Needle Load And Go - Notify ER (Trauma Pre-Alert) Secondary Survey - Vitals / SAMPLE / Head-to-Toe Advanced Circulation - Obtain IV access (large bore x 2) Reassessment - Vitals / Further Treatment (Splinting/Dressing)

Question 65

OPEN HEAD INJURY

Answer 65

CLAPS / TICS-D - Basal Skull Fracture: - rhinorrhea - ottorrhea - battle sign - racoon eyes

Question 66

CLOSED HEAD INJURY

Answer 66

Widening pulse pressure - Bradycardia (X) - Ipsilateral dilation (III) - Ataxic respirations - Decorticate positioning - Decerebrate positioning

Question 67

CLOSED PNEUMOTHORAX

Answer 67

CLAPS / TICS-D -  A/E Affected side

Question 68

OPEN PNEUMOTHORAX

Answer 68

CLAPS / TICS-D - Open Wound -  A/E Affected side

Question 69

TENSION PNEUMOTHORAX

Answer 69

CLAPS / TICS-D - Absent A/E Affected side -  A/E Unaffected side - Mediastinal shift - Tracheal Deviation

Question 70

HEMOMOTHORAX

Answer 70

CLAPS / TICS-D -  A/E Affected side - Hypotension - S + S of Shock

Question 71

CARDIAC TAMPONADE

Answer 71

CLAPS / TICS-D - Sternal Trauma - Hypotension - JVD - Muffled Heart Sounds

Question 72

BLUNT ABDOMINAL TRAUMA

Answer 72

CLAPS - Pain - Distension - Rigidity - Guarding - Doughyness

Question 73

PENETRATING ABDOMINAL TRAUMA

Answer 73

CLAPS - Pain - Distension - Rigidity - Guarding - Evisceration

Question 74

HEMORRHAGIC SHOCK

Answer 74

Tachycardia - Tachypnea - Pale, Cool, Clammy - Narrowing Pulse Pressure (Hypotension) - Decreasing LOC

Question 75

FRACTURED PELVIS

Answer 75

CLAPS - TICS-D - Pain - Instability - Crepitus

Question 76

HEMORRHAGIC SHOCK

Answer 76

Tachycardia - Tachypnea - Pale, Cool, Clammy - Hypotension - Decreasing LOC

Question 77

NEUROVASCULAR ASSESSMENT

Answer 77

Pain - Pallor - Pulselessness - Parasthesia - Paralysis

Question 78

NEUROVASCULAR DEFICIT

Answer 78

Manipulate x 1 - Reassess - Splint As Found - Load And Go

Question 79

CRITICAL INJURY

Answer 79

Bilateral Fractured Femurs - Load And Go

Question 80

HEMORRHAGE CONTROL

Answer 80

Direct Pressure - Elevate Limb - Rest Patient - Pulse Point Pressure - Tourniquet (BP Cuff)

Question 81

HEMORRHAGIC SHOCK

Answer 81

Tachycardia - Tachypnea - Pale, Cool, Clammy - Hypotension - Decreasing LOC