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

Direct blows may affect – Clavicle – Scapula – Shoulder girdle – Humerus – Knee – Hip – Femur

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

Forced bending or extension tend to affect

– Elbow – Wrist – Fingers – Femur – Knee – Foot – Cervical

spine

Indirect blows may affect – Pelvis – Hip – Femur – Knee – Tibia/fibula – Shoulder – Humerus – Elbow – Ulna/radius

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

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

Scenario #1 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

Facial droop Arm drift Speech pattern

Scenario #6

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 Allergic Reaction

STABLE

WITH AIRWAY INVOVLEMENT

ANAPHYLACTIC SHOCK

Benadryl 1 mg/kg IVP or

IM (Adult max 25 mg)

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

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?

Pre-quiz August 2012 Reading the Scene P & B

7. List at least 3 components of a field neurological assessment. 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