IVMS -ICM New Patient Assessment

1. The New Patient Assessment
is...“F U N O”
Website: http://ivmsicm.blogspot.com/
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2. The New Patient Assessment
is...“F U N O”
Marc Imhotep Cray, M.D.
Companion Online Folder:
IVMS-Physical Diagnosis Notes and Reference Resources

3. The New Patient
Assessment is...
• First Impression
• Urgent Survey (ABCD)
• Non-Urgent Survey
• Ongoing Survey
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4. Advanced Assessment
Further develop assessment techniques
 Fully assess a situation, name and describe
probable injuries or illnesses, and report
treatment
 Obtain a relevant medical history from a
responsive patient
 Properly prioritize treatment of multiple injuries
and/or multiple patient situations
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5. Think, Look, Listen, and Feel
• Look
– For deviations from normal (compare sides)
– For swellings, lumps, bruises, and open wounds;
deformities, abnormal angles and motion (or lack of
motion); medic alert tags
• Listen
– To what patient says (avoid leading questions)
– For abnormal sounds, especially respiratory
• Feel
– Pulses
– Skin temperature and moisture
– Body for lumps, indentations, abnormal soft or hard areas,
and tender areas
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6. Vital and Diagnostic Signs
• Pulse - rate, rhythm, strength
• Respiration - rate, depth, quality, sounds
• Blood pressure
– Slope vs. aid room
– Radial vs. carotid pulse
• Temperature
– Skin
– Body core
• Capillary refill
• Facial expression, skin color, moisture, turgor
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7. Level of Responsiveness –
AVPU
• Alert
• Responsive to verbal stimuli
• Responsive to pain
• Unresponsive
= Level of consciousness (LOC)
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8. First Impression and Primary
Survey Decision Tree
First Impression,
Probable Mechanism of Injury,
Need for Extrication?
Danger to Patient
Remove Danger Yes or Rescuers?
Remove from Level of Responsiveness,
Danger “Are You Okay?”
Responsive Unresponsive
Responsive Patient Unresponsive Patient
Decision Tree Decision Tree
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9. Responsive Patient Decision Tree
1st Impression; MOI
Help Refusal Introduce Self, Offer
Help
Follow Local Refusal of Help Protocol Assess Major Problems Sites(s)
Indicated
Rapid Survey
SAMPLE
Injured or Ill? No Abnormal ABC? Yes Lifesaving
Intervention
Treat Major or
Chief Problems Call for Transportation,
Any Special Equipment
Transport
Monitor
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10. Unresponsive Patient Decision Tree
First Impression, Unresponsive
Mechanism of Injury Call for Help, Transportation, Any
Special Equipment; Notify EMS
Open Airway, Guard Cervical Spine
No Breathing?
Rescue Breathing, Remove
Any Airway Obstruction Yes
Carotid Pulse? No Begin CPR
Yes
Yes Successful?
Observable Severe
Control Bleeding Yes
Bleeding? No
No
Continue CPR
Abnormal Breathing
and/or Pulse? Yes
Transport Decision
No
Assess Head; Monitor LOR,* Assess: Neck, Chest, Abdomen,
Stabilize Body Temperature
Responses of Extremities to Pain Pelvis, Extremities
Transport Decision
Treat Urgent Problems
*Level of Responsiveness
Secondary Survey
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11. Threats to Life
 Head injury, especially with altered LOC > 5 minutes or open
skull fracture
 Unresponsiveness, shock
 Femur, pelvis, or two or more long bone fractures
 Chest injury or illness with respiratory distress
 Cervical spine injury, especially with paralysis, loss of sensation,
or respiratory distress
 Limb amputation
 Crushing injury to abdomen or pelvis
 Heart attack, especially with cardiac arrest
 Stroke
 Anaphylactic shock
 Internal bleeding
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12. Threats to Limb
 Major eye injuries
 Injury to extremity blood supply or nerves
 Crushing injury to extremity
 Hip, knee, or ankle dislocation
 Fractures or fracture-dislocations near elbow
or knee
 Open fractures
 Back injury, especially with weakness,
paralysis, or loss of sensation
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13. Patient History
 Events from patient and bystanders
 Mechanism of injury
 Chief complaint
 SAMPLE
– Signs and symptoms
– Allergies - drugs, foods, insect bites
– Medicine and drugs
– Previous injury and medical history
– Last meal
– Events leading to injury and “anything else”
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14. Head and Neck
 LOC; Expression
 Wounds, indentations, deformities,
Meninges
Cerebrum
lumps
Cerebral cortex
Corpus callosum
Thalamus
 Ears and nose - blood, CSF
Hypothalamus
Optic tract
Nasal Cerebellum
 Mastoid process - Battle’s sign
 Eyes - PERL, raccoon eyes
Pituitary
gland
Pons
Zygomatic
Medulla
oblongata
Atlas  Mouth - dentures, foreign objects,
blood
Axis
Mandible
3rd Cervical vertebrae
 Cervical spine
 Deviation of trachea
 Stoma
 Medic alert tag
SKULL, LEFT SIDE
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15. Chest, Abdomen, and Pelvis
Wounds, indentations,
deformities, lumps
Unusual breathing or
noises
Equal chest expansion
Distension, tenderness,
swelling, rigidity, masses
Quadrants - especially
upper - liver and spleen
Crepitus, range of motion
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16. Extremities
Skul l
Cr aniu m
 Wounds, shortening,
Face
Cer vic al ver t ebr ae
Shoulder gir dle
M andib le
deformities, unusual
positions, tenderness
Clavicle
Scapula
Thorax
U pper l i m b St er num
Rib
 Circulatory function - pulses
Hum er us
Spi nal col um n
and capillary refill
Disk
Radius Ver t ebr a
Pel vi s
I lium
Sacr um
Ulna
 Nervous function - motor
Pubis
Hand Coccyx
I schiu m
Carpals
M et acar pals
Phalanges
Low er l i m b
Fem ur and sensory
Pat ella
 Medic alert bracelets
Fibula
Tibia
Foot
Tar sals
M et at ar sals
Phalanges
Calc aneus
S K E LE TON , A N TE R IO R V IE W
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17. Back
Cra n iu m
Sp le n iu s c a p its
L e v a to rs c a p u la e Ma n d ib le
 Wounds, deformities,
C la v ic le
Sc a p u la
Rh o mb o id e u s min o r
Hu me ru s
Rh o mb o id e u s ma jo r
In fra s p in a tu s
Te re s ma jo r
Sa c ro s p in a lis
Se ra tu s a n te rio r
Bra c h io ra d ia lis &
Ex te n s o rc a rp ira d ia lis lo n g u s
An c o n a e u s
Tric e p s b ra c h i
Ob liq u u s E x te rn u s a b d o min is
unusual positions
Pa lma ris lo n g u s
 Lumps and tenderness,
Fle x o rd ig ito ru m s u b limis
Glu ta e u s me d iu s
P e lv is
Fle x o rc a rp iu ln a ris
Ex te n s o rd ig ito ru mc o mmu n is & Sa c ru m
Uln a
Dig itq u in tip ro p riu s
Co c c y x Ra d iu s
Fe mu r Se mite n d in o s u s
especially spine
Ad d u c to r
ma g n u s
Va s tu s la te ra lis
Bic e p s fe mo ris
Gra c ils
F ib u la
T ib ia
Pe ro n a e u s lo n g u s
So le u s
MU S C LE S , D E E P LA Y E R , P OS TE R IOR V IE W
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18. History Taking
Document:
Vital signs
Abnormal findings
Important normal findings
At regular intervals
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19. Assessment and
Complications
• Assessment
– Determine mechanism of injury!
– Monitor and record vitals!
– Ask specific pain questions!
• Signs and complications
– Anticipate vomiting - keep airway open!
– Watch for and treat shock!
– Be aware of peritonitis and position!
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20. “OPQRST” Pain Questions
• Onset - when start, sudden or gradual
• Provoke - position, movement, local or
general
• Quality - sharp, dull
• Radiating - if so, from where to where
• Severity - mild-moderate-severe or scale of
1-10
• Time - how long, continuous or intermittent,
worse or better
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21. Multiple Injuries and Patients
• Polytrauma - “life over limb”
• Emphasize ABCDE
• Immobilize whole body vs. multiple splints
• Critical transport decision
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22. Pediatric Concerns
 Provide special emotional handling
 Expect frightened, modest, or shy behavior
 Move slowly, explain, use simple terms, maintain eye contact
 Be kind and soft-spoken
 Be honest about pain and procedures
 Use help from parent or sibling
 Remember trauma most common cause of death
 Keep in mind small children and hypothermia risk
 Size basic life support to size of patient
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23. Probable Occurrence of Death
 Mechanism of injury or preceding illness
 Early
 Injuries incompatible with life
 No pulse, respiration, heartbeat, response to pain over several
minutes
 Widely dilated, unresponsive pupils, rapid glazing
 Pale, cool skin, blue lips and nails
 Relaxed body sphincters, wastes
 Late
 Rigor mortis
 Livor mortis - lividity
 Odor of decay
 “Cold and dead” vs. “warm and dead”
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