Goal Directed Patient Assessment
Dan Batsie
dbatsie@apems.org
• How is an EMT
different than a taxi
driver?
Goals of the EMT
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Go home
Identify resuscitation
Identify/intervene in immediate life threats
Identify ongoing (subtle) life threats
Symptom relief
Customer service
Dr Reuben Strayer
Bottom Up Approach
Bottom Up Approach
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Final diagnosis
Ancillary testing
Differential diagnosis
Diagnostic testing
Comprehensive physical examination
Comprehensive history
•Symptoms
•Allergies
•Medications
•Past medical history
• Last meal
• Events
• What’s wrong with the
patient?
• What does the patient
need?
iv. Specific respiratory conditions—definition, causes,
assessment findings and symptoms, complications, and
specific prehospital management and transport decisions
A. Asthma
B. Pulmonary Edema
C. Chronic Obstructive Pulmonary Disease
D. Pneumonia
E. Spontaneous Pneumothorax
F. Pulmonary Embolism
G. Epiglottis
H. Pertussis
I. Cystic Fibrosis
J. Environmental/Industrial Exposure/ Toxic Gasses
K. Viral Respiratory Infections
Asthma
Pulmonary edema
COPD
Pneumonia
Spontaneous pneumo.
PE
Epiglottitis
Cystic fibrosis
Pertussis
Respiratory infections
Toxins
Although there are many pathologies to
consider, the emergent needs of the patient
are relatively few.
Interventions
Medications
1.
2.
3.
4.
5.
6.
7.
8.
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10.
11.
12.
13.
14.
15.
16.
17.
1.
2.
3.
4.
5.
6.
7.
8.
Restraints
CPR
Defibrillation
Hemorrhage control
Foreign body airway/suction
NPA/OPA
BIAD
PPV
CPAP
Supplemental O2
Splinting/immobilization
Cool/warm
Childbirth
Transport
Request ALS
PASG
Wound care/bandaging
O2
Epi auto-injector
Albuterol
Charcoal
Aspirin
Nitronox
Glucose
NTG
Simple ≠ Dumb
Top Down Approach
(What does the patient need?)
• Safety
• Identify the need for resuscitation/correction of a
primary assessment problem
• Identify the need for other immediate action
• Identify life threatening conditions
• Symptom relief
• Customer service
Primary Assessment
1.
2.
3.
4.
Airway
Breathing
Circulation
Disability
Primary Assessment
4.
1.
2.
3.
Circulation
Airway
Breathing
Disability
Primary Assessment
Circulation
Airway
Breathing
Disability
Circulation
What are the goals of our assessment?
Primary Assessment
Is it safe?
Primary Assessment
ID Resuscitation
Prevent Hypoxia
Prevent Hypoperfusion
EXsanguinating hemorrhage
Airway
Breathing
Circulation
Disability
Massive hemorrhage
Airway
Respiration
Circulation
Hypothermia/Head injury
Airway
• Is it open?
• Will it stay open?
X
A
B
C
D
Prevent Hypoxia
Initial Assessment Revisited
Breathing
Is it adequate?
<8 >20
Breathing Adequacy
• Oxygenation
• Ventilation
Identify Respiratory Failure
Bad signs
• Hypoxia despite O2
• Hypercapnia
• Poor tidal volume
• Anxiety/Combativeness
Super bad signs
• Tiring
• Rate changes
• Respiratory pattern
changes
• Lethargy, somnolence
• Silent chest
Are the perfusing?
Prevent Hypoperfusion
Do we need to leave right now?
• Airway
• Breathing
• Circulation
• Disability
• Expose
• Fit into CUPS
• Get Vitals
• History/Head to Toe
• Scene Survey
• Primary Assessment
– ABCD
• Secondary
Assessment
– History
• OPQRST, SAMPLE
– Physical
• Diagnostic testing
• Reassess
• Safety
• Resuscitation
• Correction of a
primary assessment
problem
• Identification of life
threatening condition
• Symptom relief
• Customer service
Secondary Assessment
• Not important if
interventions are
necessary or ongoing
• May not be an
achievable goal.
Assessment is more than just identifying
interventions
N Engl J Med, Vol. 345, No. 19
Every 10 minute increase
in the time to reperfusion
therapy increases
mortality by 1%
Missed AMI doubles mortality
Eastern Maine Medical Center Average
Door to Balloon Time 2011:
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Self transported - 70.56 min.
EMS Transported with activation - 40.29 min.
ED Bypass- 16 min.
EMS transported without activation - 77.69
min.
EMT’s
don’t
diagnose!
Cardinal Presentations
iv. Specific respiratory conditions—definition, causes,
assessment findings and symptoms, complications, and
specific prehospital management and transport decisions
A. Asthma
B. Pulmonary Edema
C. Chronic Obstructive Pulmonary Disease
D. Pneumonia
E. Spontaneous Pneumothorax
F. Pulmonary Embolism
G. Epiglottis
H. Pertussis
I. Cystic Fibrosis
J. Environmental/Industrial Exposure/ Toxic Gasses
K. Viral Respiratory Infections
iv. Specific respiratory conditions—definition, causes,
assessment findings and symptoms, complications, and
specific prehospital management and transport decisions
A. Asthma
B. Pulmonary Edema
C. Chronic Obstructive Pulmonary Disease
D. Pneumonia
E. Spontaneous Pneumothorax
F. Pulmonary Embolism
G. Epiglottis
H. Pertussis
I. Cystic Fibrosis
J. Environmental/Industrial Exposure/ Toxic Gasses
K. Viral Respiratory Infections
Asthma
Pulmonary edema
COPD
Pneumonia
Spontaneous pneumo.
PE
Epiglottitis
Cystic fibrosis
Pertussis
Respiratory infections
Toxins
• Ask questions to get answers
• Use history to make decisions
• One question leads to the
next
• Questions are used to narrow
your focus
Don’t ask a questions if
you already know the
answer.
1 Question
• Are you
sexually
active?
• Is there a wheeze?
Is there a wheeze?
How long has this
been going on?
Do you still have your
appendix?
Have you had a fever?
Do you have CHF?
Are you a diabetic?
Have you ever had
kidney stones?
Do you feel the urge
to push?
How far did you fall?
Were you trying to
hurt yourself?
Any hives?
Have you ever had a
seizure before?
How fast were you
going?
When did this start?
When was the last time
you were normal?
Do you have
asthma?
Did you just eat a
greasy meal?
How big was the
knife?
Are you able to
speak?
Do you still have your
appendix?
What exactly did you
take and how much?
Ripping or tearing pain?
Are you a smoker?
Have you
urinated/moved your
bowels recently?
Are you allergic to…
Are you sexually
active?
Have you been coughing?
Has this ever
happened before?
Any recent injuries/illness?
Can you describe the pain?
Do you have any
pain?
Is anyone else sick in
the house?
Do you take an
ED medication?
Do you have a history
of alcohol abuse?
Turn possibilities into
probabilities
General
Impression
Primary
Assessment
History
Field
Diagnosis
History
Physical
Exam
Better
Diagnosis
Assemble the Pattern
Use physical exam and specific diagnostic
testing to prove your conclusions
Other Important and often forgotten goals
Patient safety
Symptom Relief
Symptom relief?
• Can be done without
diagnosis
• Not always an ALS
procedure
Cool Air and Dypsnea
• Stimulation of mechanoreceptors mediated through
the trigeminal nerve on the face may alter afferent
feedback and modify the perception of dyspnea.
• Shown to reduce dyspnea in normal volunteers in
response to hypercapnia and inspiratory resistive
loads
Schwartzstein, R. et al. Cold facial stimulation reduces breathlessness induced in normal subjects. Am.
Rev. Respir. Dir. 13658-61 1987
Customer service
Customer service
Questions?
Dan Batsie
dbatsie@apems.org
• Scene Survey
• Primary Assessment
– ABCD
• Secondary
Assessment
– History
• OPQRST, SAMPLE
– Physical
• Diagnostic testing
• Reassess
• Safety
• Resuscitation
• Correction of a primary
assessment problem
• Other immediate
action
• Identification of life
threatening condition
• Symptom relief
• Customer service
What are the goals of our assessment?
Primary Assessment
Airway
Breathing
Circulation
Disability
CPR
Airway
PPV
Hemorrhage control
Seal chest wounds
Transport
N Engl J Med 2004;351:647-56.
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Symptoms
Allergies
Medications
Past medical history
Last meal
Events
• What’s wrong?
(symptoms/events)
• Has this ever
happened before?
(PMHx)
• Allergies
• Medications
• Last meal