Evaluacion de Paciente

Su

tureand

Nee

dles

Anatom

yIllu

stratio

ns

Chap

ter4

Prep

ping

and

Position

ing

BasicSu

pplie

sCh

1Title

toCom

e

1

Assessment

Assessm

ent

pAtient Assessment flow DiAgrAml

Scene Size-UpPersonal protection equipment (PPE)

as appropriate

Interventions and transport considerations

Primary Assessment

Reassessment(as needed)

Hand-off report to otherhealth care providers

MedicalTrauma

NoncriticalCritical

Focusedhistory

Vital signsFocusedphysical

examination

RapidassessmentVital signsSAMPLEhistory

NoncriticalCritical

Focusedphysical

examinationVital signsSAMPLEhistory

RapidassessmentVital signsSAMPLEhistory

SecondaryAssessment

Chapleau_Sect01_3rdPgs-Tab.indd 1 1/21/09 2:19:57 PM

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Assessm

ent precAutions

for entering A scene

Never enter a scene that is not safe.Always have an exit plan for leaving a scene.

personAl protective equipment

TaskorActivity Gloves Gown Mask Eyewear

Bleeding X X X Xcontrolwithspurtingblood

Bleeding X No No Nocontrolwithminimalbleeding

Emergency X X X Xchildbirth

Oral/nasal X No No, No,suctioning, unless unlessmanually splashing splashingclearing islikely islikelyairway

Measuring No No No Nobloodpressure

Measuring No No No Notemperature

FromCentersforDiseaseControlguidelinesforpreventionoftransmissionofhumanimmunodeficiencyvirusandhepatitisBvirustohealthcareandpublicsafetyworkers,MMWR1989;38[NOS-6:35].(FromLejeuneDA,LejeuneJR:RAPID EMT,revised,StLouis,2006,Mosby.)

Chapleau_Sect01_3rdPgs-Tab.indd 2 1/21/09 2:19:58 PM






















Scene Safety checkliStType of Scene Questions to Consider

Crash and rescue Is the traffic controlled? scenes Are police on scene? Are downed electrical wires or poles present? Do you see any leaking fluids? Is the vehicle stable? Are broken glass and torn metal a hazard? Is fire or smoke present?

Confined spaces How stable is the area? Could toxic substances be present? Is this a low-oxygen area?

Crime scenes What is the potential for violence at this scene? Were weapons involved? Are police on scene?

Environmental Are the surfaces stable? concerns Is water or ice present? Is the slope manageable? Is fog, snow, or lightning a hazard? Could extremes in heat or cold be a problem?

Violent conditions Do you hear yelling and shouting? Is anyone making wild or aggressive gestures? Are weapons present or reported?

Continued

Chapleau_Sect01_2ndPgs-Text.indd3 3 1/14/09 11:15:48 PM






















Scene Safety checkliStcontdType of Scene Questions to Consider

Violent conditions Does this person have a contd known history of violence? Is the crowd controlled or in danger? Is there an animal on the scene?

Residence/building Is the area well lit or dark? response Is someone present to help you gain access? Does the nature of the call suggest violence? Is gang graffiti present or any activity present that might indicate danger? Does the area have history of violence? Is the building structurally stable? Is fire or smoke present? Are noxious fumes present?

(Adapted from Dalton A et al: Advanced medical life support, Upper Saddle River, New Jersey, 1999, Pearson Education, Inc.)

ommon mechaniSmS of injury























co

mm

on

me

ch

an

iSm

S o

f in

jur

y a

nd

Pa

tte

rn

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f in

jur

y

Mec

hani

sm o

f Inj

ury

Pred

icto

rs

Ass

ocia

ted

Patte

rns

of In

jury

Mot

or v

ehic

le c

rash

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e of

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rest

rain

ed

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tiple

trau

ma,

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d an

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ck in

jurie

s, s

calp

im

pact

and

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age

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e

an

d fa

cial

lace

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inte

rior o

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car

may

hel

p

Air b

ag

Head

and

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k, fa

cial

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inju

ries

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ict i

njur

ies)

Re

stra

ined

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est a

nd a

bdom

inal

inju

ries,

cer

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l and

lo

wer

-spi

ne fr

actu

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vicl

e fra

ctur

es

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or v

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edes

trian

cra

sh

Low

spe

ed

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er-e

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ture

s (c

hild

ren

are

mor

e co

mm

only

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gh s

peed

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est a

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inal

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d an

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ck

stru

ck h

ead-

on, w

here

as a

dults

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ity fr

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ar

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ruck

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)

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from

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per-

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ower

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ity fr

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M

ediu

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ad a

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ex

trem

ity fr

actu

res

Continued























co

mm

on

me

ch

an

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S o

f in

jur

y a

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Pa

tte

rn

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f in

jur

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td

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eat h

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est a

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ries,

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d an

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ck

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patie

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ht 5

inju

ries,

upp

er- a

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criti

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njur

ies)

fract

ures

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from

a b

icyc

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out a

hel

met

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ad a

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ould

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ever

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fe-th

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et

c.)

(Ada

pted

from

Tea

chin

g Re

sour

ce fo

r Ins

truct

ors

in P

reho

spita

l Ped

iatri

cs [T

RIPP

], ve

rsio

n 2.

0, N

ew Y

ork,

199

8, C

ente

r for

Pe

diat

ric E

mer

genc

y M

edic

ine

[CPE

M].)























hazardS and available reSourceS

Hazards Resource

Electrical lines down Fire service Electric utility company

Natural gas leak Fire service Gas company Public utilities

Fire Fire service

Hazardous materials Fire Service (chemical spill, indus- Hazardous materials trial incident, etc.) team

Rescue (such as water, Fire service confined space, high Specialty rescue teams angle, trench, extrication)

Mass (or multiple) Law enforcement casualties Fire service Local emergency management agency

Violent scene Law enforcement

Loose animals on scene Animal control

elementS of Primary aSSeSSment

General Medical or trauma (stabilize the impression spine) or unsure (treat as trauma) Environmental clues Age Gender























elementS of Primary aSSeSSmentcontd

Assess Are patients awake when you responsiveness get there?

Do they respond when you talk to them? Do you need to touch them or use painful stimuli to get them to respond? How do they respond? Are they unresponsive to any stimuli?

Airway Do you hear any noises (e.g., gurgling, snoring, stridor, or grunting)? If you open an airway or suc- tion, does the noise improve?

Breathing Are they breathing? Is the breathing fast or slow? Do you hear any wheezing or other noises? Are they using accessory muscles to breathe? How hard are they working to breathe? Can they speak? How many words between breaths? What is (are) their position(s)?

Circulation Do they each have a pulse? Is it slow, fast, regular, or irregular? What are their skin colors and temperatures? Is there any major bleeding?

Continued























10

elementS of Primary aSSeSSmentcontd

Disability What are the patients GCS scores?

Priority Are any of these critical patients?

GCS, Glasgow Coma Scale (see p. 12).

avPu Scale

AAlert The patient is alert, awake, and talking to you. The patient knows his or her name, where he or she is, what day or time it is, and what happened.

VResponds to The patient responds to voice. verbal stimuli The patient may not be alert or open the eyes spontane- ously, but he or she responds appropriately when you speak to him or her.

PResponds to The patient responds only to a painful stimuli painful stimulus such as a pinch of an earlobe or a sternal rub.

UUnresponsive The patient is not awake and is completely unresponsive to any type of stimuli.























11

Pulse locations

Patient PulseLocation

Adult responsive Radial pulse Unresponsive Carotid pulse #10 seconds

Child responsive Brachial or radial pulse Unresponsive Carotid or femoral pulse

Infant Brachial pulse

Newborn Central pulse at base of umbilical cord

Figure 1-1. Pulse locations.(From McSwain N, Paturas J: The basic EMT: comprehensive prehospital patient care, ed 2, St Louis, 2003, Mosby.)

Carotid artery

Radial artery

Femoral artery

Brachial artery

Chapleau_Sect01_3rdPgs-Text.indd11 11 1/18/09 2:51:36 PM






















12

Gla

sG

ow

Co

ma

sC

ale

Gla

sgow

Com

a Sc

ale

Adu

lt/Ch

ild

Scor

e In

fant

Eye

Open

ing

Spon

tane

ous

4 Sp

onta

neou

s

To v

erba

l 3

To v

erba

l

To p

ain

2 To

pai

n

No

resp

onse

1

No

resp

onse

Best

Ver

bal R

espo

nse

Orie

nted

5

Coos

, bab

bles

Diso

rient

ed

4 Irr

itabl

e cr

y

Inap

prop

riate

wor

ds

3 Cr

ies

only

to p

ain

In

com

preh

ensi

ble

soun

ds

2 M

oans

to p

ain

N

o re

spon

se

1 N

o re

spon

seBe

st M

otor

Res

pons

e Ob

eys

com

man

ds

6 Sp

onta

neou

s

Loca

lizes

pai

n 5

With

draw

s fro

m to

uch

W

ithdr

aws

from

pai

n 4

With

draw

s fro

m p

ain

Ab

norm

al fl

exio

n (d

ecor

ticat

e)

3 Ab

norm

al fl

exio

n (d

ecor

ticat

e)

Ab

norm

al e

xten

sion

(dec

ereb

rate

) 2

Abno

rmal

ext

ensi

on (d

ecer

ebra

te)

N

o re

spon

se

1 N

o re

spon

seTo

tal 5

E 1

V 1

M

3

to 1

5; h

ighe

st s

core

5 1

5; c

ritic

al p

atie

nt #

13(F

rom

Aeh

lert

B: R

APID

ped

iatri

c em

erge

ncy

care

, St L

ouis

, 200

6, M

osby

.)























13

IndIcators of crItIcal PatIents

General Unresponsive/not moving impression/ Poor general impression responsiveness

Airway Obstructive sounds such as stridor, snoring, or gurgling (grunting in infants)

Compromised airway

Breathing Inadequate rate and quality of breathing

Absence of breathing

Difficulty breathing

Accessory muscle use

Circulation Uncontrolled bleeding

Weak, absent, or irregular pulse

Signs of cyanosis

Cool, clammy skin (shock)

Disability GCS #13

Confusion, disorientation

Changing level of consciousness

Pediatricflaccid; glassy stare; does not acknowledge caregiver or emergency first responder

GCS, Glasgow Coma Scale.

Chapleau_Sect01_3rdPgs-Text.indd13 13 1/21/09 10:09:46 AM






















1

SamPle mnemonic for hiStory takinG

S Signs/symptoms Signa condition you can see or measure Symptoma problem a patient describes

A Allergies Allergies to medications, the environment, or food Medical insignia

M Medications Prescription, over-the- counter, herbs, vita- mins, recreational drugs Medical insignia

P Pertinent medical Recent medical, history surgical, or trauma problems Seeing a doctor for problems Recent hospitalizations Medical insignia

L Last oral intake What was consumed? How much? How long ago?

E Events leading to What were you doing the injury or when you got ill? illness What were you doing when you were hurt? Does anything else hurt or bother you?























1

oPQrSt mnemonic for evaluation of Pain

or SiGnS and SymPtomS

O Onset When did the problem start? What were you doing when the problem started?

P Provocation What, if anything, makes the problem worse? What, if anything, makes the problem better?

Q Quality How does the patient describe the problem? What does it feel like?

R Radiation Where is there pain? Does the pain spread any- where else in the body?

S Severity On a scale of 1 to 10 (with 10 being the worst pain you have ever felt in your life), how bad is the problem?

T Time How long has the patient had the problem?























1

dotS mnemonic for PhySical eXamination

D Deformities

O Open wounds or injuries

T Tenderness

S Swelling

In the physical examination, you should look and feel for signs of injury. Using the dotS mnemonic above, each body part should be assessed for deformities, open wounds or injuries, tenderness, or swelling. You should assess the following:

HeadNeckChestAbdomenBackPelvisExtremities























1

vit

al

SiG

nS

by

aG

e

Resp

irat

ory

Rate

Blo

od P

ress

ure*

Age

(b

reat

hs/m

in)

Puls

e Ra

te (b

eats

/min

) (s

ysto

lic/d

iast

olic

)

New

born

Bi

rth-6

wk

30-5

0 12

0-16

0 (7

4-10

0)/(5

0-68

)

Infa

nt

7 w

k-1

yr

20-3

0 80

-140

(8

4-10

6)/(5

6-70

)

Todd

ler

1-2

yr

20-3

0 90

-130

(9

8-10

6)/5

0-70

)

Pres

choo

l 2-

6 yr

20

-30

80-1

20

(98-

112)

/(64-

70)

Scho

ol a

ge

6-13

yr

18-3

0 (6

0-80

)-100

(1

04-1

24)/(

64-8

0)

Adol

esce

nt

13-1

6 yr

(1

2-20

)-30

60-1

00

(118

-132

)/(70

-82)

Adul

t .

16 y

r 12

-20

60-1

00

(100

-150

)/(60

-90)

*The

nor

mal

sys

tolic

pre

ssur

e in

chi

ldre

n ag

ed 1

to 1

0 ye

ars

old

can

be c

alcu

late

d as

90

mm

Hg 1

(chi

lds

age

in y

ears

3 2

) mm

Hg.

Th

e lo

wer

sys

tolic

pre

ssur

e in

chi

ldre

n ag

ed 1

to 1

0 ye

ars

old

can

be c

alcu

late

d as

70

mm

Hg 1

(chi

lds

age

in y

ears

3 2

) mm

Hg.























1

Skill 1-1: auScultatinG a blood PreSSure

1. Place blood pressure cuff on patient and place stethoscope in your ears.

2. Palpate for the brachial artery.























1

Skill 1-1: auScultatinG a blood PreSSurecontd

3. Place the diaphragm of the stethoscope over the brachial artery and hold it in place.

4. Tighten the valve on the bulb and inflate the cuff by squeezing on the bulb.























20

Skill 1-1: auScultatinG a blood PreSSurecontd

5. Slowly let the air out of the cuff and listen to the sounds. The first sound is the sys-tolic pressure.

6. Where the sound stops is the diastolic pressure. Record the blood pressure as systolic/diastolic.























21

Skill 1-2: PalPatinG a blood PreSSure

1. Place blood pressure cuff on patient.

2. Place your index and middle fingers over the radial pulse.























22

Skill 1-2: PalPatinG a blood PreSSurecontd

3. Tighten the valve on the bulb and inflate the cuff by squeezing on the bulb.

4. Slowly let the air out of the cuff and feel for a pulse. The systolic pressure is when a pulse can be felt. Record as systolic/palp.























Evaluacion de Paciente

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