Principles of Patient Principles of Patient Assessment in EMS Assessment in EMS

Making a Priority DecisionMaking a Priority Decision

IntroductionIntroduction

Priority decisions are made to set the Priority decisions are made to set the tone for patient care and tone for patient care and management.management.

Perform the initial assessment first.Perform the initial assessment first. When more than one patient is When more than one patient is

present you must triage (to sort):present you must triage (to sort): Triage use in pre-hospital and hospitalTriage use in pre-hospital and hospital Many triage systems availableMany triage systems available

The Priority DecisionThe Priority Decision

Priority decision making is an essential Priority decision making is an essential skill for EMS providers.skill for EMS providers.

Failure to make a priority decision may Failure to make a priority decision may have serious life-threatening implications.have serious life-threatening implications.

Consider the “golden hour” and the Consider the “golden hour” and the “Platinum ten minutes.”“Platinum ten minutes.”

Stable vs. UnstableStable vs. Unstable When two priority choices are possible “up When two priority choices are possible “up

triage.”triage.”

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Systems of PrioritizingSystems of Prioritizing

Become familiar with the system Become familiar with the system used in your area: used in your area: Hot / coldHot / cold Red / yellow / greenRed / yellow / green High / LowHigh / Low Minor / Moderate / SevereMinor / Moderate / Severe P-1, P-2, P-3P-1, P-2, P-3 C U P S C U P S

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A Close Up on One SystemA Close Up on One SystemC U P SC U P S

Acronym that stands for:Acronym that stands for: criticalcritical unstableunstable potentially unstablepotentially unstable stablestable

First introduced in the BTLS courseFirst introduced in the BTLS course Adapted in many statesAdapted in many states

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Examples of “Critical Examples of “Critical Patients”Patients”

Actual or impending Actual or impending cardiorespiratory arrestcardiorespiratory arrest

Respiratory failureRespiratory failure Decompensated shock Decompensated shock

(hypoperfusion)(hypoperfusion) Rising intracranial pressureRising intracranial pressure Severe upper airway difficultiesSevere upper airway difficulties

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Examples of “Unstable Examples of “Unstable Patients”Patients”

Cardiorespiratory instabilityCardiorespiratory instability Respiratory distressRespiratory distress Compensated shock (hypoperfusion)Compensated shock (hypoperfusion) Two or more long bone fracturesTwo or more long bone fractures Trauma with associated burnsTrauma with associated burns Amputation proximal to wrist or ankleAmputation proximal to wrist or ankle Penetrating injury to: head, neck, chest, Penetrating injury to: head, neck, chest,

abdomen, pelvisabdomen, pelvis

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Examples of “Unstable Examples of “Unstable Patients” Patients” (continued)(continued)

Uncontrollable external bleedingUncontrollable external bleeding Chest pain with a systolic BP < 100Chest pain with a systolic BP < 100 Severe painSevere pain Poor general impressionPoor general impression Unresponsive patientsUnresponsive patients Responsive patients who do not Responsive patients who do not

follow commandsfollow commands

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Examples of “Potentially Examples of “Potentially Unstable Patients”Unstable Patients”

Cardiorespiratory instabilityCardiorespiratory instability MOI indicating a possible hidden MOI indicating a possible hidden

injuryinjury Major isolated injuryMajor isolated injury General medical illnessGeneral medical illness An uncomplicated childbirthAn uncomplicated childbirth

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Examples of “Stable Examples of “Stable Patients”Patients”

Patients with a low potential for Patients with a low potential for cardio-respiratory instabilitycardio-respiratory instability

Low grade feverLow grade fever Minor illnessMinor illness Minor isolated injuryMinor isolated injury An uncomplicated extremity injuryAn uncomplicated extremity injury

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Tools to Determine PriorityTools to Determine Priority

Developed to logically examine, Developed to logically examine, evaluate, and rate severity of a evaluate, and rate severity of a patient using a numbering systempatient using a numbering system

Developed initially for trauma patients Developed initially for trauma patients yet also used on medical patientsyet also used on medical patients

Glasgow Coma ScoreGlasgow Coma Score The Trauma ScoreThe Trauma Score

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Glasgow Coma Score (GCS)Glasgow Coma Score (GCS)

Measures:Measures: Eye openingEye opening Verbal responseVerbal response Motor responseMotor response

The best responses are given a The best responses are given a numerical score numerical score

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Trauma Score (TS)Trauma Score (TS)

Developed in 1980 as a triage toolDeveloped in 1980 as a triage tool Used to predict patient outcomesUsed to predict patient outcomes Numerical grading system combining GCS Numerical grading system combining GCS

and the following:and the following: Respiratory rateRespiratory rate Respiratory expansionRespiratory expansion Systolic BPSystolic BP Capillary refillCapillary refill Conversion scale for GCSConversion scale for GCS

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Triaging and Triaging and Prioritizing Burn PatientsPrioritizing Burn Patients

Burn severity determined by:Burn severity determined by: Source typeSource type Body surface area (BSA)Body surface area (BSA)

Rule of nines used to calculate BSARule of nines used to calculate BSA Classifications of burns include:Classifications of burns include:

Mild -sunburnMild -sunburn Moderate – uncomplicated partial thickness < Moderate – uncomplicated partial thickness <

30% BSA30% BSA Severe – inhalation injuries or electrical burnsSevere – inhalation injuries or electrical burns

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Triage to Aeromedical Triage to Aeromedical TransportTransport

Refer to established regional Refer to established regional protocolsprotocols

Weather conditions – visibility and Weather conditions – visibility and windwind

Medical considerationsMedical considerations Injury factors – MOI, length of Injury factors – MOI, length of

extrication, distance to trauma centerextrication, distance to trauma center

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Triage in MCI’sTriage in MCI’s

Triage is needed when there are Triage is needed when there are multiple patients and limited multiple patients and limited resources.resources.

Triage helps to ensure the most Triage helps to ensure the most serious are treated and transported serious are treated and transported first.first.

Designate a “triage officer” and use Designate a “triage officer” and use “triage tags.” “triage tags.”

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The START SystemThe START System Acronym - simple triage and rapid Acronym - simple triage and rapid

treatmenttreatment Developed in the 1980’s, separating Developed in the 1980’s, separating

patients into:patients into: MinorMinor DelayedDelayed ImmediateImmediate DeceasedDeceased

Few responders can triage many rapidly.Few responders can triage many rapidly. Assessing:Assessing:

Respiratory statusRespiratory status Hemodynamic statusHemodynamic status Mental status Mental status

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Triage TagsTriage Tags

Used in MCI’sUsed in MCI’s Several types availableSeveral types available Eliminates need to reassess each patient Eliminates need to reassess each patient

over and overover and over Most tags have 4 priorities:Most tags have 4 priorities:

P-1 (immediate or red)P-1 (immediate or red) P-2 (delayed or yellow)P-2 (delayed or yellow) P-3 (hold, “walking wounded,” or green)P-3 (hold, “walking wounded,” or green) P-0 (deceased, no priority or black)P-0 (deceased, no priority or black)

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Trauma CentersTrauma Centers

Hospitals capable of caring for the Hospitals capable of caring for the acutely injured patientacutely injured patient

Must meet strict criteria to use this Must meet strict criteria to use this designationdesignation

Classified into 4 levelsClassified into 4 levels Some hospitals also specialize in Some hospitals also specialize in

specific care (burns, peds)specific care (burns, peds)

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Trauma Centers Trauma Centers (continued)(continued)

Each community has different needs Each community has different needs and resourcesand resources

Criteria for a regional structure is Criteria for a regional structure is often found in local protocolsoften found in local protocols

What is the trauma center in your What is the trauma center in your region? region?

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ConclusionConclusion

Important care and transport decisions Important care and transport decisions are based on the priority decision!are based on the priority decision!

Practice is needed to gain proficiency.Practice is needed to gain proficiency. Be familiar with the tools in your system Be familiar with the tools in your system

or region.or region. Patient conditions are dynamic and can Patient conditions are dynamic and can

quickly change the priority. quickly change the priority.

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.