Rapid Field Assessment Chuck Gipson Expected Outcomes
Understand triage process Calculate Glasgow Coma Scale Accurately assess a patient Understand and use Mechanism of Injury Organize a call from dispatch to delivery Absolute First Action
Determine Scene Safety! Additional resources
Communicate findings and needs Request additional resources early Preferably before being in the thick of an event
What event? Any Event! Time is of the essence
Decisions need to be made quickly Decisions need to be made accurately It starts with a call
Field assessment begins with a 911 call EMD (Emergency Medical Dispatch) is performed A “diagnosis” is made Instructions are given Crews arrive
Crews have a head start on assessment Assessment continues from 911 call Crews confirm accuracy of call info Triage
the process of prioritizing sick or injured people for treatment according to the seriousness of the condition or injury Translation
Sorting patients by level of severity Treating the sickest people first
More to follow Windshield Assessment
Scene size up
What do I see when I drive up.
Resources, vehicles, hazards, patient location, numbers, smoke, bystanders, etc… Mechanism Of Injury
What the heck just happened? Predictable pattern? Potential injuries based on MOI? Based on physics and previous experience Index of Suspicion for Injury
Starred windshield Bent steering wheel Intrusion into vehicle Roll over Ejection High speed crash Time Matters
Golden Hour Platinum Ten Minutes
Time is from incident not EMS call Trauma System Goal
To get the right patient to the right hospital at the right time Extenuating Circumstances
Extreme weather conditions Extrication Scene hazards Multiple patients Bystanders Distracting or complex injuries Rapid Trauma Assessment
Should take less than 90 seconds Quick head to toe Identify life threatening injuries Airway Mental status Perfusion
Thinking, Breathing, Pumping ABCDE
Airway Breathing Circulation Deformity / Disability Exposure Airway
Manual opening and maintenance of airway Includes C-spine stabilization
Jaw thrust vs head tilt chin lift
EMD Head and Neck Breathing
Yes / No? Rate Depth Quality
Pulse Ox Circulation
Yes / No? Rate Quality
Perfusion – Capillary refill, color, moisture, temperature
Includes Hemorrhage control Deformity / Disability
Obvious injuries Distractors Inability to perform tasks Level of consciousness Exposure
Make them naked
Appropriate time and place Keep them warm Make a complete assessment Mental Status
Glasgow Coma Scale AVPU
Alcohol will alter reality. Glasgow Coma Scale (Adult)
Eye Opening 4 Spontaneous 3 To Speech 2 To Painful Stimuli 1 No Response Verbal 5 Answers appropriately 4 Confused 3 Inappropriate words 2 Moans to Pain unintelligible sounds 1 No Response Motor 6 Spontaneous Movement 5 Withdraws to Touch 4 Withdraws to Pain 3 Abnormal Flexion 2 Abnormal Extension 1 No Movement / Flaccid Glasgow Coma Scale (Peds) Eye Opening 4 Spontaneous 3 To Speech 2 To Painful Stimuli 1 No Response Verbal 5 Coos, Cries, or Babbles Spontaneously 4 Irritable Cry but Consolable 3 Cries to pain or Weak Cry 2 Moans to Pain 1 No Response Motor 6 Spontaneous Movement 5 Withdraws to Touch 4 Withdraws to Pain 3 Abnormal Flexion 2 Abnormal Extension 1 No Movement / Flaccid AVPU
Alert Verbal Painful Unresponsive Focused Physical Exam
DCAPBTLS
Depressions, Contusions, Abrasions, Penetrations, Burns, Tenderness, Lacerations, Swelling
Don’t forget the back side Vital Signs
Get them if you can Tell them to the receiving facility
Why can’t I get a pressure? What if I can’t get a pressure? No Blood Pressure?
Warm, dry, and pink. Cap refill <2 seconds Strong regular radial pulse CAOX4
What does this say? Pupils
Eyes are the window to the body
PEARL / PERRL
What does it mean? Is this a normal finding for this patient? Detailed Physical Exam
Range of motion Pulse, Motor, & Sensory Skin color, temp, and condition Trauma Score
Glasgow Coma Scale Systolic Blood Pressure Respiratory Rate Coded Value (GCS) (SBP) (RR)
13-15 >89 10-29 4
9-12 76-89 >29 3
6-8 50-75 6-9 2
4-5 1-49 1-5 1
3 0 0 0 Ongoing Assessment
Repeat assessment
When? Why? SAMPLE History
Signs and Symptoms Allergies Medications Past Medical History (Pertinent) Last Oral Intake Events preceding (What Happened?) Compile Information
Create a plan Execute your plan Communicate your plan Get help with your plan Have a backup plan Have a backup plan for your backup plan Basic ALS care
Should be done en-route to hospital. Does not save lives
Definitive care saves lives
But my protocol says I HAVE to ALS my significant trauma patient Communication
Assessments are great
Don’t to forget to communicate them
Use the words Trauma Alert and say why
Twice! Creation of a Trauma Alert
Think like a PIMP
No really! Physiologic
Trouble thinking, breathing, or pumping
Decreased GCS <14 High or low respiratory rate <10 or >29 Poor pulse>120 Systolic BP <90 Injuries
Multiple long bones Abdominal Chest Head Pelvis Amputation proximal to wrist or ankle Mechanism of Injury
High speed crash Ejection Run over Intrusion >18 inches Unrestrained rollover Fall greater than 20 feet Pre-existing
Anticoagulation and bleeding disorders Age extremes Pregnancy >20 weeks See, think PIMP
P Box 1 Iowa Level 1 Illinois I Box 2 Iowa Level 1 Illinois M Box 3 Iowa Level 2 Illinois P Box 4 Iowa Level 2 Illinois
START and JumpSTART
Formal way of sorting out patients of all ages
Widely accepted and universal What is this START Triage Stuff? Simple Triage And Rapid Treatment Goals to START Triage
Do not spend too much time on any one patient. Move quickly from one patient to the next.
Assess each patient’s RPMs
Respirations
Perfusion
Mental Status Adult Pediatric How to Identify
Field Triage Tape or tags
Brief and simple Blue Triage Tape???
Very local Blue color is used Assigned to refusal patients Simple field Assessment
Mechanism? Access? Hazards? # of Patients? Level of injuries Summary
Assessment should be quick Assessment Should be accurate Trauma Field care should be limited Communication should be concise Make a plan and stick to it Have plenty of help Do the best you can References
START Jump START Triage Lou Roemig MD Lt. S. Albright – Paramedic SCEMS Triage Tag Training Scott County Protocols Principles in EMS Training, Thomson Learning Field Triage Decision Scheme, CDC PHTLS Instructor Guide Questions??? Thank You!