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SOAP Note and Wilderness First Aid Guide

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SOAP Note and Wilderness First Aid Guide Pulse/Pressure Points Wilderness First Aid Reference Cards Carotid Brachial Adapted from: Andrea Andraschko, W-EMT Radial October 2006 Femoral Posterior Dorsalis Tibial Pedis Abdominal Quadrants Airway Anatomy (Looking at Patient) RIGHT UPPER: LEFT UPPER: ANTERIOR: ANTERIOR: GALL BLADDER STOMACH LIVER SPLEEN POSTERIOR: POSTERIOR: R. KIDNEY PANCREAS L. KIDNEY RIGHT LOWER: ANTERIOR: APPENDIX CENTRAL AORTA BLADDER Tenderness in a quadrant suggests potential injury to the organ indicated in the chart. Patient Assessment System SOAP Note Information (Focused Exam) Scene Size-up BLS Pt. Information Physical (head to toe) exam: DCAP-BTLS, MOI Respiratory MOI OPQRST • Major trauma • Air in and out Environmental conditions • Environmental • Adequate Position pt. found Normal Vitals • Medical Nervous Initial Px: ABCs, AVPU Pulse: 60-90 Safety/Danger • AVPU Initial Tx Respiration: 12-20, easy Skin: Pink, warm, dry • Move/rescue patient • Protect spine/C-collar SAMPLE LOC: alert and oriented • Body substance isolation Circulatory Symptoms • Remove from heat/cold exposure • Pulse Allergies Possible Px: Trauma, Environmental, Medical • Consider safety of rescuers • Check for and Stop Severe Bleeding Medications Current Px Resources Anticipated Px → Past/pertinent Hx • # Patients STOP THINK: Field Tx ast oral intake • # Trained rescuers A – Continue with detailed exam L S/Sx to monitor vent leading to incident • Available equipment (incl. Pt’s) VPU – EVAC NOW E Evac level Patient Level of Consciousness (LOC) Shock Assessment Reliable Pt: AVPU Hypovolemic – Low fluid (Tank) Calm A+ Awake and Cooperative Cardiogenic – heart problem (Pump) Comment: Cooperative A- Awake and lethargic or combative Vascular – vessel problem (Hose) If a pulse drops but does not return Sober V+ Responds with sound to verbal to ‘normal’ (60-90 bpm) within 5-25 Alert stimuli Volume Shock (VS) early/compensated minutes, an elevated pulse is likely caused by VS and not ASR. V- Obeys simple commands with verbal • ↑pulse Causes of Abnormal Consciousness: stimuli • Pale skin Tx: Stop visable bleeding, elevate legs, Sugar P+ Pulls away from source of pain • ↑respiration rate keep warm, manage psychological Temperature P- Moves toward source of pain • Normal AVPU factors, ventilate if respirations are Oxygen U Totally unresponsive Volume Shock late/decompensated inadequate, give O2 and IV fluids if Pressure • ↑↑↑pulse available and appropriately trained. Electricity • Pale skin Altitude • ↑↑↑respiration rate Toxins • ↓AVPU Acute Stress Reaction Head Injuries Sympathetic (fight or flight) Parasympathetic (rest and digest) Concussion: ↑ICP: • ↑pulse • ↓pulse Patient must be awake, cooperative, S/Sx – early • Pale skin • Pale skin improving, and have amnesia. • Patient is A- or lower • ↑respiration rate • ↓respiration rate • C/O headache S/Sx • Normal AVPU • May feel light headed, dizzy, • Persistent vomiting • Patient is awake now • Pain masking nauseous, faint, anxious • Ataxia • Amnesia • Looks like early VS (neumonic = PASR = passout) S/Sx – late (neumonic = SASR = Spin up) • Can’t have S/Sx of ↑ICP • Patient is VPU • Nausea/vomiting (once) 2° to • Vomiting persists P-ASR Tx: For either condition, calm patient and remove stressors as much as possible • Seizure • Headache • Coma • Tired • Cardiac and respiratory arrest Spine Ruling Out Process (WFR or WEMT) Wound Cleaning Patient must: Motor Exam: Compare strength in both Partial thickness: Full thickness, high risk: • Be reliable hands and feet. Have pt. resist: • Soap and water wash Clean as previous, PLUS: • • Report no pain when focused on • finger squeeze; pushing down on • Scrub to remove particles Remove dead skin and tissue spine hand • 10% P.I. • Remove foreign material • • Report no tenderness when spine • push ‘gas pedal’; pull up on foot • Keep moist Finish flushing process with 1% P.I. solution (strong tea or amber beer) palpated • Dress lightly • Do not close in field • Have normal motor exam Sensory Exam: compare pt’s ability to Full thickness, low to moderate risk: • Pack with thin layers of gauze • Have normal sensory exam distinguish between pin prick and soft touch on back of hand and shin • Clean w/in 2 hours of bleeding end soaked in 1% P.I. Remove and • Report no shooting, tingling or • Use pin to prick • Clean around area with 10% P.I. repack bid electric “pain” radiating from • Dress with several layers of gauze. • Use cloth for soft touch • Pressure flush with drinkable water in extremities May place 10% P.I. between layers, short bursts along axis In cases where the spine can’t be ruled out but the injury can be localized to the • Bring edges toward(not touching) each but not directly on wound lumbar area, consult medical direction regarding need to continue c-spine other and hold in place with an occlusive • Consider splinting if wound is over a stabilization. dressing and/or steri-strips etc. joint. Common Causes of Pulse Changes Focused Survey Acronyms Strong, Slow: Strong, fast: From Patient: Observed by Rescuer: • Normal sleep • Early heat stroke • Simple fainting • Fever SAMPLE = Signs/Symptoms, CMS = Circulation, Motion, • Early ↑ICP • Hyperthyroid Allergies, Medications, Sensation Previous Injury, Last Meal/Drink, • Well-conditioned athlete • Early shock OPQRST = Onset, Provocation, Events • Hypothyroid • ASR Quality (dull, sharp), Radiation, • Strenuous physical activity Severity (1-10), Time Weak, slow: Pt = Patient • Hypothermia Weak, fast: Hx = History DCAP-BTLS = Deformities, • Late ↑ICP • Overwhelming infection Px = Problem Contusions, Abrasions, • Late heat stroke S/Sx = Signs/Symptoms Punctures/Penetrations, Irregular: • Late shock Tx = Treatment Burns/Bleeding, Tenderness, • Sinus arrhythmia • Diabetic coma Lacerations, Swelling • Heart disease • Some types of heart disease Hypothermia Heat Related Symptoms 98.6° to 90°: <90°: If heat is identified as a potential MOI Heat exhaustion: Pt will be A to A-, shivering, have Pt will be V, P or U; shivering will stop; and patient exhibits irrational behavior: A-(irritable), temp. 99°-104°, pale ↑urine output, ↓coordination and HR and respirations will decrease; Pt dexterity may appear dead 1) ALWAYS COOL PATIENT FIRST Heat stroke (early): 2) Assess hydration status A- (irritable, combative), temp. >105°, Tx: Tx: • If dehydration is established, pale if dehydrated, flushed if hydrated Active rewarming – give food (carbs Passive rewarming – add insulating hydrate with electrolyte solution first), liquids, remove from elements, layers (hypowrap), handle with care, • If hx includes copious H2O, give Heat stroke (late): exercise, shelter, layers, add external no rapid warming or movement, no CPR electrolytes only V,P or U, seizures, coma, death heat (heat packs or hot water bottles) (AED may be used). PPVs may be 3) Complete focused survey given. 4) Treat symptoms as indicated by Electrolyte Sickness: survey; continue to support cooling A-, V, P or U; Hx of H2O but no food; mechanisms can rapidly progress to ↑ICP Patient SOAP Note Rescuer: Past relevant medical Hx = relate to MOI Patient Information Name: Age: Weight: Male Female Address: Phone: Last food & fluids = intake & output Date: H2O Calorie Electrolyte Time: Urine color Urine output Stool Contact: Phone: Events = Patient’s description of what happened Amnesia Yes / No Scene Size-Up: Major Trauma Environmental Medical Describe MOI Describe Environmental Conditions Objective Information = What you see Physical Exam = look for discoloration, swelling, abnormal fluid loss & deformity. Feel for Position Patient Found Initial Px A V P U on arrival tenderness, crepitus & instability. Check ROM and CSM. R / L side Front / back No respirations No pulse Unstable spine Time Laying / Sitting / Standing Severe Bleeding Vomiting Blocked Airway Initial Tx Subjective Information = What the patient tells you Symptoms = Describe onset, cause & severity (1-10) of chief complaints Time Allergies = Local or systemic, cause, severity & Tx Vital Signs = get a baseline, then record changes Time Pulse Resp BP Skin Temp AVPU Medications = Rx, OTC, herbal, homeopathic & recreational Drug Reason Dose Current Yes / No Yes / No Notes Assessment = What you think is wrong Plan = what you are going to do Possible Px Time Current Px Anticipated Px Field Tx Monitor Trauma Ç ICP / Concussion Respiratory Distress Volume Shock Unstable Spine Trunk Injury Unstable Extremity Injury Stable Extremity Injury Wounds Environmental Dehydration / Low Na Hypothermia / Cold Heat Stroke / Exhaustion Frostbite / Burns Local / Systemic Toxin Local / Systemic Allergy Near Drowning Acute Mountain Sickness Lightning Injuries SCUBA / Free Diving Medical S/Sx Evacuation Circulatory Level 1 2 3 4 Respiratory GPS / Grid Coordinates Request ALS: Yes / No Nervous Endocrine Genitourinary Musculoskeletal Skin / Soft Tissue Ears/Eyes/Nose/Throat Teeth / Gums Additional Notes Radio Report Sequoia Dispatch, Channel Islands Radio #: I have a ________ year old male/female whose chief complaint is:______ ___________________________________________________________ ___________________________________________________________ as a result of:________________________________________________ ___________________________________________________________ Patient is currently A V P U and was found Laying/Sitting/Standing on R/L/Front/Back side. Patient exam revealed _____________________ ___________________________________________________________ ___________________________________________________________ Spinal assessment revealed____________________________________
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