PATI 5400

• What you were taught
• Done and seen before
• Believe to be right and true
• People you work with
• Employer Expectations
• Medical director expects
• Medical directives
• Impression patient makes
• Physical evidence
• Receiving hospital expectations

• Evidence based decision making
• Application into practice
• Self awareness
• Reflective practice

Concept formation, data interpretation, application of principle, evaluation, reflection on action

• Role playing
• Review
• Reflection
• Research
• Consultation

• Requires evidence
• Know when you have enough for a decision
• Need to re-direct evidence collection and assessment based on findings
• History taking should provide structure to physical assessment and vice versa

• Life threats
• ABC's
• Priority management
• Transport priority
• How much help do you need? Allied agencies
• When are you over your head?

• How sick is the patient?
• How emergent is the patient?
• Intervene now or after?
• Which interventions are needed?

• Chief complaint: level of distress, general impression
• Incident history: onset, provocation/palliation, quality, region/radiation/referral, severity, time factor
• Past medical history: including dates
• Medication: drug, dose, regimen, compliance, prescription and non-prescription
• Allergies
• Last oral intake

• Neurologic
• Respiratory
• Cardiovascular
• Musculoskeletal
• Gastrointestinal
• Genitourinary
• Endocrine
• Integuementary
• Immune

• Head and neck
• Chest
• Abdomen
• Pelvis
• Extremities
• Back

• Primary Assessment
• General Impression
• Airway Sounds
• Chief complaint
• Primary Decisions
• Assessment
• Risk Factors
• Medical History
• Medications
• History
• Common Symptoms

• How long
• Onset, what came first?
• SOBOE (on exertion?) At rest? Positional?
• Cough? Productive?
• Sleeping position?
• Other S+S
• Meds use? Puffers? When? Did they work?

• Cough
• Expectoration
• Hemoptysis
• Dyspnea
• Chest pain
• Wheezing

• Cough
• -present
• -strength
• -chronic vs acute
• -productive vs non productive

• Expectoration (cough out from respiratory tract)
• -Content
• -Quantity
• -Appearance
• -Consistancy
• -Odour

• Initial Impression
• -posture and body position (posture, tripod, sitting, laboured breathing)
• -face (speaking)
• -surroundings (able to care for themselves)
• -skin colour

• Focused examination
• -head and neck
• -chest
• -abdomen
• -extremities

• Flaring
• colour
• speaking ability
• distractibility
• tracheal position
• JVD
• tracheostomy

• Wheezes (high and low pitch)
• Crackles (coarse or fine; wet or dry)

• High - passage of air through narrowed bronchi; swelling bronchospasm, foreign body or growth, continuous musical whistling noise.
• Low - air through secretions, continuous, low pitch
• Mechanism - rapid airflow through obstructed A/W by bronchospasm, mucousal edema
• Causes: asthma, CHF

• Fine: clicking or popping, brief and explosive, usually on inspiration, produced when small airways pop open. Pneumonia, CHF, pulmonary fibrosis
• Course: lower pitch coarse popping and bubbling sounds, inspiration and expiration. Larger airways cleared with coughing, pulmonary edema, retained, secretions
• Mechanisms: excess A/W secretions moving with airflow
• Causes: CHF, pulmonary edema, opening of collapsed airways, respiratory infections

• Low-pitched most often during expiration
• Mechanisms: rapid airflow through obstructed A/W by excess sputum, bronchospasm
• Causes: bronchitis, asthma

• Moves jerkily/delayed by increased friction when inflamed
• Vibrations produce a creaking sound
• May sound like crackles

• Poor oxygenation
• Peripheral cyanosis (poor peripheral circulation)
• Central cyanosis (poor systemic oxygenation)

• Oxyhemoglobin to extremities
• Limitations: poor perfusion, CO poisoning

• Sampling and reference cell
• CO₂ is 35-45 mmHg

• Primary (Environment, ABC's, Auscultation)
• Primary Decisions (CC, Priority Management, Load & Go, oxygen therapy, back up allied)
• History (focus on immediately need to know for treatment verses what can wait (clinical picure)
• Assess Head and neck -LOA, JVD, cyanosis, expression, breath sounds, chest - inspection - symmetry, indrawing, scars, CLAPS; palpation integrity, TICS; abdo - pulsating masses and general appearance, pain, tenderness, distension, ascites; extremities - dependant edema, pulses and pulse variation, colour, temperature, capillary refill.
• Medical History: PMHx, medications, allergies

• Cardiovascular (ACS, pericarditis, thoracic dissection)
• Respiratory (pulmonary embolism, pneumothorax, pneumonia, pleural irritation)
• Gastrointestinal (cholecystitis, pancreatitis, etc)
• Musculoskeletal (costochondritis, trauma, tumors)

• Sudden ischemia, undifferentiated in first few hours
• Angina, unstable angina, and myocardial infarction
• Central anterior chest pain, dull, fullness, pressure, tightness, crushing pain, radiates, onset at rest.
• Usual history only applies to males 55-75 y/o.
• Atypical is fair game.

• Decision Making
• symptomatic vs asymptomatic
• stable vs unstable
• treat rate problems first
• live better electrically

• usually time limited, rarely pathologic
• stable management: atropine, dopamine
• unstable management: pacing

• almost always pathologic
• straight to pacing
• atropine etc. can make it worse

• SVT, PSVT
• Rarely pathologic, palpitations,
• Stable management: adenosine, ACLS: verapamil, diltiazem
• Unstable management: cardioversion

• Controlled vs uncontrolled
• rate vs embolus
• 24 hour rule
• Stable management: ACLS - amiodarone, procainamide
• Unstable management: cardioversion, extreme caution due to risk, generally more difficult to cardiovert

• always pathologic
• amio, lido, cardiovert

• CPR First
• Rule out reversible causes (statistically patient has a better chance of survival if cardiac arrest is the result of a reversible cause that is identified and reversed

• 5H's and 5T's
• Hypovolemia
• Hypoxia
• Hypothermia
• Hypo/hyperkalemia
• Hydrogen ions (acidosis)
• Tamponade
• Tension pneumothorax
• Thrombosis (pulmonary embolus)
• Thrombosis (ACS)
• Tablets/Toxins, OD

• <4 minutes (electrical phase) - responds to electrical stimulation
• 4-10 minutes (circulatory phase) - increased acidosis, CPR first
• >10 minutes (metabolic phase) - too far gone for conventional therapies

• V-fib: chaotic, bizarre, disorganized electrical activity. No recognizable QRS. Coarse or fine.
• V-Tach: wide, fast rhythm (>180) with out pulse
• Management: R/O reversible causes, defibrillation, no supportive research for drugs, vasopressor (epi), antiarrhythmica (amio, lido)

• Asystole: no electrical activity
• Management: R/O reversible causes, assumption that rhythm is autonomic imbalance, supportive pacing if caught early.
• PEA: electrical mechanical dissociation; should generate a pulse but doesn't.
• Management: R/O reversible causes, directives give you something to do while you think (Fluid - hypovolemia; Epi - MI; Ventilation/Intubation - Hypoxia)

• Primary Assessment/Management
• -attending to immediate life threats
• -airway, breathing, circulation
• -transport priority
• -how much help do you need?
• -when are you over your head?
• -priority managements

• Evidence
• -History (incident, past medical history)
• -Physical assessment and complete vital signs (enough info to make the decision)

• Decisions
• -pt needs what?
• -can I provide care? (Yes - scope of practice, directives, BHP; No - transport)
• -when will I be over my head (ideal time to transfer care)

• Ongoing decisions
• -assessment and history gatherin to complete the clinical picture
• -new decision based on additional information and evidence; patient response to treatment
• -change in clinical presentation implies reassessment and a new management plan

• Decision Making - not a question of ruling in or out, but a question of risk.
• General Management Decisions (treat rate first, assess and treat simultaneously)
• Nitroglycerine - venous and coronary artery dilator
• ASA - platelet aggregating inhibitor
• Analgesia - morphine still the standard, vasoactive effects
• Diagnosis - 12 lead
• Transport

• Airway management
• Epinephrine (alpha and beta effects; provides some stabilization of MAST cells membrane, still only supportive care)
• Benadryl (diphenhydramine - anti-histamine inhibits smooth muscle constriction and reduces capillary permeability)
• Transport

• Hyperglycemic Emergencies (HHNKs, DKA)
• Hypoglycemic Emergencies (rarely occurs outside of diabetes)
• Management: Addressing the symptoms
• -Oxygen vs ventilation
• -Fluid resuscitation
• -Monitor for Acidosis
• -Dextrose vs Glucagon
• -Require follow up

• oxygen
• preload reduction (morphine, nitro, lasix)
• treat complications
• afterload reductions (ACE inhibitors)
• worse case - intubate (preferred CPAP)

• General: forward failure, inability of the heart to meet the bodys metabolic needs, often remains after correction of other problems, severe form of pump failure, high mortality rate.
• Causes: MI (impaired contractility), impaired ventricular emptuomg. dusrjutj,oas. tension pneumothorax and cardiac tamponade, trauma
• Management: transport, treat the cause, and vasopressors (dopamine)

• Primary Survey
• Physical Exam: (pt hx, incident hx, VS, physical assessment)
• Physical Findings: (distal strength, sensation, mobility, gait, balance, posture)
• History: (Event, LOC, consider LOC as result of intracranial bleed)
• Vital Signs: ICP (Cushings Triad)
• Neurological Evaluation: (AVPU, GCS, Orientation, Memory, Response to stimuli)

• A pathologic impairment of memory
• May be transient
• Anterograde amnesia (for events after incident)
• Retrograde amnesia (events before the incident)

• abnormal flexor responses of one or both arms with extension of the legs
• result from structural impairment of certain cortical regions of the brain

• abnormal extensor response of arms with extension of the legs
• worse prognosis than decorticate rigidity
• result from impairment of certain subcortical regions of the brain

Disconjugate Gaze: failure of the eyes to turn together in the same direction

• Abnormally deep state of unconsciousness from which the patient cannot be aroused by external stimuli
• Two catagories - structural, metabolic
• Causes: Acidosis or alcohol, Epilepsy, Infection, Overdose, Uremia, Trauma, Insulin, Psychosis, Stroke

• General Management (airway, ventilations, oxygen, recognition, rapid transport, blood glucose testing and dextrose administration)
• Comfort and support
• Positioning: semmi-sitting, lateral if LOA decreases, affected size down if hemiplegia.
• Treatments: A/W protection (increase ICP potential resistant to A/W maneuvers, difficulty clearing secretions/suctioning), Ventilations (effect on free oxygen radicals, controversies for hyperventilation)
• Follow up: District stroke centres, CT Scan, Thrombolytic therapy, LTC - occupational and physical therapy, anti-platelet drugs, surgical interentions if appropriate, long term physio.

• Thought to reduce ICP by blowing off CO2 and reducing cerebral vasodilation
• peak 30 minutes, diminishes of 1-3 hours
• abrupt cessation of hypoventilation can cause rebound increased ICP
• Moderate hyperventilation may have some effect but if underlying cause is not resolved then the ICP will continue
• Anything more will likely cause cerebral vasospasm
• Prolonged severe hyperventilation can worsen cerebral edema

• Types: Grand mal, status epilepticus, casual factors, consequences
• Assessment: head and neck (tongue bites, lips, stiff neck), Chest (decreased breath sounds, aspiration), GU (incontinence), Extremities (injuries from seizures)
• Management: Protect pt, stop seizures. Oxygen as tolerated, manage byproduct injuries, manage underlying problem, pt privacy, blood sugar assessment, transport.
• Long Term Management: Therapy to address underlying problem, no one drug controls seizures, phenytoin especially in children, most common cause of status seizure is non-compliance.

• Extrication and transport is priority
• Cannot get ahead of the underlying cause
• Support management
• Multi-system
• High risk groups (elderly, very young)
• Alcohol is most complicating factor (impaired thermogenesis, vasodilation, judgement, glucose stores)

• Extrication
• Immobilization (risk of crystal formation and increased tissue trauma)
• Prevention of further heat loss (strip off wet clothes, passive rewarming)
• Gentle handling (risk of VF dramatically increases at CBT of 28 degrees C)
• Weight the cost/benefits of anything else (A/W management, dysrhythmia management, fluid replacement)

• Extrication - consider diving injury possibility
• A/W management - increased risk of aspiration and laryngo/bronchospasm, advanced management may become more of a priority
• Hypothermia - lose more heat to water, complicating facor

• Extrication and transport remains priority
• decreased LOA
• A/W Management
• Dehydration - responds well to crystalloid fluid administration
• Heat Stroke - seizures to be expected, may/not respond to benzodiazepines, fluid replacement tends to be beneficial

• Environment
• Initial assessment - pediatric assessment triangle (first impression), primary survey)
• Secondary assessment - vital signs, focused history, physical examination
• Ongoing assessment

• oxygenation
• ventilation
• brain perfusion
• central nervous system function