EMERGENT ASSESSMENT

LESSON #16

Part One: Heather Hull, ARNP

Part Two: Karen Hayes, PhD, ARNP

PART ONE: HEATHER HULL, ARNP

Emergent Care FocuS

• Most common emergent problems
• How to assess patients
• Primary survey
• Secondary survey
• Significant aspects of history & physical
• Lab, X-ray & other diagnostics
• Emphasis is on diagnosis, not therapy
• In assessment of acutely ill patients, time is a critical factor
• Identifying the pathopysiologic abnormality is key
• Most serious threat to life? Ruled out?
• Provide protection & safety for examiner/provider

Triage Systems
• Emergent
• Urgent
• Non-urgent

Emergent
• Condition requires immediate medical attention
• Time delay is harmful to patient
• Disorder is acute & potentially threatening to live & function

Urgent
• Condition requires medical attention within the period of a few hours
• There is possible danger to the patient if medical attention is not given
• Disorder is acute but not necessarily severe

Non-urgent
• Condition does not require the resources of an emergency service
• Referral for routine medical care may or may not be needed
• Disorder is nonacute or is minor in severity

Nature of Problem
• Trauma
• Surgical
• Medical
• Age related factors

Trauma
• Leading cause of death in 1 - 45 year-old
• Fourth leading cause of death for all ages
• 70 million people have non-fatal injuries each year
• Approximately 140 thousand trauma deaths per year

Three peak times of death

• First hour: Immediate or at scene: Examples: massive brain injuries, high spinal cord injuries, massive
MI, ruptured aortic aneurysm
• Two hours post event: Stabilized (by EMS) & @ ER: Examples: subdural & epidural hematomas,
pneumothorax, ruptured spleen, lacerated liver, fractured femur. Goal, ordinarily to further stabilize &
transport to ICU
• Delay of days to weeks: May be due to etiology or treatment outcome. Examples: sepsis or multiple
system failure.
• Treatment causes may be due to:
– too much fluid replacement: later pulmonary edema
– too little fluid replacement: later renal failure

Epidemiology & Mechanism of Injury

• Important in predicting type of injuries
• History of event from patient or EMS significant

Categories to Consider
• Mechanical/gravitational forces: MVA, falls, firearms, machinery
• Thermal: heat, fire
• Radiant: Sun, Nuclear
• Chemical: Poisonings: plant & animal toxins, drugs
• Electrical: wires, sockets, lightening
• Hypoxia: asphyxiation, drowning, gases. Carbon monoxide poisoning
Categories to Consider
• Kinetic forces: energy transferred to body (greater force = greater damage)
• Predicable Injuries: acceleration/deceleration, penetrating, caliber of gun, velocity

Common Injuries
• Car: 43%
• Pedestrian: 10%
• Cycle: 20%
• Falls: 13%

Most Common Causes of Fatal Injury

• MVA: 31.7%
• Suicide: 16.3%
• Homicide: 12.5%
• Unknown: 6.7%
• Other 32.7%

Protective Devices Help Prevent Fatal Injuries

• Motor Cycle:
• 60.4% Unprotected
• 19.7% Protected (helmets)
• 19.7% Unknown

Protective Devices help Prevent Fatal Injuries

• Auto:
• 64.4% Unprotected
• 27.2% Protected (seat belts, car seats, air bags)
• 8.5% Unknown

Mechanical Forces & Predictable Injuries

• EMS protocols require cervical immobilization & back boards for trauma victims
• The medical decision to release from cervical immobilization is the greater medical decision

MVA: Important History

• “Windshield Star:” Cephalohematomas, skull fractures, cervical spine injuries
• Steering wheel impact: chest injuries, sternal & rib fractures, pericardial tamponade
• Front seat: patella & femur fractures & posterior dislocation of femur @ acetabulum
• Back seat: hyperextension of neck & cervical spine
• Children, facing forward: head & chest injuries, leg fractures
• Delayed air bag deployment: inhalation of dust, contusions of chest

MVA - Pedestrian History

• Adult: Leg injuries expected on same side as impact
• Fractures: tibia, fibula, femur on side of impact
• If thrown on hood: head, neck, jaw, chest injuries
• If thrown off & upper body hits pavement: dislocation of shoulder
• If dragged by vehicle: pelvic fractures

MVA - Pedestrian History

• Child: Waddell’s Triade (usuallly face car)
• Fractured femur: either side of impact or bilateral
• Trunk Injuries
• Contralateral head injury

Falls, Landing on Feet

• Compression of lumbar vertebrae
• Fractures of ankle, calcaneous
 Initial Assessment: Assumption
• Cardiopulmonary arrest
• Unstable patient
• Primary Survey
• Key Vital Functions
• Secondary Survey
• Relate calmness

Primary Survey
• Airway
• Breathing
• Circulation
• Brief Neurological

Primary Survey
• A rapid survey to recognize an acutely ill patient
• Note any unusual appearance or behavior
• Breathing difficulties, clutching chest or throat, slurring of speech confusion, unusual odor to breath,
sweating or diaphoresis, or uncharacteristic skin color (pale, flushed, cyanotic)

Airway
• Ineffective breathing: decreased LOC, cyanosis, chest wall asymmetry, accessory muscles, sucking chest
wounds, tracheal shift, distended neck veins
• Patient (back board & cervical collar): do not hyperextend neck
• Check for loose teeth, foreign objects
• Consider oral or nasal airway, intubation or cricothyroidotomy

Breathing
• Most ER s provide 02: @6L/NC or non-rebreathing mask @ 100%
• Check Arterial Blood Bases
• Keep head & neck immobilized, if trauma

Circulation
• If skin is warm, dry & normal color: indicates adequate O2 & flow to periphery
• In shock, peripheral blood is shunted centrally: skin changes are early indicators of hypovolemia or
cardiogenic shock (low cardiac output), delayed capillary refill
• Key skin changes: gray, mottled, or cyanotic, cold temperature, diaphoresis
• Arterial bleeding

Arterial Bleeding & Shock

• Apply direct artery pressure (pulse points)
• Elevate, if not fracture
• IV: large bore needle & blood tubing
• IV fluids (warmed LR often the choice)
• Lab: CBC, Chem, enzyme profiles, ABG, X-ray (especially C-spine)

Shock: Vital Signs

• BP by palpation for systolic measure:
• Radial: 80
• Femoral: 70
• Carotid: 60

CNS Function
• Initially assess patient’s ability to respond appropriately to questions
• Overdose: Drug screen, Narcan
• Diabetic coma: dextrose, accucheck

CNS Function

• Eye opening
• verbal response
• motor response
• Pupil Responses

CNS: AVPU
• A - Alert
• V - Responds to verbal stimuli
• P - Responds to painful stimuli
• U - Unresponsive

Open Chest Injuries

• Tension Pneumothorax
• Open Pneumothorax
• Flail Chest
• Massive Hemothorax

Tension Pneumothorax
• Air enters but cannot escape
• Tracheal shift toward uninjured side
• Distended neck veins
• Absent breath sounds & expansion on affected side
• Severe respiratory distress, cyanosis
• Treatment: needle thoracostomy, 2nd ICS, MCL (followed by chest tube & water-sealed drainage)

Open Pneumothorax
• “Sucking” chest injury
• Air moves in & out
• Respiratory distress
• Treatment: Cover wound on 3 sides with non-porous dressing
• Chest tube & water-sealed drainage: 5th ICS, MAL (3-4 ICS, MCL)

Flail Chest
• Paradoxical chest wall movement
• Rib fractures & loss of chest wall integrity
• Treatment: high flow O2, intubate, ventilator, IV fluids

Spontaneous Pneumothorax
• Bleb ruptures
• Hypoxic & dyspnea
• May seal itself
• May be insidious for degree of pneumothorax
• Treatment: Chest tube & water-seal drainage, O2

Massive Hemothorax
• Blood inside chest cavity
• Dyspnea, without the other above 3 characteristics
• Treatment: Chest tube &water-sealed drainage

• Secondary
• Head - Toe Survey
• Analyze injuries

AMPLE
• A - allergies
• M - medications
• P - past medical history
• L - last meal

Head, Neck, Skull, Face

• Soft Tissue
• Bone deformities
• Step Depressions
• Foreign Material

Contusions & Cephalohematomas

• Epidural: arterial: rapid (fractures of temporal or parietal skull)
• Subdural: venous: slower

Eyes
• Raccoon eyes: anterior fossa basilar skull fracture
• Le Fort Fractures:
• I top of maxilla
• II through zygomatic arch
• III inferior orbin of eye

Eyes
• Optic disc
• EOMs
• Hyphema
• Lacerations
• Foreign bodies

Ears
• Battle’s Sign: middle fossa or posterior basilar skull fracture
• Ecchymosis behind ears
• Check TM for blood
• Check for CSP
 Nose
• Check for CSF

Jaw
• Bite down
• Clench

Neck
• Crepitus
• Distended vessels

Thorax
• Soft tissue
• Breathing
• Bony deformities
• Abdomen/flank pain
• Distention

Abdomen & Flank

• Distention
• Pain
• Kehr’s sign
• Ecchymosis
• Cullen sign
• Grey Turner sign
• Pregnancy

Pelvis & Genitalia

• Soft tissue
• Bone deformities
• Bleeding (genitalia & rectum)

Altered Neurological Functioning: Extremities

• Sensory Function
• Motor function
• Soft tissue injuries
• Fractures
• Strains & Sprains

Posterior Assessment

Pediatric Considerations
• Temperature elevations & heat loss
• Respiratory distress
• Dehydration
• Neurological changes

Geriatric Considerations
• Skin: malignant changes, heat loss, decubitus
• HEENT: skull trauma, temporal arteritis, polymyalgia rheumatica, carotid bruits, thyroid
• Eyes: visual acuity, macular degeneration, glaucoma, cataracts
• Ears: hearing, dizziness, cerumen
• Chest & Respiratory: vital capacity, infection risk, kyphosis
• Cardiovascular: Aortic dilatation, sclerotic valves, heart block or arrhythmias, HTN, MI
• Abdomen & GI: absorption & hepatic flow changes, diverticulosis, increased half-life of medications
• GU: Renal flow & glomerular filtration changes
• Endocrine: diabetes, thyroid, fluid balance
• Musculoskeletal: muscle atrophy, osteoarthritis, falls
• Neurologic: atherosclerosis & mulitiple infarcts, TIAs, dementia, delirium, depression, reduced reflexes
• Altered presentation of disease
• Nonspecific presentation of disease
• Underreporting
• Multiple conditions
• Polypharmacy
• Chief complaint (variations)

PART TWO: KAREN HAYES, PhD, ARNP

Medical Emergencies
• Goal of emergent assessment is to rule out serious illness- not to make diagnosis
• Unusual behavior or appearance may be only clue
• Use your nursing judgment
• Look first at two systems
– Neurological- responsive, grossly intact
– Skin- warm, dry, normal color

4 Common Emergent Problems

• Headache
• Respiratory Distress
• Chest Pain
• Abdominal Pain

Headache

• History
– Meds- CV, Psych, Anticonvulsants, BCP’s
– Pre-existing disease- DM, hypertension, CVA, CV, Seizures, HIV
– Recent problems- HI, Toxic exposure, Sinusitis, Dental problems
– Associated symptoms- N+V, fever, visual disturb, photophobia (old or new)
• Physical
– General appearance and awareness
– Look for cranial nerve signs
– Extremity weakness
– Drainage from nose, ears, mouth
– Blood behind TM
– BP and Pulse, skin temp
– meningeal irritation
• Refer
– Sudden onset
 – Worst of life
– Increased BP
– Meningitis symptoms
– Associated with hypoxia, CO poisoning
– Signs of CVA
– Glaucoma

Respiratory Distress

History
• Recent Illness or Surgery
• MI
• Malignancy
• Infection
• Risk Factors
• Smoking
• Obesity
• Hx asthma
• Family history
• Cooling or heating source
• Pregnancy
• BCP
• DM
• Poor circulation
• Current meds
– Steroids
– Antibiotics
– Beta Blockers
– Inhalers
– Cardiac
– BCP’s
– NSAID’s
• Allergies
– Dust
– Pollen
– Mold
– Food
– Meds

Respiratory Distress: Physical Exam

• Look
– Skin for rash, cyanosis, diaphoresis, pale, flushed
– Anxious
– Sniffing position
– Chest movements
– Rate and depth
• Ascultate

• Refer
– Obvious emergency
– Possible FB
– Severe asthma
– Pulmonary edema
– Allergic reaction
– Possible pneumo
– Croup
– PE
– OD
– COPD exacerbation
– DKA

Chest Pain
• History
– Hx of illness (respiratory) or surgery
– Use of crack or other street drugs
– Meds
Nitrates
BP meds
Diabetic agents
Steroids: inhalers
Antiarrhthmics

Chest Pain: History of the Symptom

• P rovokes
• Q uality
• R egion
• S everity
• T iming

Referral
• Emergent
– MI, dysrhythmia, PE
• Urgent
– Angina
– CHF
– Pancreatitis

• Non-urgent
– Pneumonia, Costochrondiritis
– hiatal hernia, ulcer, GERD, esophageal spasm

Abdominal Pain: History

• Previous surgery or illness
– Intestinal obstruction
– Ulcers
– Gallstones
 – Diverticular disease
• Meds
– Steroids
– Antibiotics
• Allergies
• LMP
• Stool
– last BM
– diarrhea or constipation
– melana

Abdominal Pain: Physical Exam

• Physical appearance
• Fever
• Low or high BP; rapid pulse
• Shallow rapid respirations
• Abdominal assessment- divide into 4 quads
• Lung sounds

• Consider
– FB
– Heavy Metal Poison
– Lactose Intolerant
– PE
– Sickle Cell
– Drug OD
– Pneumonia
– Early Herpes

• Refer
• Emergent
– Dissecting aneurysm
– Mesenteric artery occlusion
– Ruptured spleen
– Ruptured ectopic
– Perforated bowel
– Torsion

• Urgent
– Appendicitis
– Bowel obstruction
– Incarcerated hernia

Summary
• Emphasis is first on discovery of emergent condition, then diagnosis, stabilization, and treatment if possible
• Rule out serious, life-threatening situations
• Refer if appropriate