Initial Patient Assessment in Emergency Care

Initial Patient Assessment

• Perform scene size-up to identify the number of patients and request additional resources as needed
• Conduct a primary survey to form a general impression and note the patient's level of consciousness
• Rapidly examine for obvious injuries, such as:
  • Difficulty breathing
  • Noisy or irregular breathing
  • Asymmetrical chest rise
  • Accessory muscle use
  • External jugular vein distension
• Identify life threats and protect the spine as early as possible

Respiratory Assessment

• Examine the neck for penetrating wounds and tracheal position
• Determine if breathing is present and adequate
• Expect equal expansion of the chest wall and look for:
  • Retractions
  • Puncture wounds
  • Open chest injuries
• Absent or decreased breath sounds on one side indicate significant lung damage

Chest Injuries

• Rib fractures:
  • Most frequent in older patients
  • Increase mortality rate with age and number of fractures
  • May lacerate the lung, causing subcutaneous emphysema
• Flail chest:
  • Segment of the chest wall detached from the rest of the thoracic cage
  • Produces a free-floating segment
  • Often caused by MVCs, Falls, or industrial accidents
  • Mortality rate increases with age and number of associated injuries
• Sternal fractures:
  • Isolated fractures have a high mortality rate
  • Increase mortality rate with age and additional injuries
• Clavicular fractures:
  • Most common in children
  • Often caused by Falls or crushing injuries
  • Patients may report pain in the shoulder and hold the arm across the front of the body

Cardiac Arrest

• Commotio cordis:
  • A direct blow to the chest during the critical portion of the heart's repolarization phase
  • Leads to immediate cardiac arrest
  • Survival rate depends on public awareness, CPR, and AED access

Pneumothorax

• Occurs when air enters the plural space through a hole in the chest wall or surface of the lung
• Presentation:
  • Sudden sharp chest pain
  • Shortness of breath
  • Decreased breath sounds
  • Hyperresonance on percussion
• Tension pneumothorax:
  • Pressure builds up in the plural space
  • Collapse of the affected lung
  • Shift of the mediastinum
  • Decreased breath sounds, pulseless paradoxus, and Taria

Hemothorax

• Accumulation of blood in the plural space
• Causes:
  • Tears
  • Penetrating wounds
  • Blunt trauma
  • Deceleration shearing of major vessels
• Presentation:
  • Decreased breath sounds
  • Hypovolemia
  • Shock
  • Dullness on percussion
  • Flat or distended neck veins

Pulmonary Contusion

• Most common injury from blunt thoracic trauma
• Often associated with rib fractures
• Causes:
  • Implosion effect
  • Inertial effect
  • Spalling effect
• Presentation:
  • Respiratory distress
  • Hypoxia
  • Carbon dioxide retention
  • Wheezes, rhonchi, or crackles
  • Diminished breath sounds

Cardiac Tamponade

• Collection of blood or fluid in the paricardium
• Prevents the heart from filling completely during diastole
• Causes:
  • Penetrating injuries
  • Blunt trauma
• Presentation:
  • Narrowing pulse pressure
  • JVD
  • Muffled heart tones
  • Hypotension
  • Hypovolemia

Traumatic Aortic Disruption

• Rupture of the aorta
• Causes:
  • Blunt trauma
  • MVCs
  • Falls
• Presentation:
  • Retrosternal or interscapular pain
  • Dyspnea
  • Dysphagia
  • Hoeness
  • Strider
  • Upper extremity hypertension
  • Absent or decreased femoral pulses### Traumatic Asphyxia
• Caused by sudden severe compression injury to the chest, producing rapid increase in thoracic pressure
• Force squeezes the chest, causing blood to back up into the head and neck
• Leads to jugular veins engorgement and capillaries rupture

Characteristic Appearance

• Distended neck veins
• Cyanosis in the face and upper neck and extremities
• Swelling and cyanosis of the tongue and lips
• Ocular hemorrhage (mild or extreme)
• Skin below the area of compression remains normal in color

Key Features and Management

• Hypotension occurs when pressure is released
• Early recognition and rapid transport are crucial
• Treat symptoms with cervical spinal precautions
• Obtain IV access with two large bore IVs

Initial Patient Assessment

• Initial assessment should include a scene size-up to identify the number of patients and request additional resources if needed
• Conduct a primary survey to form a general impression and note the patient's level of consciousness
• Identify life threats and protect the spine as early as possible

Respiratory Assessment

• Examine the neck for penetrating wounds and tracheal position
• Determine if breathing is present and adequate
• Check for equal expansion of the chest wall and look for signs of respiratory distress, such as retractions, puncture wounds, or open chest injuries
• Absent or decreased breath sounds on one side may indicate significant lung damage

Chest Injuries

• Rib fractures are more common in older patients and increase mortality rate with age and number of fractures
• Flail chest occurs when a segment of the chest wall is detached from the rest of the thoracic cage, often caused by MVCs, Falls, or industrial accidents
• Sternal fractures have a high mortality rate, especially with age and additional injuries
• Clavicular fractures are most common in children, often caused by Falls or crushing injuries

Cardiac Arrest

• Commotio cordis is a direct blow to the chest during the critical portion of the heart's repolarization phase, leading to immediate cardiac arrest
• Survival rate depends on public awareness, CPR, and AED access

Pneumothorax

• Occurs when air enters the plural space through a hole in the chest wall or surface of the lung
• Symptoms include sudden sharp chest pain, shortness of breath, decreased breath sounds, and hyperresonance on percussion
• Tension pneumothorax can lead to collapse of the affected lung, shift of the mediastinum, and decreased breath sounds, pulseless paradoxus, and Taria

Hemothorax

• Accumulation of blood in the plural space, often caused by tears, penetrating wounds, blunt trauma, or deceleration shearing of major vessels
• Symptoms include decreased breath sounds, hypovolemia, shock, dullness on percussion, and flat or distended neck veins

Pulmonary Contusion

• Most common injury from blunt thoracic trauma, often associated with rib fractures
• Caused by implosion, inertial, or spalling effects
• Symptoms include respiratory distress, hypoxia, carbon dioxide retention, wheezes, rhonchi, or crackles, and diminished breath sounds

Cardiac Tamponade

• Collection of blood or fluid in the pericardium, preventing the heart from filling completely during diastole
• Caused by penetrating injuries or blunt trauma
• Symptoms include narrowing pulse pressure, JVD, muffled heart tones, hypotension, and hypovolemia

Traumatic Aortic Disruption

• Rupture of the aorta, often caused by blunt trauma, MVCs, or Falls
• Symptoms include retrosternal or interscapular pain, dyspnea, dysphagia, hoarseness, strider, upper extremity hypertension, and absent or decreased femoral pulses

Traumatic Asphyxia

• Caused by sudden severe compression injury to the chest, producing rapid increase in thoracic pressure
• Symptoms include distended neck veins, cyanosis in the face and upper neck and extremities, swelling and cyanosis of the tongue and lips, ocular hemorrhage, and skin below the area of compression remains normal in color
• Hypotension occurs when pressure is released, and early recognition and rapid transport are crucial

Learn about the initial steps to assess a patient in emergency situations, including scene size-up, primary survey, and identifying life threats.