Clinical Decision Making PDF

EHS 206 Toxicology Clinical Decision Making 1/13/2025 CLINICAL DECISION MAKING 1 Learning Objectives By the completion of this class, the student should be able to: demonstrate and describe appropriate patient history- taking related to toxicological, overdose and env...

EHS 206 Toxicology Clinical Decision Making 1/13/2025 CLINICAL DECISION MAKING 1 Learning Objectives By the completion of this class, the student should be able to: demonstrate and describe appropriate patient history- taking related to toxicological, overdose and environment emergencies; demonstrate and describe justified clinical decision making in relation to toxicological and environmental emergencies as they relate to paramedic practice; demonstrate a systematic clinical approach including the differential diagnosis of medical emergencies or other conditions related to the patient presentation. 1/13/2025 CLINICAL DECISION MAKING 2 Introduction This course continues to develop the role of the paramedic as a clinician by extending clinical examination and decision- making skills that were introduced in previous clinical courses. The course covers commonly encountered toxicological and environmental emergencies across the lifespan. The course will merge evidence-based theoretical concepts with clinical skills laboratories, case studies, and simulations to develop essential clinical skills, clinical problem solving and decision-making competencies. The scope of the course includes the development of skills needed to provide effective out-of-hospital care for patients experiencing health emergencies related to toxicological or environmental exposure. 1/13/2025 CLINICAL DECISION MAKING 3 Prior Experiences What were some of your experiences in taking histories and clinical assessments in these situations? How did the history get told? How difficult was it to get the important information and be able to distinguish it from the “noise” or “red herring” information? What if there were no visual clues – what did you go on? 1/13/2025 CLINICAL DECISION MAKING 4 Information Gathering What are some of the questions that you think are important to ask in a toxicological or overdose emergency? What are some of the questions that you think are important to ask in an environmental emergency? Why these questions? How would these change your assessment or management of the situation? 1/13/2025 CLINICAL DECISION MAKING 5 History What was taken? How much? – number and dose of each tabs - confirm by looking for empty packets and calculating the number as often the patients aren’t sure How long ago? Have they taken anything else? –if deliberate, it is seldom only one drug 1/13/2025 CLINICAL DECISION MAKING 6 History Have they eaten/vomited? How do you feel? Have they done this before? Check with poisons hot line what to expect in the way of effects – A MUST Poison and Drug Information Centre 800-424 1/13/2025 CLINICAL DECISION MAKING 7 Pharmacokinetics 1/13/2025 CLINICAL DECISION MAKING 8 Clinical Processes in Decision Making Concept formation – gathering information Interpretation of the information Application – patient care Evaluation Reflection 1/13/2025 CLINICAL DECISION MAKING 9 More Information Needed? Go through it again - history taking – other questions? Scene evaluation. What is normal for this patient? What changes could we expect? Are there any red flags? 1/13/2025 CLINICAL DECISION MAKING 10 Other Considerations Other medical conditions/family history? On other medications? How do these interact? (need to think about this) Are they compliant with their medications? 1/13/2025 CLINICAL DECISION MAKING 11 Other Considerations Do you ever use other drugs/IV drugs, share needles, and other paraphernalia – how often/periods of abstinence If you don’t get drugs, do you have any withdrawal symptoms? Is there anything else you would like to tell me about? eating and sleeping habits/toilet habits? any others you can think of? 1/13/2025 CLINICAL DECISION MAKING 12 Red Flags What are red flags? Indicators of potential or actual severe illness where urgent intervention may be required. Severity (or potential) of the illness often dictates how aggressively the patient is managed 1/13/2025 CLINICAL DECISION MAKING 13 Red Flags With another student, identify examples of red flags you might find in: patient history clinical assessment / investigations patient presentation to indicate a possible toxicological problem. 1/13/2025 CLINICAL DECISION MAKING 14 Case Study You are called to a 25-year-old male at 11 pm Saturday night, complaining of chest pain and generally feeling unwell He states he is generally fit and healthy, takes no medication, and has no PMHX. The pain started when he was exerting himself polishing his car and nothing has relieved it. He has rested and taken paracetamol, but he just feels a bit off. Vital signs HR 76 / ECG NSR BP 115/60 RR 16 / SPO2 97% GCS 15 Pain 3/10 1/13/2025 CLINICAL DECISION MAKING 15 Discussion What is the chief complaint? Clinical impression? Red flags? Any other information you may want and why? Differential diagnoses? How would you manage this patient? 1/13/2025 CLINICAL DECISION MAKING 16 Interpretation Diagnosis – 80% of the diagnosis is based on the history taken. How important are gut feelings? Differential diagnosis What is this? 1/13/2025 CLINICAL DECISION MAKING 17 Points to Remember The patient assessment should be accurate and complete Changes in presentation may change your clinical impression and how you manage the patient Determine what is abnormal and what is the cause and manage it Don’t rule anything out but rather look for evidence that makes the possibilities more or less likely 1/13/2025 CLINICAL DECISION MAKING 18 Challenges Mental paralysis in novice practitioners Know how to use all of the equipment you have access to Know how to conduct a patient assessment, including obtaining a history Think under pressure Safety – what do we need to think about? 1/13/2025 CLINICAL DECISION MAKING 19 Factors That Influence your Assessment Your attitude Patient’s willingness to cooperate/compliance Distracting injuries Labelling and tunnel vision The environment Your past experiences Crew level single crewed or double qualifications of the crew Stress 1/13/2025 CLINICAL DECISION MAKING 20 Case Study Called to a 65 year old female at 3 pm Complains of shortness of breath and feeling generally unwell Assessment: sinus tachycardia Shortness of breath – working reasonably hard to breathe but chest clear History reveals recent shortness of breath on exertion and increased orthopnea Patient History family history of cardiovascular disease being treated for hypertension and cholesterol 1/13/2025 CLINICAL DECISION MAKING 21 Discussion Red flags? Clinical impression? Diagnosis and why? Differential diagnosis and why? Management? 1/13/2025 CLINICAL DECISION MAKING 22 Justified Decision Making Pattern recognition (fast) vs Justified decision making (slow) Experienced clinicians tend to do both – seen on placement? You must be able to justify your treatment for your patient, what your clinical impression is and how you arrived at that decision. 1/13/2025 CLINICAL DECISION MAKING 23 Justified Decision Making You will also need to justify why you need backup and what you want them to do. You need to be comfortable with the fact that you may not always know the cause of the problem. You can still manage the patient, however. Base it on the information you do have and the symptoms they have. Treat the symptoms rather than the cause. 1/13/2025 CLINICAL DECISION MAKING 24 Case Study At approximately 2am, Mr A, aged 55 years, woke with pain in his chest and stomach area. The pain increased and by around 3am Mr A was becoming quite distressed. His wife, Mrs A, called emergency services at 3.23. Ambulance arrived at 3.29. Patient was sitting on a couch in a distressed state Hyperventilating Pain indicated in chest and lower torso HR 80 reg, RR 30, O2sats 98% 1/13/2025 CLINICAL DECISION MAKING 25 Discussion What further information do you want? Diagnosis? Differential diagnosis? Treatment/management? 1/13/2025 CLINICAL DECISION MAKING 26 Considerations for Management of a Toxicological Problem Can we decontaminate? Can we alter pharmacokinetics - increasing elimination rate, decreasing absorption? Do we have antidotes? What guideline do they fit into? How do we best manage (and/or treat) this patient? may not fit into any guideline! So what can we do? 1/13/2025 CLINICAL DECISION MAKING 27 Questions? 1/13/2025 28 References Murray L., Daly F., Little M. & Cadogan M. (2007) Toxicology Handbook, Elsevier. Curtis, K. & Ramsden, C. (2011). Emergency and trauma care for nurses and paramedics. Mosby. Rang, HP., Dale, MM., Ritter, JM., Flower, RJ & Henderson, G. (2012) Rang and Dale’s Pharmacology Seventh Edition. Elsevier. 1/13/2025 CLINICAL DECISION MAKING 29