Copyright © 2004, Mosby Inc. All rights reserved.

Case History You respond to a 28-year-old male who has been struck by a car. You take the appropriate BSI precautions and ensure that the scene is safe and begin to assess the patient. Slide 2 Copyright © 2004, Mosby Inc. All rights reserved.

General Impression of the Patient
The general impression is formed to determine priority of care and is based on the EMTs immediate assessment of the environment and the patient's chief complaint. Determine if the patient is ill or injured. Reconsider mechanism of injury. Patient data Age, sex, race Identify and treat life-threatening conditions. Slide 4 Copyright © 2004, Mosby Inc. All rights reserved.

Initial Assessment Components
Life-threatening conditions so treatment can be given immediately Lifesaving treatments Opening/maintaining the airway Positive-pressure ventilations Supplemental oxygen Automated external defibrillation Cardiopulmonary resuscitation Bleeding control Slide 5 Copyright © 2004, Mosby Inc. All rights reserved.

Assess the Airway Note abnormal sounds. Snoring Denotes obstruction by the tongue Oropharyngeal or nasopharyngeal airway to maintain patency Gurgling Suction may be needed to clear fluids. Slide 9 Copyright © 2004, Mosby Inc. All rights reserved.

Assess the Airway Stridor or inability to speak May denote airway obstruction Heimlich or other maneuvers may be needed. Patient may be having severe allergic reaction. Positive-pressure ventilation, epinephrine, and rapid transport may be needed. Slide 10 Copyright © 2004, Mosby Inc. All rights reserved.

Assess the Airway In unresponsive patients Maintain an open airway. Oropharyngeal or nasopharyngeal airway may be needed for continued airway control. Slide 11 Copyright © 2004, Mosby Inc. All rights reserved.

Assess the Infant’s or Child’s Airway
Place head in a sniffing or neutral position. Be careful not to hyperextend the neck. Slightly extend the head and neck of the child (1 to 8 years old) if no trauma is present. Slide 13 Copyright © 2004, Mosby Inc. All rights reserved.

Infants and Children Look carefully for signs of Nasal flaring Seesaw breathing (alternate use of chest and abdominal muscles during breathing) Retractions of the chest wall when assessing for inadequate breathing When needed, provide positive-pressure ventilation. Slide 14 Copyright © 2004, Mosby Inc. All rights reserved.

Assess Breathing Look, listen, and feel method Look for chest and abdominal movements, accessory muscle use, and retractions. Listen for air movement and abnormal sounds of breathing. Feel for warm air from the lips and mouth. Slide 15 Copyright © 2004, Mosby Inc. All rights reserved.

Adequate Breathing Rhythm Regular Irregular Quality Breath sounds — present and equal Chest expansion — adequate and equal Minimum effort of breathing Depth (tidal volume) – visible chest rise Quality of Breathing <t>The quality of breathing can be assessed by looking at chest and abdominal movements, observing use of accessory muscles of breathing, listening for breath sounds, and feeling air movement through the mouth and nose. You can also inspect the skin and evaluate the patient’s mental state. Identifying abnormal findings may give clues to the underlying problem. <4>Chest and Abdominal Movement <t>Visible chest and abdominal movements at a rate normal for the patient’s age characterize normal breathing. Equal chest expansion should be present on both sides of the chest. In contrast, a patient who has multiple rib fractures may have normal expansion on only one side of the chest. <4>Effort of Breathing <t>Use of accessory muscles is usually obvious with inspection, particularly in children because they have softer rib cages. Look for prominent neck muscles bulging and retractions, which are exaggerated indentations between the ribs or above and under the sternum. Retractions may indicate inspiration through narrowed or obstructed airways or an increased work of breathing because lungs are “stiff” from the accumulation of fluid. The abdominal muscles may be prominent during breathing, indicating forced exhalation. An infant may have movement of the abdominal and chest wall muscles in opposite directions, with chest retraction and abdominal distention, called seesaw breathing. Other infants and small children struggling to breathe may have noticeable nasal flaring, or widely dilated nostrils . <4>Breath Sounds <t>Sounds of breathing may be heard with or without a stethoscope. To assess breath sounds, listen with the stethoscope to both sides of the chest. Are breath sounds present and equal, diminished, absent, or not equal on both sides? Diminished or absent breath sounds in both lungs may indicate respiratory failure and very low tidal volumes. When absent or diminished breath sounds are noted on one side, a collapsed lung or massive bleeding in the chest cavity may be present. You may hear wheezing or a high whistling sound during exhalation, as in asthma or bronchitis. Or you may hear crackles created by fluid in the alveoli. You will learn more about the technique of auscultation and specific breath sounds in later lectures. You may also hear audible breath sounds without a stethoscope. Because breathing is normally quiet, these sounds are usually abnormal and may indicate respiratory distress or obstruction. Audible breath sounds may include the following: <blf>• Snoring. A snoring sound indicates obstruction of the upper airway caused by collapse of soft tissues in the oropharynx or the tongue. • Gurgling. Gurgling is a sound created by air moving through fluid. It sounds similar to blowing through a straw beneath water. This usually indicates the presence of fluid in the upper airway. • Stridor. Stridor, also called crowing, is a high-pitched sound usually heard on inspiration and suggests upper airway obstruction. • Wheezing. Wheezing is a high-pitched, “whistling” noise usually occurring on exhalation. It is generally associated with a lengthening of the expiratory phase of breathing. Narrowing of the lower airways, as in asthma, often causes wheezing. • Grunting. Grunting is a sound heard at the end of exhalation. This sound is caused by contraction of the diaphragm against partially closed vocal cords in an effort to keep the small airways open during exhalation. • Gasping. Gasping is characterized by short, irregular breaths with a rapid inspiratory phase associated with severe respiratory distress and fatigue. <3l>Skin <t>Cyanosis, or a blue-gray skin color, is a sign of oxygen-depleted hemoglobin in the blood. You should inspect the patient’s lips and tongue, which are your best indicators of central cyanosis. Cyanosis of the extremities may be caused by circulatory problems to the limbs, particularly in small infants; therefore you should always check the lips. Remember that the absence of cyanosis does not mean that there is good oxygenation. Pale, cool, or clammy skin might also be seen in patients with respiratory distress. <3l>Mental Status <t>A variety of alterations in mental state may be observed as a result of hypoxia. Variances range from agitation and restlessness to lethargy (sleepy appearance) to coma. Patients with respiratory emergencies who have mental status changes require supplemental oxygen treatment and, if indicated, positive-pressure ventilation. Slide 16 Copyright © 2004, Mosby Inc. All rights reserved.

Adequate Breathing Rate
Adult: 12-20/minute Child: 15-30/minute Infant: 25-50/minute Slide 17 Copyright © 2004, Mosby Inc. All rights reserved.

Review of Definitions Respiratory distress Any patient who experiences difficulty breathing and increased work of breathing as evidenced by dyspnea, accessory muscle use, retractions, increased respiratory rate, cyanosis, and other signs Respiratory failure A state when the respiratory system can no longer support life Failure of the respiratory system to adequately remove carbon dioxide and deliver oxygen Evidenced by multiple signs Altered mental state, decreased breath sounds, very rapid or slow respiratory rate, minimal chest rise, cyanosis Respiratory arrest Complete cessation of breathing Slide 18 Copyright © 2004, Mosby Inc. All rights reserved.

Respiratory Distress Shortness of breath Agitation or restlessness Active accessory muscle use Retractions Cyanotic skin Increased pulse rate Increased respiratory rate Slide 19 Copyright © 2004, Mosby Inc. All rights reserved.

Respiratory Failure Inadequate Breathing
Depressed mental state (e.g., responsive to voice, responsive to pain, or unresponsive) Rate – very fast or very slow Rhythm — irregular Quality Breath sounds — diminished or absent Chest expansion — unequal or inadequate Depth (tidal volume) — inadequate/shallow Cyanotic skin color Slide 21 Copyright © 2004, Mosby Inc. All rights reserved.

Management of Respiratory Distress
High-concentration supplemental oxygen Airway adjuncts Assisted ventilations, if indicated Slide 22 Copyright © 2004, Mosby Inc. All rights reserved.

Assess the Circulation
Pulse check Radial pulse in children and adults Brachial pulse in infants Carotid pulse in unresponsive adults and children when unable to feel a pulse in the arm Slide 23 Copyright © 2004, Mosby Inc. All rights reserved.

Assess Circulation and Perfusion
Assess for color, temperature, and condition (moisture). Skin Nail bed Conjunctivae and mucous membranes Note cyanosis. Signs of hypoperfusion — pale, cool, clammy skin Slide 25 Copyright © 2004, Mosby Inc. All rights reserved.

Assess Capillary Refill
Assessment for perfusion in infants and children Note a delay of more than 2 seconds. Check for normal color to return. Slide 26 Copyright © 2004, Mosby Inc. All rights reserved.

Transport and ALS Backup
Consider need for rapid transport and ALS backup for patients with Poor general impression Unresponsive with no gag or cough Responsive but not following commands Difficulty breathing Slide 27 Copyright © 2004, Mosby Inc. All rights reserved.

Transport and ALS Backup
Consider need for rapid transport and ALS backup for patients with Shock or hypoperfusion Complicated childbirth Chest pain with low blood pressure (< 100 mm Hg systolic) Uncontrolled bleeding Severe pain Slide 28 Copyright © 2004, Mosby Inc. All rights reserved.

Summary Form a general impression. Identify life-threatening conditions. Note level of responsiveness. Evaluate Airway Breathing Circulation Provide lifesaving treatments. Rapidly transport critical patients. Slide 29 Copyright © 2004, Mosby Inc. All rights reserved.

Copyright © 2004, Mosby Inc. All rights reserved.

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