Chapter 2. Approach to the patient
The approach to the patient follows scene safety and scene assessment. In trauma cases you will already have information about the patient’s likely injuries after ‘reading the wreckage’ or understanding the nature of the accident. In medical cases, important clues will be gained on approach such as looking at the patient’s medications on the bedside table. While examining a patient, any Medic-Alert bracelet or card should be identified.
• Wherever possible, relevant medical history, current medication and allergies should be established. Use the mnemonic SAMPLE:
• S – Signs and symptoms
• A – Allergies
• M – Medication
• P – Past history
• L – Last meal
• E – Event (i.e. current problem).
Life-threatening associations
• Patient falling from a height greater than 5 metres
• Road traffic collision with an extrication time greater than 20 minutes
• Patient ejected from a vehicle
• Loss of life in the same vehicle
• Child (less than 12 years old), pedestrian or cyclist struck by a vehicle
• Pedestrian struck by a vehicle and thrown
• Vehicle intrusion greater than 30 cm.
Primary and secondary surveys
The patients seen by ambulance personnel may be divided broadly into two groups:
1. Medical patients
2. Trauma patients.
The initial approach to these two groups is similar. The components of the systematic approach are:
• Primary survey
• Resuscitation
• Secondary survey
• Definitive care.
The role of the primary survey is to identify any life-threatening problems or injuries. Whenever possible, treatment of any life-threatening problem is carried out as soon as that problem is identified and before moving on to the next stage of the assessment.
• Primary survey and resuscitation take place simultaneously
• The primary survey identifies life-threatening problems
• The secondary survey identifies non-life-threatening problems.
The primary survey
The primary survey follows the simple system of <C>ABCDE.
Although this system was originally designed for use in trauma, it is equally relevant to the management of life-threatening medical conditions.
<C< – Identify and manage catastrophic external haemorrhage
• Rapid bleeding from a main vessel requires immediate management with direct pressure and elevation
• Rarely it may be necessary to apply pressure over a pressure point or to use a designated tourniquet (never use improvised tourniquets)
• Remember that blood may be hidden under the patient or within thick clothing
• Can be skipped if external haemorrhage is clearly not an issue.
A – Airway with cervical spine control
• Assess the airway
• Anticipate the development of problems. In burns patients, for example, it is important to check for evidence of soot in the nose and on the lips or evidence of oedema of the upper airway
• Establish and maintain a patent airway
• In-line cervical immobilisation should be maintained during all airway manoeuvres in trauma patients.
Of unconscious trauma patients, 5% have a cervical spine injury.
• Patients with injury above the clavicle should be assumed to have a cervical spine injury until proved otherwise
• Medical patients with rheumatoid arthritis are at higher risk of having cervical spine injury.
The airway takes priority over the cervical spine.
B – Breathing with adequate ventilation/oxygenation
• Look, listen and feel for 10 seconds to ascertain whether the patient is breathing
• Assess rate and effort.
The normal respiratory rate in adults is between 12 and 18 breaths/minute.
• All patients with a reduced (<12) or increased (>18) respiratory rate should receive oxygen and if the rate is below 10 or above 29, assisted ventilation may be required
• A raised respiratory rate is a sign of both hypoxia and hypovolaemia
• In trauma patients, a structured approach to the assessment of the respiratory system can help to identify time-critical life-threatening problems (e.g. ‘TWELVE FLAPS’ acronym):
– Trachea – is it central?
– Wounds in the neck – must be sealed to prevent air embolus and to control haemorrhage
– Emphysema – is surgical emphysema present (potentially indicating tension pneumothorax)?
– Laryngeal crepitus present (indicating fracture)?
– Veins – is there distension of the neck veins (indicating tension pneumothorax or cardiac tamponade)
– Expose the thorax
– Feel the chest for symmetrical expansion, crepitus, rib fractures, flail segments
– Look at the chest for bruising, wounds (seal sucking wounds immediately), patterning from clothes or seatbelts, asymmetrical or see-sawing movement
– Auscultate – equality of breath sounds, added sounds
– Percuss – dullness, hyper-resonance, symmetry
– Sides – check under the sides of the chest and the shoulders for bleeding and deformity.
C – Circulation with control of external haemorrhage
• It is first essential to determine if the patient has a cardiac output and to start basic life support (BLS) if this is absent
• Think ‘blood on the floor and four more’ (chest, abdomen, pelvis, long bones)
Check the entire surface of the patient for bleeding
Chest (already assessed)
Abdomen
Femurs
• Assess rate and strength of radial pulses bilaterally (if absent check a central pulse), a radial pulse in the supine adult trauma patient implies a systolic blood pressure of ≥ 90 mmHg
• Assess colour and temperature of skin and measure the blood pressure in all patients
• Obtain intravenous access (this should not delay transfer to hospital)
• 250 mL boluses of (warm) intravenous crystalloid may be required to bring the systolic blood pressure to 90 mmHg or to achieve a radial pulse.
D – Disability and neurological examination
• Pupils (PEARL, Pupils Equal And Reactive to Light)
• AVPU
A – alert
V – responds to verbal stimuli
P – responds to painful stimuli
U – unresponsive
• Posture.
E – Evaluation and environment
• Is this a time-critical patient?
• Are they protected from the elements (trauma patients who are allowed to become cold have significantly higher rates of mortality and morbidity).
If the patient’s condition deteriorates, always revert to the ABCs and repeat the primary survey.
Handover
A clear handover of the patient in hospital is essential. Take 45 seconds to handover the patient, during which all members of the receiving medical team listen, unless there is a problem with the airway or cardiopulmonary resuscitation is in progress. Only key information needs to be given at this stage. This can be remembered by the acronym MIST:
• M – Mechanism of injury
• I – Injuries – apparent and suspected
• S – Signs – abnormal vital signs
• T – Treatment given.
Secondary survey
In trauma cases, a secondary survey may be performed in order to identify non-life-threatening injuries. In medical emergencies, a similar approach to the patient may uncover vital clues to the patient’s condition – injection marks, bruises, rashes or scars.
If the patient’s injuries are non-critical, then a secondary survey may be undertaken. Depending on circumstances, this may best be done in the shelter and protection of the ambulance. The secondary survey should begin with reassessing the airway.
The secondary survey must never delay transfer to definitive care.
Head
Assess:
• Pupil size and reaction
• For evidence of bruising, lacerations, tenderness and other signs of fractures
• The nose and ears for blood and cerebrospinal fluid leakage.
Neck
Assess:
• For signs of trauma, although in-line stabilisation must be maintained
• Larynx and trachea for evidence of injury and for tracheal deviation
• Neck veins (distended in tension pneumothorax and cardiac tamponade)
• Carotid pulse.
Chest
The chest is inspected for:
• Open wounds
• Contusion (bruising)
• Seatbelt markings
• Flail segment
• Respiratory rate and effort.
Palpation may reveal:
• Local tenderness indicative of rib fractures
• Chest wall instability with a flail segment
• Surgical emphysema following a pneumothorax.
Auscultation may demonstrate:
• Reduced air entry
• Added sounds (e.g. wheeze).
Percussion may be used to identify a haemothorax (dull, like a full barrel) or pneumothorax (resonant, like an empty barrel).
Abdomen
The abdomen is inspected or palpated for:
• Open wounds
• Seatbelt markings and contusion
• Tenderness in all four quadrants.
Pelvis
Examination of the pelvis may precipitate deterioration in its patient’s condition. Splintage should be undertaken on the basis of risk of injury determined by the mechanism of injury.
Upper and lower limbs
Major injuries which might be associated with life-threatening haemorrhage should be identified in the primary survey.
The limbs are inspected for swelling, deformity and wounds. They are palpated for fractures (a step in the cortex) or crepitus (broken ends grating together – very painful).
The limb examination should include assessment of:
• Motor response – test for active movements
• Sensation – response to touch
• Circulation – pulse and skin temperature.
Limb injuries are treated as necessary, with dressings and splintage. Analgesia should be a high priority with suspected long-bone fractures. The choice may include:
• Reassurance
• Splintage (possibly with traction splint)
• Nitrous oxide inhalation (Entonox, Nitronox)
• Morphine.
Be aware that unnecessary delay at the scene may well jeopardise patient outcome.
For further information, see Ch. 2 in Emergency Care: A Textbook for Paramedics.
