The system of assessment and care of the primary survey positive patient

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Chapter 2 The system of assessment and care of the primary survey positive patient

The primary survey positive patient

A number of excellent reference texts and resources exist describing the priorities and immediate actions for assessing acutely unwell patients in the hospital and general practice setting.310 The approach and techniques advocated are equally applicable in the resource limited community care environment and during transport to hospital. Similarly, the ABCDE approach taught on standard life support courses is as applicable to acute medical emergencies as it is to resuscitation from cardiac arrest and the management of major trauma. This structured approach is illustrated in Figure 2.1. This reflects the central doctrine of emergency care that immediate assessment and management of a life threatening condition does not require a precise diagnosis. It also illustrates the importance of considering early transport to definitive care with emergency treatment compared with resuscitation en route.

After ensuring the scene is safe, the practitioner should aim to undertake a rapid primary survey (Box 2.3). In many patients, the primary survey may be completed very quickly. The common pathways to cardiac arrest in acute medical emergencies are airway obstruction, respiratory failure, circulatory failure, and neurological failure. The aim of the primary survey is to seek out evidence of these in order to target specific resuscitative interventions.

If the patient is not talking normally then a more detailed airway assessment is required. Look for signs of obstruction and check that the patient is maintaining and protecting the airway. The unconscious patient is at significant risk of passive regurgitation and pulmonary aspiration even if the airway is maintained with simple techniques and positioning. Failure to clear blood, saliva or mucus from the oropharynx and absence of spontaneous swallowing indicate a failure of airway protection. Although the full range of basic and advanced airway management interventions should be available to manage such patients, simple adjuncts (especially nasopharyngeal airways), postural drainage, and head and neck positioning may be sufficient during the remainder of the primary survey and transfer to hospital.

To assess breathing, look for signs of increased respiratory effort, inadequate ventilation, and common physical signs associated with respiratory and cardiovascular disease. An increased respiratory rate, use of accessory muscles, splinting of the diaphragm, and recession of the chest wall are sensitive indicators of an increased work of breathing. Tachypnoea alone may reflect a very wide range of disease processes and it should not be assumed to reflect a breathing problem in the absence of other signs of respiratory distress. If wheeze is present, decide if the sound occurs mainly during inspiration (stridor) or expiration (most likely to be attributable to lower airways obstruction).

Detailed assessment of the circulation should identify the presence of shock and a systemic inflammatory response to infection. Shock is a failure of tissue oxygenation. The classic signs include prolonged capillary refill, tachycardia, tachypnoea, and sympathetic nervous system stimulation (pallor, sweating and peripheral vasoconstriction). ‘Sepsis’ refers to evidence of systemic infection (for example, pneumonia, meningococcal disease) accompanied by systemic inflammatory responses. These include a pulse rate greater than 90, a respiratory rate greater than 20, and a temperature above 38° C or below 36° C. Acute gastrointestinal haemorrhage may be missed if the clinical signs of bleeding are not assessed. Finally, assessment of the circulation in medical emergencies includes an assessment of heart rhythm and a search for evidence of heart failure and myocardial dysfunction (tachycardia, 3rd or 4th heart sounds, systolic murmur).

Detailed assessment of disability entails a mini-neurological examination starting with level of consciousness, mental state, pupil signs, localising signs, posture, and limb function (see below). The patient should also be exposed as much as practicable to look for evidence of a rash (urticaria or purpura), jaundice, anaemia, pitting oedema, and physical manifestations of chronic disease. An accurate assessment of temperature is essential in assessing whether the patient is feverish or hypothermic.

The secondary survey

All acutely unwell patients should undergo a primary survey to identify their immediate resuscitation needs but most patients asking for assessment through their primary care service are not likely to need immediate life saving treatment or to be rushed to hospital. There is time to perform a more detailed secondary survey. This follows the more traditional medical model of history and examination.

Any further clinical examination should then be dictated by history and clinical suspicion. A differential diagnosis can then be reached and further decisions made regarding treatment, transportation and definitive care.

The SOAPC system

The system that we have adopted (Box 2.4) is based heavily on problem oriented methodology:11

S – The subjective assessment

The history is the key to correct patient assessment.13 When errors are made, they are usually attributable to inadequate history taking. It is not possible or desirable to probe every part of the patient’s medical history. Instead it is important to have a system that obtains key information. A much more detailed history will be needed in the patient who is likely to be treated at home than the patient who is going to be transported to hospital. Box 2.5 sets out the main parts to history taking.

The presenting complaint is the main problem for the patient. When there are several presenting symptoms, choose the main problem. Explore its onset. What was the patient doing when it started? Is it getting better or worse?

Ask about associated symptoms relevant to the main complaint. For example, in chest pain ask about nausea, vomiting, sweating and shortness of breath. At this point ask questions relevant to the presenting complaint, for example in a patient with chest pain, ask about hypertension, diabetes and family history of heart disease.

The history of previous episodes may give important pointers to the diagnosis and treatment.

The medical history needs to be explored along with the patient’s current medications. Most patients will have a list of their medications either in note form, on repeat prescription sheets, or in dispensing containers. Use these sources of information where possible.

The social context must be noted as this may have more bearing on the patient’s future management than the diagnosis. Is there a carer who can observe the patient? Is the patient capable of performing the activities of daily life such as washing, eating, dressing and toileting?

O – The objective assessment (examination and tests)

The most important parts of the examination can usually be performed but may be limited at the scene or in the patient’s home. This inability to examine the patient properly must be taken into account when making transport, referral and treatment decisions.

As with history the examination should be targeted to the specific complaint but must always include vital signs and a general examination of the patient and their social context.

Respiratory system

Use the look-feel-listen system (Box 2.7).

Look – Measure the respiratory rate and assess if the patient has any difficulty in breathing. Look for tracheal tug, the use of accessory muscles (Fig. 2.2), or in-drawing of intercostal muscles. Assess if the patient is becoming exhausted and look for excess sputum production, inhaler or home nebuliser use.

Feel – Is the chest expansion the same on both sides (Fig. 2.3)?

Listen – Check the percussion note (Fig. 2.4) and listen to the breath sounds on both sides at the apex, in the axilla and posteriorly at the top, middle and base (McGill virtual stethoscope, http://sprojects.mmi.mcgill/mvs/mvsteth.htm). The aim of auscultation is to determine whether air entry is normal and equal on both sides. Normal sounds are described as vesicular. If the lung is solid, sound transmission is different and the noise is similar to the sounds heard when the stethoscope is placed over the trachea (bronchial breathing). The next step is to assess if there are added sounds, these can be wheeze (inspiratory, expiratory or both) or crackles.

Function – In patients with respiratory symptoms check the oxygen saturation and in patients with asthma and other obstructive pulmonary disease check the peak expiratory flow rate.

Gastrointestinal system

Hydration, nutrition and looking at the mouth and tongue are part of the general examination of the patient. While examining the mouth, smell the breath. Fetor is a characteristic smell of the breath in a patient who is unwell. If the patient is complaining of abdominal pain the chest should also be examined.

All books of surgical examination emphasise the importance of exposing the whole abdomen, including the genitalia. In the community setting the same principle applies but it can be difficult to do this because of facilities and lack of a chaperone. If conditions do not permit a full examination then it is important to recognise that examination is incomplete. Rectal examination and vaginal examination are even more problematic. Without adequate patient consent, privacy and a chaperone these examinations should not be undertaken except in life threatening situations.

The objective of the examination is to decide if there are signs of a condition requiring hospital assessment. Signs of peritonitis, intestinal obstruction, or a vascular emergency are especially important.

The abdomen is examined using the ‘look-feel-listen’ system.

Look – for distension and note how the abdomen moves. Ask the patient to cough. Pain on movement and coughing is a good indicator of peritoneal irritation. Note scars and any swelling or hernias.

Feel – gently at first to try to detect any rigidity in the abdominal muscles. If there is inflammation of the peritoneum then the overlying muscles will protect the area, this is known is guarding. Identify the areas of maximum tenderness. Another sign of peritoneal irritation is percussion tenderness. Place fingers over the area of tenderness and percuss these with fingers of the other hand (Fig. 2.7). Pain during this test is indicative of peritoneal irritation.

If gentle palpation is not painful then palpate more deeply trying to find any masses. Check for enlargement of the liver and spleen. Check in the groins for swellings that might indicate a hernia (this might be quite small).

Listen – for bowel sounds. If they are absent this is a worrying finding. They may be increased in gastroenteritis but in obstruction as well as being increased they may be higher pitched or tinkling in quality.

Central nervous system screening exam

If the patient is lucid and able to give a full history and walk normally, can hold their arms out steadily with their eyes closed (Fig. 2.8), can stand on each leg with eyes closed and has normal facial expressions and eye movements there is no severe neurological deficit. This screening test is not sufficient for anyone with a primary neurological complaint.

Tests of higher mental function are a sensitive indicator of acute neurological dysfunction but they are not so specific, being very commonly affected by pre-existing problems. For example, the older patient may not be fully orientated but this may well be attributable to dementia. It is therefore important to seek information regarding the previous level of function and any change. Always take seriously a carer’s view that there has been a sudden deterioration in mental function.

Record orientation in time, place and person and the Glasgow Coma Score. The Abbreviated Mental Test Score is more detailed (Box 2.8). It is especially useful in the older patient, particularly if there is access to previous records. Patients should be able to score 8/10.

The examination for the main neurological presentations can be tailored to suit the situation.

In the patient with sudden onset of headache (see ‘headache’ in Chapter 10) a full general examination is very important. Vital signs including pulse, blood pressure and temperature may give clues. There should be a full examination of the whole body looking for any signs of rash. Photophobia and neck stiffness should be sought (Fig. 2.9). Other signs such as muscle tenderness and Kernig’s signs may be checked.

In the patient with an acute stroke, the focus will be on determining the extent of deficit and if vital functions such as airway protective reflexes are preserved.

Detailed examination of the nervous system is usually divided into testing the function of the cranial nerves, the nerves that provide motor and sensory function to the head and neck (or structures derived from this area of the embryo) and testing of the neurological function of the limbs.

A – Analysis

Decision making and diagnosis are necessary evils. Necessary as it is not possible to decide on treatment without a working diagnosis, an evil because clinical decision making can be imprecise. A diagnosis is reached by a synthesis of the information you have. Each ‘bit’ of information will carry different weights. Some features, either in the history or examination, will carry so much weight that the diagnosis is easy (Fig. 2.15).

The skill of diagnosis lies firstly in eliciting the right information and secondly in the ability to ‘weigh up’ the evidence. This should allow you to place the patient into one of five diagnostic categories:

If you are unsure about the diagnosis then a number of options will be available:

The course of action you will take depends on the illness, the severity of possible alternative diagnoses, the patient location, your capabilities and resources, and the social context. For example, if there is uncertainty about the diagnosis in a patient with central chest pain, they should be referred or transported to hospital. Equally the young man with non-specific abdominal symptoms and signs might be best treated by active observation at home.

References

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