[PCL] The Basics of Patient Assessment

Michael Burton, BA, MS, PA-C, MMs

Mike is a fellow critical care PA in Atlanta, GA. He has extensive former EMS experience in the field and brings these skills to critical care arena. In our practice he is part of the difficult airway faculty and is the main airway guru; he runs our sim program and mock code program for both our new trainees and established PAs. He is passionate about airway and patient assessment and is the main source for all things first, second and third assessment.

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in our training

we spend a lot of time learning how to get a history and physical - which is all important and good - IF that patient is stable enough for you to spend an hour thinking through it

Breaking it Down

Primary Survey (First pass) - keep patient alive, LOC ABC

• Goal: Keep patient alive despite all other information coming our way - treat life threatening illnesses

• LOC (level of consciousness)

  • Make sure patient is responsive: should we do CPR or continue on?

  • GCS - can be cumbersome

  • AVPU - alert, verbal (only responsive to verbal stimuli), pain (only alert to sternal rub), unresponsive

• A/B/C in responsive patient, C/A/B in unresponsive patient

  • A: Airway - is airway open and patent?

    • Patient isn’t slumped over, neck isn’t flexed

    • Open it using head tilt chin lift or modified jaw thrust

    • Most common upper airway obstruction: tongue

    • Oral or nasal airway as needed

  • B: Breathing -

    • Are they breathing adequately? If adequate in current state, can they sustain that breathing?

      • No increased WOB or accessory muscle use

    • Oxygenation: check SpO2, skin color

    • Ventilation: actually moving air; can use BVM, BiPAP, intubate

    • Any doubt: can place NRB

  • C: Circulation -

    • Is the patient perfusing adequately?

    • In unresponsive patient, you go straight to here

    • Check pulse - carotid then peripheral

      • Strong radial pulse = SBP at least 80-90, good perfusion

      • Central pulse but not radial pulse = not perfusing adequately

    • Color of skin, capillary refill time, look for mottled skin

Secondary Survey (Second Pass)

• Overall principle is to gain working knowledge on information that would change management of the patient and allow us to reverse life threatening illnesses. Not focused on diagnosis, it’s focused on what brought you do this critical care situation in the first place

• Only focus on things that will directly change their care

• Don’t look for things you cannot directly change in this part - i.e. for patient on heparin gtt, get CTA if you can give tPA or EKOS; otherwise a CTA would not change your management

• Broken down into three main sections:

  1. Information about patient from the past few hours that led to this situation

     1. Pertinent history from primary nurse (one or two sentences)

     2. Review of recent meds given (any anxiety, antihypertensive or pain meds in particular)

  2. Labs pertinent to event

     1. Simple labs at bedside: glucose, ABGs (on some can check electrolytes + renal function)

     2. other examples: CBC, CMP, Troponin

  3. Imaging

     1. EKGs, CTs, CXR

     2. Point of care ultrasound - portable and noninvasive, can be done at bedside

        1. Look for tamponade, RV strain, qualitative estimates of LVEF, tension PTX

Tertiary Survey (third Pass)

• Looking for the actual diagnosis - tie up all the loose ends. Do everything else

• This is the only point you should sit at a computer - No-one deserves to die with your back to them

  • Look at previous history, chart review

  • Family updates

  • Provider updates, call consultants

some pearls:

• Often we recognize life threatening emergency but you must also always take swift action to reverse it

• Getting a good set of vital signs can be a distractor = do not delay treatment just because you can’t “prove” hypotension or hypoxemia

  • Can’t get a good SpO2 waveform? throw patient on NRB

  • Can’t get BP? start vasopressors

• Seems like it may take a while but in real life, but after practice, you can do in as little as 10 seconds in an uncomplicated patient; although you may be in pass one much longer during longer resuscitation (think cardiac arrests)

• “Unable” - in aviation, you fly airplane before anything else; pilots use phrase respond on radio “unable” if they have to get airplane under control and focus on flying

  • Sometimes you walk into a room and are bombarded by information and questions, if you don’t have ability to basically say “unable” and get to ABCs you may be standing in the room for a minute before you realize patient doesn’t have a pulse or is hypotensive

• It takes time to get results from second pass: follow up on these labs/imaging and assess responsiveness to things given during second pass during your third pass

• You constantly are restarting this method as you reassess the patient - STOP second/third pass and go back to first pass if there has been a patient clinical change

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