Transcript
Again, welcome to this webinar, and this first session is on the we're breaking down looking at critical assessments or critical findings in the primary assessment.
And this one's gonna focus really on the general impression in mental health and mental status that we encounter in sports injury.
So there's something we keep that in mind, and we're gonna we're gonna three steps, you saw the different topics here as well for this first one.
So as far as disclosures, I am the owner chief executive officer officer for Action Management Consultants.
I have no personal endorsement or relationships.
Any device or product that's I allude to in this presentation is used simply for demonstrations, not any particular endorsement for one product or service.
So as I mentioned or we talked about many of the it's in the title implies, and what the objectives are today is we're gonna talk about the general impression the things we see and and also with mental status in the emergency assessment, then that really, that first minute or 2, once we go into a situation.
We reassess the situation, and we're determining what potential threats there are.
We're moving right down into determine where what this what we may find specifically to those 2 areas.
We're gonna talk about the Appu and GCS scale.
That becomes kind of a towards the end of the presentation.
We're gonna talk about that because it it can be confusing to some people.
I'm trying to remember a number versus using and I'll talk about the reliability of that as well.
Then also, we're gonna talk about the key point is hitting on interventions, and we're not going into specifically everything that goes on, but it's definitely we're gonna hinting on the key things to think about as as you're moving through and how to implement now that where that gets into specific values and levels again, goes back to protocol and where you're what that sits into place.
So let's take a it's a thirty thousand foot view so to speak on the assessment process and emergency care.
And the first thing we have to do is number 1 is think about, what's your minimum equipment?
Yeah.
And do you what do you have on-site?
And is it operational?
Do you have this do you have staff training Those are all critical points that we have to think about in the assessment process.
And where that comes in.
So if you don't have the equipment, you it's hard to do the things you need to do.
Talk about that in a minute.
Obviously, from a the situational size up, look at what what they're seeing safe or patient is safe, what determining what the mechanism of injury are the or the nature of the illness.
Think about spine motion restriction or is bleeding control needed.
Those things precipitate needing additional resources and how you activate those immediately.
The focus for this presentation as well is as today is on the primary assessment.
We're gonna talk about specifically in this.
We're gonna this one area here.
And and think about what jaw impression and mental status is.
And then we're gonna also dip into the interventions.
What you should do not necessarily what length or time, etcetera, but just simply this is what it looks like for these these areas.
Then also think about course as you move through the process of managing the patient.
Think about your secondary assessment.
You're doing core vitals.
You're doing additional diagnostic like, tech taking blood sugar.
You're gonna conduct that head to toe assessment, making sure you did not miss anything that you didn't catch on the first the first round.
And then also you're moving into where it's when it's appropriate to getting the getting a sample on OPQRC, questionings as well to determine what that problem may may be.
And then finally, again, you're gonna still continue to inter inter the interventions assess and then you reassess and transfer to EMS if needed.
Real quick, this is not gonna go through all these, but this is just a a snapshot of what what should you have available from based on your training and what's in your emergency kits.
But these are the it's a pretty extensive list, but it should you you should be taking note of this and look at this.
It's not inclusive.
But just need to consider that you have to save a life and, you know, not just your athlete, training license, but even license as well, have those things available.
Let's talk about the criminal findings in general impression and mental status.
So what we are looking for are these five things.
So obvious bleeding body fluids or other obstruction blocking the airway, significant chest trauma, with that specific open chest wound or paradoxical flail chest or having a flail chest a chest motion.
Major bleeding, and then also any mechanism of injury, think about spinal injury.
And then also from mental status with the ARAPPU, look at what that presents to is pain.
And then the question is, but some think about we think about is where does where a confusion fall into this because we may see that very often.
So very simply, let's talk about the obvious bleeding body fluids or other obstructions in the airway.
So what how this is gonna flow and you'll see this as well, I'm gonna give some examples.
Which is something we think about to kind of give you that visual mindset of work or things to think about And then also what's that what's the initial intervention?
So, obviously, you see this patient here has had some significant trauma to the head, you can see head trauma addressing, but what else is occurring with that person?
They're having difficulty breathing or not.
This person appears that I have breathing what you can tell, but think about the obviously things that are gonna be the threats to the airway, you know, open mandible fracture, or or a cheek wound, which is is impaled object, or it's been, you know, puncture or laceration where you're having bleeding into the airway.
Especially if they're unconscious and they're, you know, smooth that blood's moving back into the airway.
Nasal fractures without the staxes, that eliminates one mode of air getting into the system potentially.
So now you're thinking about what that may do as well.
You have vomitus with altered mental status, and excuse me.
Go with that.
Think about what the the the VVM, also other things you're thinking about with that as well.
When you're thinking about critical interventions, think about what the big thing is is trying to clear out as being a suction or a clear you're trying to clear the obstruction.
So how to do that.
So if they're vomiting, you wanna be able to be in a position to roll them on their side.
Think about what the suction looks like.
Moving on to next one is thinking about what think about significant chest trauma.
Now this is an example of a a significant laceration.
The the question concern is, is it now now you're having to is it open chest wound?
Are they having difficulty breathing?
Are they having a, you know, open open thorax with this?
Potentially, this is a pretty significant wound on the backside, but does get near the near the the post the lateral side of the chest wall or potential may be seen because of bleeding.
So, again, with this, if you're having a problem with either the anterior, the posterior, or the lateral chest wall, we you're and and they're having other signs of a pneumothorax, then the intervention is simply going to be you gotta use a a chest vent.
And that's a three sided tape.
It's spinning.
And I see here as an example of a commercial.
However, you could always, you you know, if you had to improvise, you have tape, you have plastic, you know, like, for example, plastic bag and seal that that side as well, have a three side seal with tape.
So, however, to close that side off and to provide the vent during that process as well.
So just trying to relieve that that pressure.
When we also think about Excuse me.
Others out of chest trauma.
And you see here in the picture here, you're looking simply at this is an example of a a flail chest.
This is multi segmented.
So we think about what that looks like, and the simple the there are 2 things to think about with this.
One is you can put either a you do some stabilization with your hand or padding to hold that in hold that paper in place, but also we're we gotta think about or put a padding.
You're not trying to press down on it, but you are trying to trying to relieve that pressure.
Or put some out of the pad.
But also, we have to think about adding supplemental oxygen with osmosis pressure ventilation or BBM.
And we're using or a CPAP.
That should be a CPAP.
I apologize about that.
So we even have to actually and control the breathing and and also get them into a stabilized position.
So either they are they are hyperventilating, or there there also, it could be hypo perfused as well.
So those are some things we wanna think about with what that looks like as well.
So when we think about also moving forward, we think about major bleeding, as an example, as a third type and it's spurting and it's pretty easy to see what that looks like.
If you see, you know, open fractures, you have lacerations where you're having a steady flow of blood.
It could be over a vein or artery where you're losing that steady flow as well.
Again, the simple pressure, the technique is where you see this.
This is again, these are these are critical threats.
Is one doing direct pressure, wound packing, or how does the ABV pads, Those are thicker pads.
You can get absorbent pads or you press good for putting direct pressure.
And then also applying a tourniquet also consider hemostatics as well as needed.
But the first thing is getting the direct pressure to determine if it's gonna stop completing and then moving right down into a tourniquet based on the location.
As far as the other side of this is thinking about what would be the general impression again what is a, you know, the mechanism of entry for a suspected spinal injury.
So I have a couple of things here to think about.
This is a really good article found recently that was was looking on this a bit more.
You're thinking about what are the indications you think from an EMS perspective, what they're looking at than also what what's in the field in terms of types of equipment as well.
So there are there are 5 big indications where you would think of having spine motion restriction.
Obviously, if they're having altered level consciousness, you know, acutely, Definitely, they're gonna be have a below a GCS of 15.
They're gonna have some evidence of intoxication where they're having some vinyl pain, a combination of these.
So, you know, midline neck or back pain and or tenderness, and not is mildly, but I think more of the sniffing, you would know that the person has inability to move, or they are very painful to move with with exacerbating pain in the neck or back pain.
Think about those vocal neurologic signs or symptoms.
They're having you know, numbness or indoor motor weakness and what how that's presenting.
Think about any, you know, anatomic deformity of the spine that's observed on palpation or visual.
And then also think about the distracting circumstances of an injury.
And, you know, is a long bone fracture?
Did they fall how how far do they fall?
Keep that in mind as well if it's a fall you know, from a from apparatus, like, fell off bleachers, etcetera.
We think, you know, they're seeing that long bone fracture you know, other types of issues that maybe you it's it's preventing you from getting a good examination.
But also think about what's happening.
They may be having other things going on.
So, again, the indication is gonna be on spine motion restriction.
And use that accordingly.
And that's how that is those are things that just to be aware of it, from an EMS perspective, they're looking in to this as well.
Also, alluded to, if you've not read this, is the consensus recommendation to prehospital care of the injured athletes suspected catastrophic cervical spine injury.
This is the late some of the latest evidence out.
There were several pieces of several papers that came from this, and it alludes to if you have any equipment on how to how to address equipment issues such as a face mask or they have other pads and how to remove how to safely immobilize and provide spine motion restriction to the to the athlete.
And then the final thing we're thinking about It's looking like this is altered mental status.
And when we think about this, we're we're thinking about just these examples.
When you look at these two pictures here, you know, you have this you know, obviously, the first thing is, oh, that person has there's something on the on the forehead.
Like a contingent or abrasion, etcetera.
But the question is is, was it already there?
And, you know, you're trying to think of what may have happened and and going down the list of questions.
So think about these examples being, you know or why they may have an altered mental stat.
Could they be hypoglycemic?
Are they having a trans ischemic attack or stroke?
Obviously, a head injury may may we you may have seen that numerous times, infections, and not just a regular infection, but think about something like a bigger picture like sepsis.
They have something that's now now they're showing up as a significant medical issue.
Hypoxia, any from a lack of you know, based on environment, exercise, induced, etcetera.
Did they have something with a drug overdose drug overdose our intoxication.
Electrolytic imbalances or significantly can cause some altered mental status changes as well.
The history of a seizure or in they've they've experienced 1, you're coming on that patient.
Where we had several men's afterwards, they're gonna have an, obviously, that popsicle state and move into that they maybe for several hours, that matter.
Having some other type of psychiatric condition or having some other endocrine disorders coming into play.
So regardless of what all this looks like.
It's not, you know, trying to make a diagnosis is is harder, but thinking about how the patient's presenting.
And, obviously, you gotta make sure they have that they have a patent airway, patent breathing.
You're gonna think about where in the abs of this, think about what their blood glucose levels using the CVG and then SVO 2.
And identifying what that looks like or what those levels are Then based on, accordingly, you're gonna ploss up metal oxygen.
I would say if they have a diminished SPO2, and then or even living with CVG, think about glucose 15 having that in your kit, that definitely addresses the the hypoglycemic issue doesn't really resolve everything, but if you're if you're going to those lines, it's an easy fix.
Thinking about what the circulation and the pulse skin temperature, those things also come into play with this.
Is addressing that.
So it may be having a mylar sheet or other morktown to keep them warm.
And trying to maintain their body temperature as well and trying to con trying to address that to appropriate interventions.
Let's talk again briefly about altered mental status.
So when we think about this, the easy one is actually AFPU.
And here's a article that was that you'll see below.
You could look you can review that if you need to.
But, any case, there's a there's a high correlation between the glascoma scale and what that descriptor looks like in those values of glascoma scale and whether they are work, verbally responsive, painful responsive, or unconscious.
So those numbers are barely cons consistent.
With that.
And what they what they found is some several studies.
The thing the questing gets into is whereas, you know, confusion gets into that they appear to be confused.
So you think of being between alert and verbally responsive, they are doing both of those, but that's where that would fit into.
And you see, you may see some indicators of that and some they're starting to come out more where they're having that that other that that ACDPU are where that fits within that level as well.
So in review, so those are the 5 areas.
So think of again, and think about what your equipment checks are, what the situation are seen size up.
In that primary assessment, we're gonna go through several of these today.
This is the first part of this one is as we've gone I'm sorry.
As we already gone through already today in this presentation, thinking about general impression, and mental status, what are the and what are those appropriate interventions are.
So if you would, I'm a have you jump into the in your in your chat.
And just what's your immediate concern?
This this I'm a roll through a couple of slides where we have a couple minutes left.
Again, if you have any questions, We wanna ask those as well.
What you may have as we're moving through as we get ready to wrap this up.
So what if you would put your first immediate concern based on this presentation, if you throw that in a chat, if you would, please.
Alright.
Great.
Looks like difficulty breathing.
And it's definitely the one I would go with.
Hard to tell between chest pain and breathing because that's my first impression.
Yeah.
I mean, you're kind of thinking of some of the ones that you think about.
Obviously, What that may occur?
Like chest pain?
Is it are they difficult asthmatic?
You know, other types of issues they're having?
Those are problems probably the most ones upper, you know, upper based on where they're holding their you know, the hand presentation says a lot, but also how they're they're holding up against something trying to keep the chest wall rising as well.
Again, that's the immediate difficult.
You know, those things in how you're going to address those You don't wanna think of it in whole, but you've gotta don't identify what that is pretty fast.
And the the vital sign assessment comes into that based on what any history you have.
So what's your go back to them right real quick.
What would you give her mental status?
ABPU, what would you classify as limited knowledge?
Well, this could still still be alert.
I think she's, you know, she's responding.
Her eyes are open.
The again, the question is how she's responding.
If you get into that web and they're confused, and you're thinking now this becomes more or they're they're in distress or they're anxious, they're actually being sporadic in their conversation.
Or that anxiety, that that threat of impending doom, then that moves into a greater level of acuity, at least it would be in my opinion.
So Pretty good.
Got a couple of those are things that are pretty straightforward based on, again, it's just a picture we look at.
So how about this one?
You know, the athlete collapsed, but with no direct contact.
So is would SMR be indicated?
That could be a simple a simple yes or no as your response for is.
We're simply asking is, you know, they person collapsed.
They have no direct contact with you would you consider spine motion restriction?
Thinking a couple of responses moving forward on this, and I think definitely yes.
Even though they did that, but depending on, you know, how they how the how the patient collapsed, If you weren't there and they told you that you still have to assume and if you're not there present, you have to assume there is a cervical involvement until otherwise noted.
So or being very cautious with that.
If you know that if the person just went down and laid down and you saw that, Most likely it's not, but still bearing what that is.
Alright.
We got 2 more quick ones right here is what is you know, your sum into the dressing room and we, you know, probably all of us have done that at one point of time.
You know, one point of you know, we go to a technical athlete, and what's your impression of the what do you think of the athlete's mental status?
Go ahead and type those in, the your screen as well.
Yep.
Daniel, I'll kinda put it with it.
Hey, and and verbal.
Yep.
You're not sure.
The question gets into probably would be what's the what's what's verbal.
You know, hard to, you know, They looked hard as well again without asking a question, but if they're not responsive, I think, you know, that as well.
Like Daniel, you mentioned there, but they're they are in work.
They're sitting up, but what's the problem with that as well?
Could be tired, distressed, The other thing that gets into is why would a why would someone come in to get you what that problem is as well?
So there's something to be aware of that is that someone's telling me something's not right, they're not acting right, etcetera.
There's something to be aware of could be distressed.
They're talking and see what they're could it be a mental health crisis?
Could it be other some type of issue as well that they're they're not dealing with or dizzy?
And and you move down accordingly.
And then here's one right here just to look at here.
You know, what do you have if and, obviously, this is a minor.
This is not a lot of bleeding, but if we think about it, what is the do you have the necessary equipment to control it?
To manage this if a person's having significant bleeding in the area.
And spitting out may not be a good option, especially they have a have a mandal or maxillary the direct front trauma or side trauma.
Those are some things to think about also And I I I I think I overlooked this.
I'm I'm thinking of as far as the breathing side is and I did this, and I don't realize I I even did it till this now, but one of the slides of his phone up, which is front of front of neck access is where you had damage to the neck as well, whether it's causing that as well from an airway.
So There's some things to think about if we're having equipment where that ties in.
So I know we got Brandon probably running close here a little bit.
Let's go ahead and I think we can make this up, still keep this on on track.
Any questions or if you'd like to ask a question, jump on, we can turn your audio on, and you can ask me a question directly or just type your question in for Doctor Harper.
Any questions?
No.
I think that's a great overview Ray.
If you can notice the framework we're trying to build here is we're we'd go straight into primary assessment, Ray, has tackled the the large life threats with the idea that there are a lot of bad statements that can happen that we need to be prepared for and have a plan for.
We didn't break down each one.
We can if we want to for a minute or 2, but that was a thirty thousand foot view of the really bad life threats that could take place.
And with a with a medical staff covering athletic events.
Yeah.
I think this go goes online Doctor Harper and and the audience, you know, there another another talk we will do is something we'll I think we it's definitely worth talking about is is, you know, what do we think about loading those situations?
So, you know, that they're not as you know, what the different list is for this, but that's the one that's kind of a easy view of, hey.
This is what the problem is.
This is what you look at.
These are things we definitely have to take in consideration that these are These are all critical.
Any of these things you saw in this presentation are all would warrant a you're calling EMS for additional support and they're being they are they are critical.
I mean, this is a these are all critical issues to be concerned with.
So Any other questions for moving on in audience?
Alright.
Well, if there there are none, thank you very much, and appreciate your time on this first session.
5 Key Signals: Decoding General Impression and Mental Status in Sports Emergencies
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Updated Jan 22, 2024
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