Transcript
Is the this is the 3rd part, 3 of 3 presentations on critical assessment findings, an unstable patient.
And the last one kind of full brings everything in.
We've had 2 of the presentations.
1 on general first was all, want another one on one presentation on general impression and mental status.
We have another presentation that was on airway and breathing components, those critical findings, and this one's gonna hit into the the circulation.
This is the roundabout where you also see from some sand where there may be a a tie in with even when you look at from a airway from oxygenation, perfusion as well.
So we're gonna tackle into this or this this morning.
So, again, I have no I have no disclaimers.
I have no financial interest.
I meant to put that in there as well.
That as well.
Think about it.
But in this presentation, Any any device I'm covering will be from a standpoint of I'm not as an example, nothing specific with that.
As no endorsement.
So with this, making sure that we think about, you know, what are accurate measures of circulation, both visual and with diagnostics and then also palpation.
We wanna think about the circulatory changes and unstable patient.
What are those things look for?
And then also we think about what are these what are the appropriate interventions if we're addressing poor or deteriorating circulatory findings.
And these will come in, they can show up pretty rapidly.
So, again, think about the journal components.
What's your equipment check what's their available situational size up as you're approaching the patient on scene, on the field, or on a court, or an addressing room, etcetera.
Well, you know, one is it safe?
Is it patient safe?
Identifying rapidly to questioning the patient or a bystander what the nature of the illness or what's the mechanism of injury.
Think about what if you're having to use.
In this case, we're doing bleeding.
We aren't thinking our circulation, but we have to think about spine motion restriction.
We wanna talk about that in a little bit.
Well, you know, where that fits into play, also be con, and other resources we need.
Think about this is we're thinking of if we're calling in EMS or calling EMS on scene, if they're not there, anything involving the really significant issues related, you know, airway breathing circulation.
Those things these are critical things all the these in this session as well.
That we need to consider having ALS on-site if we don't have necessary equipment, but also they need to need an additional follow-up here.
They need to get to where they go.
Go to these are all low and go type of situations potentially based on what we're gonna talk about.
And then but, again, we're gonna hit on the circulatory side and primary assessment.
And then we'll talk about those interventions.
So, again, going back into emergency equipment supplies, We think about circulation.
What are some things that we have to think what or what's equipment that we were dressing just for circulation?
Obviously, trauma dressings and bandages, etcetera, a cat ternicate hemostatic agents.
We wanna think about also what are things we need to also improved circulation.
So is oxygen airway management also can affect that and have an AED and so on and so forth in CPR training So there's some things and all and, honestly, about be having the PPEs as well with that as well.
Pulse oximetry, other devices as well we need to.
So we're thinking about the 6 things.
These are 6 critical findings for circulatory deficits.
So what are the the 6 rapid and weak pulse?
Do they have a carotid pulse, but their absent peripheral pulses?
Do they have pale cool planting skin?
We think about what's the utility of a plus 2 second capillary refill and whether it's assigned for poor perfusion.
Think about major with in one of the previous presentations, we've we've talked about this this this series, all major bleeding.
But, again, it's it's this directly impacts circulation.
So we're definitely gonna touch base on this again.
And then the question is whether they actually have absent carotid pulses in adult child or it's a brachial pulse, you see that in an infant.
So first off, let's talk about rapidly pull.
So there are a number of different this is such a wide range of things that occurring with the patient.
And 1, they're being hypovolemic shock.
They could have some type of cardiogenic nature shock or having cardio cardio cardiovascular, the origins, sepsis is worth it's not just infections, but sepsis.
And this is when you start seeing papillitis, when they they may have an infection, they may have truly ill, but if they're getting into a sepsis phase, this is definitely an area that We need to take into consideration, and we're thinking about SPO2 from a medical standpoint.
If the patient's anaphylactic, they have a head injury, They have an arrhythmias that gets into some cardiogenic natures as well.
And then neurogenic as well, we think about having a spine injury that's impacting the neurovascular I mean, the the circulatory system as a as a response.
With this, we definitely wanna have SPO2, and and I put this picture up here specifically, simply because one of the most The easiest things we can do in a rapid assessment, if you have one in your pocket, you're there, grab it, you're getting You're gonna get there skin color temperature.
It saves time without having to get a pulse and having to wait 15, 20 seconds to find a pulse.
You just simply throw this on someone, and then also you're looking at SPO2.
So from a general standpoint, we're thinking of anything.
If it's if it's a medical issue, anything below 95 would be if it's medical in nature or not being trauma, it's 95, but anything below I'm sorry.
95 being for trauma related, and at 94 and below is medical related.
If you know one of the tubes, it's gonna be a medical issue or a trauma issue, we know they're starting to have a decompensated they're decompensating at the initial sign of this before they're even showing other signs.
So we have to address this.
1 is stop if they are bleeding.
We're gonna stop major bleeding.
And if they're not, we have to rule out.
There's not, like, for example, abdominal abdominal trauma where they're having some internal bleeding and being being a high level suspicion for that if they got hit in the abdominal region or other mechanisms as well.
And then we ask but in that, the initial opportunity there is or we need to do is to apply supplemental oxygen.
And in the other one, the other the second presentation on in this series talk about air when you're breathing.
When we think about if we if you're not allowed to buy protocol or buy state practice tricks in having something with oxygen, then you'd have to be thinking about the utilization of window plus positive pressure ventilation or VVM to assist in that breathing our our system oxygenation for that person as a as a not the adjunct for oxygen, but it is the next best thing for that for that.
So The next thing, this is probably would not see this very often, but it can occur.
It's having a patient.
It's presenting.
They have a carotid pulse.
But they have absent or significantly diminished peripheral pulses.
This person more than likely based on the situation.
They're having hypovolemic shock, severe hypovolemia.
That either can be through blood loss or it could be through dehydration.
Whether it's a they're an endurance race, etcetera, or they've just been had some type of full fluid restriction.
Thing about cardiogenic shock, an aortic dissection is a prime example of that of a of a situation that may occur They're having they're holding their chest or abdominal region.
They're starting to have severe pain or several minutes after a situation, and then they are starting to the each way it's starting to crack, so to speak, they're they're losing blood internally.
And the and, again, it could be from a splitting standpoint, there've been several Number of cases into this is well worth reading case studies on aortic section in athletics but cause your rapid things you do in the 1st couple of in the 1st 2, 3 minutes will may very well save that person.
Think about hypothermia in in cold environments.
Also, think about hypothermia And I've seen this before, like, working an endurance event like an marathon where you have a heat stroke where a patient they've had, like well, I've seen this, like, 108, 109.
And they move past with move them out of clothing, keep them dry, but their their body their regulatory system is so out of whack.
So now they're moving they start moving into into hypothermic state.
And this was in move moving, like, to, like, 90 at 95, you start getting into hypothermia mildly, but then this first this patient was at 92, and then with that point, we were able to stabilize them enough to then transport with EMS.
But EMS was on scene.
We're monitoring the patient.
Were trying to stabilize them as well, and they kept moving on, so we had that we made that decision.
And moving very rapidly to hypothermia.
Very significant swing in in vitals there.
So you may see that, like, for example, over heat stroke, you may actually see that case as well.
So that's why you have to be keep preventing.
Having vasopressor medications, also other types of severe trauma.
Again, if they're having noticeable bleeding, you have to do stop the obvious bleeding if it's external.
If it's internal, then you have to put them into into a position, keep them warm with a blanket also administered supplemental oxygen and comfort care until that patient can be transported.
Pale cool climbing skin.
We see this.
So it's probably one of the more common things that we see, and it could be For the most part, it could be either, like like, you know, anxiety stress.
Like, for example, they could have that flight or flight syndrome or response, so to speak, where they're scared.
They do something.
They have a pain.
A pain may have been initiated, and they feel nauseous like I've seen somebody get hit in the hand or their foot, you know, and it just has an unusual pain response where they get light headed.
We see this also, like, you know, when you say shock, different forms of hypoglycemia is a very common Example, again, these are outward signs.
This this person is having a significant issue.
So we have to address why are they having pale, cool, clammy skin when it's not indicated from an environment otherwise.
Again, going back and getting your pulse oximetry, doing vital skin color, skin temp, those things, additional other signs, those are those will help in identifying the most appropriate intervention.
But In order to this, this person is having they are they're they're, you know, having a perfusion issue that's at the at the end of the day.
And, for example, basal vagosyncope, except sepsis or other medications may cause this or blood loss.
So, again, it's they're trying we've gotta supplement them with oxygen.
They they don't have and if you put someone, any of these cases, you put a pulse oximeter on them, they're gonna have a decreased and which is an indication for this.
So here's an interesting you know, we think about having plus 2 seconds of capillary refill and other signs of poor perfusions.
We look at capillary refill.
1, it becomes difficult if the patient has, you know, has acrylic nails on or something along those lines.
Makes it very diff it can be difficult.
You wanna think about what the utility of this is.
And this article, I listed below, is looking at where there's, you know, a level of agreement, and it's not for the most part, capillary refill is not necessarily a great indicator that there's a problem with the patients.
You still need to do this.
But some of the research out there, it's gonna be variable whether using it, earlobe, etcetera.
You wanna see that there's perfusion.
You can see this and tell what it is, but telling whether or not it's 2 seconds or not, maybe other things as well.
Not to say to not do it.
But again, think about where this this patient is going.
Are there better they're better diagnostics than capillary refill.
And the short answer is getting a pulse pulse oximetry other things as well.
You just kinda see that they're getting some type of response in the extremity.
So use that as a utility, but whether it's it's not the indicator, oh, they have a problem.
You see this more often when in the elderly, even if they're gonna have a diminished capillary refill, that's that's typical.
But cause with just natural aging process, if anything else, But in the day, find something that's very reliable in hell that moves into.
So, again, you you have to if they if you notice you're not a with this, think about this, capillary refill is a problem, especially if they're having a diminished pulse or where they're having other signs that may be having signs of shock.
But in the day, you have to identify that they have they're have they are hypo perfused, and you have to move them.
You have to get them into a higher level of perfusion.
Whether through nasal cannula, whether through a mask, or it's other type of oxygenation, like a or using a BBM.
With oxygen.
So major bleeding is pretty self explanatory.
We see what that looks like not, you know, lacerations, compound fractures, you know, GSI or gunshot gunshot injuries.
Think about our other penetrating trauma, those are things we have to be prepared for.
And and and through it, maybe you'll see bleeding or repetitive work, not or puncture wound, but you can see that based on where in in a day you're seeing a flow steady flow of blood or it is spreading.
Excuse me.
Again, this is very simple applying direct pressure, apply tourniquets and hemostatics indicated.
So in the in the case of extremity, you're applying tourniquets for that for that patient and apply and it can continue with direct pressure until that bleeding is stopped and and also working to stabilize other vital signs.
All you're doing with mate, with stopping bleeding and something to keep in mind is you're not stopping the the patient for having poor symptoms or signs and symptoms, you're just keeping them trying to keep them from moving further down the line.
And, again, what you do in the first thirty seconds is very crucial from a response standpoint.
The you know, there's a lot of research on alternate use that you have a in the if you apply a term again before the onset of suck, shock, there's a 90 96, 97% survivability.
Versus if you apply it after the onset of shot, it now goes to, like, a 4%.
And those 2 consistent studies that come out even from military, and it also translates to the civilian infield or in the prehospital care.
The last one is this.
It's thinking about what is excuse me.
Like, the carotid pulse, it absent.
Well, if they had their cardiac arrest severe hypotension, they have aortic dissection, comedocommodio Cortis, or the tamponade, other type of high skin toxic skinning a bit, such as drowning or pest or drowning.
Very simple.
You're going in that CPR and AED.
With that, then you're also thinking about using basically, if it's the provider level, you're using having the BBM and using that as supplemental as positive pressure ventilation in addition with these compressions and using an AED.
So those are the 6.
So, again, in review, we were tackling this as the circulatory component for this of what we looked at.
We The other sessions have talked about airway breathing, also general impression in that as well, and what interventions are the base level, what we're going to be providing.
So let's move into this, and I guess in your question is, you know, this like, use example, I hear this coach.
And in the chat box, just put in what you think is your impression.
This coach has significant pain in the thorax without trauma or significant exertion.
What's what's possibly going on with the with the patient?
What are some possible possible conditions?
And while you're doing that, I see there's a question example.
So the the different he said there's QuickClot is one example.
There's some as you're all kite and some are different.
I'm gonna different brand that's just the brand the brand it is.
It's not the one.
They're different ones out there, but they're easily ordered.
They have some stop bleed type stuff.
It's a powder.
Or it becomes it's a a a a powder that goes on the on the dressing or or z.
Z fold type of works in there as well.
Different ones you look in there as a as a powder form in power itself or the powder is in mixed in or in with a gauze or a or a pressure, like a packing dressing.
Yep.
Daniel, cardiac arrest.
What about potential aortic dissection?
Is something to think about as well.
Did they had something could they have a spontaneous pneumothorax?
We're talking about, you know, there's a number of different things that go into place here, it but one thing that Coach may have been yelling, it could have spontaneous pneumothorax.
That's not focus here, but think about what definitely cardiac event is most you know, what's the 2 things you see here?
1, He's not holding with both hands.
He's holding with one hand, and he looks mean holding and painting the left hand.
So that's one thing that not necessarily, but could be an issue in itself.
Oh, sorry.
I got one just one more here.
So here's the example.
So you're still runner.
You come across a runner, and a park is not responsive and checks up pulses.
Has a carotid but no radial pull.
So what what are the what's the potential problem this person is this this runner is having?
Or what what's a condition or condition to take in consideration without any other issues?
Yep.
Could be heat stroke.
That's that's definitely one based on the environment.
And, again, their presentation, that's you know, it gets into height.
Their their thermal regulatory systems out of is is black.
So Yep.
There's one Carrie gives 1 is one about the go safe warriors coach who does a heart attack at the team dinner.
Thing about also internal you know, they could have internal bleeding or shock that was they start experiencing something like an aortic gut section.
Or other issue that could be having some significance there as well.
So the the goal the purpose of this was really just to think back on what you're seeing and what they're presenting and get that, you know, you may have had a similar situation.
You've encountered where oh, this person's having this.
At the end of the day, you're checking a pulse.
They have a pulse.
Then you may check also the Tremedies.
The Tremedies tell a lot about what the what the patient is, you know, as well.
So we're you're gonna do a quick body scan.
Do they have cool cleaning scan?
Are they getting a capillary refill if you can get that?
But definitely getting to just determine if they have a pulse if you don't have that equipment available.
And then whether or not the person is breathing and from that and look at the other life threats for that as well.
So that kind of sums up what this had this one session here is pretty straightforward from a circulatory standpoint.
So I'll going out there for any questions or if you all have a question, just raise your hand, and either higher, Doctor Harper will turn your audio on and give you the give you the floor.
Any question or doctor Harper?
Any any quest any follow-up?
No.
On
the on the skin color and temperature, evaluation.
Does cool and clammy always come with pale?
Are are they all typically clumped together?
You you have to well, I guess that's the question whether or not they're you're you're gonna you're assessing that all at one time.
You're looking at you know, again, think about the color is whether or not they're getting blood flow, what that looks like, the extremity or the facial expression as well.
Whether or not this drop you know, a person may have a normal low body temperature, especially and, again, we have to think about the context of what What are they doing?
Have they been I think this allude to one of the answers earlier.
Have they been doing exercise or not exercise?
Is it you know, if they've been outside for extended amount of time, like, it is now we're not used to having below 40 degree weather here in Louisiana.
So it that becomes itself, you know, not knowing.
But but, you know, you think about where that looks into place, but it should run fairly Consistent with that, if you have whether they have cool and cleaning the the cleaning side or moist or I mean, as a, you know, they're sweating or it just feels kind of that odd, you know, that with that as well, that's what you're gonna look forward.
Whether or not they're having that's a that's getting into a different responses while they're sweating.
So it starts out with a circulatory system, and then they're also it will run it may run its course if the person is having some type of shock.
Or presentation of early shock.
Got you.
And again, if they're warm or they dry, those are just easy things you can determine whether or not they're on fire and they have they've been sitting there.
You know, like like like, there's a there's a as a very loose term.
Like, they're really warm, but they're not do you know, if you're on if you're having hot skin and you've been sitting at a table for an hour, Yeah.
I'm thinking, you know, my first thought is and it's a normal temperature and not having other problems, and they're now having they're decompensated in a number of different levels.
You look at the whole assessment.
Probably the first thing I'm thinking of is sepsis.
If I don't know they have a illness, I'm thinking of a if they have an infection, if it's or, you know, check the other parts of the body as well versus cool, slimy skin, you know, maybe more if you're getting a more of acute, true impairment in circulation from that standpoint.
I think one you know, this this kind of hits in think, you know, that's a good question you have, Doctor Harper, because, you know, for everybody in the audience, you know, think about how Most of the time, if we're in an athletic environment, they're doing some formal participation.
It's the time what they're not is where you really have to think what's normal and what's abnormal and where that context flows in really about where and it's taking a very systematic you have to have a systematic approach, and it takes a lot of practice going through, you know, just identifying what that is, tells a lot about a skin color, whether or not you have this pulse what the pulses are and where that person is based.
And then also tying in The earlier slide on the whole the in the in the review, what you're looking at, if they're having blood loss you're it's to be you're gonna have that change in in skin color, skin temperature.
Those the body is starting to try they're trying it's decompensating and it's fighting for whatever it can to keep that homeostasis.
So that's just a really critical you know, just have to pull that in really fast.
And to make that determination, what's obvious is it with the person like they're they're bleeding, then you gotta stop bleeding.
And then there still may have those problems, but cause also they're they're gonna be excited, you know, an excitatory state.
So you're having to calm the propensity for a significant laceration.
That changes, you know, that adds a whole another dimension into how they're responding and also their bodily response.
Not to mention that they have blood loss, they have oxygen decreased oxygen carrying capabilities based on the amount of blood loss and how long it's it's occurred.
So that reminds me of that track meet we worked not too long ago.
This girl was this female track athlete was unconscious.
And so she was in,
oh, yeah.
She was not pale.
She was unconscious.
So I couldn't get her response.
She was unconscious.
Her vitals were normal or CBD was normal.
Like, everything was checking out.
We're expecting, like, these major decompensation.
She wasn't pale cold and climbing, but she was unconscious.
And so then we, you know, going like, wait.
Things don't make sense.
Like, if you're unconscious, you should have start to have other clues.
You don't have to have other clues, but you should start to see other clues of decompensation.
Start to show up, and she did not, which led us to think that there was more psychological aspect taking place because when they inserted the RV, if I'm mistaken, she started to become a lot.
Is that
what what I gathered from the EMS was after the fact was that and they they were they were they were they were dead.
They were stationary, and they they called a unit to pick the pick people up.
So they were there for that one event.
I just put it in context.
And one thing we talked talked about with got EMS is they were so confused because it was it was showing as a initially, as a seizure.
And they were but though the patient responded had some unusual responses, like you mentioned, they were actually do you they insert a needle from doing apply the paramedics are playing IV to an IV administration, then they it was a different response.
They were actually getting a response.
So it's not typical.
So those are things those are those are the, you know, those those off filter type responses or there's one off responses where you start looking at with us.
But at the end of the day, you know, It's not whether they have that or not.
It's what the pay what the patient is presenting with and you're treating, and it's important that the only you get from this presentation We're not talking about what the diagnosis is.
We didn't you know, we talked about different conditions.
It could be very general.
It's about treating the what the treat the patient.
What they're presenting at that time, clipping this data very rapidly in, you know, in the first 2 or 3 minutes.
You've already gone through it.
It's hard, you know, taking mine in the context.
Not just of this with circulation, but other from assessment standpoint.
If you go do with your assessment, taking blood pressure, pulse, polyoxygenatereat.
You had to take a glucose measurement.
That's gonna take 2 minutes at least if you're doing it by yourself.
So you have to think about this, how how how you're in integrating this pit crew or this team approach, you work that takes practice to do that.
That's another you know, area of refinement in the emergency response process.
As you work through with your you know, if you were the only provider there, you have coaches there, they can still do certain things.
If there's some you know, you could you could work that within your protocol, within training, number of different things to help speed that process up.
But as soon as you get the most data you can get, you need to find but it goes back what you just said, Doctor Harper, you're asking about, is the person predicts unusual things until you can figure that out or determine what it is, you have to treat that as on and what available information you have there.
So that's the if you don't have a pulse oximetry, then You just gotta go off of what that looks like.
So any questions from the audience for where where we wrap things up?
But there are none.
Thank you very much for attending today.
The session.
Appreciate you all being here.
Again,
5 Critical Pulse Points: Circulation Assessment in Unstable Patients
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Updated Jan 22, 2024
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