A systematic approach for the evaluation of a newly arrived ED patient will allow the emergency department (ED) technician to properly evaluate and help prioritize the patient. The ED technician (EDT) may be the first person to have contact with the patient, and the information gathered and the initial decisions made are critical to providing rapid, effective care. Remember, if an ED Tech ever feels uncomfortable about a patient, they should escalate the evaluation to an ED physician or nurse.
Doorway Examination
There is a significant amount of information that can be ascertained simply by seeing a patient for the first time from the “doorway,” and this “first impression” is valuable in answering the initial question: “Is this patient sick or not sick?”
Among the observations that the tech should consider are:
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What do you see, hear, and smell?
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Was the patient ambulatory?
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How old do they appear relative to their chronologic age?
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Do they appear to be in any respiratory distress?
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Is there any obvious trauma?
The answers to these questions should inform the speed with which a patient should be treated. For example, an older-appearing male with a “gray” appearance who is clutching his chest and breathing hard requires a more rapid response than that of a nondistressed, younger female who walked to her bed, speaks in full sentences, and appears “well.” The EDT will refine their clinical judgment as they gain more experience. This chapter will provide guidelines and suggestions to assist with the process of building the EDT’s assessment judgment.
Primary Survey: ABCDE
The ABCDE framework provides a systematic method of evaluating and assessing patients for life-threatening conditions. This approach is standard in advanced trauma life support (ATLS), but it has been widely adopted to help evaluate any patient.
The ABDCE approach is stepwise algorithm, meaning that the first step must be addressed before going on to the next ( Table 5.1 ). The sequence is as follows:
A:Airway—Is the airway patent? Are there any signs of obstruction?
B:Breathing—Does the patient have symmetric chest rise? Is the patient working hard to breathe, or is their respiratory rate either very slow or very fast?
C:Circulation—Are the patient’s extremities cool to the touch? Are you able to feel peripheral pulses (pulses in each extremity should be palpated)? Is their heart rate unusually rapid or slow?
D:Disability—What is the patient’s level of consciousness? In most patients, the AVPU (alert, voice, pain, unresponsive) scale is sufficient ( Table 5.2 ). In trauma patients, the Glasgow Coma Scale ( Table 5.3 ) is used.
Table 5.2
This is a simple bedside tool to describe the patient’s level of alertness.
A = Alert
Patient is fully alert and does not need to be repeatedly stimulated to maintain alertness.
V = Verbal
Patient will not remain alert, but regains alertness in response to verbal stimuli.
P = Pain
Patient will not remain alert, but regains alertness after painful stimuli.
U = Unconscious
Patient will not arouse to either voice or pain.
Table 5.3
The best score is 15, and the worst score is 3, reported either as the total number or by category (e.g., E4, V5, M6).
Revised Scale
Score
Eye opening (E)
Spontaneous
4
To sound
3
To pressure
2
None
1
Nontestable
NT
Verbal response (V)
Oriented
5
Confused
4
Words
3
Sounds
2
None
1
Nontestable
NT
Best motor response (M)
Obeys commands
6
Localizing
5
Normal flexion
4
Abnormal flexion
3
Extension
2
None
1
Nontestable
NT
E: Exposure—What other injuries or deformities might be present on exam? Are there any burns, bullet wounds, signs of bleeding, or other obvious signs of trauma? It is important to completely expose the patient to identify all injuries.
Primary Survey | Assessment | Intervention/Management |
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A: Airway | Can the patient talk normally? If yes, then the airway is open.If the patient cannot talk normally, listen for:
| If the patient is unconscious, not breathing normally, and there are no signs of trauma:
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B: Breathing | Look for:
| Start bag-valve mask ventilation for the following scenarios:
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C: Circulation | Look and feel for signs of poor perfusion:
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D: Disability |
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E: Exposure |
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