Wilderness and Rescue Medicine 8th Edition

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Wilderness and Rescue Medicine

a complete head-to-toe checklist, mentally if not physically. The complaint of a sprained thumb by an other- wise healthy person does not warrant a complete survey with vital signs and a full physical exami- nation; however, a person with altered mental status and a mechanism for significant injury certainly does. The less information the patient can give you, the more information you will need from your exam. Your secondary assessment catalogs anything abnormal, such as tenderness, discoloration, swelling, and deformity. You do not have to be an experienced anatomist to recognize a deformed long bone or bruises and abrasions . If your patient is at all responsive, you will be able to find out what hurts. Advanced practitioners listen for breath sounds with a stethoscope , look in ears, and peer down throats. The abdominal exammight also include listening to bowel sounds or palpating specific spots for tenderness. The secondary assessment of the nervous systemmay be as simple as talking to the patient to determine mental status or as complex as testing cranial nerves and deep tendon reflexes. The complexity of your examwill depend on your level of comfort and training. In all but the simplest case, any exam is better than no exam. In an unresponsive or unreliable patient, your exam should also include the patient’s pockets, wallet, and pack. A medication bottle, insulin syringe, or medical identification bracelet or card can provide valuable information in a confusing case. Respect privacy but get the data you need. Vital Signs During the primary assessment we look at pulse, respiratory effort, and mental status as part of our quick look for serious problems. During the secondary assessment, the measurement of vital signs provides a more complete view of critical system function and compensation. Decay or improvement in the patient’s condition is revealed by changes in the vital sign pattern over time. This can serve to reassure you that the patient is okay or provide an early warning of developing trouble.

The detail with which you measure vital signs will depend on the equipment available and your level of training. How often you measure vital signs will depend on the logistical situation and your level of comfort with the patient’s condition. Pulse rate (P) is usually easy to measure accu- rately and reflects almost any change in the circu- latory system. During the primary assessment, we were concerned only with the presence of a pulse and the estimation of fast, slow, or normal. During our secondary assessment, we have the time to measure pulse rate more accurately in beats per minute—quickly obtained by counting the pulse for 15 seconds and multiplying the count by four. Noting the rhythm (irregular or regular) can be helpful in some cases, but subjective assessments like weak, thready, or bounding are rarely useful in the field setting. You can find the pulse in any artery , but the radial (wrist), carotid (neck), and temporal (temple in front of the ear) are the most accessible. Blood pressure (BP), like pulse, is a measure- ment of circulatory system function. A reading of 120/80 mm Hg is considered normal for a healthy adult. The systolic reading (top number) indicates the pressure produced by the force of each heart contraction. The diastolic reading (bot- tom number) reflects the resting pressure of the system maintained by arterial muscle tone. The systolic pressure is the most useful and the easiest to measure in the emergency setting. Systolic BP is usually measured by inflating a blood pressure cuff around the arm and apply- ing enough pressure to stop arterial blood flow completely. The cuff is then slowly deflated while the examiner watches the gauge and feels for the return of a pulse in the wrist. The reading on the gauge when the first beat is felt is the systolic BP. Diastolic BP is obtained by listening to arte- rial flow with a stethoscope or Doppler device. Portable automated BP cuffs capable of measuring systolic and diastolic are often used in ambulances and emergency departments, and now appear in the jumps kits used by some ski patrols and back- country rescue teams.