Beyond the Basics: Patient Assessment

CEU Review Form Patient Assessment (PDF)Valid until September 5, 2006

The ability to perform an accurate patient assessment is one of the most important skills in EMS. The information gained during the assessment is used to make decisions regarding emergency interventions, such as the need for immediate airway management and ventilation; to formulate a differential field diagnosis; and to provide continued and advanced prehospital care. Since this information is used in clinical decision-making, it is important that the assessment findings are interpreted correctly and efficiently. Some findings elicited from a patient may provide confusing or misinterpreted results. Following is a variety of clinical insights intended to clarify and reinforce the assessment skills already being practiced by EMTs and paramedics.

Painful Stimuli
     Following the scene size-up, determining the patient's neurologic status is the next step in assessment. These assessment findings are extremely important, as they provide a baseline of information regarding arousal and cognitive function that will be used throughout the entire time you are managing the patient. Thus, interpreting the assessment findings accurately is essential.

     If the patient does not spontaneously open his eyes, or fails to open his eyes to verbal stimuli of shouts and calling his name, a painful stimulus is applied to elicit a response. The intent of applying a painful stimulus is to test the integrity of cerebral function, which is determined by the patient's response. A more purposeful response is interpreted as a higher level of cerebral function. A nonpurposeful or no response would be an ominous sign and indicate poor cerebral function.

     There are two different types of painful stimuli: central and peripheral. Central stimuli are applied to the core of the body; whereas, pain applied to the extremities is considered peripheral stimuli. In 1974, neurology professors Graham Teasdale and Bryan J. Jennett suggested using fingernail pressure as a form of peripheral painful stimuli to determine if a response is present. A central painful stimulus is then applied to assess for localizing, or the patient's ability to attempt to remove the stimulus. More current literature suggests caution when applying and interpreting the results of peripheral stimuli. When pain is applied to the fingernail bed, lower legs or elsewhere in the periphery, it might elicit a spinal reflex response. That is, the pain impulse travels via a sensory nerve tract to the spinal cord, where it is immediately turned around by a spinal reflex and sent out via a motor nerve tract to the muscle of that extremity, causing the patient to move. The movement may be withdrawal, where the patient pulls the finger or distal extremity away from the painful stimulus, which is interpreted as localizing the pain. Since the impulse was never transmitted to the brain and interpreted by the cerebrum, what appears to be purposeful movement is not a positive indication of cerebral function, but only an indication of intact peripheral nerve tracts. Thus, be skeptical of withdrawal or localizing effects when painful stimulus is applied to the extremities.

     To avoid misinterpretation, assessment for localizing should be performed using a central painful stimulus. Localizing to pain is an important assessment finding, since it identifies the level of cerebral function. It is also a necessary component of the Glasgow Coma Scale scoring for best motor response. When pain is applied to the central portion of the body, the sensory stimulus is sent to the cerebrum, suggesting interpretation within the higher centers of the brain. If the brain is intact, it wants to remove the pain, which it attempts to do by sending a motor response to eliminate or remove the painful stimulus. The assessment finding is an extremity that moves upward toward the pain in an attempt to remove it. True localizing is distinguished from withdrawing to pain by the amount and direction of movement involved. True localizing is defined as the patient bringing his arm up to the level of his chin or to the site of pain. Withdrawing from pain, or withdrawal, is where the patient typically flexes his arms toward the pain; however, he does not make a "purposeful" attempt to remove the pain or move his arms beyond chin level.

     The type of central painful stimulus applied may make a difference in the interpretation of localizing or withdrawal of pain. Acceptable central stimuli include a trapezius muscle squeeze, supraorbital pressure, mandibular pressure or the common sternal rub. The trapezius is a flat muscle that extends from the back of the neck to the shoulder girdle. To apply the trapezius squeeze, grab approximately 1" to 2" of the trapezius muscle near the base of the neck between your thumb and index and middle fingers, squeeze and twist. To apply supraorbital pressure, feel for a notch along the ridge of the orbital rim along the underside of the eyebrow. Using a thumb, apply firm upward pressure to the notch. Mandibular pressure is applied with the index and middle finger pushing upward and inward at the angle of the mandible--the same landmark used when sizing an oropharyngeal airway.

     The most common of the painful stimuli applied by EMS is the sternal rub. To perform it correctly, apply firm downward pressure with your knuckles to the midsection of the patient's sternum and grind back and forth in a rotating pattern. Do not use a motion like you are rubbing a washboard. It may be necessary to apply a sternal rub for up to 30 seconds to get an accurate response. Thus, a patient's failure to respond after receiving a sternal rub for less than 30 seconds may not be due to the brain's lack of integrity, but to failure of the practitioner to apply the painful stimulus properly. Likewise, other types of painful stimuli should be applied for at least 15 seconds, or until a response is produced, but for no more than 30 seconds.

     When assessing for localizing, the trapezius squeeze, supraorbital pressure and mandibular pressure are preferred over the sternal rub. With the sternal rub, it is difficult to distinguish whether movement of the hand toward the sternum is actual localizing in an attempt to remove the pain, or just a response of withdrawal. With the other types of central painful stimuli, the patient has to bring his hand up above chin level to interpret the response as localizing. Since the sternal rub does not clearly distinguish between localizing and withdrawal, and it may take up to 30 seconds of firm pressure to the sternum to elicit a response, it may be the least recommended painful stimulus. Supraorbital and mandibular pressure must not be done on a patient with any type of facial injury. Thus, it appears the trapezius squeeze may be the best painful stimulus applied to test cerebral integrity.

     As a point of clarification, withdrawal, or normal flexion, is considered a purposeful movement. The patient flexes his arms at the elbow without rotating his wrist when a central painful stimulus is applied. The nonpurposeful or abnormal flexion, also referred to as decorticate posturing, is similar to normal withdrawal; however, as the arms flex at the elbows, the wrists also rotate in a spastic-type posture. Extension, also known as decerebrate posturing, is when the arms extend at the elbow with inward rotation. Both abnormal flexion and extension are grave signs of brain injury, with extension having the worse prognosis of the two.

Sensory Assessment in Suspected Spinal Cord Injury
     The sensory impulses of light touch and pain are carried by different tracts within the spinal cord. Because a patient can feel light touch, it does not automatically imply that he can also feel pain, since the impulses are carried by tracts independent of each other. Thus, when performing an assessment of the spinal cord, it is necessary to test both light touch and pain. This is best achieved by breaking a wooden cotton swab in half. Retain the end with the cotton swab and discard the broken stick end. To test for pain, have the patient close his eyes while you use the broken end of the wooden stick to prick his hand. Have the patient identify in which hand and what sensation is felt. Repeat this test in all the extremities. To test for light touch, have the patient close his eyes, reverse the end of the cotton swab and lightly brush the cotton swab end over one hand. Have the patient identify the sensation and in which hand it is felt. Repeat this on all four extremities.

Agitated and Confused Patients
     Mental status is a good indicator of oxygen and carbon dioxide levels in the body. Hypoxia typically causes the patient to become anxious and agitated. Hypercarbia, high carbon dioxide levels, typically causes the patient to become confused. Thus, suspect hypoxia and hypercarbia in an anxious or agitated patient who is confused until proven otherwise.

Blink Test
     A common test performed to rule out a psychogenic coma--one in which the patient is not truly comatose--is to drop the arm on the patient's face. If the arm moves to the side and misses the face on repeated attempts, it is likely the patient is faking the coma. Another method that may be used erroneously is the "blink test" in which the fingers are quickly flicked or snapped in front of the patient's eyes. It is thought that blinking is an indication the patient is faking the coma. However, even if the patient is truly comatose, snapping or flicking the fingers near the eyes may cause air to cross over the cornea, trigger the corneal reflex and cause the eyelids to blink.

Bell's Phenomenon
     The patient with psychogenic or pseudocoma, who is not truly comatose, may attempt to keep his eyes tightly closed and resist attempts to open them for examination. When the eyelids are pulled upward, the patient with pseudocoma will exhibit Bell's phenomenon, where the eyes roll upward until only the sclera are showing. In the truly comatose patient, the eyes will remain in a neutral position with the pupils facing forward.

Pupil Reactivity
     Pupil reactivity is one of the best methods to determine if an altered mental status or coma is due to a metabolic or structural etiology. If the pupils in the altered mental status or comatose patient are unequal or not reacting to light, the cause is likely due to a structural lesion, such as a subarachnoid hemorrhage, tumor, stroke or epidural hematoma. Pupillary reflex and reactivity is typically preserved in patients who have a metabolic etiology of altered mental status or coma, such as hypoglycemia, hypoxia, electrolyte imbalance and drug overdose. If the patient has unequal pupils and is alert and oriented, it may be due to a direct injury to the eye globe, the oculomotor nerve or dilating eye drops, or it may be a normal condition for the patient. Approximately 8% of the population normally has unequal pupils (anisocoria). These patient's pupils both remain reactive to light.

Stroke and Hypoglycemia
     Initially, the condition most commonly misdiagnosed as stroke is hypoglycemia. The hypoglycemic patient, especially the elderly, may present with slurred speech, weakness or paralysis to one side of the body, drooping face and confusion that presents like a classic stroke patient. Be sure to check the blood glucose level on any patient with stroke-like signs and symptoms. If the blood glucose is low, typically less than 60 mg/dL, administer glucose. Follow your local protocol on glucose administration. Never give glucose to a patient presenting as a stroke unless hypoglycemia is confirmed by a glucose meter reading. Research has shown that administering glucose to a patient experiencing an intracranial pathology will worsen the neurologic outcome.

Cerebrospinal Fluid Test
     Leakage of cerebrospinal fluid (CSF) from the ears, nose or mouth is an indication of skull fracture. CSF is a clear fluid that may be confused with other secretions. One way to determine true CSF is to test the glucose content of the fluid using a standard capillary glucometer. CSF contains glucose, but at a much lower concentration than the blood. If glucose is found in the clear fluid, suspect it is CSF.

Narcotics and Pinpoint Pupils
     One of the most common toxidromes seen in the prehospital setting is from narcotics or opiate-derivative drugs. Most often, you will find the classic presentation of an altered mental status, respiratory depression and constricted (pinpoint) pupils. Pinpoint pupils (miosis) are often thought to be the hallmark sign of narcotic overdose. This is true for many narcotics, including morphine, heroin and codeine; however, not all narcotics cause the classic pinpoint pupil presentation. Meperidine (Demerol), propoxyphene (Darvon) and pentazocine (Talwin) will not present with pinpoint or constricted pupils. Do not disregard a possible narcotic overdose due to the lack of constricted pupils in a patient. If there is evidence or a high index of suspicion for narcotic overdose, administer naloxone (Narcan) regardless of pupil size.

"Turtle Sign"
     A shoulder dystocia may be recognized during an obstetrical delivery where the shoulders of the fetus are too wide to be delivered, or the fetus' anterior shoulder is hung up behind the posterior portion of the mother's pubic bone. During delivery of a fetus with a shoulder dystocia, the head is typically delivered normally, but the progress of labor is halted once the head is delivered. Two primary indications that a shoulder dystocia has occurred are:

  1. The fetus' body does not continue to be delivered despite continued contractions and the mother pushing; and
  2. "Turtle sign" is present. Turtle sign is when the fetal head retracts back against the perineum once it is delivered. The cheeks bulge as the head is retracted, resembling a turtle pulling its head back into the shell.

     If you recognize a shoulder dystocia, do not attempt to facilitate delivery by pulling traction on the baby's head and neck. Flex the mother's thighs upward until they are resting on or near her abdomen (McRoberts position). This displaces the pubic bone toward the head and flattens the sacrum. This positioning alone may be enough to allow the shoulders to be delivered. If the delivery is still not progressing, apply firm pressure with the hand immediately above the symphysis pubis. This may reposition the baby's shoulders and allow delivery to progress.

Syncope
     The typical syncopal episode, or "fainting," is associated with an abnormal vasovagal response to blood pooling in the legs and abdomen while the patient is in a standing or seated position. It is extremely rare for a patient to suffer vasovagal syncope while supine. The autonomic nervous system fails to increase the heart rate and vasoconstrict to compensate for the decrease in venous blood return to the right atrium. This produces orthostatic hypotension, which results in decreased cerebral blood flow. The patient often complains of lightheadedness or dizziness prior to syncope, and also complains of nausea and may vomit, appear diaphoretic or yawn prior to the faint. The patient is aware of the signs and symptoms in advance of syncope. The episode will usually not last for more than one minute.

     When a patient experiences a sudden onset of syncope or syncope related to activity or effort, it is most often due to a cardiac etiology. A cardiac dysrhythmia that produces a decrease in left ventricular function or cardiac output with a resultant decrease in cerebral blood flow may be the etiology of the syncope. The patient typically does not experience the signs and symptoms that precede a typical episode of vasovagal syncope.

Todd's Paralysis
     A transient focal weakness (paresis) or paralysis (plegia) of the arm or leg may occur following an epileptic seizure. The patient presents with the focal plegia or paresis during the postictal phase. This finding is transient; thus, it will resolve itself after a period of time. This is important to document, since Todd's paralysis may indicate a focal lesion as the etiology of the seizure disorder.

Babinski Reflex
     The Babinski reflex is assessed by stroking the lateral sole of the foot and across the medial aspect of the ball of the foot with the thumb or a capped pen. A negative Babinski, a normal response, is when the toes curl downward and there is plantar flexion (toe moves toward the bottom of the foot) of the great toe (big toe). A positive Babinski, which typically indicates an abnormal response, is dorsiflexion (toe moves backward toward the top of the foot) of the great toe (big toe). The other toes may fan outward. This may be an indication of a cerebral lesion, specifically to the pyramidal tract of the upper motor neuron. However, a positive Babinski may be a normal finding in a child up to 2 years of age or before they are able to walk, and also in a postictal patient.

Heart Rate and Fever
     An increase in heart rate of 10 beats per minute will typically occur in a young healthy adult for every body core temperature increase of 1ºF or 0.6ºC. Certain diseases, such as typhoid, malaria and Legionnaire's disease, will produce a relative bradycardia where a dissociation occurs between the temperature increase and the expected increase in heart rate. Tachycardia that is excessively high in relation to fever may be seen in early septic shock.

Conclusion
     These are only a small representation of some of the clinical insights related to patient assessment. Understanding the assessment findings and what they may or may not indicate is imperative to providing accurate and efficient prehospital care.

CEU Review Form Patient Assessment (PDF)Valid until September 5, 2006

Bibliography
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Jones DH. Bell's phenomenon should not be regarded as pathognomonic sign. BMJ 323(7318):935.
Lower J. Using pain to assess neurologic response. Nursing 2003 33(6):56-57, 2003.
Mackowiak P. Fever: Basic Mechanisms and Management. New York, NY: Raven, 1991.
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Joseph J. Mistovich, MEd, NREMT-P, is a professor and the chair of the Department of Health Professions at Youngstown (OH) State University, author of several EMS textbooks and a nationally recognized lecturer.

William S. Krost, BSAS, NREMT-P, is an operations manager and flight paramedic with the St. Vincent/Medical University of Ohio/St. Rita's Critical Care Transport Network (Life Flight) in Toledo, Ohio, and a nationally recognized lecturer.

Daniel D. Limmer, AS, EMT-P, is a paramedic with Kennebunk Fire-Rescue in Kennebunk, Maine, and a faculty member at Southern Maine Community College. He is the author of several EMS textbooks and a nationally recognized lecturer.

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