Paramedics For Brachial And Rradial Artery Short Answer Quiz

Short Answer Quiz

Discuss about the Paramedics for Brachial and Rradial Artery.

1. Important information required for recording history of the cardiovascular diseases include noting down of the onset time of the symptom, its duration, the severity of the symptom, its course, whether the symptoms are continuous or intermittent and its associated features such as fever or malaise.Finally consideration should be given to whether the patient has experienced similar symptom previously or not. 
2. Commonly palpated pulse sites are carotid artery, brachial artery, radial artery, femoral artery and popliteal artery.  The carotid artery is palpated on the neck below the jaw and lateral to the larynx/trachea using the middle and index fingers. The brachial artery papates on the anterior side of the elbow by applying pressure gently on the artery against the underlying bone with the middle and index fingers. The radial pulse is palpated immediately above the wrist joint near the base of the thumb or in the anatomical snuff box, by applying pressure gently against the underlying bone with the middle and index fingers.The femoral pulse is palpated over the ventral thigh between the pubic symphysis and anterior superior iliac spine with the middle and index fingers and the popliteal pulse is palpated on the posterior knee with the middle and index fingers; the palpation of this pulse is more difficult as compared to other pulse sites.
3. It is required to assess the palpating pulse for full 60 seconds as it highlights the abnormalities which are not detected during the shorter assessment interval. This is required as using shorter time period increases the errors of calculation up to four to six fold. A patient possessing atrial fibrillation, is generally seen to have a regular pulse when 9t is being assessed for a period of 30seconds or less than that.
4. With the beating of the heart, there is pumping of blood round the body to give it the needed energy and oxygen. On blood movement, it pushes against the sides of the blood vessels. Blood pressure is this pressure with which these blood vessels are pushed.
5. Blood pressure is measured by using two numbers. The first of which is called systolicblood pressure. This is used to measure the pressure in the blood vessels when the heart beats. The number of the top in 120/80 blood pressure reading is systolic blood pressure. 

1. The second number used for measuring blood pressure is called diastolicblood pressure. This measures the pressure in the blood vessels when the heart rests in-between the beats. The number of the bottom in 120/80 blood pressure reading is systolic blood pressure.
2. Patient assessment is of great importance for determination of what management therapies need to be provided. Perfusion is part of vital sign assessment. With the deficiency of systemic perfusion there is usually a loss of initial blood flow and pressure to the organs that are less crucial like the skin and the gastro-intestinal system. This is needed to maintain more flow of blood to the vital organs like the brain and the heart.
3. For determining the patient perfusion, various easily measurable evaluations are made. These include the pulse rate, blood pressure, skin appearance and conscious state assessment.
4. Pulse 50-100 bpm, 60-80 mmHg systolic, altered conscious status in relation to time -  Adequate perfusion
5. Skin – cool, pale, clammy, alert, BP 50-100bpm – Borderline perfusion
6. Unconscious, no pulses, unrecordable BP – No perfusion

Short Answer Quiz

1. Maintenance of privacy and confidentiality
2. Neurological assessment is also known as neuro exam is an assessment of evaluation of the nervous system of a person and is done via instrument like lights and reflex hammers. Some areas tested in the neurological assessment include measurement of the head circumference, mental status of the person (patient’s level of awareness and interaction with the surrounding environment); motor function or balance of the patients (via pushing or pulling the patient against the hands of healthcare provider via his or her legs or arms); detection of the sensory function (done via dull needles, alcohol swabs, tuning forks or other objects); evaluation of the functioning of the 12 different cranial nerves originating from the brain and assessment of the hand-eye co-ordination. 

1. 
   Common cause behind the alteration of the patient’s mental status include psychiatric illness like schizophrenia or depression and acute brain dysfunction.

Serial number	Eye opening Response	Best verbal response	Best motor response	Total score
a	2	4	5	11
b	4	3	6	13
c				8 or less (Comatose client)
d	1	1	1	3 (totally un responsive)

  Romberg Test is use to examine the neurological function for balance and also use to text driving under the influence of certain intoxication. The overall examination is based on the premise that the person requires minimum two out of three senses to maintain the body balance while in a standing position. Three main senses include proprioception, vestibular function and vision

5. Examination limb strength of the patients helps in the assessment of the sensory modalities of the limb and this help in the further assessment of the body balance. It provides additional information about the motor movement and provide vital information about the developing hemiparesis in the leg or arm in one side of the body that is either left or right.
7. Space-occupying lesions: occurs in brain because of malignancy or other abnormal pathological condition including haematoma or abscess. Majority of the intracerebral tumours are primary and the remaining mainly originates outside the CNS. Examples: brain tumours (primary of metastatic) 

1. Oedema: characterised by excess accumulation of watery fluid in the cavities or tissues of the body. Examples for oedema include cerebral oedema (extracellular fluid accumulation in brain)
2. Pupillary reactivity is an early indicator which indicates increase of  intracranial pressure and is common among patients having severe traumatic brain injury There exist an inversely proportional relationship between the intracranial pressure and papillary reactivity. Increase intracranial pressure signifies decreased papillary activity.
3.  ‘Cushing’s triad’ should not be confused with Cushing reflex. ‘Cushing’s triad’ is a sign of increased intracranial pressure. The Triad mainly consists of hypertension (progressive increase in the systolic pressure), bradycardia and widening pulse pressure (progressive increase in the differential relation between the systolic and diastolic pressure).
4. Vital signs of neurological assessment includes

• Level of consciousness
• Blood pressure
• Heart rate

11. Assessment of pupil response and size in relation to light is not directly a part of the Glasgow Coma Scale but is regarded as vital addition to the GCS assessment. Assessment of pupil is done in both conscious and unconscious patients. The main process of assessment involves

• Looking at the size of both the pupils
• Observation of shape of both the pupils
• Observation of whether both the pupils react to light in equal manner

12. A low Glasgow Coma Scale scoredoes not always accurately led to the determination of severe traumatic brain injury. Proper examination of the verbal score is also important to detect the presence of severe traumatic brain injury. 

CASE STUDY

1. The first reaction on seeing the patient in this condition will be to try to comfort him possibly by laying him down. The next step will be trying to identify his signs and symptoms in order to make out the cause of his distress. There is a chance trying to get to know of his problems by asking him when such symptoms started occurring. Next step will be to call 911 or a local emergency contact number of the patient if such is available. In case aspirin is available, the patient can be made to chew and swallow an aspirin. If the patient is able to inform that there was a history of heart attack earlier, and if the doctor had prescribed nitro-glycerine for the patient, make the patient take it as directed by the doctor (Pasqualucci et al., 2015).
2. Looking at the visible symptoms of the patient the most probable guess would be a heart attack as the patient tends to clutch his chest and looks pale, sweaty and anxious and breathing at a fast rate. An additional information is that the patient is a quite aged, which increases the chances of heart attack.  The symptoms of heart attack generally involves:

• Uncomfortable pressure, fullness or squeezing pain in the centre of the chest
• Spreading of discomfort or pain beyond the chest to the shoulders, back, neck, jaw, teeth, or one or both arms, or occasionally upper abdomen
• Shortness of breath
• Light-headedness, dizziness, fainting
• Sweating
• Nausea (Patra, & Mishra, 2017). 

3. In such situations of chest pain occurring in a patient, performanceof an accurate assessment is an important requirement. Although there are various methods of assessing the chest pain, one of the most popular methods is ‘PQRST’ pain assessment which involves the following:  P for Position/Provoking Factors, Q for Quality, R for Radiation, S for Severity/Symptoms and T for Time. The questions involved for Position/Provoking Factors includes “when the pain started what were your actions? How did it take place? Is there anything that makes it better or worse? Does any stimuli trigger it like Stress or a certain Position or maybe certain activities?” For Quality/Quantity, the questions are “How does it feel? Words can be used to describe the pain such as sharp, dull, stabbing, burning, crushing, throbbing, nauseating, shooting, twisting or stretching”, for Region/Radiation it is “Where does the pain seen to be located? Does the pain seem to be radiating? If so, where? Does the pain feel to be travelling or moving? was the pain focused when it started?”, for Severity Scale,  “
4. Mention the severity of the pain on a scale of 0 to 10 where zero is no pain and 10 is the worst pain ever? Does the pain interfere with the daily activities? How bad is it at its worst? Does the pain force you to sit down or slow down? For how much time does the episode last?” and for Timingthe questions are “When did the pain start?for how long did it last ? How often does the pain does it occur? Is the pain sudden or gradual? When the pain was fists experienced, what were you doing? When do you usually experience it? Are you ever awakened by the severity of the pain? Does the pain lead to any other symptom? When does the pain occur the most? Is it during or after meals? Is the occurence seasonally?” (Ioannidis & Khoury, 2014).
5. HR = 120 rapid, and weak– it is more than the normal range as the normal rate of heart beat is 100 beats per minute.

BP = 180/70 – the blood pressure is also quite high compared to the normal range. The normal range of blood pressure is 120/70 for an adult.

SaO2 = 93% - This is below the normal range as the normal is between 95 to 100%

RR = 25 with crackles heard on auscultation – This respiratory rate is normal.

6. Some of the basic symptoms of heart attack included an experience of extreme pressure on the chest and chest pain which includes a squeezing or full sensation. This is generally followed by pain in one or both arms, jaw, back, stomach, or neck. Other such symptoms of heart attack include shortness of breath, nausea, vomiting, light-headedness, and breaking in cold sweat. Although the characteristic symptoms are chest pain and pressure, it is likely that women suffer more incidents of heart attack than men that does not occur in the traditional way. Instead, some women with heart attacks may experience more of the other symptoms, like light-headedness, nausea, extreme fatigue, fainting, dizziness, or pressure in the upper back (Patra, & Mishra, 2017).

CP2 8.10 - CASE STUDY QUIZ

1. The AVPU scale which is the acronym for alert, voice, pain and unresponsive, is a system that is used by health care professional in order to measure and record the level of the consciousness of the patient. According to this system, the patient is alert as he is fully awake. The eyes are open spontaneously and he can respond to the commands, although there may be confusion. The next is voice. Although the patient can respond to the voice or a verbal stimulus, the patient is not able to speak. Next there is pain. In this category the patient responds upon application of pain stimulus. Here the patient is unable to respond to such pain stimulus. The next is unresponsiveness. Here the patient is evidently unresponsiveness as there is no response to the voice or the pain (Hoffmann et al., 2016). 

1. 
   The Glasgow coma scale (GCS), an effective neurologicalscale which helps in giving an efficient and objective way for recording of the state of a person when the individual is conscious. This is required for the initial as well as the assessments that follow after the initial one. The elements of the GCS includes eye response, motor response and verbal response. According to this scale the patient described here the eye response of the patient can be recorded as 4 as the eyes are open spontaneously. The verbal response is 2, as the patient can only moan in order to respond to a verbal stimuli. Lastly the motor response is 2, as the patient is able to show some motor response on the left side but not on the right side (Teasdale et al., 2014)
2. The important questions that can be asked in  order to assess such conditions indicating towards brain injury includes the occurrences and the severity of :

• headaches,
• ‘pressure in head’,
• neck pain,
• nausea or vomiting,
• dizziness,
• blurred vision,
• balance problems,
• sensitivity to light,
• sensitivity to noise,
• feeling slowed down,
• difficulty in concentrating,
• difficulty remembering,
• fatigue or low energy,
• confusion,
• drowsiness,
• excessive tiredness,
• more emotional,
• irritability,
• sadness
• Nervousness or anxiety (Roozenbeek, Maas & Menon, 2013).

4. The vital signs assessment required for such patient includes measuring blood pressure, heart rate, respiratory rate and blood glucose level (Yue et al., 2013).
5. The probable disorder that the patient seems to be suffering from is stroke. Therefore treatment should be given according to this (Jauch et al., 2013).
6. According to the clinical practice guidelines of the QAS Clinical Practice Manual, in case of a stroke the following guidelines must be followed:

• IV access considering  oxygen, antiemetic, analgesia, IV fluid, and stroke mimics
• Consider acute stroke referral   

Stroke identification algorithm;

Source (Krebes et al., 2013)

8. The assessment tool that can be used for this patient includes the physical examination which assesses the facial droop, strength in the arms, handshake and speech (Anon, 2018).
9. In accordance to this assessment tool, the examinations conducted require for raid referral since there was a positive facial drool, no strength in the arms, the patient was unable to shake hands and there was absent of any kind of speech apart from moaning (Clinical Management Guidelines – ACT Ambulance Service, 2018).

Fundamentals of Paramedic Practice – a systems approach

1. Percussion is used to elucidate whether organs present in the abdomen are enlarged or not (organomegally). It is based on the principle of setting tissue and spaces in between via vibration. The generation of sound is used to determine whether the tissue is healthy or has certain abnormal pathological significance (Phillips, 2018).
2. Acute appendicitis

Cause: Appendix is a organ that branches out of the first part of the large intestine and is located on the left side of the abdomen. Appendix is a vestigial organ means it has so functions within the body however at times it becomes victims of organomegally leading to pain this condition is known as acute appendicitis. Acute appendicitis is defined as an acute or chronic inflammation or enlargement of appendix. Appendicitis can occur anytime however, it is common between the age group of 10 to 30 years. It is more common among males in comparison to females (Buckius et al. 2012)

Presentation:  abdominal pain in the lower right side of the abdomen and pain around the belly button

Signs and Symptoms: nausea; vomiting; constipation; diarrhoea; abdominal swelling and mild to moderate fever; blood in urine, rapid heart beat

Examination: Abdominal imaging via Ultra Sonagraph.

(Alvarado, 2016)

3. Ascultation of the abdomen is done in order to detect altered bowel sounds, rub or vascular bruits. Normal process of peristalsis of abdomen generates a typical bowel sound which may be altered or may be completely absent in any diseased condition. For example, irritation of serosal surface might produce a typical sound of rub like a organ moving against certain serosal surface. Another example is atherosclerosis which altered the arterial blood flow and thus a typical bruit is produced (McPherson & Pincus, 2017).
4. Scars signify the history of previous abdominal surgery of injury and this is important while inspecting for hernia (Summers, 2018).

• Kocher's Incision scar signifies: biliary surgery like cholecystectomy or hepatic surgery
• Upper Midline Laparotomy: Upper gastrointestinal surgery
• Lower or long midline laparotomy scars: Splenic surgery or repair of the congential diaphragmatic hernia
• Ramstedt's Pyloromyotomy Scar: treatment of pyloric stenosis
• Grid- Iron Incisions at the McBurney's Point: Appendicectomy
• Umbilical or sub-umbilical scars: Hernia repairs or gastroschisis repair

(Mistrangelo et al. 2014)

5. Visceral pain results from the activation of nociceptors of the pelvic, thoracic or abdominal viscera (organs). It represents a serious clinical problems including cancer. Functional gastrointestinal disorders (FGID) underline the one of the common representations of the visceral pain (Sikandar & Dickenson, 2012). Under FGID, there comes irritable bowel syndrome which is characterised abdominal pain along with discomfort in bowel habits. The main clinical feature of visceral pain differs in different phases of pathology. "True visceral pain: airses in the form of poor or poorly defines sensation which is perceived in the midline of the body and at the lower sternum of the abdomen. Visceral pain is often related to autonomic phenomena like profuse sweating, nausea, disturbance in the gastro-intestinal tract and change in the body temperature (Sikandar & Dickenson, 2012).
7. Masses: Formation of lump at any portion of the abdomen which signifies either the formation of tumour (both malignant or non-malignant) or signs of hernia
8. Scars: Indication of previous medical history of abdominal surgery or injury related to sudden accidental. Location and shape of scars help in the identification of the type of medical surgery

• Lesions: Presence of masses or mass like lesions inside the abdominal wall. While doing abdominal assessment this lesions appear to be uneven presence of sudden particles inside the abdominal wall

1. Abdominal distension: occurs when fluid or air (gas) accumulates inside the abdomen causing an outward expansion of the abdomen beyond the normal girth of the waist and stomach.
2. Ascities: Abnormal build-up of fluid inside the abdomen

(Sanders et al. 2012)

8. Chronic pancreatitis
9. Acute appendicitis
10. Enlargement of colon (Macaluso & McNamara, 2012)

• Ectopic pregnancy
• Ruptured abdominal aortic aneurism (AAA): occurs mainly due to the dilation or rupture of the aorta within the abdomen
• Peritonitis and sepsis: Occurs due to inflammation of the serosal membrane present inside the abdominal cavity. It mainly caused via the perforation of the visceral organ
• Testicular/ovarian torsion: It cause interruption in the vascular supply and thereby leading to ischaemic pain
• Uncontrolled gastro intestinal tract (GT) haemorrhage Like upper GIT and lower GIT. Upper GIT is common in oesophagus, stomach and duodenum and lower GIT is common in small bowel and in the colon
• Acute bowel obstruction

(Macaluso & McNamara, 2012)

9. The risk factors associated with the abdominal pain include transient disorder to serious disease like organomegally, gastritis and inflammatory bowel syndrome 

Case Study

1. Location of pain, for how long the pain is occurring
2. Acid reflex. Acid reflux and heartburn which is felt burning sensation along with pain can cause pain in the right scapula that is towards the shoulder. This again coincides with the lack of breathing. This is because immense acid reflux in the abdomen leads to the generation of shortness of breath.
3. The stomach acid gradually creeps into the oesophagus and then subsequently enters into the lungs and this causes swelling of the airways leading to shortness in breadth.
4. Heart burn or acid influx 

References

Alvarado, A. (2016). How to improve the clinical diagnosis of acute appendicitis in resource limited settings. World Journal of Emergency Surgery, 11(1), 16.

Anon (2018). Retrieved from https://www.ambulance.qld.gov.au/clinical.html

Buckius, M. T., McGrath, B., Monk, J., Grim, R., Bell, T., & Ahuja, V. (2012). Changing epidemiology of acute appendicitis in the United States: study period 1993–2008. Journal of Surgical Research, 175(2), 185-190.

Clinical Management Guidelines – ACT Ambulance Service. (2018). Retrieved from https://esa.act.gov.au/actas/about-us/clinical-management-guidelines/

Hoffmann, F., Schmalhofer, M., Lehner, M., Zimatschek, S., Grote, V., & Reiter, K. (2016). Comparison of the AVPU Scale and the Pediatric GCS in Prehospital Setting. Prehospital emergency care, 20(4), 493-498.

Ioannidis, J. P., & Khoury, M. J. (2014). Assessing value in biomedical research: the PQRST of appraisal and reward. Jama, 312(5), 483-484.

Jauch, E. C., Saver, J. L., Adams, H. P., Bruno, A., Demaerschalk, B. M., Khatri, P., ... & Summers, D. R. (2013). Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 44(3), 870-947.

Krebes, S., Ebinger, M., Baumann, A. M., Kellner, P. A., Rozanski, M., Doepp, F., & Wellwood, I. (2013). Development and validation of a dispatcher identification algorithm for stroke emergencies. Stroke, 43(3), 776-781.

Macaluso, C. R., & McNamara, R. M. (2012). Evaluation and management of acute abdominal pain in the emergency department. International journal of general medicine, 5, 789.

McPherson, R. A., & Pincus, M. R. (2017). Henry's Clinical Diagnosis and Management by Laboratory Methods E-Book. Elsevier Health Sciences.

Mistrangelo, M., Gilbo, N., Cassoni, P., Micalef, S., Faletti, R., Miglietta, C., ... & Morino, M. (2014). Surgical scar endometriosis. Surgery today, 44(4), 767-772.

Pasqualucci, D., Fornaro, A., Castelli, G., Rossi, A., Arretini, A., Chiriatti, C., ... & Matta, G. (2015). Clinical spectrum, therapeutic options, and outcome of advanced heart failure in hypertrophic cardiomyopathy. Circulation: Heart Failure, CIRCHEARTFAILURE-114.

Patra, L. B., & Mishra, A. K. (2017). Cardiogenic shock as the initial presentation of systemic lupus erythematosus. International Journal of Scientific Reports, 3(4), 106-107.

Phillips, R. E. (2018). Abdomen. In The Physical Exam (pp. 179-199). Springer, Cham.

Roozenbeek, B., Maas, A. I., & Menon, D. K. (2013). Changing patterns in the epidemiology of traumatic brain injury. Nature Reviews Neurology, 9(4), 231.

Sanders, M. J., Lewis, L. M., McKenna, K. D., & Quick, G. (2012). Mosby's paramedic textbook. Jones & Bartlett Publishers.

Sikandar, S., & Dickenson, A. H. (2012). Visceral Pain–the Ins and Outs, the Ups and Downs. Current opinion in supportive and palliative care, 6(1), 17.

Summers, S. L. (2018). Chronic Pelvic Pain. In Ambulatory Gynecology (pp. 91-109). Springer, New York, NY.

Teasdale, G., Maas, A., Lecky, F., Manley, G., Stocchetti, N., & Murray, G. (2014). The Glasgow Coma Scale at 40 years: standing the test of time. The Lancet Neurology, 13(8), 844-854.

Yue, J. K., Vassar, M. J., Lingsma, H. F., Cooper, S. R., Okonkwo, D. O., Valadka, A. B., ... & Puccio, A. M. (2013). Transforming research and clinical knowledge in traumatic brain injury pilot: multicenter implementation of the common data elements for traumatic brain injury. Journal of neurotrauma, 30(22), 1831-1844.