Patient Assessment and Management

Scenario Overview

• Location: Miramar College
• Patient: Mid-20s male
• Chief Complaint: Difficulty breathing

Initial Assessment

• Scene Safety: Confirmed safe
• Nature of Illness: Difficulty breathing
• Number of Patients: 1
• Initial Actions:
  • Called for ALS
  • Withheld C-spine

Patient Interaction

• Introduction and Patient Contact:
  • Introduced as Jesse, EMT
  • Patient identified as Mark
  • Confirmed orientation (location and year)
  • Chief Complaint: Difficulty breathing and itchiness

Primary Assessment

• Airway: Patent, patient speaking in full sentences
• Breathing:
  • Rate: 24 (rapid, labored but adequate)
  • Intervention: Pulse oximetry showed 91% on room air, placed on non-rebreather at 15 L/min
• Circulation:
  • Pulse: Rapid and weak
  • Skin: Warm, flushed, and moist
  • Blood Sweep: No blood

Patient History (SAMPLE)

• Signs/Symptoms:
  • Rapid onset difficulty breathing
  • Itchiness
  • Lightheadedness
• Allergies: Known allergy to peanuts
• Medications: Prescribed epinephrine pen, not present
• Past Medical History: Previous anaphylactic reaction to peanuts
• Last Oral Intake: Cookie suspected to contain peanuts
• Events: Onset after consumption of cookies shared by classmates

Secondary Assessment

• Chest Examination:
  • Rash, hives across chest and arms
  • Expiratory wheezes noted in lung fields
• Vital Signs:
  • Pulse: 100 (rapid)
  • Blood Pressure: 80/50 (hypotensive)
  • Respiration: 24 (rapid, labored but adequate)
  • SPO2: Increased to 95% on O2

Field Impression

• Condition: Anaphylactic reaction based on history and assessment
• Action: Administered epinephrine

Epinephrine Administration

• Description:
  • Confirmed right patient, medication, dose, route, and time
  • Dose: 0.3 mg via auto-injector, IM in right lateral thigh
  • Procedure: Administered with triple check and monitored for 10 seconds
• Reassessment:
  • Monitored every 5 minutes
  • Patient reported decreased difficulty in breathing (6/10 to 3/10)

Hospital Turnover Report

• Summary:
  • Transported patient to hospital with updated vitals
  • Provided detailed handover to nurse, including interventions and patient improvement

Conclusion

• No further interventions required at handover.