Assessment Principles

  • Emergency Department (ED) assessment should be holistic and should be geared towards trying to rule out sinister pathology as in ED, it may not be possible to develop an exact diagnosis
  • Non-musculoskeletal causes for presenting complaints should be considered and potentially disproven
  • Focus should be on what is imperative to show in the emergency department presentation TODAY (as an EMERGENCY) and to make an appropriate referral for followup to arrange whatever care / investigations might need to be made not as imperatively
  • It is not necessary (and may not be possible / accurate) to complete every possible test – complete the ones which help you to understand if there is a serious problem that needs attention TODAY
  • The LIFE OF PATIENT is most important, then the LIFE OF LIMB is next and everything else falls behind that
  • Know pathologies that are prevalent or unique for particular populations eg paediatric
  • Know pathologies / patterns that are associated with a particular mechanism of injury – UNDERSTAND THE MECHANISM AND WHAT FORCES COULD DO, e.g.:
    • Axial loading and compression fractures
    • Correlation between calcaneal fractures and spinal injury
    • Buckle fractures
  • If no mechanism or vague symptoms, be excessively thorough
    • Full limb or spinal assessment
    • Take observations
  • If a mechanism or pattern:
    • When did it happen?
    • What happened exactly?  Try to understand the mechanism and forces involved (if present)
    • What symptoms initially?
      • Where were the symptoms initially?
      • Describe pain – sharp / superficial / deep / ache / burning etc
      • What aggravates and what eases?
      • For LL problems, include ability to WB
    • What symptoms now?
      • Have the symptoms changed? Better / Worse? Location?
  • If no mechanism
    • How long has it been there?
    • Is there anything that they believe may have contributed to the development of the problem? Recent activity / inactivity
    • What symptoms are present?
    • Are they there all the time?
  • What treatment has been sought so far?
    • Assessment
    • Investigations
      • If imaging, do they have it with them?
      • If not, can we view it?
        • Private providers use online applications
        • If in another public hospital in Victoria, then can use the “Synapse Mix” service to get the images temporarily put on local network diagnostic imaging servers.
  • What management has been undertaken? Has it been effective
    • Splinting
    • Ice
    • Medications
  • History of problems in that area before
    • When?
    • How was it managed?
      • Assessment undertaken?
      • Investigations
      • Medications
    • Any ongoing problems?
  • Any associated symptoms (if a non mechanical cause or if at all suspicious)
    • Recent illness / fevers / sweats
    • Recent overseas / long haul travel / immobilisation (eg for suspected DVT)
    • Loss of appetite / loss of weight, etc
  • If has a wound
    • Tetanus status
  • If potentially needing procedural sedation or surgery (and consider this for anyone you are contemplating an x-ray for)
    • Fasting status (and tell them not to eat and drink until you tell them it is ok to do so
  • Questions specific to injury area (see specific assessment section)
Subjective
  • Did the patient ACTUALLY trip or slip?
    • What was the exact mechanism?
    • Are they unsure of exactly what happened?
      • Recent illness?
      • Any preceding symptoms?
      • What was the last thing they remember before the fall?
      • What was the first thing they remember after the fall?
      • Has this ever happened before?
        • How many times?
        • When?
        • Result?
        • Investigations?
  • If fall from a height
    • How high did they fall from (3m or more is a trauma call)
    • How did they land?
    • Did they hit their head? On what?
      • Any loss of consciousness? If so, for how long (if they can figure it out or if witnesssed)
      • Any neck pain?
      • Visual disturbance
      • Headache
      • Nausea
      • Vomiting
      • Seizures
      • Memory loss
      • Unusual behaviour
      • Excessive drowsiness
      • Shortness of breath
      • Dizziness
      • Palpitations
      • Limb weakness
Objective
  • General overview of patient
    • Making sense, carrying a normal conversation
  • If headstrike
    • Clear cervical spine FIRST
    • If unable to clear
      • Need to lay flat
      • Likely apply cervical collar
      • Discuss with Senior Medical Staff (SMS) immediately
    • Once cervical spine has been sorted
      • Assess and support potentially limb threatening injuries
      • Continue with assessment as appropriate
  • If possible collapse
    • Obs – BP (consider postural BPs), HR, O2 Sat, Temperature
    • Discuss with SMS
      • Likely for ECG, potentially other tests
  • Start with open ended questions, but need to be specific with:
    • Asthma / respiratory difficulties
    • Cardiac problems
    • Hypertension
    • Diabetes
    • Cholesterol
    • Surgery
    • Hospitalisations
  • Medications
    • List any used (drug names preferable) and dose include timing for analgesia
  • Allergies
    • Medications
    • Food
    • Other (eg latex)
  • If cannot complete medical history as patient unsure, then call GP clinic or place where received last Rx and ask for a discharge / medication summary.
  • Handedness (for upper limb issues)
  • Occupation
  • Recreation
  • Social support
    • Who do they live with?
    • Does the patient normally need assistance?
    • Does the patient provide assistance for someone else?
  • Home layout (if relevant)
    • Steps?
    • Shower over bath or recess?
  • Drug use
    • Tobacco
      • How many and for how long (pack years)?
    • Alcohol
      • How often and how much?
    • Recreational drugs
      • What and when last used?
  • Observation
    • Need to look at site of interest, as well as joints above and below
      • EXPOSE THE BODYPART!
    • Deformity / Swelling / Bruising
  • Wounds
    • Size
      • Width (mm) * length (mm)
    • Type
      • Abrasion
      • Skin Tear - with or without skin loss
      • Laceration
      • Incisional injury
      • Penetrating injury
  • Distal Neurovascular Function
    • Colour
    • Movement
    • Warmth
    • Sensation
    • Capillary Refill
    • Pulses
      • Upper Limb (Radial, Brachial)
      • Lower Limb (Dorsalis Pedis, Posterior Tibial, Popliteal)
  • Active ROM
    • Physiological Movements (including joints above and below)
      • Ask to the patient to move actively
      • Active assisted if reluctant to move and does not cause distress
  • Palpation
    • Palpate the bones from the joint above the problem, to the joint below
    • Palpate soft tissue structures
    • Be specific to what you are palpating
  • Special Tests
    • Specific to the area(s) of interest
    • Used to:
      • Clear a region
      • Potentially diagnose pathology eg Lachmans
  • Develop a preliminary diagnosis
  • Determine the need for further investigations
    • Diagnostic Imaging
    • Pathology
    • Other tests
  • Determine the need for medications
    • Analgesia
    • Tetanus
    • Other
  • What needs to be done TODAY?
  • Can the patient be discharged TODAY or do they need ADMISSION?
    • If for DISCHARGE, inform the patient of the following:
      • What is the diagnosis (or preliminary diagnosis)?
      • How long will this problem take to settle?
      • What does the patient need to do to manage the problem?
      • What medications might they need to take?
      • Who do they need to see NEXT and WHEN?
        • For example
          • GP if not improving in a week
          • Physio in a week’s time to commence rehab
          • Fracture clinic in 2/52.
      • When should they be concerned / when should they return to the Emergency Department?
        • Eg Neurovascular compromise