Five Assessment Findings That Should Concern You

Did you ever watch the old Star Trek TV show? No of course you didn’t, but this is just you and me talking here right? OK, remember when something would threaten the ship. The captain’s first response was to say, “Go to red alert.” or “Set condition red.” and the lighting would change and a little alarm would sound. That funky shaped light on the front console would start pulsing red. Everyone knew to treat the situation with importance.

I don’t know about you, but I have a list in my head of assessment findings that cause me to shift mental gears into condition red. I don’t need to say anything overly dramatic, but everyone on who works with me can tell when I’ve switched gears to condition red.

For one thing, I start moving just a bit faster than my usual casual pace. I delegate tasks in a laundry list fashion. “I’m going to need an O2 mask. Lets get the pram to the door and bring a stair chair up here. Jesse strip me a line in the rig and check the status of Swedish ER.” The patient may not know the difference, but people who work with me can tell that I’ve set condition red.

Here are a few of the assessment findings that send off alarm bells is my head.

Syncope From The Sitting Position

The more benign causes of syncopetend to occur when the patient has shifted from the sitting to the standing position or was exerting themselves in the standing position. We always need to assess syncope with a high index of suspicion, but be particularly concerned with people who report syncopal episodes while sitting in a chair.

Often this is the first sign that differentiates simple vasovagal and positional syncope’s from more serious neurological and cardiac episodes. “We were just sitting here playing cards when Marge sort of slumped over and wouldn’t talk to us.” Now Marge is embarrassed and wants you to go away. Don’t do it. Set condition red. Marge needs a detailed neurological evaluation and a full cardiac workup. Get  busy.

Unilateral Neurological Deficits

There are very few reasons to experience a neurologic change on one half of the body and not on the other. If you walk in to a call and the patient has a facial droop, unequal pupils or can’t move one arm the chances are likely that you’re dealing with something serious. Sure, it may end up being something benign like Bells Palsy, but it’s far more likely that we’re dealing with a stroke, tumor or neurologic injury.

A unilateral (one sided) neurologic change needs to be addressed with a high degree of concern regardless of the patients age or apparent level of distress.

A Change in Voice After Throat Trauma

This one can be subtle, so you need to really pay attention to your patients voice. Any time you’re assessing someone who has experienced trauma to the throat, ask someone on scene who knows them, “How does his voice sound to you?” The structures of the trachea are complex and fragile. One of the first signs of injury to these structures can be a change in voice or discomfort while swallowing. These patients can deteriorate rapidly into complex airway issues.

Common throat injury mechanisms are seat belts, sports injuries and choking. All throat injuries should be addressed with great caution and someone with a voice change should be transported emergent to the ER for evaluation. Potentially penetrating throat trauma should be evaluated with an even greater degree of concern.

The Silent Chest

There are a lot of junky lung sounds out there that should be cause for concern, but nothing puts me in high gear quite like hearing … nothing. Whether the respiratory issue is congestive like pneumonia or CHF or obstructive like asthma or emphysema, the final, most severe end of the lung sound spectrum is silence.

If you place your stethoscope on the chest of a person struggling to breath and hear nothing, you have minutes to fix the problem. Hit the red alert buzzer and get out your BVM, CPAP, medications and all of your airway skills and tools. What you are able to accomplish in the next five minutes will determine a lot about this patients course of care.

Pale, Cool, Diaphoretic Skin

Once upon a time I explained that skin doesn’t lie and that’s probably one of the most compelling reasons why we need to pay attention to pale, cool, diaphoretic skin.  Unless your patient is a Canadian hockey player, there’s really no good reason for them to be pale, cool and diaphoretic at the same time. One of these signs is interesting, two are concerning and all three in combination should make the red flag warning pop in your subconscious.

There are a long list of ailments that produce the PCD triad (Yes, I just coined that term right now.) But when you see it, think generalized hypoxia and / or peripheral vasoconstriction. Both are suggestive of urgent medical needs. You need to figure out why. Soon would be nice.

There’s a highly incomplete list of red alert scenarios. I’m sure there will be a “Five more Assessment Findings …” article in the future. What should be on that list?

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Comments

  1. How about quiet infants? A listless baby that doesn’t fuss at all while you’re poking and prodding during an assessment sends me right into red alert.

  2. Chest pain that wakes someone up from sleep?

  3. Steve Whitehead says:

    Good ones guys. Keep em coming. And thanks.

  4. Patient that asks for the “breathing machine” – meaning they have had CPAP before and know they need it now.

  5. Decrease in the patients mental status…….

  6. Steve Whitehead says:

    @Greg, That’s a great one to teach in the field instructor process. When respiratory patients start talking about tubes and machines they have history. And they are more likely to need those interventions … and know when they’re going to need those interventions.

    @Ari, Yes, a decreasing mental status should be a red flag alert. As well as a patient who gets tired.

  7. And that impeding feeling the patients have “That I am going to die.” Is usually spot on.

  8. Mini-Medic says:

    I get nervous when a pt (especially an elderly one) has back pain between the shoulder blades, especially following any kind of trauma. No matter what the textbooks say, patients don’t always use the words “ripping, tearing pain”…

  9. 1. Patient not responding adequately to verbal communication, or not responding at all.
    2. A silent/”floppy” (cant find a better word) child who doesnt cry, fight (muscle tonus) or respond.
    3. 90-30-90-120. Oxygenation 30, Systolic bloodpressure <90mmHg

    /Stefan, ICU-Nurse, Sweden

  10. Sorry, some text fell away:

    90-30-90-120
    Oxygenation below 90%,
    Reaspiration rate above 30breaths/minute
    Systolic pressure below 90mmHg
    Pulse rate above 120bpm
    Are all usually signs of shock/septic shock.

  11. A good way to distinguish between a stroke or bells palsy is to remember this

    C lose your eyes
    O pen (the examining physician tries to open the patient’s eyes)
    W rinkle your forehead
    S mile

    I believe with bells its not uncommon to be unable to close the eye on the side of the droop. It also could tear alot. If the pt is unable to wrinkle forehead it is also likely to be a case of bells palsy as the cranial nerve is affected by a virus. By no means am I say you make that call but it can help and guide a ER doc if you give him those findings as well. My experience is that they are still going to cat scan the pt quickly to definitely rule out strokes.

  12. Central cyanosis.

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  9. […] The team took my vitals every 5 minutes. These included pulse, respiration rate, blood pressure, and oxygen saturation. My glucose was measured and my pupils were marked as =R, which I think means equally responsive or reactive. Skin color/condition was “pale, diaphoretic, cool.” Diaphoretic means sweating. When these three descriptions appear together, something is wrong. […]

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