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PASTHAM – Assessing Dyspnea Complaints

Paramedics have long utilized mnemonics to aid in the assessment of common medical complaints. Mnemonics are useful in jogging memories of essential elements of an assessment when dealing with the critically ill patient. Memory aides become very important in the prehospital environment due to the severity of the patient, and the unstable and chaotic atmosphere surrounding an EMS call. However, mnemonics do have major drawbacks and limitations.

A paramedic who chooses to assess only through the use of these memory aides will fail to be skilled in drawing the appropriate information from complicated patients. Experience teaches us patients do not follow protocol. Patients will easily deviate from a structured mnemonic. Few patients will offer information in a regimented SAMPLE format, or sequentially fill in the blanks of OPQRST. Paramedics who rely solely on these assessment tools produce broken and disjointed assessments when confronted with “poly-protocol” or “poly-mnemonic” patients. Therefore, it is important to realize these tools should be used as a backstop to catch important information that could be lost in the frenzied prehospital environment.

One of the more difficult assessments is the patient complaining of dyspnea. The severity of these patients is usually high which adds to the anxiety of the call. It is important to discern important information quickly. Omission of certain observations can hinder appropriate patient treatment. A mnemonic is a valuable tool when evaluating the detail of a dyspnea assessment. Few mnemonics achieve the details required to assess a patient complaining of shortness of breath. The OPQRST mnemonic is commonly used but is inadequate. The PASTMED mnemonic is designed specifically for the dyspnea complaints.

P – Provoke, Progression
A – Associated Chest Pain
S – Sputum, color & amount
T – Time, Trauma
M – Medications
E- Exertion, Exercise
D – Diagnosis by physician

The PASTMED memory aid is an improvement on OPQRST but still omits important queues. With some additions this mnemonic can be adapted to include the most important pieces of a good assessment. The PASTHAM builds upon and improves the PASTMED memory aid.

P – Progression, Palliation, Position, and Provocation
A – Associated signs and symptoms, and Accessory muscle use
S – Severity, Speech, and Sputum
T – Time, Treatments
H – History
A- Allergies
M – Medications

“P” – Stands for Progression, Palliation, Position, and Provocation. It is important to establish the progression of shortness of breath. Sometimes this information can narrow your differential diagnosis between an exacerbation of chronic bronchitis or pneumonia, or acute onset due to myocardial infarction, pulmonary embolism, or asthma. Palliation is an observation of what makes the dyspnea better. Conversely, and sometimes more importantly, what makes the dyspnea worse. This is a memory aide to prompt the paramedic to ask questions like “Does it get worse when you walk around?” Or “Have you tried anything to make it better?” The later is a reminder to the medic to ask about temporizing measures attempted prior to the activation of 911 such as inhalers. Noting the patient’s position is important in your assessment, documentation, and pass down to the emergency department either via radio or in person. Relaying the position can paint a picture of intensity more accurately than using mild, moderate and severe descriptors. Then impression of a patient that is sitting bolt upright in tripod position, is very different from one lying prone on the couch with legs crossed. The final “P” stands for provokes. What caused or provoked the shortness of breath? Determining what provoked the dyspnea whether smoke, trauma, allergies, exertion, or other innumerable intrinsic and extrinsic factors is important information to gather.

“A” – Stands for Associated signs and symptoms, and Accessory muscle use. Associated symptoms refer to the subjective findings the paramedic must include or exclude. The subjective findings include, but are not limited to nausea, dizziness, carpal pedal spasms, perioral numbness, and chest pain. If the presence of chest pain is established it is important to differentiate whether chest pain preceded the dyspnea or vice versa. Associated signs are those objective findings you will discover during you physical exam. These findings include adventitious lungs sounds, peripheral edema, diaphoresis, and includes the next “A”, accessory muscle use. Accessory muscle use observations should include costal and sternal retractions, belly breathing, and pursed lip breathing. These observations communicate the severity of the dyspnea when documenting or transfer of care.

“S” – Stands for Severity, Speech, and Sputum. When assessing severity the paramedic can use the 1-10 scale to achieve a quantitative measure of the intensity of dyspnea. Rather than using the 1-10 scale it may be more valuable to establish whether this episode of dyspnea is the worst the patient has ever had. Speech is a prompt to note the ability of the patient to speak. This is usually noted as full sentences, partial sentences, 3-5 word sentences, 1-2 words, or nonverbal. Since there is a direct correlation between the ability to speak and the severity of dyspnea this is a valuable objective finding. It is important to the presence, or absence of a productive cough. If the patient does have a productive cough the color and consistency should be determined. The possibilities could be green, yellow, brown, white and creamy, clear, blood-tinged, dark red blood, or bright red blood.

“T” – Stands for Time, and Treatments. The PASTHAM memory aid already addresses the progression of onset. Time is the duration of the current episode. This measure is vital in determining how long the patient has suffered the current signs and symptoms. Treatments have also been addressed using Palliation. This is an additional reminder to ask the patient what treatments they have attempted prior to EMS arrival.

“H” – Stands for History. This is where the PASTHAM mnemonic deviates from the standard PASTMED to the greatest extent. History is the single most important aspect for assessing shortness of breath. It seems almost comical that it should need to be included in an assessment memory aid. There is no way to obtain a thorough history using a mnemonic. Thorough history for a patient with dyspnea can narrow your differential diagnosis between airway obstruction, chronic lung disease, cancer, asthma, viral illness, infections, bronchospasm, pulmonary embolism, trauma, anemia, and cardiac origins of dyspnea. When evaluating a patient’s history it is important to ask “When was the last time you were in the hospital for this?” Or, “Have you been intubated before?”

“A” – Stands for Allergies.

“M” – Stands for Medications. Aside from general impression of a patient there is not greater assessment tool to evaluate a patient with dyspnea than an evaluation of current medications. Is the patient a fragile asthma patient who requires high dose inhaled glucocorticoid (GC), or continuous oral GC to control their asthma? Or, is the patient taking cardiac glycosides, ACE inhibitors and diuretics for treatment of congestive heart failure? Does the patient take quinolones, or macrolides for chronic bronchitis? Having an in depth understanding of home medications can greatly assist the paramedic when assessing a poor historian or a patient that in unable to communicate secondary to dyspnea.

It is important to hold true to the paradigm that mnemonics should be used only to check the completeness of an assessment and not used as a script. The best choice for a memory aid is the PASTHAM mnemonic. It can serve as an effective tool to aid the paramedic in assessing a patient with dyspnea.

Russell Barnum, CCEMTP

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