Scene Size Up & Primary Assessment

What is scene size up?

the evaluation of the conditions in which you will be operating

What are some considerations for scene size up? What should the scene size up combine?

considerations:

• road and traffic hazard

• incident hazards such as fire, hazardous materials, or scenes of violence

scene size ups must combine:

• understanding of the situation and conditions prior to responding

• information dispatch provided

• observation of scene itself to help ensure safe and effective operations

How to ensure scene safety?

look for dangers or difficulties. is it safe to approach and manage the patient? if not, do what is possible to make it safe or call for additional resources

• look for issues like water, mud, ice, uneven/unstable surfaces

• when in an active roadway, wear a high visibility class 2 or 3 safety vest

• if you need equipment for environmental hazards, move away from scene to take cover for environmental hazards → provide patient with same if possible

• be aware of scenes that have a potential for violence, and be observant for objects that may be used to commit violence when entering homes

before you begin primary assessment, what should you do?

determine mechanism of injury

determine nature of illness

take standard precautions

determine number of patients

consider additional/specialized resources

how is mechanism of injury classified?

• type/amount of force

• how long force was applied

• where force was applied to the body

what is blunt trauma?

• force of injury occurs over a broad area

• skin not always broken

• tissues and organs underneath area of impact may be damaged

what is penetrating trauma?

• force of injury occurs at a specific point of contact between skin and object

• objects pierces skin and creates an open wound that carries a higher potential for infection

what is the nature of illness?

general type of illness the patient is experiencing, as illnesses/conditions not caused by an outside force also require EMS

what is chief complaint?

most serious thing the patient is concerned about, and the reason EMS was called

how to quickly determine MOI/NOI?

• talk with patient, family, or bystanders about the problem

• check for clues at the scene

• keep observations in mind as patient assessment occurs

what are some examples of MOI?

falls, motor vehicle crashes, assaults, industrial accidents

what are standard precautions?

protective measures recommended by the CDC for use in dealing with objects, blood, bodily fluids, and other potential exposure risks of communicable disease

• consistent handwashing before and after care

• gloves → AT MINIMUM, gloves must be worn before patient contact

• eye protection → reduce risk of eye injury or exposure from different directions

• mask → level of protection from splash or spray depends on type, proper fit, and ability to wear it properly

• gown

what is PPE?

clothing or specialized equipment that protects the wearer

what do you do when exposed to a communicable disease?

follow local agency’s protocols for postexposure reporting, testing and prophylaxis

what do you do if patient has signs and symptoms of coughing, stiff neck with headache, sore throat, or fever with shortness of breath?

assume some sort of infectious respiratory disease is at play, and wear a mask even if local standard precaution doesn’t include a mask for all patient encounters

what should you do if there’s multiple patients involved at a scene?

1. use incident command system

2. identify number of patients

3. begin triage

what is the incident command system?

emergency responders work in groups according to their function/assigned area, and the leader of each group reports to the incident commander

what is triage?

process of sorting patients based on severity of their condition → helps allocate personnel, equipment, and resources in the most effective way

what resources are available through the fire department?

• EMS and fire suppression

• hazardous materials management

• technical rescue services

  • complex extrication from motor vehicle crashes

  • wilderness search and rescue

  • high-angle rope rescue

  • water rescue

what should you ask yourself if you think you require additional resources?

• does the scene pose a threat to you, the patient, or others

• how many patients are there?

• do you have the resources to respond to their conditions

what is the primary assessment?

identification and treatment of immediate or imminent life threats

must physically examine the patient and assess:

• level of consciousness [LOC]

• airway, breathing, and circulation [ABCs]

!!! NOT an in-depth physical exam or assessment of vital signs

what is a general impression?

formed to determine the priority of care and if the first part of the primary assessment, which includes noting:

• age, sex, race

• level of distress

• overall appearance

how to carry out the general impression?

1. make sure the patient sees you coming

2. note patient’s position and if they are moving or still

3. avoid standing over patient

4. refer to patient by name

5. introduce yourself

6. ask about chief complain

7. if life threatening condition is found, treat it immediately

8. define patient’s condition as stable, stable but potentially unstable, or unstable to direct further assessment and treatment

what assessment takes priority over all others?

uncontrolled external bleeding

• suggested by a large amount of bleeding that is squirting or gushing, has soaked through clothing, or is pooling under the patient

what is the AVPU?

the APVU scale tests a patient’s responsiveness [LOC]

What does the A in AVPU stand for?

AWAKE AND ALERT

• patient’s eyes open spontaneously as you approach, they are aware of you and responsive to the environment

• patient is awake, able to follow commands, and eyes visually track people and objects

what does the V in AVPU stand for?

responsive to VERBAL STIMULI

• patient is not awake and alert,

• patient’s eyes do not open spontaneously, but they do when you speak to them, able to respond in some meaningful way when spoken to

• patient does not respond to normal speaking voice but responds when you speak loudly [responding to loud verbal stimuli]

what does the P in AVPU stand for?

• responsive to PAIN

  • patient does not respond to questions but moves or cries out in response to painful stimuli

  • to determine whether patient will respond to painful stimulus:

    • gently but firmly pinch skin [ear, back of upper arm, muscle above the collar bone]

    • apply upward pressure along ridge of orbital rim along the underside of the eyebrow

  • note type and location of stimulus and how patient responded

  • if patient does not respond to stimulus on one side, try to get a response on other side

what does the U stand for in AVPU?

UNRESPONSIVE

• patient does not respond spontaneously or to a verbal or painful stimulus

• no cough or gag reflex, lacking the ability to protect airway

• if in doubt whether a patient is truly unresponsive, assume the worse and treat appropriately

what to next evaluate for a patient that is alert or responsive to verabl stimuli?

ORIENTATION: tests mental status by checking patient’s memory and thinking ability. most common test evaluates ability to remember 4 things:

• PERSON: patient is able to remember their name → long term memory

• PLACE: patient is able to identify current location → intermediate memory

• TIME: patient is able to tell current year, month, and approximate date → intermediate memory for year/month, short term for approximate date

• EVENT: patient is able to describe what happened [MOI/NOI] → short term memory

what is considered when a patient passes or fails orientation test?

patient knows all 4 things:

• “alert and fully oriented”

• “alert and oriented to person, place, time, and event”

• “alert and oriented x 4”

any deviation from any of the 4 things and/or a normal baseline is considered ALTERED MENTAL STATUS

what are indications for spinal mobilization?

• blunt or penetrating trauma with any of the following:

  • pain and tenderness on palpation of neck or spine

  • patient report of pain in neck or back

  • paralysis or neurologic complain [numbness, tingling, partial paralysis of legs and arms]

• only blunt trauma with any of the following:

  • altered mental status

  • intoxication [alcohol or drugs]

  • difficulty or inability to communicate

• distracting injury: any injury that distracts patient’s attention from other injuries they may have even severe injuries [ex: femur fracture that prevents patient from noticing back or neck pain]

what do to for spinal immobilization?

ensure the patient’s CERVICAL spine is manually stabilized by you or another provider

• if not possible to manually stabilize, do your best to ensure the patient’s spine remains in a stable position during primary assessment

what are the conditions that cause sudden death?

• airway obstruction

• respiratory failure

• respiratory arrest

• shock

• severe bleeding

• primary cardiac arrest

what are the ABCs?

• identifying and correcting life-threatening issues begin with the airway, following by breathing and circulation [ABC]

  • in cardiac arrest, ABCs should be assessed simultaneously to minimize time to first compression

  • with life-threatening bleeding, it’s more appropriate to first address it as circulation, airway, and breathing [CAB]

how to assess the airway for responsive patients?

for responsive patients

• patient who cannot speak or cry → severe airway obstruction

• if airway problem is identified, stop assessment and work to clear airway

  • positioning patient so air moves in and out

  • suctioning liquids from airway

  • removing obvious foreign body from patient’s mouth

    • possible requires abdominal thrust or chest compressions

• if signs of difficulty breathing or not breathing is identified, take corrective actions using appropriate airway management techniques

how to assess airway for unresponsive

for unresponsive patients

• assess patency of airway

  • if there’s potential for trauma, use jaw-thrust maneuver to open airway

  • if jaw-thrust does not work, or if it is confirmed that patient did not experience a traumatic event, use head tilt-chin lift maneuver

• if airway obstruction is caused by relaxation of tongue muscle, position airway and place oral or nasal airway

• remove or clear away blood clots, vomitus, mucus, food, and other foreign objects with manual techniques or suctioning

what are signs for airway obstruction in an unconscious patient?

• obvious trauma, blood, or other obstruction

• noisy breathing [snoring, bubbling, gurgling, crowing, stridor, or other abnormal sounds

• extremely shallow or absent breathing

how to assess breathing?

• ask yourself:

  • is patient breathing?

  • is patient breathing adequately?

  • is patient hypoxic?

• perform positive pressure ventilation for patients who are not breathing/breathing is too slow or too shallow

• if patient is breathing adequately but remains hypoxic, administer oxygen [goal is oxygen saturation of 94%]

• if patient develops difficulty breathing after primary assessment, reevaulate the airway

• when respirations exceed 28 breaths/min or are fewer than 8 breaths/min, or are too shallow to provide adequate air exchange, provide positive pressure ventilations WITH an airway adjunct

what are shallow and deep respirations?

shallow respirations: little movement of the chest wall [reduced tidal volume] or poor chest excursion

deep respirations: significant rise and fall of the chest

what are physical signs of inadequate breathing?

• observable increased effort to breath

• retractions: movements in which the skin pulls in around the ribs during inspiration

• use of accessory muscles [neck, chest, and abdominal muscles] of respiration

• nasal flaring and seesaw breathing in pediatric patients

what is two to three-word dyspnea?

condition in which a patient can speak only 2 to 3 words without pausing to take a breath, indicative of a serious breathing problem

what are the positions that indicate patient is trying to increase air flow?

• tripod position: sitting and leaning forward on outstretched arms with head and chin thrust slightly forward

• sniffing position: most commonly seen in children, sitting upright with head and chin thrust slightly forward, appearing to be sniffing

what are signs of respiratory distress?

respiratory distress:

• agitation, anxiety, restlessness

• stridor, wheezing

• accessory muscle use

• tachypnea

• mild tachycardia

• nasal flaring, seesaw breathing, head bobbing

respiratory failure:

• lethargy, difficulty to rouse

• tachypnea with periods of bradypnea or agonal respirations

• inadequate chest rise

• inadequate respiratory rate or effort

• bradycardia

• diminished muscle tone

how to access circulation?

• determine if patient has a pulse via palpation

  • hold together intex and long fingers and plase tips over pulse point

  • press against artery until you feel intermittent pulsations

  • pulse should be easily felt at radial or carotid artery and have regular rhythm → if not, the patient may have problems with the circulatory system

• if patient has pulse but is not breathing:

  • provide ventilations at a rate of 10 to 12 breaths/min for adults

  • provide ventilations at a rate of 12 to 20 breaths/min for an infant or a child

• continue to monitor pulse to evaluate effectiveness of ventilations

• if patient becomes pulseless, start CPR and apply AED

how to assess pulse in children and adults:

patients older than 1 year:

• palpate radial pulse in responsible patients at wrist

• palpate carotid pulse in neck in unresponsive patients

how to assess pulse in infants

patients younger than 1 year

• palpate brachial pulse [medial area of upper arm]

• with infant lying supine, access brachial pulse by elevating arm over infant’s head

• because most infants are chubby, press adjacent fingers firmly along the brachial artery, which lies parallel to the long axis of the upper arm

how to assess skin condition by color

patients with deeply pigmented skin, change in color may only be apparent in:

• fingernail beds

• mucous membrane in the mouth

• lips

• underside of arm and palm

• conjunctiva of the eyes

assess palms and soles of feet in infants and children

cyanosis makes lips, mucous membranes, nail beds, and skin over blood vessels appear blue or grey → insufficient air exchange/low oxygen levels in blood

abnornally flushed and red → high blood pressure, significant fever, heat stroke, sunburn, thermal burns, etc

jaundice makes skin and sclera turn yellow → liver disease or dysfunction

how to assess skin condition by temp

• normal body temp is 98.6 degrees F (37 degrees C)

• abnormal skin temp is hot, cool, cold, clammy [feel forehead with back of hand]

  • hot: significant fever, sunburn, hyperthermia

  • cool, clammy: early shock, mild hypothermia, inadequate perfusion [body pulls blood away from surface or skin and diverts it to core of the body]

how to assess skin condition by moisture

dry skin is normal

• clammy, damp, moist → early shock

• wet or diaphoretic → skin bathed in sweat, full shock

how to assess skin by capillary refill

CAPILLARY REFILL TIME [CRT] provides indication of pediatric patient’s level of perfusion

to test capillary refill:

• place thumb on patient’s fingernail with fingers on underside of patient’s finger and gently compress → remove pressure → nail beds remain white for a brief period → underlying capillaries refill and nail bed returns to pink color

• adequate perfusion, color in nail bed should be restored to normal pink color in 2 seconds → report and document CRT as normal [2 seconds or less]

• when it takes longer, document CRT as delayed or CRT > 2

to assess in newborns and young infants, press on forehead, chin, or sternum

what affects capillary refill time in adults?

• position

• age

• smoking history

• medical history

• medications

• exposure to hypothermia [frostbite, vasoconstriction]

• injuries to bone and muscles of extremities → hypoperfusion of an extremity rather then hypoperfusion of the body in general

how to access and control external bleeding?

• assess: quickly and lightly running gloved hands from head to toe, pausing periodically to see if gloves are bloody

• control: directing pressure with gloved hand and soon thereafter a sterile bandage over the wound

  • if unsuccessful, or arterial hemorrhage is encountered, apply a tourniquet

how to perform a rapid exam to identify life threats

takes 60-90 seconds

• step ONE: assess the head, looking and feeling for DCAP-BTLS; have partner maintain in-line spinal stabilization

  • D - Deformity: misshapen body part

  • C - Contusions: bruising

  • A - Abrasions: loss or damage to surface of skin by rubbing or scraping

  • P - Punctures: small penetration into soft tissue

  • B - Burns: redness, blisters, or white areas of skin

  • T - Tenderness: pain when an area is palpated

  • L - Lacerations: deep cut in skin

  • S - Swelling: raised or enlarged area of soft tissue on surface of the body

• step TWO: assess the neck

• step THREE: assess the chest → listen to breath sounds on both sides

• step FOUR: assess the abdomen

• step FIVE: assess the pelvis → if no pain, gently compress pelvis downward and inward to look for tenderness and instability

• step SIX: assess all four extremities → assess the pulse and motor and sensory function

• step SEVEN: assess the patient’s back → if spinal immobilization is indicated, do so with minimal movement to the patient’s spine by log rolling the patient in one motion

what is priority designation?

system used to determine if a patient needs immediate transport or will tolerate a few more minutes on scene

what are the conditions associated with a high-priority patient [should be transported immediately]

• unresponsive

• poor general impression

• difficulty breathing

• uncontrolled bleeding

• responsive but unable to follow commands

• severe chest pain

• pale skin or other signs of poor perfusion

• complicated childbirth

• severe pain in any areas of the body

what is the golden hour / golden period?

refers to the time from injury to definitive care, during which treatment of shock and traumatic injuries should occur because survival potential is best

• 20 mins → discovery of incident and activation of EMS

• platinum 10 mins → initial assessment, intervention, and packaging

• 30 mins → EMS transport and initial hospital stabilization

decision to stay on scene or transport immediately is based on:

• patient’s condition

• availability of more advanced help

• distance you must transport

• local protocols

how often should you reassess vital signs? why?

• stable patient: every 15 mins until you reach ED

• unstable patient: every 5 minutes, looking for trends in patient’s condition

even patients who have experienced severe medical or traumatic conditions may initially exhibit normal vital signs → body’s ability to compensate eventually decreases and the vital signs may deteriorate rapidly [especially in children]

treating shock before obvious signs appear increases patient’s chance of survival