Patient Assessment and Scene Safety

• Ensure Scene Safety

  • Ensure the scene is safe before entering. Issues can range from minor to major dangers.

  • Always enter and exit through the same way.

  • Wear high-visibility safety vests on roadways.

  • Consider factors like:

  • Terrain difficulty

  • Traffic safety issues

  • Environmental conditions

  • Protect bystanders to prevent them from becoming patients.

  • Hazards can include extreme weather and potential violence.

  • Remember that emergency scenes are dynamic and can change rapidly.

• Determine Mechanism of Injury (MOI) or Nature of Illness (NOI)

  • Calls for assistance can typically be categorized into:

  • Medical conditions

  • Traumatic injuries

  • Both

  • MOI:

  • Type or amount of force applied.

  • Duration of force application.

  • Location of impact on the body.

  • Blunt Trauma:

  • Force occurs over a broad area.

  • Skin usually remains unbroken; tissues/organs may be damaged underneath.

  • Penetrating Trauma:

  • Force occurs at a small point of contact.

  • High risk of infection with open wounds.

  • For medical patients, investigate the NOI by gathering information from the patient, family, or bystanders and using sensory clues.

• Patient Assessment Overview

  • Patient assessment is crucial; EMTs must master it.

  • It consists of five main parts:

  1. Scene size-up

  2. Primary assessment

  3. History taking

  4. Secondary assessment

  5. Reassessment

  • Signs and Symptoms:

  • Symptom: Subjective condition the patient reports.

  • Sign: Objective condition observable by the EMT.

• Scene Size-Up

  • Evaluate the conditions for operation.

  • Maintain situational awareness -

  • Combine information from the dispatcher and your original observations.

  • Assess:

    • Scene safety

    • MOI/NOI

    • Number of patients

    • Additional resources needed

• Take Standard Precautions

  • Always wear Personal Protective Equipment (PPE) suitable for the task.

  • Standard precautions address threats from:

  • Blood

  • Body fluids

  • Hazards of communicable diseases

  • Initiate precautions prior to exiting the emergency vehicle.

  • At minimum, gloves should be worn; consider masks and goggles as needed.

• Determine Number of Patients

  • Critical for resource determination.

  • In cases of multiple patients:

  • Use the Incident Command System

  • Begin triaging patients based on the severity of their conditions.

• Consider Additional/Specialized Resources

  • When required, document the need for:

  • Additional ambulances

  • Advanced Life Support (ALS)

  • Air medical support

  • Law enforcement assistance

  • Evaluate:

  • Threats to yourself, your patient, or others

  • The resource capacity regarding patient needs

• Primary Assessment

  • Commences upon greeting the patient to identify life-threatening conditions.

  • Key assessments include:

  • Level of consciousness (LOC)

  • ABCs (Airway, Breathing, Circulation) or CAB (Circulation, Airway, Breathing)

  • General impression of the patient

• Form a General Impression

  • Avoid standing over the patient; maintain a level of comfort.

  • Introduce yourself and address immediate life threats, like uncontrolled bleeding.

• Assess Level of Consciousness (LOC)

  • LOC provides insight into neurological and physiological status.

  • Unconsciousness may indicate serious problems in respiratory, circulatory, or CNS.

  • Altered LOC might result from:

  • Inadequate perfusion

  • Medications, drugs, alcohol, or poisoning

  • Use the mnemonic AVPU for responsiveness assessment:

  • A: Awake & Alert

  • V: Responsive to Verbal Stimuli

  • P: Responsive to Pain

  • U: Unresponsive

  • Orientation tests mental state about:

  • Person

  • Place

  • Time

  • Event

Assess Level of Consciousness

• Evaluate the following memory types:

  • Long-term memory

  • Intermediate-term memory

  • Short-term memory

• Identify altered mental status if there is any deviation from being alert and oriented to:

  • Person

  • Place

  • Time

  • Event

• Look for deviations from the patient's normal baseline.

Identify & Treat Life Threats

Conditions Leading to Sudden Death

• Airway obstruction

• Respiratory failure or arrest

• Shock

• Severe bleeding

• Primary cardiac arrest

Assessment Order

• Typically start with Airway, Breathing, and Circulation (ABC).

• In certain situations, might start with Circulation (CAB).

Assess the Airway

For Responsive Patients

• Signs of an open airway include patients who can talk or cry.

• Monitor how the patient speaks for potential airway obstruction.

• If an airway problem is identified, stop assessment and clear the airway.

For Unresponsive Patients

• Immediately assess the airway using:

  • Jaw-thrust technique when needed.

  • Head tilt-chin lift technique when suitable.

• Tongue muscle relaxation can lead to airway obstruction.

Determine Priority of Patient Care & Transport

• Transport decisions based on:

  • Patient's condition

  • Availability of advanced care

  • Distance of transport

  • Local protocols

History Taking

• Provides detail about the chief complaint and patient's signs/symptoms.

• Information includes:

  • Demographic data

  • Date of incident

  • Patient specifics (age, gender, race, past medical history, current health status).

• Use open-ended questions to gather information from the patient or bystanders.

• Use the OPQRST mnemonic for assessing symptoms:

  • Onset

  • Provocation or palliation

  • Quality

  • Region

  • Severity

  • Timing

  • Identify pertinent negatives.

Assess Circulation

For Trauma Patients

• Control any external bleeding prior to airway/breathing concerns.

• Types of bleeding:

  • Venous Bleeding: Steady flow of blood.

  • Arterial Bleeding: Spurting flow of blood.

Methods for Controlling Bleeding

• Apply direct pressure.

• Use a tourniquet if:

  • Direct pressure is unsuccessful quickly.

  • There is obvious arterial hemorrhage of an extremity.

Perform a Rapid Exam

• Identify injuries needing management or protection before transport.

• Time taken: 60-90 seconds.

• Not a systematic or focused physical examination.

Determine Priority of Patient Care & Transport (Cont.)

• High-priority patients include those with:

  • Altered level of consciousness

  • Difficulty breathing

  • Uncontrolled bleeding

  • Severe pain

  • Pale skin or signs of poor perfusion.

• "Golden Hour" refers to the critical time from injury to definitive care.

• Immediate transport is crucial for survival in life-threatening situations.

The Platinum 10 Minutes

• Encompasses initial assessment, intervention, and packaging within the first 10 minutes.

Assess Circulation (Cont.)

Assess Mental Status, Pulse, and Skin Condition

• Pulse: A pressure wave from heartbeats.

• To assess:

  • Palpate pulse at arteries.

  • If absent, begin CPR for unresponsive patients.

Evaluate Skin Condition

• Skin color, temperature, moisture, and capillary refill should be assessed:

  • Poor circulation results in pale, ashen, or gray skin.

  • Skin oxygenation issues can lead to a blue appearance.

• Normal skin is warm and dry, while abnormal temperature and moisture can indicate problems.

Assess Capillary Refill

• Press on the patient’s fingernail, release, and observe how quickly it returns to normal pink color (should take <2 seconds).

Signs of Airway Obstruction in Unconscious Patients

• Obvious trauma or obstruction.

• Noisy breathing (snoring, gurgling).

• Extremely shallow or absent breathing.

Assess Breathing

• Ensure the airway is open and breathing is adequate:

  • Ask if:

  • Is the patient breathing?

  • Is the patient breathing adequately?

  • Is the patient hypoxic?

• Consider positive pressure ventilations for:

  • Respirations > 28 breaths/min.

  • Respirations < 8 breaths/min.

Oxygenation Goals

• Aim for oxygen saturation around 94%-99%.

Signs of Respiratory Distress

• Observe for:

  • Retractions

  • Tripod position

  • Accessory muscle use

  • Nasal flaring

  • Shortness of breath (2-3 word dyspnea)

• Increased work of breathing indicates respiratory distress and can lead to respiratory failure if untreated.

SAMPLE History in Patient Assessment

• S = Signs & Symptoms

• A = Allergies

• M = Medications

• P = Pertinent past medical history

• L = Last oral intake

• E = Events leading up to injury/illness

Critical Thinking in Assessment

• Gathering: Seeking facts

• Evaluating: Considering what the information means

• Synthesizing: Putting the information together to plan scene management and patient care

Sensitive Topics in Patient History

Alcohol & Drugs

• Signs may be confusing, hidden, or disguised.

• Patient may deny any problems; history gathered may be unreliable.

• Approach with professionalism; do not judge the patient.

Physical Abuse or Violence

• Report all instances of physical abuse or violence to appropriate authorities.

• Follow local protocols and involve law enforcement without accusation.

Secondary Assessment

• Use the mnemonic DCAP-BTLS:

  • D = Deformities

  • C = Contusions

  • A = Abrasions

  • P = Punctures or penetrations

  • B = Burns

  • T = Tenderness

  • L = Lacerations

  • S = Swelling

• Conduct a systematic assessment to identify hidden injuries missed during the primary assessment.

Focused Assessment

• For patients with non-significant MOIs or responsive medical patients, focused on their chief complaint.

• Understand the affected body part or systems for tailored assessment.

Respiratory System Assessment

• Inspect for signs of airway obstruction, chest symmetry, and listen to breath sounds.

• Measure respiratory rate (normal for adults is 12-20 breaths per minute).

• Count breaths over a 30-second period and multiply by 2.

Special Challenges in Obtaining Patient History

Language Barriers

• Use interpreters if available; keep questions straightforward and brief.

• Use hand gestures and find alternatives to facilitate communication.

Hearing Problems

• Speak slowly and clearly, utilize a stethoscope as an assistive tool, and consider learning basic sign language.

Visual Impairments

• Identify yourself verbally, restore moved items, and explain actions during assessments.

Anger & Hostility

• Stay calm and reassuring amidst any anger directed toward you; secure the scene.

Intoxication

• Avoid positioning intoxicated patients in a threatening manner to minimize potential confrontation risks.

Psychological Concerns

• Watch for signs of confusion or behavior changes possibly due to medical conditions like hypoxia or trauma.

• Keep questions simple and be aware of the presence of confusion due to cognitive decline or psychological stress.

Taking History on Sensitive Topics

Sexual History

• Consider all females of childbearing age reporting lower abdominal pain as potentially pregnant.

• Ask about their last menstrual period and STD potential when appropriate.

Addressing Silence and Over-Talkativeness

• Patience for silence is essential; closed-ended questions can facilitate responses.

• Be mindful of overly talkative patients; reasons may include anxiety, substance use, or psychological issues underlying their behavior.

Prioritizing Symptoms

• In triage, prioritize patient's complaints starting from the most serious to the least serious.

Signs of Anxiety

• Symptoms may include pallor, diaphoresis, shortness of breath, numbness, dizziness, or even losing consciousness.

Respiratory System

• Respiratory Rhythm

  • Regular

  • The time from one peak chest rise to the next is fairly consistent.

  • Irregular

  • The respirations vary or the rate changes frequently.

• Quality of Breathing

  • Normal breathing is silent.

  • Breathing accompanied by other sounds may indicate a significant respiratory problem.

• Depth of Breathing

  • The amount of air exchanged depends on the patient's category and tidal volume.

• Breath Sounds

  • Breath sounds are usually better heard from the patient's back.

  • Normal Breath Sounds:

  • Snoring

  • Wheezing

  • Crackles

  • Rhonchi

  • Stridor

Cardiovascular System

• Evaluate for trauma to the chest and listen for breath sounds.

• Monitor:

  • Pulse

  • Respiratory rate

  • Blood pressure

• Key factors in assessment:

  • Rate, quality, and rhythm

  • Correlate findings with skin assessment

  • Compare distal pulses

  • Auscultate for abnormal heart sounds.

• Pulse Rate Classification:

  • Normal resting pulse for adults: $60-100$ bpm

  • Younger patients exhibit faster pulse rates:

  • Adult (>10): $60-100$

  • School Age (2-10): $60-140$

  • Toddlers (3m-2yrs): $70-100$

  • Infants (0-3m): $80-205$

Anatomic Regions

• Abdomen

  • Palpate for tenderness, rigidity, and patient guarding.

  • Four Quadrants:

  • Left Upper (LUQ)

  • Left Lower (LLQ)

  • Right Upper (RUQ)

  • Right Lower (RLQ)

• Pelvis

  • Inspect for symmetry and any obvious signs.

  • Press on pubis and down on hips.

• Extremities

  • Check for injury, bleeding, deformity.

  • Inspect for symmetry, cuts, bruises, swelling, injuries.

  • Palpate for deformities.

  • Check for PMS (pulse, motor & sensory function).

• Posterior Body

  • Check for DCAP-BTLS, symmetry, open wounds.

  • Palpate the spine for step-offs, tenderness, and deformity.

Vital Signs

• Assess vital signs:

  • Pulse

  • Respirations

  • Blood Pressure

• Skin Color & Condition

• Pulse Oximetry

• Pupils assessment

• Use monitoring devices appropriately but comprehensive assessment is essential.

• Pulse Oximetry:

  • Evaluates effectiveness of oxygenation.

  • Measures hemoglobin saturation in capillary beds.

  • Patients with breathing difficulties should receive oxygen regardless of Pulse Ox value.

Pupils Assessment

• PEARRL is a useful assessment guide:

  • Pupils Equal

  • Round

  • Regular in size

  • React to light

Neurologic System

• Neurologic Assessment should be performed with:

  • Changes in mental status

  • Possible head injury

  • Stupor, dizziness/drowsiness, syncope.

• Evaluation Tools:

  • Level of consciousness and orientation

  • AVPU scale

  • Glasgow Coma Scale (GCS)

• Pupil Information:

  • Normally round and equal in size.

  • In absence of light, will relax and dilate.

  • Anisocoria: unequal pupils in some individuals.

• Causes of Depressed Brain Function:

  • Injury to brain or brainstem

  • Trauma or stroke

  • Brain tumor

  • Inadequate oxygenation or perfusion

  • Drugs or toxins.

Blood Pressure Assessment

• Normal Blood Pressure Ranges:

  • Adults: $90-120$ (systolic)

  • Adolescents (15 years): $110-131$ (systolic)

  • Child (7 years): $97-115$ (systolic)

  • Child (2 years): $86-106$ (systolic)

  • Infant (1-12 months): $72-104$ (systolic)

  • Neonate (96 hours): $67-84$ (systolic).

• Blood Pressure Monitoring:

  • High BP: May result in rupture or critical damage.

  • Blood Pressure Cuff Components:

  • Outer cuff

  • Inflatable bladder

  • Ball-pump with one-way valve

  • Pressure gauge

  • Auscultation and palpation techniques used for measurement.

• Clinical Terms:

  • Hypotension: Blood pressure lower than normal.

  • Hypertension: Blood pressure higher than normal.

Assess Vital Signs

• Vital signs are crucial for evaluating patient's health and can indicate various physiological conditions.

Capnography

• Quickly provides information on a patient's:

  • Ventilation: Helps in assessing how well air is exchanged in the lungs.

  • Circulation: Can indicate blood flow and perfusion.

  • Metabolism: Assesses the metabolic status of the patient.

Blood Glucometry

• A test that measures the level of glucose in the bloodstream.

  • Important for identifying hypoglycemia or hyperglycemia.

Reassessment

• Regular Intervals: Perform reassessment at consistent intervals during the assessment process to monitor patient status.

  • Repeat Primary Assessment: Conduct a primary assessment again to check for any changes in condition.

  • Reassess Vital Signs: Take new vital signs and compare them with baseline data from the primary assessment.

  • Look for Trends: Analyze any changes or patterns in the vital signs.

  • Reassess Chief Complaint: Important to inquire the following:

  • Is the current treatment improving the patient's condition?

  • Has an already identified problem gotten better or worse?

  • What is the nature of any newly identified problems?

Recheck Interventions

• Reevaluate all interventions, focusing on:

  • ABCs (Airway, Breathing, Circulation): Ensure they are being managed effectively.

  • Management of Bleeding: Confirm that any bleeding is adequately managed.

  • Adequacy of Other Interventions: Assess if current interventions are successful and consider if additional interventions are needed.

  • Identify & Treat Changes: Stay vigilant for any changes in the patient's condition to promptly address them.

  • Document Changes: Note any changes (positive or negative) for future reference.

Reassess the Patient

• Frequency of reassessment depends on stability:

  • Unstable Patients: Every approximately 5 minutes.

  • Stable Patients: Every approximately 15 minutes.