Comprehensive Study Notes on Patient Assessment: Emergency Care and Transportation of the Sick and Injured

Introduction to Patient Assessment

• Patient assessment is considered one of the most critical skills for an EMT, as it forms the foundation for all subsequent treatments.

• Rarely will a single sign or symptom reveal the patient’s complete status or the underlying problem.

• Symptom: A subjective condition that the patient feels and describes (e.g., pain, nausea).

• Sign: An objective condition that a clinician can observe, hear, or feel (e.g., bleeding, swelling).

• Field Impression: The evident cause of the patient’s condition, determined by synthesizing the situation, history, and examination findings.

The Five Main Parts of Patient Assessment

1. Scene Size-up

2. Primary Assessment

3. History Taking

4. Secondary Assessment

5. Reassessment

Scene Size-up

• Evaluation of the conditions under which the patient will be treated. It requires maintaining constant situational awareness.

• Scene Safety:

  • Do not enter a scene until it is safe for you and your team.

  • Identify potential traffic safety issues on roadways.

  • Consider environmental conditions and protect bystanders from injury.

  • If violence is suspected, stage at a safe location until law enforcement advises it is safe to proceed.

• Mechanism of Injury (MOI) and Nature of Illness (NOI):

  • Traumatic Injuries: Result from physical forces applied to the body, often from objects striking the body or the body striking an object.

  • Blunt Trauma: Injury without breaking the skin.

  • Penetrating Trauma: Injury that pierces the skin.

  • Nature of Illness (NOI): Required for medical patients.

  • Chief Complaint: The most serious sign or symptom reported by the patient.

  • Chief Concern: The condition requiring the most urgent intervention as determined by the clinician.

  • If MOI suggests spinal injury, manually stabilize the cervical spine immediately.

• Standard Precautions:

  • Assumes all blood, body fluids (except sweat), non-intact skin, and mucous membranes pose an infection risk.

  • Protective measures should be in place before patient contact, often before exiting the vehicle.

  • Minimum requirements: Gloves and eye protection.

  • Masks are required for protection against airborne diseases.

• Number of Patients: Identifying the total number of patients is critical for resource determination. Use the Incident Command System and begin triage if multiple patients are present.

• Additional Resources:

  • Consider Advanced Life Support (ALS), air medical support, fire departments (for Hazmat or technical rescue), and law enforcement.

  • Assess: "Does the scene pose a threat?", "How many patients?", "Do we have enough resources?"

Primary Assessment

• Goal: To identify and treat immediate or imminent life threats.

• The assessment begins the moment you greet the patient.

• Life-Threatening Conditions:

  • Airway obstruction, respiratory failure, respiratory arrest, shock, severe bleeding, cardiac arrest, or intracranial hemorrhage.

• General Impression: Formed by observing age, sex, race, level of distress, and overall appearance. The patient's response to your introduction provides insight into their LOC, airway, and circulation.

• XABC Assessment: Used if a patient has obvious life-threatening external bleeding. "X" stands for Exsanguinating hemorrhage.

Assessing Level of Consciousness (LOC)

• AVPU Scale:

  • Awake and Alert: Patient is aware of the environment.

  • Responsive to Verbal Stimuli: Patient responds when spoken to.

  • Responsive to Pain: Patient responds to pressure or squeezing of tissue (moaning or withdrawing). If the patient is flaccid and silent, they are unresponsive to pain.

  • Unresponsive: No response to any stimuli.

• Orientation Testing:

  • Person: Own name.

  • Place: Current location.

  • Time: Current year, month, or approximate date.

  • Event: Description of what happened.

Airway and Breathing Assessment

• Airway:

  • Responsive patients who speak or cry have an open airway.

  • Unresponsive patients: Immediately assess patency.

  • Use Jaw-Thrust maneuver for potential trauma.

  • Use Head Tilt-Chin Lift maneuver for non-trauma patients or if the jaw-thrust is unsuccessful.

  • Signs of obstruction: Snoring, bubbling, gurgling, crowing, or shallow/absent breathing.

• Breathing:

  • Assess rate, rhythm, and quality.

  • Oxygenation Goal: Oxygen saturation greater than $94\%$.

  • Positive-Pressure Ventilations: Required for patients not breathing or breathing too slowly/shallowly.

  • Effort of Breathing: Look for retractions, accessory muscle use, nasal flaring, tripod position, or sniffing position.

  • Respiratory Distress: Increased difficulty, abnormal effort, and rate.

  • Respiratory Failure: Blood is inadequately oxygenated; ventilation falls below oxygen demand. This leads to respiratory arrest if uncorrected.

Circulation Assessment

• Pulse: Palpate the pulse. If absent in an unresponsive patient, begin CPR.

• Skin Condition:

  • Color: Pale/white/ashen (poor circulation), blue (cyanosis/hypoxia), flushed/red (high BP/heatstroke), or yellow (jaundice/liver disease).

  • Temperature: Normal is warm; abnormal is hot, cool, or cold/clammy.

  • Moisture: Normal is dry; abnormal is wet/moist.

  • Capillary Refill: Assessment of blood restoration to the capillary system.

• Bleeding Control:

  • Arterial bleeding is characterized by spurts.

  • Apply direct pressure; if unsuccessful or for arterial extremity hemorrhage, apply a tourniquet.

History Taking

• SAMPLE History:

  • S: Signs and Symptoms.

  • A: Allergies.

  • M: Medications.

  • P: Pertinent past medical history.

  • L: Last known (oral intake).

  • E: Events leading up to injury/illness.

• OPQRST Mnemonic:

  • O: Onset.

  • P: Provocation/Palliation (what makes it worse/better).

  • Q: Quality.

  • R: Region/Radiation.

  • S: Severity.

  • T: Timing.

• Pertinent Negatives: Important findings the patient does not have (e.g., a patient with chest pain who does not have shortness of breath).

Secondary Assessment

• Physical Exam Techniques:

  • Inspection: Looking for abnormalities.

  • Palpation: Touching/feeling for abnormalities.

  • Auscultation: Listening to body sounds with a stethoscope.

• DCAP-BTLS: Use this acronym to look for Deformities, Contusions, Abrasions, Punctures, Burns, Tenderness, Lacerations, and Swelling.

• Focused Assessment: For patients with non-significant MOI or responsive medical patients. Focuses on the system relevant to the chief complaint.

Body Systems Review

• Respiratory:

  • Listen for breath sounds (wheezing, crackles, rhonchi, stridor).

  • Measure respiratory rate and symmetry of chest rise.

• Cardiovascular:

  • Pulse Rate (Adult): Tachycardia is $100\,\text{beats/min}$ or greater; Bradycardia is $60\,\text{beats/min}$ or less.

  • Blood Pressure: Measured via auscultation or palpation.

  • A drop in BP indicates fluid loss, loss of vascular tone, or pumping failure.

• Neurologic:

  • Evaluate LOC and GCS (Glasgow Coma Scale).

  • Pupils (PERRL): Pupils, Equal, Round, Regular in size, React to Light.

  • Anisocoria: Unequal pupils (present in a small percentage of the population).

• Anatomic Regions:

  • Abdomen: Palpate 4 quadrants (RUQ, LUQ, RLQ, LLQ) for rigidity or guarding.

  • Posterior body: Inspect for DCAP-BTLS and palpate the spine from neck to pelvis.

Geriatric Patient Considerations

• GEMS Diamond:

  • G (Geriatric): Normal aging vs. disease; treat with respect.

  • E (Environmental): Clues to condition (risks at home).

  • M (Medical): Complex medical history and polypharmacy.

  • S (Social): Decreased social networks; access 2-1-1 for referrals.

• Assessment Differences:

  • Altered LOC may be chronic (dementia). Find a baseline from caregivers.

  • Vascular changes can make radial pulses hard to feel.

  • Capillary refill is not a reliable tool in the elderly.

Pediatric Patient Considerations

• Pediatric Assessment Triangle (PAT): Used to determine if the child is "sick or not sick" in < 30 seconds. Includes Appearance, Work of Breathing, and Circulation to skin.

• TICLS Mnemonic: Tone, Interactiveness, Consolability, Look/gaze, and Speech/cry.

• Assessment Sequence: For stable infants/toddlers, assess feet-to-head. School-age children use head-to-toe.

• Vital Signs:

  • BP is usually not assessed in children < 3\,\text{years old}.

  • Formula for systolic BP (ages 1–10): $70 + (2 \times \text{age in years}) = \text{systolic blood pressure}$.

  • Evaluate respirations by abdominal rise/fall in infants.

Reassessment and Transport

• The Golden Hour: The critical period from injury to definitive care.

• Transport Priority Triggers: Unresponsive, difficulty breathing, altered LOC, uncontrolled bleeding, severe chest pain, or complicated childbirth.

• Reassessment Frequency:

  • Stable Patients: Every $15\,\text{minutes}$.

  • Unstable Patients: Every $5\,\text{minutes}$.

Special Challenges in History Taking

• Silence: Be patient; use closed-ended (yes/no) questions.

• Overly Talkative: May be due to caffeine, nervousness, stimulants (cocaine/meth), or psychological issues.

• Confusing History: Often caused by Hypoxia (the most common cause), stroke, or diabetes.

• Sensitive Topics:

  • Alcohol/Drugs: Do not judge; history may be unreliable.

  • Sexual History: Assume abdominal pain in females of childbearing age is pregnancy until proven otherwise.

  • Physical Abuse: Follow protocols; do not accuse; document objectively.

Questions & Discussion

• Q: During scene size-up, what should you routinely determine, EXCEPT?

• A: The ratio of pediatric to adult patients. (Rationale: Scene size-up focus includes safety, MOI/NOI, patient count, and resource needs.)

• Q: You see a man on a porch shot in the head in a pool of blood. What should you do first?

• A: Retreat to a safe place and wait for law enforcement. (Rationale: Scene safety is the EMT's primary responsibility.)

• Q: Where do you identify findings like inadequate breathing or altered LOC?

• A: Primary assessment. (Rationale: The goal of the primary assessment is identifying and managing life threats.)

• Q: What is NOT detected during the initial general impression?

• A: Rapid heart rate. (Rationale: General impression is what you see, hear, or smell before physical contact.)

• Q: After identifying an altered LOC and hematoma in an elderly fall victim, what is next?

• A: Perform a rapid exam. (Rationale: After primary life threats, check for other life-threatening injuries.)

• Q: A semiconscious patient pushes your hand when you pinch their earlobe. Their status is?

• A: Responsive to painful stimuli.

• Q: How do you begin assessing an unconscious patient’s breathing?

• A: Manually positioning the head. (Rationale: The airway must be patent before assessment or treatment.)

• Q: A patient speaking only 2–3 words before pausing has what condition?

• A: Two- to three-word dyspnea.

• Q: How do you determine the pulse in an unresponsive 8-year-old?

• A: Palpate the carotid pulse in the neck. (Rationale: Use carotid for unresponsive patients older than 1 year.)

• Q: Pain that starts in the chest and spreads to the legs is an example of what in OPQRST?

• A: Region/radiation.