Patient Assessment Notes

Scene Size-Up

  • Scene Safety
  • Standard Precautions
  • Determine the mechanism of injury (MOI) or nature of illness (NOI).
  • Determine the number of patients.
  • Determine the need for additional resources.
  • Consider cervical spine immobilization, especially in trauma cases.

Primary Assessment

  • The primary assessment identifies and treats any immediately life-threatening conditions before moving on.
  • Steps:
    • Form a general impression of the patient (stable or unstable).
    • Assess level of consciousness (mental status) using AVPU.
    • Assess the airway.
    • Assess breathing (and oxygenation).
    • Assess circulation.
    • Establish patient priorities.
    • Disability.
    • Expose the patient as needed for assessment.

Form a General Impression

  • Develop an initial sense of the patient’s stability upon approach.
  • Determine the chief complaint.
  • Observe the surroundings for clues.
  • Consider first impressions to gauge stability.
  • Determine the chief complaint (reason EMS was called).

Injured vs. Ill

  • Injured:
    • Penetrating trauma: Force pierces the skin and tissues.
    • Blunt trauma: Force impacts the body without penetration.
  • Ill:
    • The environment might suggest a medical issue.

Obtain the Chief Complaint

  • The chief complaint is the primary reason EMS was summoned.
  • Do not assume the initial complaint is the true underlying issue.

Position the Patient

  • If needed, logroll the patient after a posterior body check.
  • Use in-line stabilization if spinal injury is suspected.
  • If prone, roll the patient supine for assessment.
  • Establish and maintain in-line stabilization until immobilization on a backboard.

Assess Level of Consciousness (Mental Status)

  • Use the AVPU mnemonic:
    • A – Alert: Eyes open, able to speak.
    • V – Verbal: Responds only when spoken to.
    • P – Pain: Responds only to painful stimuli.
    • U – Unresponsive: No response to any stimuli.

Alertness and Orientation

  • If the patient is awake and communicative upon approach, assume alertness.
  • Note that an alert patient may still be agitated, confused, or disoriented.
  • If the patient is not alert, check their response to verbal stimuli.

Responsiveness to Verbal Stimulus

  • The patient attempts to respond only when spoken to.
  • If no speech, test if the patient obeys commands (e.g., "squeeze my fingers," "wiggle your toes").

Responsiveness to Painful Stimulus

  • If no response to speech, apply a painful stimulus.
  • Apply stimuli centrally or peripherally.
  • Note if responses are purposeful or non-purposeful.

Unresponsiveness

  • Unresponsive patients often lose gag and cough reflexes, risking airway compromise.
  • They are a high priority for emergency care and transport.
  • Assume spinal injury in unresponsive patients.

Assess the Airway

Determine Airway Status
  • An occluded airway is a critical, immediate threat to life.
  • A patient who is alert and talking clearly has a patent airway.
In the Responsive Patient
  • If alert and speaking without difficulty, assume a patent airway.
  • Indicators of airway compromise:
    • Stridor
    • Difficulty speaking
    • Gasping
    • Inability to speak
Unresponsive or Altered Mental Status Patient
  • High risk of airway compromise.
  • Take action to open or maintain the airway.
Open the Airway
  • Use manual maneuvers, suction, airway adjuncts, manual thrusts, and proper positioning.
Indications of Partial Airway Obstruction
  • Snoring
  • Gurgling
  • Crowing
  • Stridor
After Opening the Airway
  • Assess adequacy of breathing.
  • Determine the need for oxygen therapy (adequate breathing) or positive pressure ventilation (inadequate breathing).
Indicators of Inadequate Breathing
  • Inadequate tidal volume
  • Abnormal respiratory rate (bradypnea or tachypnea)
  • Retractions
  • Accessory muscle use or nasal flaring
  • Tracheal tugging
  • Pale, cool, clammy skin, cyanosis
  • Pulse oximetry < 94%
  • Asymmetrical chest wall movement

Assess Breathing

Listen and Feel
  • Listen for air movement; feel for escaping warm air.
    • Absence of breathing
    • Inadequate breathing
Oxygen Therapy
  • Apply a nonrebreather mask at 15 lpm if the patient has adequate breathing but may need additional support.
  • When in doubt, administer oxygen.
SpO2
  • SpO2SpO_2 greater than 94% on room air suggests adequate oxygenation.
  • After addressing airway and breathing, move to circulation.

Assess Circulation

  • Quickly determine:
    • Presence or absence of pulse.
    • Approximate heart rate (beats per minute).
    • Pulse regularity and strength.
Identify Major Bleeding
  • If significant bleeding is observed, expose the area immediately.
    • Bright red, spurting blood indicates arterial bleeding.
    • Dark red, steady, rapid flow indicates venous bleeding.
  • Control major bleeding.
  • Expose blood-soaked areas.
Assess Perfusion
  • Color (pink, pale, mottled)
  • Temperature (warm, cool, cold)
  • Condition (dry, diaphoretic)
  • Capillary refill (more reliable in infants and children)

Establish Patient Priorities

  • Manage life-threatening conditions immediately.
  • Critical findings in airway, breathing, oxygenation, or circulation indicate an unstable patient.
  • Unstable patients are high priority for treatment and transport.

Secondary Assessment

  • The approach differs depending on whether the patient is:
    • Medical or trauma
    • Unstable or stable

Components

  • Physical exam
  • Baseline vital signs
  • History
  • Tailor assessment to patient needs and suspected condition.

Physical Examination

  • Uses inspection, palpation, and auscultation to identify signs and symptoms.
  • An anatomical approach proceeds from head to feet.
Anatomic Approach
  • Conduct assessment systematically, head to feet.
  • Perform a rapid secondary assessment on unstable or critical patients.
Assess the Head
  • Inspect the scalp for deformities, contusions, abrasions, punctures, burns, lacerations, or swelling (DCAP-BTLS).
  • Assess eyes, ears, nose, and mouth.
Assess the Neck
  • Look for signs of injury.
  • Cover open wounds with occlusive dressings.
  • Look for jugular vein distention (JVD).
  • Palpate for tracheal deviation.
Assess the Chest
  • Inspect and cover open wounds.
  • Look for paradoxical movement; flail segment is immediately life-threatening.
  • Palpate the chest.
  • Auscultate breath sounds.
Assess the Abdomen
  • Inspect and palpate all four quadrants and laterally.
  • Look for distention and discoloration.
  • Avoid palpating pulsating masses.
  • Check for signs of peritonitis.
Assess the Pelvis
  • Pelvic injuries are critical.
  • Do not palpate if injuries are obvious.
  • Priapism may indicate spinal injury.
Assess the Lower Extremities
  • Look for signs of injury and edema.
  • Check for signs of deep vein thrombosis (DVT).
  • Check pulse, motor function, and sensation (PMS).
Assess Upper Extremities
  • Look for signs of injury.
  • Check pulses, motor function, and sensation (PMS).
  • Perform stroke assessment for arm drift.
Assess the Posterior Body

  • Inspect and palpate the area.

  • Include the thorax, lumbar area, buttocks, and lower extremities.

  • Once a problem is found, consider affected body systems.

  • Link body systems together to assess condition severity.

Respiratory System Assessment
  • Chest shape and symmetry
  • Accessory muscle use
  • Auscultation
Cardiovascular System Assessment
  • Peripheral and central pulses
  • Blood pressure
Neurological System Assessment
  • Mental status
  • Posture and motor activity
  • Facial expression
  • Speech
  • Mood
  • Memory
Musculoskeletal System Assessment
  • Pelvis
  • Lower/Upper extremities
  • Perfusion
  • Posterior body
Assess Vital Signs
  • Breathing (rate and tidal volume)
  • Pulse (location, rate, strength, regularity)
  • Skin (temperature, color, condition)
  • Capillary refill
  • Blood pressure (systolic, diastolic)
  • Pupils (equality, size, reactivity)
  • SpO2SpO_2
Obtain a History: SAMPLE & OPQRST
  • S – Signs and symptoms
  • A – Allergies
  • M – Medications
  • P – Past medical history
  • L – Last oral intake
  • E – Events prior to this event
  • O – Onset
  • P – Provocation/palliation
  • Q – Quality
  • R – Radiation
  • S – Severity
  • T – Time
Reconsider Mechanism of Injury
  • Significant MOI, multiple injuries, or altered mental status: Rapid secondary assessment
  • No significant MOI, no multiple injuries, and no altered mental status: Modified secondary assessment

Significant Mechanisms of Injury (MOI)

  • Ejection from vehicle
  • Death in same vehicle
  • Fall greater than 20 feet
  • Vehicle rollover
  • High-speed collision
  • Intrusion of 12”+ into passenger compartment
  • Pedestrian/bicyclist struck by vehicle
  • Motorcycle crash > 20 mph with rider separation
  • Blunt/penetrating trauma with altered mental status
  • Penetrating injury to head, neck, torso, or proximal extremity
Significant MOI for Children
  • Fall > 10 feet or 2-3 times child's height
  • Bicycle vs. motor vehicle
  • Pedestrian vs. motor vehicle at medium speed
  • Unrestrained child during MVC

Rapid Secondary Assessment (Trauma)

  • For significant MOI, altered mental status, multiple injuries, or critical findings (unstable).
  • Continue spinal stabilization.
  • Consider ALS but do not delay transport.
  • Follow local protocols.
Rapid Secondary Assessment Techniques
  • Inspect
  • Palpate
  • Auscultate
  • Listen
  • Smell
Detailed Assessment Areas
  • Head: Scalp, skull, face, ears, pupils, nose, mouth
  • Neck: Trauma, midline trachea, JVD
    *Clinical Features
    *Hyperresonance to percussion
    *Diminished breath sounds
    *Hypotension: Decreased venous return
Cervical Collar (C-Collar)
  • Apply after neck assessment.
  • Maintain in-line spine immobilization.
  • Chest: Expose, inspect, palpate, auscultate
  • Abdomen: Inspect, palpate, Markle test
  • Pelvis: Inspect, palpate
  • Lower Extremities: Pain, deformity, discoloration, and swelling of the thigh can indicate a fractured femur, which is associated with significant hemorrhage. Inspect,palpate,pulses,motor function, sensation
    Upper Extremities: Inspect, palpate, pulses, motor function, sensation
  • Posterior Body: Inspect, palpate
Prepare for Transport
  • Once immobilized, do not delay.
  • Limit scene time to ≤ 10 minutes for critical trauma.
Assess Baseline Vital Signs
  • Breathing
  • Pulse
  • Skin
  • Pupils
  • Blood pressure
  • Pulse oximetry
  • Blood glucose test
Obtain a SAMPLE History
  • Signs/symptoms
  • Allergies
  • Medication
  • Past pertinent history
  • Last oral intake
  • Events leading to injury
Provide Emergency Care
  • Prioritize management of critical injuries/conditions at the scene and during transport.
Trauma Score
  • Respiratory rate
  • Systolic blood pressure
  • Glasgow Coma Scale (GCS)
Revised Trauma Score

*Respiratory rate (breaths/min)
10−29=410-29 = 4
>29 = 3
6−9=26-9 = 2
1−5=11-5 = 1
0=00 = 0

*Systolic blood pressure (mm Hg)
>89 = 4
76−89=376-89 = 3
50−75=250-75 = 2
1−49=11-49 = 1
No pulse = 0

Glasgow conversion scale
13−15=413-15 = 4
9−12=39-12 = 3
6−8=26-8 = 2
4−5=14-5 = 1
<4 = 0

Call Hospital
  • Early notification for major trauma.
Reassess Patient (En Route)
  • Continuously reassess:
    • Primary assessment components
    • Vital signs
    • Rapid secondary assessment
  • Reassess intervention effectiveness.
  • Detailed Assessment.
Modified Secondary Assessment (Trauma)
  • For stable trauma patients (no significant MOI, altered mental status, multiple injuries, or critical findings).
  • Focuses on injury site and surrounding areas.
  • Obtain baseline vital signs and SAMPLE history.
  • If a stable patient deteriorates, perform a full head-to-toe secondary assessment.
  • When in doubt, conduct a complete secondary assessment.

Secondary Assessment: Medical Patient

  • Tailor the physical exam to the chief complaint.
  • Responsive: History -> Modified secondary assessment -> Vital signs
  • Unresponsive: Rapid secondary assessment -> Vital signs -> History (from bystanders)
Critical Medical Patient
  • Not alert, disoriented, or unresponsive.
  • Rapid secondary assessment, prompt transport.
  • Look for environmental clues.
Assess the Head (Medical)
  • Inspect for trauma.
  • Check mouth for pale mucosa, bleeding, secretions, or vomitus.
  • Inspect nose/ears for fluid or blood.
  • Check pupils (PERRL).
Assess the Neck (Medical)

inspect
JVD

  • Accessory muscle use
    Zones 1,2 and 3 for the neck
Assess the Chest (Medical)

Inspect
Auscultate
Crackles
Wheezing

Assess the Abdomen (Medical)
  • Inspect for distention/discoloration.
  • Look for scars from prior surgeries.
  • Palpate for tenderness, distention, rigidity, or pulsating masses.
  • Assess for rebound tenderness.
Assess the Pelvic Region (Medical)
  • Look for incontinence.
  • Inspect/palpate for distention or tenderness.
  • Suspect ectopic pregnancy if female with lower quadrant pain, missed period, and poor perfusion.
Assess Lower Extremities (Medical)
  • Note peripheral edema (CHF, fluid overload, clot).
  • Assess PMS
  • Note the response of the patient.
  • Look for MedicAlert tags.
Assess Upper Extremities (Medical)
  • Assess PMS
  • Note Response
    Look for MedicAlert tags.
Assess the Posterior Body (Medical)
  • Inspect/Palpate for discoloration, edema and tenderness
  • Sacral edema may indicate congestive heart failure
Assess Baseline Vital Signs (Medical)
  • Breathing
  • Pulse
  • Skin
  • Pupils
  • Blood pressure
  • Pulse oximetry
  • Blood glucose
Position the Patient (Medical)
  • Position of comfort.
  • Recovery position.
  • Have suction available.
Obtain a SAMPLE History (Medical)
  • For disoriented/unresponsive patients, gather information from family/bystanders.
  • SAMPLE is a quick way to get important information.
  • A detailed history beyond SAMPLE may not be possible.
Provide Emergency Care (Medical)
  • Oxygen via NRB or BVM if needed.
  • Provide care based on signs, symptoms, and history.
Make a Transport Decision (Medical)
  • Manage life threats.
  • Expedite transport.
  • Reassess en route.

Responsive Medical Patient

  • Assess patient complaints: OPQRST
  • Complete SAMPLE history
  • Obtain additional information for continuance of care.
Perform a Modified Secondary Assessment (Medical)
  • Focused or complete based on complaint.
  • If non-specific, do a complete assessment.
Assess Baseline Vital Signs (Medical)
  • Watch for changes.
Provide Emergency Care (Medical)
  • Contact medical direction if necessary.
  • Maintain patent airway and ventilation.
Make a Transport Decision (Medical)
  • By ground or air transport.

Reassessment

  • Determine changes in the patient’s condition and assess the effectiveness of your emergency care.
  • Repeat the primary assessment, reassess vital signs, repeat the secondary assessment, check interventions, and note trends in the patient’s condition.
  • Detect changes.
  • Identify missed injuries.
    Adjust care
    Note trends in patient condition.