9/20/2018 Patient Assessment

Outline Scene Size-Up Initial Assessment Physical Examination Patient History Ongoing Assessment Hand-Off Report

Patient Assessment Determining the problems a patient is experiencing Goal is to identify and treat critical problems

Scene Size-Up First step of patient assessment Personal safety 9/20/2018 Scene Size-Up First step of patient assessment Personal safety Safety of scene Assessment of Mechanism of Injury (MOI) or Nature of Illness (NOI)

Size up this scene 9/20/2018 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

9/20/2018 Personal Safety First concern is PPE BSI Protective clothing

Size up this scene 9/20/2018

Common hazards Unstable vehicles Undeployed airbags Leaking fluids 9/20/2018 Common hazards Unstable vehicles Undeployed airbags Leaking fluids Traffic Agitated or violent patient or bystanders

9/20/2018 Hazardous Materials Tractor-trailer crashes, train derailments, industrial sites, farm incidents Notify HAZMAT team Do not approach scene until directed

Crimes Scenes and Environment Crime Scenes Violent crime Domestic violence Environment Slopes, ice, water, etc. Weather conditions

Bystanders Often not aware of hazards and may put themselves at risk 9/20/2018 Bystanders Often not aware of hazards and may put themselves at risk May also put others at risk Smoking in presence of oxygen or spilled fuel

Safety First If the scene is not safe, and you cannot make it safe, do not enter Wait for specially trained rescue personnel to make scene safe or bring patient to you STOP!

MOI An evaluation of forces that caused an injury 9/20/2018 MOI An evaluation of forces that caused an injury May help anticipate injuries Systematically survey scene and question bystanders

What would you ask or look for? 9/20/2018 What would you ask or look for? Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Determine If patient assaulted (shot, beaten, stabbed) Weapon used 9/20/2018 Determine If patient assaulted (shot, beaten, stabbed) Weapon used Height of fall Surface patient landed on Position patient landed Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

What are some clues to illness? 9/20/2018 Nature of Illness What are some clues to illness? Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Nature of Illness Why did patient call for help? 9/20/2018 Why did patient call for help? What is the patient’s complaint? Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Copyright © 2004 Elsevier (USA). All Rights Reserved

Clues to Illness Patient confined to bed Patient uses walker or cane 9/20/2018 Clues to Illness Patient confined to bed Patient uses walker or cane Patient lacks adequate food/shelter Patient takes medications Other clues?

Number of Patients Incident may involve more than 1 patient 9/20/2018 Number of Patients Incident may involve more than 1 patient Must be determined before patient care Call for additional resources if needed If more than 1 patient, perform triage

9/20/2018 The initial assessment is performed to identify any immediate threats to the patient’s life

Initial Assessment GILT Level of responsiveness Checking ABCDEs 9/20/2018 Initial Assessment GILT General impression / life threatening Level of responsiveness Checking ABCDEs

GILT Gather information about patient and patient’s environment 9/20/2018 GILT Gather information about patient and patient’s environment What is the patient’s position? What is the patient’s appearance? Any sights/sounds/smells? Does it appear to be medical or trauma?

LOC Evaluate level of consciousness using the AVPU Alert Verbal Pain Unconscious

If trauma, begin by stabilizing patient’s cervical spine 9/20/2018 Caution! If trauma, begin by stabilizing patient’s cervical spine Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Unconscious Patient Speak to patient If no response 9/20/2018 Unconscious Patient Speak to patient If no response Shake patient’s shoulder Pinch earlobe or shoulder 2485 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Infants & Children AVPU not a good scale 9/20/2018 Infants & Children AVPU not a good scale Note if interaction with parents and actions normal for age

A - Airway Responsive Patient Unresponsive Patient 9/20/2018 A - Airway Responsive Patient Can patient speak without difficulty? Unresponsive Patient Perform head-tilt chin-lift/jaw-thrust Inspect airway Clear airway as needed

If patient’s airway is not open …. Before moving on to B - Breathing 9/20/2018 Assess & Treat If patient’s airway is not open …. OPEN IT! Before moving on to B - Breathing Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

B - Breathing Responsive Patient 9/20/2018 B - Breathing Responsive Patient Ability to speak without stopping to catch breath Noisy breathing Patient position Use of accessory muscles Rate and depth of ventilations

B - Breathing Unresponsive patient Look Listen Feel 9/20/2018 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Assess & Treat If breathing is absent, too fast, too slow, too shallow, Immediately begin ventilations before moving to C - Circulation

C - Circulation Evaluation of circulation of patient’s blood 9/20/2018 C - Circulation Evaluation of circulation of patient’s blood Look for major blood loss Assess pulse Assess skin 2489 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Check for Blood Loss Major external bleeding Actively bleeding? 9/20/2018 Check for Blood Loss Major external bleeding Actively bleeding? Pool of blood anywhere? Collection of blood in patient clothes/hair?

Assess & Treat Control major bleeding Often times this goes hand-in-hand with A - Airway

Assess Pulse - Where? Responsive adult Unresponsive adult Radial pulse 9/20/2018 Assess Pulse - Where? Responsive adult Radial pulse Unresponsive adult Carotid pulse Photos of radial pulse and carotid pulse

Assess Pulse - Where? Responsive child Unresponsive child 9/20/2018 Assess Pulse - Where? Responsive child Radial or brachial pulse Unresponsive child Carotid or femoral pulse

Assess Pulse - Where? Infant Brachial pulse 9/20/2018 Photos of brachial pulse for infant

Assess Pulse Determine Presence or absence Rate Strength Regularity 9/20/2018 Assess Pulse Determine Presence or absence Rate Strength Regularity 2489 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

before moving to D - Disability Assess & Treat If no pulse, Immediately begin chest compressions before moving to D - Disability

Assess Skin Color Temperature Moisture 9/20/2018 Assess Skin Color Temperature Moisture Inadequate circulation causes pale, cool, clammy skin

D - Disability Assessment of brain function 9/20/2018 D - Disability Assessment of brain function Use Glasgow Coma Scale (GCS)

Glasgow Coma Scale Eye Opening Spontaneous 4 To Voice 3 To Pain 2 9/20/2018 Glasgow Coma Scale Eye Opening Spontaneous 4 To Voice 3 To Pain 2 None 1 Verbal Response Oriented 5 Confused 4 Inappropriate Words 3 Incomprehensible Words 2 Motor Response Obeys Command 6 Localizes Pain 5 Withdraw (pain) 4 Flexion (pain) 3 Extension (pain) 2

E – Expose / Environment 9/20/2018 E – Expose / Environment Expose the patient’s body as needed or appropriate to assess for injury or illness Consider the environment and keep the patient warm

Make a decision! Is the patient critical? Is the patient non-critical? 9/20/2018 Make a decision! Is the patient critical? Is the patient non-critical?

What is critical? Any life-threatening problems identified in the ABCDEs!

Communicate and Ask Questions 9/20/2018 Communicate and Ask Questions Helps determine Patient’s age and sex Chief complaint Level of responsiveness Status of airway and breathing Status of circulation and disability

Vital Signs Respiratory Rate Heart Rate Blood Pressure Note depth, regularity, and effort Heart Rate Note location, regularity, and strength Blood Pressure Auscultated vs. palpated

Physical Examination (PE) 9/20/2018 Physical Examination (PE) Begins once life-threatening problems addressed Purpose is locating and beginning management for signs and symptoms of injury and illness

9/20/2018 Take Note! May not perform detailed PE if life-saving care still required Not all patients will require all steps of a detailed PE Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Examination Inspection Look for signs of illness or injury 9/20/2018 Physical Examination Inspection Look for signs of illness or injury EMT-99 Slide Set Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Examination Palpation Feel for signs of illness or injury 9/20/2018 Physical Examination Palpation Feel for signs of illness or injury EMT-99 Slide Set Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Systematic and Orderly 9/20/2018 Systematic and Orderly Often done “head to toe” Assess all body areas for DOTS D = Deformities O = Open injuries T = Tenderness S = Swelling

Physical Examination Listen to lung sounds 9/20/2018 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Examination Look for medical alert tags 9/20/2018 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

9/20/2018 Patient History Take patient history either before, after, or during physical examination Depends on situation

If patient can’t answer 9/20/2018 Begin with patient If patient can’t answer Ask family members Ask bystanders EMT-99 Slide Set Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

SAMPLE History S – Signs and symptoms A – Allergies M – Medications 9/20/2018 SAMPLE History S – Signs and symptoms May also ask S – Social drugs A – Allergies M – Medications P – Past history (medical / surgical) L – Last oral intake E – Events leading to injury or illness

9/20/2018 Signs and Symptoms A sign is a finding you can hear, see, feel or measure A symptom is something a patient describes

Ask Questions … Can you describe the problem? What kind of symptoms? 9/20/2018 Ask Questions … Can you describe the problem? What kind of symptoms? What makes the symptoms better/worse? When did the symptoms start? How long have you had problem? Anything like this happen before?

A - Allergies Medications Foods Substances in environment 9/20/2018 A - Allergies Medications Foods Substances in environment Any medical alert tags? Shade

M - Medications Prescription medications Over-the-counter medications 9/20/2018 M - Medications Prescription medications Over-the-counter medications Another person’s medications Has patient recently stopped taking any medications

P – Past History Are you seeing physician for anything? 9/20/2018 P – Past History Are you seeing physician for anything? Ever been hospitalized? Any medical problems? Any pertinent surgeries? Any significant injuries?

L – Last Oral Intake When did you last eat or drink? What was it? 9/20/2018 L – Last Oral Intake When did you last eat or drink? What was it? How much?

E – Events leading up to injury or illness 9/20/2018 E – Events leading up to injury or illness What were you doing when the problem started? Were there any other symptoms at that time?

9/20/2018 Ongoing Assessment Assessment doesn’t end after physical examination and patient history Continue to reassess patient until additional help arrives Frequency depends on patient’s condition

What do I Reassess? Airway Breathing Circulation 9/20/2018 What do I Reassess? Airway Breathing Circulation Disability (mental status) GCS Reassure the patient while waiting for help

When EMS Unit Arrives Provide: Patient age and sex Chief complaint 9/20/2018 When EMS Unit Arrives Provide: Patient age and sex Chief complaint Assessment and history findings Summary of care provided Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

9/20/2018 Summary Initial assessment provides a general impression of the patient’s condition Correct life-threats during the initial assessment Other assessment activities help provide clues to the nature of illness or injury

Questions?