“It’s amazing what you can see when you look” Yogi Berra

Patient Assessment not a basic skill

do not diagnose the question is... Do I have a critical patient?

Patient Assessment Scene size-up Initial assessment Focused history and physical exam –Vital signs –History Detailed physical exam Ongoing assessment

Scene Size Up Body Substance Isolation/Standard Precautions Safety, Safety, Safety, Safety,... Mechanism of injury or Nature of illness # of patients Need for additional resources Need for extrication / spinal precautions

Body Substance Isolation Assumes all body fluids present a possible risk for infection Protective equipment –Latex or vinyl gloves should always be worn –Eye protection –Mask –Gown –Turnout gear

Scene Safety Look for danger Park in a safe area Speak with law enforcement first if present. The safety of you and your partner comes first! Next is safety of patient(s) and bystanders. Request additional resources.

Mechanism of Injury Force body was exposed to –Chief complaint Evaluate: –Amount of force applied –Length of time it was applied –Area involved

Nature of Illness Search for clues This is chief complaint Gather information from the patient/bystanders Observe the scene.

Chief Complaint Most serious problem voiced by the patient May not be the most significant problem present

Number of Patients # of patients and condition. Additional resources needed? Triage to identify severity of each patient’s condition.

Additional Resources Medical resources –Additional units –Advanced life support Nonmedical resources –Fire suppression –Rescue –Law enforcement

Spinal Immobilization Consider early during assessment. Do not move without immobilization. Err on the side of caution.

Initial Assessment Develop a general impression Assess mental status Assess airway Assess the adequacy of breathing Assess circulation Establish patient rapport Identify patient priority

Develop a General Impression As you approach the scene –Assessment of the environment –Patient’s chief complaint –Presenting signs and symptoms of patient No vitals yet, only skin signs/cap refill

Assessing Mental Status Checking responsiveness Check for orientation

Checking Responsiveness A - Alert V - Verbal P - Pain U - Unresponsive

Checking Orientation Person Place Time Event

Glasgow Coma Scale More advanced LOC indicator Eye Verbal Motor point scale

GCS Eye Opening spontaneous = 4 to voice= 3 to pain= 2 none= 1

GCS VERBAL Oriented= 5 Confused= 4 Inappropriate words= 3 Incomprehensible sounds= 2 None= 1

GCS MOTOR obeys command= 6 localizes pain= 5 withdraws (pain)= 4 flexion (pain)= 3 extension (pain)= 2 none= 1

Assessing ABC’s We know how to assess the unresponsive More evaluation needed in responsive pt. Is patient speaking to you? –A and B –Full sentences –2 or 3 word What are skin signs like? Cap refill? –C –Indicates perfusion

Establish Patient Rapport People Skills Do what you can to make the patient comfortable Listen to the patient Make eye contact Base questions on the patient's complaint –More to follow Mentally summarize before starting treatment Obtain consent

Decision point Regardless if trauma or medical Is patient critical? Do they need rapid transport?

Identifying Priority Patients Poor general impression Unresponsive with no gag or cough reflexes Responsive but unable to follow commands Difficulty breathing Signs of poor perfusion Complicated childbirth Uncontrolled bleeding Severe pain Severe chest pain Inability to move any part of the body

The Golden Hour

Medical vs. Trauma Determination should come after initial assessment is finished. Patients may have traumatic injuries caused by a medical reason. Initially assume all patients have both medical and traumatic aspects to their condition.

Trauma Patients With significant MOI Unresponsive or disoriented Extremely intoxicated Patients whose complaint cannot be identified or understood Proceed with rapid trauma assessment Rapid transport Consider ALS backup

Significant Mechanism of Injury Ejection from vehicle Death in passenger compartment Fall greater than 15´-20´ Vehicle rollover High-speed collision Unresponsiveness or altered mental status Penetrating trauma to head, chest, or abdomen

Auto vs auto SAFETY observe/ask questions about mechanism Speed position of patient before accident (driver, backseat, etc..) KO? restrained? airbag? Passenger space intrusion?

Auto vs pedestrian or bicycle/motorcycle SAFTEY observe/ask questions about mechanism helmet? KO? Injuries more likely to be severe

Rapid Physical Exam seconds head-to-toe exam –Significant trauma patients –Unresponsive medical patients

DCAP-BTLS D Deformities C Contusions A Abrasions P Punctures/ Penetrations B Burns T Tenderness L Lacerations S Swelling

Rapid Physical Exam (1 of 3) Maintain spinal immobilization while checking patient’s ABCs. Use DCAP BTLS Assess the head. Assess the neck. Apply a cervical spine immobilization collar.

Rapid Physical Exam (2 of 3) Assess the chest. Assess the abdomen. Assess the pelvis. Assess all four extremities.

Rapid Physical Exam (3 of 3) Roll the patient with spinal precautions. Assess baseline vital signs and SAMPLE history.

Detailed Physical Exam more in-depth only performed if time allows performed en route to the hospital have system - head to toe practice same way every time always check area before covering for our lab, rapid trauma assessment and detailed physical exam are same (Head to Toe)

Focused History and Physical Exam (medical) Medical history Baseline vital signs Physical exam

Focused History and Physical Exam (Trauma-no significant mechanism) Assess the chief complaint. –Chest pain –Shortness of breath –Abdominal pain –Any pain associated with bones or joints –Dizziness Obtain baseline vital signs and SAMPLE history

SAMPLE SAMPLE History S Signs and symptoms A Allergies M Medications P Past medical history L Last oral intake E Events leading to the episode

Alternate HAM –History –Allergies –Medications

Vital Signs After rapid assessment, obtain baseline vital signs and a SAMPLE history. Vital signs of stable patients should be reassessed every 15 minutes. Vital signs of unstable patients should be reassessed every 5 minutes.

Focused Physical Exam Investigate problems associated with chief complaint. Examine abnormalities. Assess vital signs. –Skins –Chest Auscultation Make transportation decision. Document findings.

Assessing the Responsive Medical Patient Ask general questions May not be obvious Use patient’s own words Multiple complaints?

Questions to ask: Chest pain OPQRST Shortness of breath also? Medication?

OPQRST O Onset P Provoking factors Q Quality of pain R Radiation / Region S Severity T Time / Treatment

Questions to ask: Shortness of breath How long? Sudden or slow onset? Chest pain also? Chest auscultation

Questions to ask: Abdominal pain OPQRST N/V Normal bowel movement & urination? GI bleed? FEMALES –pregnant? –LMP, normal?

Assessing the Unresponsive Patient (Medical) Perform a rapid medical assessment. Obtain baseline vital signs. Obtain SAMPLE history from family if available. Provide emergency care and transport. Document findings.

Questions to ask: Altered level of consciousness DERM AEIOU TIPS Sudden or Slow? Ask bystanders

DERM D - depth of consciousness E - eyes R - respirations (abnormal patterns) M - motor function

AEIOU TIPS A - alcohol, apnea, arrhythmia, anaphylaxis E - epilepsy/environment I - insulin O - overdose U - uremia/underdose

AEIOU TIPS T - trauma I - infection P - psychogenic S - stroke

Questions to ask: Overdose - Poisonings what how long ago route any other?

Questions to ask: Diabetes Taken your medicine? Eaten normally? Slow or fast onset? its a balance!

Questions to ask: Seizures How long did it last? Fall? More than 1? How did it start What is status epilepticus?

Questions to ask: Syncope out how long? fall? chest pain? irregular heart beat?

Questions to ask: Shootings - a.k.a. GSW SAFETY # shots heard type of gun (caliber) distance other associated trauma ?

Questions to ask: Stabbings - a.k.a. “cutting” SAFETY type of knife? (size) associated trauma?

Questions to ask: Assaults SAFETY hit with what? where? # of times? KO?

Questions to ask: Falls trip & fall? or dizzy & fall? how far? how did they land? What did they land on? KO?

Ongoing Assessment Is treatment improving the patient’s condition? Has a problem gotten better? Worse? Any newly identified problems?

Steps of the Ongoing Assessment Repeat the initial assessment. Reassess vital signs. Repeat focused assessment. Check interventions.

Documentation Skin color, temperature, and moisture Initial assessment findings Baseline and subsequent vital signs and SAMPLE history Circulation, sensation and movement in all extremities Breath sounds

That’s all folks!! questions?