PATIENT ASSESSMENT Scene Size-Up Initial Assessment Focused History

Scene Size-Up / Assessment w Definition: - an assessment of the scene and surroundings to assure the safety of the individual EMT-B, the partner and crew safety, and to provide potentially useful information about the patient and what occurred.

Scene Size-Up / Assessment w Body Substance Isolation w Need eye protection? w Gloves? w Gown & mask if necessary.

Is it safe to approach the patient? w Crash / Rescue scenes. w Toxic substances - low oxygen areas. w Crime scenes - potential for violence. w Unstable surfaces - slope, ice, water. w Protection of the patient - environmental. w Protection of bystanders - avoid injury. w If scene is unsafe, make it safe or do not enter.

Nature of Illness - Medical w Determine from patient, family or bystanders why EMS was activated. w Determine total number of patients. If more than unit can effectively handle, notify dispatch - activate mass casualty plan. w Obtain additional help prior to contact with patients. w Begin triage.

Mechanism of Injury - Trauma w Determine from patient, etc. and inspection of the scene, the mechanism of injury. w Ejection from vehicle. Falls > 20 feet. w Death in same compartment. Roll-over. w High-speed vehicle collision. Bicycle crash. w Vehicle-pedestrian collision. Motorcycle. w Determine total number of patients. Spinal?

The Initial Assessment The general impression is extremely valuable. EMT-Bs will hone this “sixth sense” as you assess more and more patients.

General Impression of the Patient w Formed to determine priority of care and is based on the immediate assessment of the environment and the patient’s chief complaint. w Determine if ill (medical) or injured (trauma). If injured, determine mechanism. w Age w Sex

General impression of the patient w Don’t be too quick to base your general impression of the patient strictly on dispatch information. w Avoid “tunnel vision”!

Determine if a life-threat exists! w Assess the patient and determine if the patient has a life-threatening condition. w If a life-threatening condition is found - treat immediately. w Assess the nature of illness or mechanism of injury.

Assess Patient’s Mental Status w Maintain spinal immobilization if needed. w Speak to the patient, introduce yourself. w LEVELS OF MENTAL STATUS Alert. Responds to Verbal stimuli. Responds to Painful stimuli. Unresponsive - no gag or cough.

Altered Level of Consciousness? w Patient should be oriented to – w PERSON w PLACE w TIME

Assess Patient’s Airway Status w Responsive patient - Is the patient talking or crying? If yes, assess for adequacy of breathing. If no, open the airway. w Unresponsive patient - Is the airway open?

Airway positioning is patient -, age -, and size-specific. w MEDICAL patients - w perform the head-tilt, chin-lift Clear Not-clear, clear the airway w TRAUMA patients, or unknown illness - w cervical spine precautions with jaw- thrust maneuver Clear Not-clear, clear the airway

Assess Patient’s Breathing w If breathing is adequate and patient is responsive, oxygen may be indicated. w All responsive patients breathing 8 breaths per minute should receive high flow oxygen (15 lpm, nonrebreather mask)

Patient’s Breathing (cont’d.) w Unresponsive, breathing is adequate - open and maintain the airway, providing high-concentration oxygen. w Breathing inadequate - open and maintain the airway, assist patient’s breathing and utilize ventilatory adjuncts with oxygen. w Not breathing, open and maintain airway, ventilate using ventilatory adjuncts with oxygen.

Assess the Patient’s Circulation w Assess the patient’s pulse by feeling the carotid. If alert, may check the radial pulse. Patient 1 year old or less - brachial pulse. If no pulse at radial or brachial, check carotid. w If pulseless medical patient > 9,* start CPR and apply automated external defibrillator, (AED). Medical patient < 9,* start CPR. Trauma patient, start CPR. –*pediatric electrodes available?

Patient Assessment (cont’d.) w Assess if major bleeding is present - control bleeding. w Assess patient’s perfusion by evaluating skin color and temperature; look at nail beds, lips and skin inside eyelids normal = pink abnormal = pale, cyanotic, flushed, jaundice

Pt. Assessment (cont’d.) w Assess patient’s skin temperature by feeling the skin. Normal = warm Abnormal = hot, cool, cold, clammy w Assess patient’s skin condition. Normal = dry Abnormal = moist w Assess capillary refill in infants & children Normal two second

Identify Priority Patients w Poor general impression. w Unresponsive patients. w Responsive, not following commands. w Difficulty breathing. w Hypoperfusion (shock). w Complicated childbirth. w Chest pain with BP < 100 systolic. w Uncontrolled bleeding. w Severe pain.

Determine a CUPS Status w Critical w Unstable w Potentially unstable w Stable Expedite transport of the patient based on determination. Consider ALS back up.

Proceed to Focused History and Physical Examination w Important for EMT-B to separate patients requiring rapid assessment and critical interventions from those who can be managed using components of focused assessment.

Focused History & Physical Exam TRAUMA

Reconsider Mechanism of Injury w Ejection from vehicle. w Death in same passenger compartment. w Falls > 20 feet. w Roll-over of vehicle. w High-speed vehicle collision. w Vehicle-pedestrian collision. w Motorcycle crash. w Unresponsive or altered mental status. w Penetrations of the head, chest, or abdomen.

Infant and Child Considerations w Falls greater than 10 feet. w Bicycle collision. w Vehicle in medium speed collision.

Consideration of Mechanism of Injury w Mechanism of Injury often results in specific hidden injuries. w Seat Belts w Airbags

Specific Hidden Injuries? w SEAT BELTS w If buckled, may have injuries. w Patient had seat belt on, does not mean they have no injuries. w Shoulder injury resulting from shoulder harness. w AIRBAGS w Not effective without seat belt. w Can hit wheel after deflation. w “Lift and look” at wheel for deformity. w Deformity = serious internal injury.

Rapid Trauma Assessment w Perform rapid trauma assessment on patients with a significant mechanism of injury to determine life threatening injuries. w In the responsive patient, symptoms should be sought before and during the trauma assessment.

Rapid Trauma Assessment Is Important In Order To: w Estimate the severity of injuries. w Make a CUPS status determination. w Make transport decisions. w Consider Advanced Life Support intercept. w Consider platinum ten minutes and the golden hour.

Rapid Assessment w Rapid assessment should be interrupted to provide life saving interventions: w AIRWAY w BREATHING w CIRCULATION

Performing a Rapid Trauma Assessment w Continue spinal immobilization. w Consider A.L.S. Request. w Reconsider transport decision. w Assess mental status. w As you inspect and palpate, look and feel for injuries or signs of injury using, w D C A P - B T L S

Look and Feel for; w DEFORMITIES w CONTUSIONS w ABRASIONS w PUNCTURES / PENETRATIONS w BURNS w TENDERNESS w LACERATIONS w SWELLING

Assess the Head w Deformities w Contusions w Abrasions w Punctures / Penetrations w Burns w Tenderness w Lacerations w Swelling w CREPITATION w FLUIDS / BLOOD from the head

Assess the Neck w Deformities w Contusions w Abrasions w Punctures / Penetrations w Burns w Tenderness w Lacerations w Swelling w JUGULAR VEIN DISTENSION (JVD) w CREPITATION w Apply cervical spinal immobilization collar (CSIC) at this time. w Tracheal Deviation

Assess the Chest w Deformities w Contusions w Abrasions w Punctures / Penetrations w Burns w Tenderness w Lacerations w Swelling w PARADOXICAL MOTION w Crepitation w BREATH SOUNDS present absent equal

Assess the Abdomen w Deformities w Contusions w Abrasions w Punctures / Penetrations w Burns w Tenderness w Lacerations w Swelling w FIRM w SOFT w DISTENDED

Assess the Pelvis w Deformities w Contusions w Abrasions w Punctures / Penetrations w Burns w Tenderness w Lacerations w Swelling w If No Pain is Noted, GENTLY COMPRESS THE PELVIS TO DETERMINE TENDERNESS OR MOTION

Assess All Four Extremities w Deformities w Contusions w Abrasions w Punctures / Penetrations w Burns w Tenderness w Lacerations w Swelling w DISTAL PULSE w SENSATION w MOTOR FUNCTION w CREPITATION

Roll Patient Ensuring Spinal Integrity w Assess posterior body, inspect and palpate, examining for injuries or signs of injury.

Vitals and SAMPLE w Assess baseline vital signs: w Respirations - rate & quality w Pulse - rate & quality w Blood Pressure w Pupils w Skin - CTC w Assess SAMPLE history: w Signs & Symptoms w Allergies w Medications w Pertinent History w Last Oral Intake w Events Leading Up To

Questions?