1. Assessment of the Patient
Concepts of Emergency Medicine
M. Rich, RN, BSN

2. Bell Work:
What are three contraindications for putting a blood pressure cuff on a patient’s arm?
What is the difference between systolic and diastolic pressure called?
How would you evaluate capillary refill?

3. Standard
18) Accurately perform the components of patient assessment to identify and manage immediate life threatening illnesses and injuries within the scope of practice of the EMR for pediatric, adult, and geriatric patients, utilizing rubrics from textbooks, National HOSA guidelines, or clinical standards of practice. Include the following areas: a. Scene Size-up b. Primary Survey or Assessment c. History Taking d. Secondary Assessment e. Vital Signs f. Reassessment

4. Objectives Understand how an EMR would coordinate Scene Size-up
Initial Assessment
Focused History and Physical Exam
Vital Signs
Secondary or Ongoing Assessment
Hand-off to EMTs

5. Patient Assessment
Bergeron, J. David & Chris Le Bandour. (2009). First Responder. 8th Edition. Pearson Prentice Hall. Upper Saddle River:NJ.

6. Scene Size-up
Every patient assessment begins with scene size-up, which includes:
Taking BSI precautions (body substance isolation)
Determining if the scene is safe
Identifying the MOI (mechanism of injury) or nature of illness
Determining the number of patients
Identifying any additional resources needed

7. Scene Size-up
BSI precautions
Rescuer wears protective eye wear.

8. Scene Size-up
BSI precautions
Rescuer dons gloves.

9. Scene Size-up BSI precautions
Rescuer wears both a gown and a simple surgical mask.

10. Scene Size-up BSI precautions
Rescuer wears a HEPA mask. (filters the air so less allergens or pollutants are being inhaled)

11. Scene Size-up *Scene Safety:
An assessment of the scene and surroundings will provide valuable information to the First Responder and will ensure the well-being of the First Responder.

12. Scene Size-up Scene Safety: Personal protection
Protection of the patient
Protection of bystanders
**If the scene is not safe, make it safe. Otherwise, DO NOT ENTER.

13. Scene Size-up
Unstable situation
HazMAT situation
Violent situation

14. Scene Size-up *Identify Mechanism of Injury: In trauma situations
An evaluation of the forces that caused an injury
May be beneficial in determining the presence of internal injuries
Determined from the patient, family, or bystanders, and inspection of the scene

15. Scene Size-up
*Identify Mechanism of injury
Trauma patient

16. Scene Size-up *Identify mechanism of injury Impact #1
“A car collides head on with a tree.”

17. Scene Size-up *Identify Mechanism of injury Impact #2
“The car collision causes the drivers chest to hit steering wheel.”
“The steering wheel causes damage to the chest area and broken ribs.”

18. Scene Size-up *Identify mechanism of injury Impact #3
“The impact of the steering wheel to the drives chest area cause additional damage to inner organs.”

19. Scene Size-up *Identify nature of illness: In medical situations
Determined from the patient, family, or bystanders
Why was EMS called?

20. Scene Size-up
*Identify nature of illness

21. Scene Size-up
Determine the number of patients and additional resources needed:
It is important to account for all patients involved.
Request additional resources if needed:
Fire department
Police
ALS crews (Advanced Life Support)
Rescue
Utilities
Call for resources early.

22. Scene Size Up

23. Objectives Understand how an EMR would coordinate Scene Size-up
Initial Assessment
Focused History and Physical Exam
Vital Signs
Secondary or Ongoing Assessment
Hand-off to EMTs

24. Initial Assessment Form a general impression of the patient.
Assess the patient’s mental status.
Assess the patient’s airway.
Assess the patient’s breathing.
Assess the patient’s circulation.
Make a decision on the priority the patient (notify dispatch)

25. Initial Assessment
The initial assessment is completed to assist the First Responder in identifying Immediate Threats to Life.

26. Initial Assessment Form a General Impression of the Patient
Based on the First Responder’s immediate assessment of the environment and the patient’s chief complaint.

27. Initial Assessment Form a general impression of the patient
Assess the Patient’s Mental Status:
Classify the patient’s mental status into one of the following categories:
Alert
Verbal
Painful
Unresponsive

28. Initial Assessment
*Assess the patient’s airway
Head-Tilt; Chin-Lift

29. Initial Assessment *Assess the patient’s airway
Jaw-thrust maneuver (with suspected neck injury)

30. Initial Assessment
*Assess the patient’s airway
Suction of needed

31. Initial Assessment *Assess the patient’s airway
Insert an airway adjunct as needed

32. Initial Assessment *Assess the patient’s breathing
Look at the effort of breathing.
Look, listen, and feel for presence of ventilations.
Ventilate as needed.

33. Airway assessment

34. Initial Assessment Assess the patient’s circulation
Check for a pulse (carotid artery in adults and brachial artery in infants).
Check for serious bleeding (control bleeding).
Check skin color.

35. Initial Assessment
Make a decision on the priority of the patient and alert dispatch.
High priority:
Poor general impression
Unresponsiveness
Breathing difficulties
Severe bleeding or shock
Complicated childbirth
Chest pain
Severe pain

36. Work it out
Finish up: BP of classmates Page 295, questions 3-5 and 7-12 Page 394, questions 2-5, 7-12

37. Bell Work:
1. What would a narrow pulse pressure indicate? 2. What would a widened pulse pressure indicate? 3. What is the first thing you would do after getting called to a scene? 4. In scene size up, what is your MOI? 5. What do you do first in your initial assessment? 6. When would you do a jaw-thrust maneuver and not a Head-Tilt Chin-Lift?

38. Standard
18) Accurately perform the components of patient assessment to identify and manage immediate life threatening illnesses and injuries within the scope of practice of the EMR for pediatric, adult, and geriatric patients, utilizing rubrics from textbooks, National HOSA guidelines, or clinical standards of practice. Include the following areas: a. Scene Size-up b. Primary Survey or Assessment c. History Taking d. Secondary Assessment e. Vital Signs f. Reassessment

39. Standard
14) Interpret the rules, guidelines, and legal ramifications related to incident documentation by EMS staff. Complete a pre-hospital care report utilizing appropriate medical terminology and the acronyms SAMPLE, DCAP-BTLS, and OPQRST

40. Objectives Understand how an EMR would coordinate Scene Size-up
Initial Assessment
Focused History and Physical Exam
Vital Signs
Secondary or Ongoing Assessment
Hand-off to EMTs

41. Focused History and Physical Exam
Trauma Patient
Medical Patient
Significant Mechanism of Injury
Unresponsive Medical Patient
• Perform a rapid trauma assessment (DCAP-BTLS) • Take vital signs • Gather SAMPLE history
• Perform a rapid physical assessment (DCAP-BTLS)
• Take vital signs
• Gather SAMPLE history
No Significant Mechanism of Injury
Responsive Medical Patient
• Perform a focused trauma assessment
• Gather SAMBLE history
• Gather SAMPLE history • Perform focused physical exam

42. Focused History and Physical Exam
Trauma Patient—Significant MOI:
Significant mechanisms of injury include:
Ejection from a vehicle
Death of another passengers in a MVC
Falls greater than 15 feet
Rollover vehicle collision
High-speed vehicle collision
Vehicle-pedestrian collision
Motorcycle crash
Unresponsiveness or altered mental status
Penetrations of the head, chest, or abdomen

43. Focused History and Physical Exam
* Trauma Patient—Significant MOI:
Significant mechanisms of injury in a child include:
Falls greater than 10 feet
Bicycle collision
Medium-speed vehicle collision

44. Focused History and Physical Exam
DCAP-BTLS: 
Deformities
Contusions
Abrasions
Punctures and Penetrations
Burns
Tenderness
Lacerations
Swelling

45. DCAP
Deformities: Is there an abnormality in the shape of a body part or organ compared to the normal shape?
Contusions: Do you notice bruising? In extreme cases, this can cause blood to seep, hemorrhage or extravasate into surrounding tissues.
Abrasions: How severe is the abrasion? Your treatment will vary depending on the severity, but be sure to always clean and remove any debris.
Punctures/penetrations: Penetrating trauma suggests an object didn't pass through, while perforating trauma is associated with an entrance and exit wound.

46. BTLS Burns: Treatment depends on the severity of the burn.
Tenderness: This shouldn't be confused with pain. Tenderness is triggered by discomfort when an affected area is touched.
Lacerations: Treatment depends on the type, cause and depth of the wound. Minor wounds heal on their own, while puncture wounds are more prone to infection.
Swelling: This is an abnormal enlargement of a body part or area. Swelling may occur in response to infection, injury or disease.

47. Focused History and Physical Exam
Trauma patient – Rapid trauma assessment
Stabilize the head and neck, and check the head (scalp and face).

48. Focused History and Physical Exam
* Trauma assessment – rapid trauma assessment
Check the neck and apply a cervical collar (if trained to do so). Note any swelling or tenderness.

49. Focused history and physical exam
Trauma patient – rapid trauma assessment
Check the chest
Check each quadrant of the abdomen (note any abnormalities, tenderness, or foreign bodies)

50. Focused History and Physical exam
Trauma Patient—Rapid Trauma Assessment
Check the pelvis, pressing gently down and inward.

51. Focused History and Physical Exam
* Trauma Patient—Rapid Trauma Assessment
Check the extremities, legs, and then arms (look for any deformity, swelling, or discoloration).

52. Focused History and Physical Exam
* Trauma Patient—Rapid Trauma Assessment
Check for distal pulse, motor function, and sensation in each extremity.

53. Focused History and Physical Exam
* Trauma Patient—Rapid Trauma Assessment
Check the back and buttocks while maintaining c-spine immobilization:
keep arms close to center of body and patient is moved keeping the entire body aligned while rolling patient on his side.
the patient is rolled on the count of the person holding c-spine.

55. Videos https://www.youtube.com/watch?v=-tKv2Bs83rI

56. Focused History and Physical Exam
* Trauma Patient—No Significant MOI:
Steps of assessment include:
Perform a focused trauma assessment.
Take vital signs.
Gather SAMPLE history.
S-signs/symptoms
A-allergies
M-medication
P-past history
L-last oral intake
E-events prior

57. Focused History and Physical Exam
* Trauma Patient—Focused Trauma Assessment
Examine the area that is injured.
Take vital signs.
Provide appropriate care (i.e. stabilize any injuries, control bleeding, dress wounds)

58. Focused History and Physical Exam
Trauma Patient:
SAMPLE History:
Signs and symptoms
Allergies
Medications
Pertinent past medical history
Last oral intake
Events leading to the illness or injury

59. Focused History and Physical Exam
* Medical Patient—Unresponsive:
Steps of assessment include:
Perform a rapid physical exam (head-to-toe).
Take vital signs (pulse, respirations, blood pressure – if equipment available, mental status).
Gather SAMPLE history.

60. Focused History and Physical Exam
* Medical Patient—Responsive:
Steps of assessment include:
Gather SAMPLE history.
Take vital signs (pulse, respirations, blood pressure-if equipment available, mental status)
Perform a focused physical exam.
Area of chief complaint
**Note any medical identification devices (i.e. allergy bracelets)

61. OPQRST
OPQRST is a useful mnemonic (memory device) for learning about your patient’s pain complaint. 

62. OPQRST
Onset: “Did your pain start suddenly or gradually get worse and worse?” This is also a chance to ask, “What were you doing when the pain started?”
Provokes or Palliates: Instead of asking, “What provokes your pain?” use real, casual words. Try, “What makes your pain better or worse?”
Quality: Asking, “Is your pain sharp or dull?” limits your patient to two choices, when their pain might not be either. Instead ask, “What words would you use to describe your pain?” or “What does your pain feel like?”

63. OPQRST
Radiates: This is another chance to use real, conversational words during assessment. Asking, “Does your pain radiate?” sounds silly and pompous to the patient. Instead use this question, “Point to where it hurts the most. Where does your pain go from there?”
Severity: Remember, pain is subjective and relative to each individual patient you treat. Have an open mind for any response from 0 to 10.
Time: This is a reference to when the pain started or how long ago it started.

64. Work it out
Page 407, questions 1-10

65. Bell Work 2-21-2018 What is DCAP-BTLS? When do you use it?
What is a SAMPLE History. How do you get it if the patient is unresponsive?
What is OPQRST?

66. Objectives Understand how an EMR would coordinate Scene Size-up
Initial Assessment
Focused History and Physical Exam
Vital Signs
Secondary or Ongoing Assessment
Hand-off to EMTs

67. Vital Signs * Pulse: Assess for three characteristics:
Rate (number of beats per minute)
Strength (weak, bounding, thready, absent)
Rhythm (regular or irregular)
Carotid pulse in the neck (most distinct pulse felt)
Radial pulse in the lateral portion of the forearm, on the thumb side of the wrist (most easily accessible)

68. Vital Signs
* Pulse:
To measure a radial pulse rate (number of beats/minute)
Use your 1st and 2nd fingertips to feel for an artery.
Do not use your thumb.
Find the artery (usually radial or carotid)
Apply moderate pressure.
Count the beats for 30 seconds.
Multiply your 30-second count by 2.

69. Vital Signs * Pulse: The normal pulse rate for adults is 60–100 bpm.
Rate > 100 = Tachycardia
Rate < 60 = Bradycardia
Newborn infants = 120 to 160 bpm
Up to 5 years old = 80 to 140 bpm
5 to 12 years of age = 70 to 110 bpm

70. Vital Signs Observation Possible Problem *PULSE Rapid, strong pulse
Internal bleeding (early stages), fear, heat emergency, overexertion, high blood pressure, fever
Rapid, weak pulse
Shock, blood loss, heat emergency, diabetic emergency, failing circulatory system
Slow, strong pulse
Stroke, skull fracture, brain injury
No pulse
Cardiac arrest
Bergeron et al. (2009) First Responder. 8th Edition. Pearson Prentice Hall. Upper Saddle River:NJ.

71. Vital Signs * Respirations: Assess for 2 characteristics: Rate: Slow
Normal
Rapid
Character:
Rhythm—(Regular or Irregular)
Depth—(Normal, Shallow, or Deep)
Sound—(Abnormal Sounds)
Ease—(Labored, Difficult, or Painful)

72. Vital Signs Respirations: To measure & assess respirations:
After pulse count, leave your hand on the wrist.
Observe the rise and fall of the chest.
Listen for sounds.
Count the number of breaths in 30 seconds.
Multiply your 30-second count by 2.
Note rhythm, depth, sound, and ease of breathing.

73. Vital Signs Observation Possible Problem Rapid, shallow breaths
Shock, heart problems, heat emergency, diabetic emergency, heart failure, pneumonia
Deep, gasping labored breaths
Airway obstruction, heart failure, heart attack, lung disease, chest injury, diabetic emergency
Slow breathing
Head injury, stroke, chest injury, certain drugs
Snoring
Stroke, fractured skull, drug or alcohol abuse, partial airway obstruction
Crowing
Airway obstruction, airway injury due to heat
Gurgling
Airway obstruction, lung disease, lung injury due to heat
Wheezing
Asthma, emphysema, airway obstruction, heart failure
Coughing blood
Chest wound, chest infection, fractured ribs, punctured lung, internal injury
Bergeron et al. (2009). First Responder. 8th Edition. Pearson Prentice Hall. Upper Saddle River:NJ.

74. Vital Signs * Respirations:
The normal respiratory rate for adults is 12–24 breaths per minute.
> 28 or < 8 are considered serious.
Newborn infants = 25–50 breaths per min.
Up to 5 years old = 20–30 breaths per min.
5 to 12 years of age = 15–30 breaths per min.

75. Vital Signs *Skin color, temperature, moisture Observation
Significant / Possible Problem
Pink
Normal in light-skinned patients; normal in inner eyelids, lips, and nail beds of dark-skinned patients
Pale
Constricted blood vessels possibly resulting from blood loss, shock, decreased blood pressure, emotional distress
Blue (cyanotic)
Lack of oxygen in blood cells and tissue resulting from inadequate breathing or heart function
Red (flushed)
Heat exposure, high blood pressure, emotional excitement; cherry red indicates late stages of carbon monoxide poisoning
Yellow (jaundiced)
Liver abnormalities
Blotchiness (mottling)
Occasionally in patients that are in shock
Bergeron et al. (2009). First Responder. 8th Edition. Pearson Prentice Hall. Upper Saddle Hall:NJ.

76. Vital Signs *Skin signs Skin Signs Significant / Possible Problem
Cool, clammy
Shock, anxiety, heart attack
Cold, moist
Body is losing heat
Cold, dry
Exposure to cold
Hot, dry
High fever, heat emergency, spinal injury
Hot, moist
High fever, heat emergency
Goose bumps accompanied by shivering, chattering teeth, blue lips, and pale skin
Chills, communicable disease, exposure to cold, pain, or fear
Bergeron et al. (2009). First Responder. 8th Edition. Pearson Prentice Hall. Upper Saddle River:NJ.

77. Vital Signs * Pupils Observation Possible Problem
Dilated, nonreactive pupils
Unresponsiveness, shock, cardiac arrest, bleeding, certain medications, head injury
Constricted, nonreactive pupils
Central nervous system damage, certain medications
Unequal pupils
Stroke, head injury
Bergeron et al. (2009). First Responder. 8th Edition. Pearson Prentice Hall. Upper Saddle River:NJ.

78. Objectives Understand how an EMR would coordinate Scene Size-up
Initial Assessment
Focused History and Physical Exam
Vital Signs
Secondary or Ongoing Assessment
Hand-off to EMTs

79. Ongoing Assessment
While awaiting the additional EMS resources, the First Responder should continue to assess the patient.

80. Ongoing Assessment Repeat initial assessment:
Repeat every 15 minutes for a stable patient.
Repeat every 5 minutes for an unstable patient.
Repeat exams as needed.
Repeat vital signs.
Check interventions.
Calm and reassure.
Provide comfort measures.

81. Hand-off Report to EMS Verbal Report:
Patient’s mental status
Age and sex
Chief complaint
Airway, breathing, and circulatory status
Physical findings
SAMPLE history
Interventions applied
Patient’s response to interventions
Accurate Documentation if Required

82. video

83. Summary Scene Size-up Initial Assessment
Focused History and Physical Exam
Vital Signs
Ongoing or Secondary Assessment
Hand-off to EMTs

84. Standard 10
Interpret scene management and safety standards and/or protocols by writing a scenario for each of the following situations: (a) traffic or highway incidents, (b) violent encounters, (c) crowds, (d) nature of illness or mechanisms of injury, (e) number of patients and/or victims, and (f) personnel injury prevention. Identify the appropriate responses from EMS professionals and any additional resources that would be involved.

85. Create an EMS Scenario
SEE Handout

86. Bell Work
1.You have an unresponsive trauma patient and have just arrived on the scene of an MVA- what do you do in an initial assessment? 2. After the initial assessment, what 3 items do you implement next? Put in correct order 3. Besides pulse rate, what else are you evaluating? 4. Besides getting respiratory rate, what else are you evaluating? 5. What other two items are you observing while taking vital signs?

87. Trauma Care