1. LESSON 10
SCENE SIZE-UP AND
PRIMARY ASSESSMENT

2. Introduction Patient assessment involves critical EMR skills
Act quickly to ensure scene is safe, assess patient and care for immediate threats to life
Care provided is based on patient assessment
Assessment begins with the primary assessment

3. Scene Size-Up
While going to scene, consider factors that may affect safety for you, bystanders and patient
Dispatcher’s information may alert you to hazards or special precautions
Begin scene size-up before you exit your vehicle and while approaching the patient

4. Scene Safety Observe for any hazards As you enter scene
While approaching patient

5. Hazardous Materials
Chemicals
Biological agents

6. Vehicle Crash Hazards Traffic hazards Downed wires
Risk of fire or explosion
Unstable vehicles
Extrication hazards
Hazardous materials

7. Potential Violence Crime scenes
Potentially violent patient or bystanders
Guard dogs, wild animals

8. Environmental Dangers
Unstable surfaces
Water, ice
Weather extremes

9. Hazards Within Structures
Low-oxygen areas
Toxic substances, fumes
Risk of collapse
Risk of fire or explosion

10. Principles of Scene Safety
Enter scene only if it is safe
If unsafe, make it safe or stay away and request specialized resources
Protect bystanders and other rescuers from hazards
Protect patient from environmental threats

11. Scene Management
As you approach the patient, begin process of scene management
Consider factors related to a medical or trauma patient
Address hazards within the scene
Consider the need for additional resources
Implement standard precautions to prevent infection

12. Trauma vs. Medical Patient
Dispatch may tell you whether there is a trauma patient or a medical patient
This focuses your attention on a mechanism of injury or the nature of the illness

13. Mechanism of Injury
With trauma patient, scene size-up includes evaluating for clues about mechanism of injury (MOI)
MOI may suggest serious injury or presence of internal injuries

14. Consider the Mechanism
What specifically caused the injury?
Was there an impact with a blunt or sharp object?
What body area received the impact? What organs may be injured?
How much force may have been involved?
Might the force have been transferred from one body area to another?

15. Examples of Mechanism of Injury
Vehicle collision may cause head or spinal injuries
Fall from a height may cause extremity fractures
Blunt impact to abdomen may cause closed injury and internal bleeding
Diving incident may cause spinal injury
Gunshot may cause extensive internal damage not apparent from the appearance of the outside wound
Fall forward onto a hand may transfer force up arm and cause shoulder dislocation

16. Importance of Time Quickly consider MOI during scene size-up
Do not delay patient assessment to examine scene in detail
Consider MOI more fully while gathering history and performing physical examination

17. Consider Nature of Illness
Consider nature of illness during scene size-up
Don’t stop to talk to family or bystanders until you are sure there is no immediate threat to life
Observe patient’s position and demeanor for clues
Use all your senses
If patient is unresponsive, move immediately to primary assessment
If patient is responsive, ask patient, family members or bystanders why EMS was called

18. Number of Patients Determine how many patients are involved
Observe for clues and ask those present if everyone is accounted for
Be certain you know how many patients are involved
Call for additional help immediately for multiple patients
If more patients than responders, triage patients first

19. Addressing Hazards Consider environmental factors as you size up scene
Protect yourself and other responders
Protect the patient
Protect bystanders

20. Additional Resources
Scene size-up includes consideration of whether additional resources may be needed
If resources not already en route, call dispatch immediately
Describe injuries in detail, so an ALS ambulance can be sent if needed

21. Additional Resources (continued)
Consider these factors:
Number of patients and types and seriousness of injuries
Possible need for air transport
Potential for fire or explosion
Potential presence of hazardous materials
Need for extrication
Need for law enforcement or traffic control
Damage to power lines or other utilities

22. BSI Precautions
Put on medical examination gloves as you approach patient
Observe scene and patient to determine whether to use other personal protective equipment:
Protective eyewear
Gown and mask
Turn-out gear
Follow standard precautions

23. Primary Assessment
Performed when you reach patient to identify any immediate threats to life
Rapid means to determine patient’s general condition and set initial priorities for care
Begin with your initial impression of patient
Check patient’s responsiveness, airway, breathing and circulation status
Perform primary assessment of all patients after scene size-up
If scene is safe, perform primary assessment before moving patient

24. General Impression Is the patient ill or injured?
Does patient’s appearance give clues about his or her condition?
Are there signs of a serious problem?
Note patient’s sex and approximate age

25. Responsiveness
You may notice immediately whether patient is responsive
Responsive means a person is conscious and awake

26. Responsiveness (continued)
Patients who cannot talk may be able to move and thereby signal responsiveness

27. Responsiveness (continued)
Patients who cannot talk or move may be paralyzed but still able to respond with purposeful eye movements or other signs

28. Assessing Responsiveness
Begin by speaking to the patient; ask the patient what is wrong
If patient isn’t speaking or moving, tap gently and shout, “Are you OK?”
Be careful not to move patient in any way
Always suspect a spinal injury and take steps to stabilize head and neck

29. Unresponsiveness
Unresponsiveness may be sign of life-threatening problem or may result from a less urgent problem
Continue the primary assessment
Unresponsiveness is considered life-threatening emergency
In an unresponsive patient lying on the back, the tongue may block the airway

30. Degree of Responsiveness
Assessed with AVPU scale
AVPU scale useful for noting changes in a patient’s responsiveness while providing care and for communicating this information
Make mental note of level of responsiveness or write it down along with time
A change in level of responsiveness generally indicates a serious condition

31. Degree of Responsiveness (continued)
AVPU Scale
A = Alert
V = Responds to Verbal stimuli
P = Responds to Pain
U = Unresponsive to all stimuli

32. Degree of Responsiveness (continued)
Responsiveness in pediatric patients
Infants and young children may respond differently from older children and adults
Look for age-appropriate responses
Assess unresponsive infant by flicking bottom of feet and noting response

33. Assess Breathing
While assessing for responsiveness, look for normal breathing
A patient who can speak, cough or make other sounds is breathing and has a heartbeat
Reflex gasping (agonal respirations) may be present just after cardiac arrest; do not confuse this with normal breathing
Lack of breathing may be caused by cardiac arrest, obstructed airway or other causes
If patient is not breathing normally, quickly move to next step and check for a pulse

34. Assess Circulation
In an unresponsive patient who is not breathing normally, check for circulation
If patient’s heart has stopped or patient is bleeding profusely, vital organs are not receiving enough oxygen to sustain life
Do not use more than 10 seconds to feel for the pulse  unless a pulse is clearly found in that time, start CPR
If the patient is responsive or breathing, the heart is beating

35. Pulse Check In responsive adult or child, check radial pulse
Note rate, rhythm and strength

36. Pulse Check (continued)
In an unresponsive adult, check carotid pulse (no longer than 10 seconds)

37. Pulse Check (continued)
In an unresponsive child, check either carotid pulse or femoral pulse
In an infant, use the brachial pulse in the inside of the upper arm

38. Pulse Check in Primary Assessment
Do not take time to count pulse, note whether it is irregular, very slow or very fast  signs that patient may not be stable
Lack of pulse along with absence of normal breathing signifies heart has stopped or is not beating effectively enough to circulate blood
If patient lacks a pulse and is not breathing normally, start CPR and call for an AED

39. Inadequate Breathing
A patient with a pulse may be breathing inadequately
Inadequate breathing is characterized by diminished mental status and any of these:
Difficult or labored breathing
Wheezing or gurgling sounds with breathing
Pale skin (ashen skin in a dark-skinned patient) or a blue (cyanotic) color of the lips and nail beds
A respiratory rate in an adult slower than 10 or greater than 30 breaths a minute
Give emergency care for a patient with a pulse who is breathing inadequately

40. Check for Serious Bleeding
Look for life-threatening bleeding
Arterial bleeding usually most serious
Bleeding from vein is generally slower

41. Check for Serious Bleeding (continued)
Don’t remove clothing to check for bleeding, but look for blood-saturated clothing and blood pooling
During primary assessment, don’t address minor bleeding or wounds
Control serious bleeding immediately with direct pressure

42. Assess Circulatory Status
Even with a pulse, circulation may be inadequate
Inadequate oxygenation of vital organs results in life-threatening shock

43. Signs of Inadequate Circulation
Heart rate in an adult <60 or >100
Irregular pulse may be normal or abnormal
Pale skin may indicate blood loss, shock or low body temperature
Bluish skin may indicate an airway problem, poor ventilation or respiration, or poor blood flow
Cool skin temperature may indicate low body temperature or shock
Sweaty or wet skin may indicate shock, severe pain or physical exertion
Slow capillary refill (>2 seconds) in children may indicate shock

44. Treat Life Threats Found
If patient is unresponsive to verbal stimulus, has a fast or slow heart rate, and has skin signs of shock, treat for shock after the primary assessment
If patient has any life-threatening condition, treat it as soon as it is discovered
If patient has no immediate threat to life, proceed to secondary assessment

45. Primary Assessment of an Unresponsive Patient
Check for responsiveness and normal breathing.
If patient is unresponsive, call for more EMS resources. If unresponsive patient is not breathing normally, also call for an AED.
If patient is not breathing, check for a pulse for no longer than 10 seconds. If no pulse, start CPR. If a pulse, start ventilations.
If patient is breathing, check for severe bleeding, shock and other threats to life.
Care for any life-threatening conditions before continuing to check the patient and provide other care.

46. Patient Priority
Primary assessment determines whether a critical condition is present and what steps you need to take
Unresponsiveness or any problem with the airway, breathing or circulation is a high priority
Continue to reassess and treat life-threatening conditions while waiting for additional EMS resources
Call EMS unit to update patient’s condition

47. Report to EMS After the Primary Assessment
Provide this information:
Number of patients
Patient age and gender
Patient’s condition
Patient’s level of responsiveness
Patient’s breathing and circulation status
Ask responding unit their estimated time of arrival
Continue to care for patient accordingly
With stable patient, proceed to secondary assessment