1. 7
Patient Assessment
in the Field

2. Standard
Assessment

3. Competency
Integrate scene and patient assessment findings with knowledge of epidemiology and pathophysiology to form a field impression.
This includes developing a list of differential diagnoses through clinical reasoning to modify the assessment and formulate a treatment plan.

4. Introduction
Patient assessment: problem-oriented evaluation of patient; establishing priorities of care.
Patient's condition determines components you use; how to use them.

5. Introduction
Proficiency in performing patient assessment will determine your ability to deliver highest quality of prehospital advanced life support (ALS).

6. Scene Size-Up First stage of every emergency call.
Ensure safe environment.
Take necessary precautions for personal protection.
Determine what resources needed.
Locate all patients.
Assess mechanism of injury (MOI) or nature of medical illness.
Class Activities
Present the students with a scenario and have them perform a complete assessment.

7. Primary Assessment
Determine whether patient “looks dead or doesn't look dead.”
If patient looks dead, quickly assess responsiveness and breathing.
If pulse absent, begin chest compressions immediately.
If patient shows signs of life, conduct primary assessment (ABC).

8. Primary Assessment Steps of Primary Assessment Form general impression
Stabilize cervical spine as needed
Assess baseline mental status
Assess airway
Assess breathing
Assess circulation
Assign priority

9. Manually stabilize the head and neck on first patient contact.

10. Primary Assessment
Should take less than 1 minute, unless you intervene with lifesaving measures.
Do not delay transport for detailed assessments and procedures.

11. Secondary Assessment
Vital signs, followed by focused history and physical exam.
Based on primary assessment and patient's chief complaint.
Includes monitoring technology.

12. Secondary Assessment Types of Patients
Major trauma patient with significant injury or altered mental status
Minor trauma patient with isolated injury
Responsive medical patient
Unresponsive medical patient
Class Activities
Present the students with a scenario and have them separate the patient into one of the four categories.
Discussion Topics
Discuss with the students how the different categories allows for improved patient care, based on patient presentation.

13. Secondary Assessment The Major Trauma Patient Primary assessment.
Rapid secondary assessment.
Package patient.
Rapid transport to emergency department.
Perform reassessment and treatments en route.
MOI could be life-threatening.

14. Secondary Assessment Predictors of Serious Internal Injury
Fall from more than 20 feet
Automobile crash with intrusion
Ejection from vehicle
Death in same passenger compartment
Automobile–pedestrian collision
Automobile–bicycle collision
Motorcycle crash

15. Secondary Assessment
MOIs can result from seat belts, air bags, child safety seats.
Look for hidden internal injuries.
Physical signs of trauma confirm index of suspicion.
If in doubt, transport patient to medical facility without delay; always best to err on side of precaution.
Class Activities
Since the students learned the full components of the secondary assessment in Chapter 5, have them perform the assessment on each other, explaining as they go what they are looking for.

16. Secondary Assessment Rapid Secondary Assessment
To identify all other life-threatening conditions.
Assess patient systematically; avoid tunnel vision.
Maintain spinal immobilization throughout rapid trauma exam.
Reconsider decision to transport; things can change unexpectedly.

17. Secondary Assessment Rapid Secondary Assessment
Assess mental status using AVPU mnemonic.
Compare findings with baseline mental status from initial assessment.
Pay special attention to head, neck, chest, abdomen, pelvis.
Major concern: internal injuries beneath superficial wounds.

18. Secondary Assessment Rapid Secondary Assessment
Deformities, contusions, abrasions, penetrations, burns, tenderness, lacerations, swelling.
Assess head for injuries and crepitus.
Simple scalp laceration can cause life-threatening hemorrhage.
Altered mental status and abnormality in structure of skull: serious emergency.

19. Secondary Assessment Rapid Secondary Assessment
Inspect and palpate neck for injuries and crepitus; significant blood loss quickly.
Examine jugular veins for abnormal distention.
Inspect and palpate trachea.
Inspect and palpate neck for subcutaneous emphysema.

20. Secondary Assessment Rapid Secondary Assessment
Palpate posterior neck for evidence of spinal trauma.

21. Procedure 7–1 Rapid Secondary Assessment— The Head and Neck

22. Procedure 7–1 Rapid Secondary Assessment—The Head and Neck 7-1a The first step in the rapid secondary assessment is to palpate the head.

23. Procedure 7–1 Rapid Secondary Assessment—The Head and Neck 7-1b Periodically examine your gloves for blood.

24. Procedure 7–1 Rapid Secondary Assessment—The Head and Neck 7-1c Inspect and palpate the anterior neck. Pay particular attention to tracheal deviation and subcutaneous emphysema.

25. Procedure 7–1 Rapid Secondary Assessment—The Head and Neck 7-1d Inspect and palpate the posterior neck. Note any tenderness, irregularity, or edema.

26. Secondary Assessment Rapid Secondary Assessment
Look for signs of acute respiratory distress.
Quickly inspect and then palpate chest.

27. Secondary Assessment Rapid Secondary Assessment
Be careful when palpating ribs; look for erythema caused by impact to ribs.
Suspect major damage to underlying organs, especially vascular structures, when ribs broken.
Observe for equal, symmetrical, effortless chest rise.

28. Secondary Assessment Rapid Secondary Assessment
Flail chest greatly reduces air movement.
Inspect patient's chest and back for open wounds.
Seal any open wounds with occlusive dressing; tape dressing on three sides.
Auscultate both lungs quickly at midaxillary line for air movement.

29. Procedure 7–2 Rapid Secondary Assessment—The Chest 7-2c Seal any sucking chest wound with tape on three sides.

30. Secondary Assessment Rapid Secondary Assessment
Tension pneumothorax: life-threatening condition.
Inspect and palpate abdomen for injuries and crepitus.
Note areas of bruising and guarding.

31. Procedure 7–2 Rapid Secondary Assessment— The Chest

32. Procedure 7–2 Rapid Secondary Assessment—The Chest 7-2a Palpate the clavicles.

33. Procedure 7–2 Rapid Secondary Assessment—The Chest 7-2b Stabilize a flail chest.

34. Procedure 7–2 Rapid Secondary Assessment—The Chest 7-2c Seal any sucking chest wound with tape on three sides.

35. Procedure 7–2 Rapid Secondary Assessment—The Chest 7-2d Perform needle decompression to relieve tension pneumothorax if authorized.

36. Secondary Assessment Rapid Secondary Assessment
Inspect and palpate abdomen for injuries and crepitus.
Note areas of bruising and guarding.

37. Secondary Assessment Rapid Secondary Assessment
Bruising over umbilicus (Cullen's sign).
Bruising over flanks (Grey Turner's sign).
Both signs indicate intraabdominal hemorrhage; immediate transport to medical facility for surgery.
Test for rebound tenderness.

38. Secondary Assessment Rapid Secondary Assessment
Examine pelvis for injuries and crepitus; stable pelvic ring.
Evaluate pelvic ring at iliac crests and symphysis pubis.
Immobilize pelvis before transport to prevent movement and possible circulatory catastrophe.

39. Procedure 7–3 Rapid Secondary Assessment—The Chest 7-3a Assess the integrity of the pelvis by gently pressing medially on the pelvic ring.

40. Secondary Assessment Rapid Secondary Assessment
Inspect and palpate all four extremities for injuries and crepitus.
Splint fractures en route to hospital.
Evaluate distal neurovascular function.
Inability to feel and move both legs indicates complete spinal cord disruption.

41. Procedure 7–3 Rapid Secondary Assessment—The Chest 7-3f Assess distal sensation and motor function.

42. Secondary Assessment Rapid Secondary Assessment
Diminished sensation, paresthesias, or diminished motor ability indicates partial disruption.
Weakness or disability on only one side of body suggests brain injury due to stroke or head injury.

43. Procedure 7–3 Rapid Secondary Assessment— The Pelvis and Extremities

44. Procedure 7–3 Rapid Secondary Assessment—The Chest 7-3a Assess the integrity of the pelvis by gently pressing medially on the pelvic ring.

45. Procedure 7–3 Rapid Secondary Assessment—The Chest 7-3b Compress the pelvis posteriorly.

46. Procedure 7–3 Rapid Secondary Assessment—The Chest 7-3c Palpate the legs.

47. Procedure 7–3 Rapid Secondary Assessment—The Chest 7-3d Palpate the arms.

48. Procedure 7–3 Rapid Secondary Assessment—The Chest 7-3e Palpate the dorsalis pedis pulse to evaluate distal circulation in the leg.

49. Procedure 7–3 Rapid Secondary Assessment—The Chest 7-3f Assess distal sensation and motor function.

50. Secondary Assessment Rapid Secondary Assessment
Check for MedicAlert tags.
Log-roll patient onto side to inspect posterior body; note tenderness in spinal area.
History: chief complaint, history of present illness, past history, current health status.

51. Inspect and palpate the posterior body.

52. Secondary Assessment SAMPLE History Symptoms Allergies Medications
Pertinent past medical history
Last oral intake
Events leading up to the incident

53. Secondary Assessment The Minor Trauma Patient
Isolated injury; no significant MOI; no signs of systemic involvement.
Does not require extensive history or comprehensive physical exam.
Ensure hemodynamic status via primary assessment.
Secondary assessment on specific isolated injury.

54. Secondary Assessment The Responsive Medical Patient
History takes precedence over physical exam.
Physical exam: identifies signs of medical complications rather than injury.
Conscious, alert patients can tell you about their illness.
Chief complaint: pain, discomfort, or dysfunction; patient requested help.

55. Begin treatment while you assess your responsive medical patient.

56. Secondary Assessment The Responsive Medical Patient
Present problem: circumstances surrounding chief complaint.
Follow acronym OPQRST–ASPN.
Past medical history: insights into chief complaint and field diagnosis.
Family/social history: history of serious disease may be “red flag” in the case.

57. Secondary Assessment OPQRST–ASPN Onset Provocation/Palliation Quality
Region/Radiation
Severity
Time
Associated Symptoms
Pertinent Negatives

58. Secondary Assessment The Responsive Medical Patient
Review of systems: system-by-system list of questions more specific than those asked during basic history.
Begin focused physical exam based on information elicited from patient.
Cardiac chest pain/respiratory distress, altered mental status, acute abdomen.

59. Secondary Assessment The Unresponsive Medical Patient
Begin with primary assessment.
Rapid head-to-toe exam.
Brief history from family or friends.
Airway protected.
Assess head, neck, chest, abdomen, pelvis, extremities, posterior aspect of body.

60. Secondary Assessment The Unresponsive Medical Patient
Assess baseline vital signs.
Perform additional tests.
Consider unresponsive patient unstable.
Expedite transport to hospital.

61. Reassessment Patient condition can change suddenly.
Reassess mental status, airway patency, breathing adequacy, circulation, any deterioration.
Every 15 minutes for stable patients.
Every 5 minutes for unstable patients.
Class Activities
Present the students with a scenario that changes during reassessment. Have them explain what the changes might indicate, and what they may need to do to improve patient outcome.

62. Procedure 7–4 Reassessment

63. Procedure 7–4 Reassessment 7-4a Reevaluate the ABCs.

64. Procedure 7–4 Reassessment 7-4b Take all vital signs again.

65. Procedure 7–4 Reassessment 7-4c Perform your focused assessment again.

66. Procedure 7–4 Reassessment 7-4d Evaluate your interventions' effects.

67. Reassessment Mental Status
Recheck mental status by performing AVPU exam frequently during transport.
Falling level of response indicates direct or indirect brain pathology.

68. Reassessment Airway Patency Can change instantly.
Endotracheal intubation best way to secure airway in patients with no gag reflex.
Be prepared for the worst.

69. Reassessment Breathing Rate and Quality
Sudden increase in rate or respiratory effort suggests deterioration.
Subtle increases in respiratory rate can suggest developing problem.
Decrease in rate and effort could mean treatments are effective.
Requires constant reevaluation.

70. Reassessment Pulse Rate and Quality
Rising pulse rate: shock, hypoxia, cardiac dysrhythmia.
Falling rate: terminal stage of shock or rise in intracranial pressure.
Sudden change in rate or regularity: cardiac dysrhythmia.
Loss of peripheral pulses: decompensating shock.

71. Reassessment Skin Condition Transport Priorities
Reflects body's hemodynamic status.
Reevaluate skin color, temperature, condition.
Transport Priorities
Depending upon patient status, you may need to either upgrade or downgrade transport decision.

72. Reassessment Vital Signs Secondary Assessment
Reassessing vital signs reveals trends.
Reevaluate critical patients every 5 minutes.
Secondary Assessment
Repeat focused assessment as chief complaint dictates.

73. Reassessment Effects of Interventions Management Plans
Know expected therapeutic benefits of interventions; evaluate whether they worked.
Management Plans
Evaluate whether care is working.
If not, consider another management plan.
Be flexible to change course of action.

74. Clinical Decision Making
Critical Thinking
Form concept
Interpret data
Apply principles
Evaluate results
Reflect on incident
Class Activities
Have students walk through the clinical reasoning steps using a scenario. Have them explain their reasoning for choosing a particular diagnosis and treatment.

75. Clinical Decision Making
Form a Concept
Assess general environment and immediate surroundings.
Conduct initial assessment.
Chief complaint, history of present illness, past history, current health status.
Conduct focused physical exam.

76. Clinical Decision Making
Interpret the Data
Consider all data.
Determine most common and statistically probable conditions that fit patient's initial presentation.
Differential field diagnosis.

77. Clinical Decision Making
Apply the Principles
Devise management plan that covers all contingencies.
Evaluate the Results
Reassess patient's condition and effects of protocol interventions.
Determine whether treatment improving patient's condition and status.

78. Clinical Decision Making
Reflect on the Case
Discuss field diagnosis and care with emergency physician.
Compare field diagnosis with physician's diagnosis.
Conduct run critique with your crew.
With every patient contact, your experience grows and clinical judgment improves.

79. Summary
Patient assessment is key to providing effective prehospital emergency medical care.
Primary assessment, secondary assessment, vital signs, reassessment.
Primary assessment: identify and treat life-threatening airway, breathing, circulation problems.

80. Summary
Secondary assessment: identify signs and symptoms surrounding chief complaint.
Problem-oriented approach; easily modified to match patient's clinical situation.
Reassessment: reevaluate patient for changes in status en route to hospital.

81. Summary
Trauma patient with significant MOI: primary assessment, rapid secondary assessment, rapid transport.
Patient with isolated, minor trauma: physical exam focused on particular problem or area.
Responsive medical patient: primary and secondary assessment; focused on chief complaint, vital signs.

82. Summary
Unresponsive medical patient: primary assessment; rapid secondary assessment and rapid transport.
You will be expected to use clinical judgment when deciding which assessment tools to use.