1. Chapter 13 Initial Assessment

2. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 2 Overview  The Initial Assessment  Steps of the Initial Assessment  Determine Priority

3. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 3 The Initial Assessment  The initial assessment is designed to rapidly find life-threatening problems  Every patient gets an initial assessment, due to the fact that every patient might have a life- threatening problem

4. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 4 Steps of the Initial Assessment  Scene size-up  Use appropriate standard precautions (PPE)  Airway, breathing, and circulation (ABCs) are the focus

5. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 5  General appearance –Form a general impression of the status of the patient (can be done in the first 15 seconds of observation) Does the patient appear to be awake? Does the patient appear to be very ill or very uncomfortable? Does the problem seem to be related to a medical illness or to a traumatic injury? Steps of the Initial Assessment

6. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 6  General appearance –General impression is the “look test” –When you first look at the patient, does he look sick? Steps of the Initial Assessment

7. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 7 Steps of the Initial Assessment  Mental status –A: Alert –V: Verbal –P: Pain –U: Unresponsive

8. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 8 Steps of the Initial Assessment  Mental status: A (alert) –If the patient’s eyes are open and she appears to be aware of the crew approaching, then the patient is referred to as alert –Alert to: Person, place, and time Abbreviated as A/Ox3 (alert and oriented times three), referring to person, place, and time

9. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 9 Steps of the Initial Assessment  Mental status: V (verbal) –If the patient opens her eyes when spoken to but closes them again when not spoken to, she is considered to be responsive to voice or verbal stimuli –Difference between “alert” and “responsive to voice” is the need to provide verbal stimuli to keep the patient awake and interactive

10. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 10 Steps of the Initial Assessment  Mental status: P (pain) –If the patient does not respond to loud verbal stimuli, the next appropriate action would be to attempt to awaken her with physical stimuli Start with a firm tap on the shoulder If this doesn’t work, try a sternal rub –The objective of the EMT is not to cause pain –Do not use unorthodox techniques that can harm the patient!

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12. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 12 Steps of the Initial Assessment  Mental status: U (unresponsive) –If no response is elicited by verbal or painful stimuli, the patient is truly unresponsive –The unresponsive patient is truly ill and requires rapid interventions

13. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 13 The Initial Assessment  Watch this clip on using AVPU for assessment of mental status

14. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 14 Stop and Review  How is mental status assessed?  What is the purpose of the general impression?

15. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 15 Steps of the Initial Assessment  Airway –Once the general impression is formed and the level of consciousness determined, address the state of patient’s airway –If the patient is awake and alert, the airway is most likely maintained without difficulty –Observe patient’s effort to breathe and speak –If air is moving in and out without difficulty and patient is speaking, airway is considered open and patent

16. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 16 Steps of the Initial Assessment  Airway –Awake but cannot speak? Continue to further assess airway –Drooling is also a sign that patient is having difficulty with the airway –The less responsive the patient becomes, the more likely the airway will not be maintained on its own

17. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 17 Steps of the Initial Assessment  Airway –An unresponsive patient is a significant cause for concern; the airway needs to be supported –Methodical approach to managing a patient’s airway Open Assess Suction –Remember: without an airway you have no patient. It’s all about airway, airway, airway!

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19. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 19 Steps of the Initial Assessment  Breathing –Check to see if there is any breathing at all Look (for chest rise and fall) Listen (for air movement) Feel (for air movement)

20. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 20 Steps of the Initial Assessment  Breathing –If no breathing, establish effective ventilations –If patient is breathing, assess breathing adequacy by determining respiratory rate –For a rate of 10–28, give supplemental oxygen by non-rebreather mask –Assist ventilations using a BVM with 100% oxygen if: Patient is breathing but it is too fast or too slow, is of inadequate depth, or requires marked effort

21. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 21 Steps of the Initial Assessment  Breathing –Other conditions should prompt the EMT to put on high-flow oxygen by non-rebreather mask Examples: Chest or abdominal pain, difficulty breathing, or any signs and symptoms of shock –Never withhold oxygen from a patient who needs it!

22. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 22 Steps of the Initial Assessment  Breathing –Look Expose chest to inspect for obvious wounds or uneven breathing Open chest wounds should be immediately covered with an occlusive dressing –Stabs, gunshot wounds; also referred to as sucking chest wounds Broken ribs can cause a flail chest segment Flail chest segments move in the opposite direction of the rest of the chest wall This is called paradoxical movement

23. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 23 Steps of the Initial Assessment  Breathing –Listen Use a stethoscope to evaluate the effectiveness of air movement Listen just below the clavicles and at their midpoint Listen to both lungs Auscultate for clear bilateral breath sounds Compare both sides. Diminished or no air movement on one side indicates the potential for a significant injury

24. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 24 SoundPotential Diagnosis  AbsentComplete airway obstruction  Diminished (volume of sound)Collapsed lung (pneumothorax)  Wheezing (whistling sound)Air moving through narrow lower airways (asthma or partial airway obstruction)  Crackles (or rales)Fluid in smaller airways (heart failure)  Rhonchi (rumbling sound)Fluid in larger airways (bronchitis) Abnormal Breath Sounds

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26. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 26 Steps of the Initial Assessment  Breathing –Feel Feel for any deformity or crepitation in the chest; use two hands to press on both sides of the chest wall and sternum Tenderness in the chest wall is suggestive of a rib fracture Crepitus should be noted –Crepitus is the sensation of air under the skin, similar to Rice Krispies popping under the fingertips

27. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 27 Steps of the Initial Assessment  Circulation –Assess for a pulse Check radial first; if present, the EMT can assume that patient has enough blood pressure to supply blood to that peripheral site Pulse should be checked in the brachial site for children less than one year Check strength, rate, and regularity If radial is not present, move directly to the carotid; blood pressure is assumed to be quite low If no pulse after 5–10 seconds, start CPR!

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29. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 29 Steps of the Initial Assessment  Circulation –Assess for bleeding Check for life threatening bleeding If the amount of bleeding seems life threatening, the EMT should immediately control it Minor or small amounts of bleeding should not be treated at this time Focus on life threatening external and interal bleeding only! Check skin temperature, condition, and color

30. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 30 Steps of the Initial Assessment  Circulation –Circulatory support CPR Control of severe bleeding Trendelenburg position Consider military anti-shock trousers (MAST) or pneumatic anti-shock garment (PASG)

31. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 31 Determine Priority  Ask the following to determine priority: –On the basis of the initial assessment, does the patient have any life threatening problems that require immediate, rapid transport to the hospital? –Do the EMTs need to arrange for an ALS intercept or aeromedical transport?

32. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 32 Determine Priority  Load and go—high priority: –Poor general impression –Decreased level of consciousness –Responsive but not following commands –Difficulty breathing –Shock (evidence of hypoperfusion) –Complicated childbirth –Chest pain –Uncontrolled bleeding –Severe pain anywhere

33. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 33 Determine Priority  Low priority—stay and play –If a patient is identified as low priority and does not have any immediate life threatening problems, the EMT must continue in the assessment of the patient

34. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 34 Stop and Review  What are three methods to determine whether a patient is breathing?  Where do you check pulse in patients less than one year old?