PATIENT ASSESSMENT Scene Size-Up Initial Assessment Focused History.

PATIENT ASSESSMENTScene Size-Up

Initial AssessmentFocused History

Scene Size-Up / Assessment

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

Body Substance Isolation

Need eye protection? Gloves? Gown & mask if

necessary.

Is it safe to approach the patient?

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

Nature of Illness - Medical

Determine from patient, family or bystanders why EMS was activated.

Determine total number of patients. If more than unit can effectively handle, notify dispatch - activate mass casualty plan.

Obtain additional help prior to contact with patients.

Begin triage.

Mechanism of Injury - Trauma

Determine from patient, etc. and inspection of the scene, the mechanism of injury.

Ejection from vehicle. Falls > 20 feet. Death in same compartment. Roll-over. High-speed vehicle collision. Bicycle crash. Vehicle-pedestrian collision. Motorcycle. Determine total number of patients. Spinal?

The Initial AssessmentThe general impression is extremely

valuable. EMT-Bs will hone this “sixth sense” as you assess more and

more patients.

General Impression of the Patient Formed to determine priority of care and is

based on the immediate assessment of the environment and the patient’s chief complaint.

Determine if ill (medical) or injured (trauma). If injured, determine mechanism.

Age Sex

General impression of the patient

Don’t be too quick to base your general impression of the patient strictly on dispatch information.

Avoid “tunnel vision”!

Determine if a life-threat exists!

Assess the patient and determine if the patient has a life-threatening condition.

If a life-threatening condition is found - treat immediately.

Assess the nature of illness or mechanism of injury.

Assess Patient’s Mental Status

Maintain spinal immobilization if needed. Speak to the patient, introduce yourself. LEVELS OF MENTAL STATUS

• Alert.• Responds to Verbal stimuli.• Responds to Painful stimuli.• Unresponsive - no gag or cough.

Altered Level of Consciousness?

Patient should be oriented to –

PERSON PLACE TIME

Assess Patient’s Airway Status

Responsive patient - • Is the patient talking or crying?• If yes, assess for adequacy of breathing.• If no, open the airway.

Unresponsive patient -• Is the airway open?

Airway positioning is patient - , age - , and size-specific. MEDICAL patients - perform the head-tilt,

chin-lift• Clear• Not-clear, clear the

airway

TRAUMA patients, or unknown illness -

cervical spine precautions with jaw-thrust maneuver• Clear• Not-clear, clear the

airway

Assess Patient’s Breathing

If breathing is adequate and patient is responsive, oxygen may be indicated.

All responsive patients breathing <29 or >8 breaths per minute should receive high flow oxygen (15 lpm, nonrebreather mask)

Patient’s Breathing (cont’d.)

Unresponsive, breathing is adequate - open and maintain the airway, providing high-concentration oxygen.

Breathing inadequate - open and maintain the airway, assist patient’s breathing and utilize ventilatory adjuncts with oxygen.

Not breathing, open and maintain airway, ventilate using ventilatory adjuncts with oxygen.

Assess the Patient’s Circulation 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.

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.)

Assess if major bleeding is present - control bleeding.

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.)

Assess patient’s skin temperature by feeling the skin.• Normal = warm• Abnormal = hot, cool, cold, clammy

Assess patient’s skin condition.• Normal = dry Abnormal = moist

Assess capillary refill in infants & children• Normal < two seconds Abnormal > two second

Identify Priority Patients

Poor general impression.

Unresponsive patients. Responsive, not

following commands. Difficulty breathing. Hypoperfusion

(shock).

Complicated childbirth.

Chest pain with BP < 100 systolic.

Uncontrolled bleeding. Severe pain.

Determine a CUPS Status

Critical Unstable Potentially unstable Stable

• Expedite transport of the patient based on determination.

• Consider ALS back up.

Proceed to Focused History and Physical Examination

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

TRAUMATRAUMA

Reconsider Mechanism of Injury

Ejection from vehicle. Death in same

passenger compartment.

Falls > 20 feet. Roll-over of vehicle. High-speed vehicle

collision.

Vehicle-pedestrian collision.

Motorcycle crash. Unresponsive or

altered mental status. Penetrations of the

head, chest, or abdomen.

Infant and Child Considerations

Falls greater than 10 feet. Bicycle collision. Vehicle in medium speed collision.

Consideration of Mechanism of Injury Mechanism of Injury

often results in specific hidden injuries.

Seat Belts Airbags

Specific Hidden Injuries?

SEAT BELTS If buckled, may have

injuries. Patient had seat belt

on, does not mean they have no injuries.

Shoulder injury resulting from shoulder harness.

AIRBAGS Not effective without

seat belt. Can hit wheel after

deflation. “Lift and look” at

wheel for deformity. Deformity = serious

internal injury.

Rapid Trauma Assessment

Perform rapid trauma assessment on patients with a significant mechanism of injury to determine life threatening injuries.

In the responsive patient, symptoms should be sought before and during the trauma assessment.

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

golden hour.

Rapid Assessment

Rapid assessment should be interrupted to provide life saving interventions:

AIRWAY BREATHING CIRCULATION

Performing a Rapid Trauma Assessment Continue spinal immobilization. Consider A.L.S. Request. Reconsider transport decision. Assess mental status. As you inspect and palpate, look and feel

for injuries or signs of injury using, D C A P - B T L S

Look and Feel for;

DEFORMITIES

CONTUSIONS

ABRASIONS

PUNCTURES / PENETRATIONS

BURNS

TENDERNESS

LACERATIONS

SWELLING

Assess the Head

Deformities Contusions Abrasions Punctures /

Penetrations Burns

Tenderness Lacerations Swelling CREPITATION FLUIDS / BLOOD

from the head

Assess the Neck

Deformities Contusions Abrasions Punctures /

Penetrations Burns

Tenderness Lacerations Swelling JUGULAR VEIN

DISTENSION (JVD) CREPITATION Apply cervical spinal

immobilization collar (CSIC) at this time.

Tracheal Deviation

Assess the Chest

Deformities Contusions Abrasions Punctures /

Penetrations Burns Tenderness Lacerations

Swelling PARADOXICAL

MOTION Crepitation BREATH SOUNDS

• present• absent• equal

Assess the Abdomen

Deformities Contusions Abrasions Punctures /

Penetrations Burns

Tenderness Lacerations Swelling FIRM SOFT DISTENDED

Assess the Pelvis

Deformities Contusions Abrasions Punctures /

Penetrations Burns Tenderness

Lacerations Swelling If No Pain is Noted,

GENTLY COMPRESS THE PELVIS TO DETERMINE TENDERNESS OR MOTION

Assess All Four Extremities

Deformities Contusions Abrasions Punctures /

Penetrations Burns Tenderness

Lacerations Swelling DISTAL PULSE SENSATION MOTOR FUNCTION CREPITATION

Roll Patient Ensuring Spinal Integrity Assess posterior body,

inspect and palpate, examining for injuries or signs of injury.

Vitals and SAMPLE

Assess baseline vital signs:

Respirations - rate & quality

Pulse - rate & quality Blood Pressure Pupils Skin - CTC

Assess SAMPLE history:

Signs & Symptoms Allergies Medications Pertinent History Last Oral Intake Events Leading Up To

Questions?