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TEACHING POINTS
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General Information:
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The assessment process recognizes that trauma patients and medical patients have different assessment priorities. Patients may be divided into four broad categories: Medical patients who are responsive; Medical patients who are not responsive; Trauma patients with a significant mechanism of injury (MOI); and, Trauma patients without a significant mechanism of injury. Trauma patients are assigned a category based on severity, or potential severity, of their injuries. Medical patients, on the other hand, are assigned based on their ability to participate, or not participate, in the assessment rather than on the severity of their illnesses.
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OBJECTIVES:
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1. To determine the presence or absence of actual or potential hazards which pose a threat to the health and safety of rescuers, patients or bystanders during rescuer operations and/or during transport
2. To determine the presence or absence of injury or illness through a systematic assessment process incorporating inspection, auscultation, palpation, and the taking of a patient history
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Safety is paramount throughout the call
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IMPORTANT POINTS:
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1. Use appropriate body substance isolation precautions
2. ALWAYS conduct a scene size-up
3. If a scene is not safe, and cannot be made safe, do not enter
4. Always obtain a general impression of the patient and conduct an initial assessment of the patient’s mental status, airway, breathing and circulation (including a visual check for life-threatening external bleeding) no matter how stable a patient appears
5. Patients who are not responsive should include those with an altered mental status and those who are unable to respond reliably or provide a history
6. Intervene immediately to correct any life-threatening problem
Remember: Any airway, breathing, circulation problem or severe external bleeding, which cannot be managed during the initial assessment, mandates urgent transport with continued efforts to manage the problem en route
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7. A patient’s condition may deteriorate rapidly. Perform frequent reassessments of the patient’s mental status, airway, breathing and circulation
8. If the patient becomes unstable at any time, immediately repeat the initial assessment
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SKILL:
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I. PATIENT ASSESSMENT
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A. SCENE SIZE-UP
1. Determine the Nature of Illness (NOI) or Mechanism of Injury (MOI)
a. En route to scene:
1) Dispatch information
2) Other units at scene
b. Upon arrival at scene:
1) Inspect the scene
2) Patient, family, witnesses, bystanders, other rescuers
2. Use appropriate body substance isolation precautions
3. Determine whether the scene is safe
a. Environmental considerations
b. Social considerations
c. Crime scene considerations
d. Unruly or violent persons
e. Unstable surfaces
f. Other hazards
g. If the scene is not safe, make it safe, or do not enter
4. Determine the number of patients
5. Determine the need for, and request, additional resources prior to patient contact
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B. INITIAL ASSESSMENT
1. Form a general impression of the patient as you approach, while telling the patient your first name and explaining that you are an EMT
a. Establish approximate age
b. Establish gender
c. Identify chief complaint
d. Assess environment clues
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e. Identify any obvious life-threatening conditions requiring urgent intervention
f. Intervene immediately to correct any life-threatening conditions
2. Assess the patient’s mental status and provide C-spine stabilization as appropriate
a. Speak to the patient
b. Alert
Responds to Verbal stimuli
Responds to Painful stimuli
Unresponsive
3. Assess the patient’s airway
a. Is the patient talking or crying?
1) Yes: Assess breathing
2) No: Open airway
4. Assess the patient’s breathing
a. If the patient is not responsive, but breathing is adequate, open and maintain the airway and initiate oxygen therapy
b. If the patient is not breathing adequately, open and maintain the airway, initiate oxygen therapy, utilize appropriate adjuncts and/or assist ventilations
c. If the patient is not breathing, open and maintain the airway, utilize appropriate adjuncts and ventilate with supplemental oxygen
5. Assess the patient’s circulation
a. Pulse - present
1) Less than one-year-old: Palpate the brachial artery
2) More than one-year-old and responsive: Palpate the radial artery
3) More than one-year-old and unresponsive; or more than one-year-old with absent radial pulse: Palpate carotid pulse
b. If pulse - absent
1) Initiate CPR
2) Implement AED protocol as appropriate
c. Assess and control major external bleeding
d. Assess skin color, temperature and condition (Assess capillary refill in patients under six years or age)
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Discuss normal rates and adequate breathing for all age ranges.
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e. Expose the patient, as needed
f. Establish a field impression and differential diagnosis
6. Determine the patient’s transport priority, consider ALS back-up
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C. FOCUSED HISTORY AND PHYSICAL EXAM
1. Assign the patient to one of the four patient assessment categories to determine which of the following items apply to that patient. The sequence in which these items are performed may depend on circumstances, the number of available EMTs and the presence of life-threatening problems requiring urgent intervention. Remember: The patient’s priority is constantly being evaluated and subject to change
2. Reconsider NOI or MOI as necessary
3. Obtain a SAMPLE history
a. Signs and symptoms
b. Allergies
1) Medicines
2) Foods
3) Environmental
c. Medications
1) Prescriptions
2) Over-the-counter
3) Alternative medication, herbal supplements
d. Pertinent/past medical history
1) Heart disease
2) Diabetes
3) Seizures
4) Recent hospitalizations
5) Recent injuries
6) Medical patients: previous similar episodes
e. Last oral intake
f. Events leading to the injury or illness
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4. Assess baseline vital signs
a. Breathing - rate, rhythm and quality
b. Pulse - rate, rhythm and quality
c. Blood pressure
d. Pupils
e. Skin color and condition (Capillary refill under 6 years of age) – if not previously done
5. Perform an appropriate physical exam
a. Physical assessment conducted for a responsive medical patient or a trauma patient with no significant mechanism of injury should be based on the patient’s chief complaint
b. Rapid trauma assessment or rapid assessment for unresponsive medical
1) DCAP/BTLS
2) While maintaining manual stabilization, apply cervical collar only after neck has been assessed
3) Assess for obvious signs of trauma, plus:
a) Head: Crepitus
b) Neck: Jugular vein distention, crepitus
c) Chest: Paradoxical motion, crepitus, bilateral breath sounds (mid-axillary, mid-clavicular)
d) Abdomen: Rigidity, guarding, distention
e) Pelvis: Gently compress for pain or crepitus, inspect for incontinence, priapism
f) All extremities: Distal circulation, movement and sensation
4) Roll patient taking appropriate spinal precautions, and assess posterior
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6. Assess history of present illness (OPQRST)
a. Onset
b. Provocation
c. Quality
d. Radiation
e. Severity
f. Time
7. Establish a management plan and initiate appropriate interventions
8. Reevaluate transport decision
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OPQRST may be used for evaluating pain associated with trauma injuries
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D. DETAILED PHYSICAL ASSESSMENT
1. Limited to the patient with a significant MOI or medical not responsive
2. Performed as time permits, in the ambulance, during transport
3. Repeat rapid trauma assessment with emphasis on:
a. Ears: Drainage or blood, cerebral spinal fluid
b. Eyes: Discoloration, equality, foreign bodies, blood in the anterior chamber
c. Nose: Drainage of blood or cerebral spinal fluid
d. Mouth: Loose or missing teeth, obstructions, soft tissue injuries
e. Careful evaluation for potentially subtle signs on trunk and extremities
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E. ONGOING ASSESSMENT
1. Repeat initial assessment and reassess vital signs
a. At least every five minutes for urgent, unstable or deteriorating patients
b. At least every fifteen minutes for non-urgent, stable patients
c. Any time the patient’s condition is noted to change
2. Repeat focused assessment regarding patient’s chief complaint or injuries
3. Reevaluate effectiveness of interventions and patient response to treatment
a. Adequacy of oxygen delivery, assisted ventilations or artificial ventilations
b. Management of soft tissue injuries
c. Adequacy of other interventions
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