patient assessment scene size-up initial assessment focused history
DESCRIPTION
Scene Size-Up / Assessment w Body Substance Isolation w Need eye protection? w Gloves? w Gown & mask if necessary.TRANSCRIPT
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?