“It’s amazing what you can see when you look”
Yogi Berra
Patient Assessment
not a basic skill
do not diagnose
the question is ...
Do I have a critical patient?
Patient Assessment
Scene size-up Initial assessment Focused history and physical exam
– Vital signs– History
Detailed physical exam Ongoing assessment
Scene Size Up
Body Substance Isolation/Standard Precautions Safety, Safety, Safety, Safety, ... Mechanism of injury
or Nature of illness # of patients Need for additional resources Need for extrication / spinal precautions
Body Substance Isolation
Assumes all body fluids present a possible risk for infection
Protective equipment– Latex or vinyl gloves should always be
worn– Eye protection– Mask – Gown – Turnout gear
Scene Safety
Look for danger Park in a safe area Speak with law enforcement first if present. The safety of you and your partner comes
first! Next is safety of patient(s) and bystanders. Request additional resources.
Mechanism of Injury
Force body was exposed to– Chief complaint
Evaluate:– Amount of force applied– Length of time it was applied– Area involved
Nature of Illness
Search for clues This is chief complaint Gather information from the
patient/bystanders Observe the scene.
Chief Complaint
Most serious problem voiced by the patient
May not be the most significant problem present
Number of Patients
# of patients and condition.
Additional resources needed?
Triage to identify severity of each patient’s condition.
Additional Resources
Medical resources– Additional units– Advanced life support
Nonmedical resources– Fire suppression– Rescue– Law enforcement
Spinal Immobilization
Consider early during assessment. Do not move without immobilization. Err on the side of caution.
Initial Assessment
Develop a general impression
Assess mental status Assess airway Assess the adequacy of
breathing Assess circulation Establish patient rapport Identify patient priority
Develop a General Impression
As you approach the scene
– Assessment of the environment
– Patient’s chief complaint
– Presenting signs and symptoms of patient
• No vitals yet, only skin signs/cap refill
Assessing Mental Status
Checking responsiveness
Check for orientation
Checking Responsiveness
A - Alert V - Verbal P - Pain U - Unresponsive
Checking Orientation
Person Place Time Event
Glasgow Coma ScaleMore advanced LOC indicator
EyeVerbalMotor
point scale 15 - 3
GCS
Eye Opening
spontaneous = 4
to voice = 3
to pain = 2
none = 1
GCS
VERBAL
Oriented = 5Confused = 4Inappropriate words = 3Incomprehensible sounds = 2None = 1
GCS
MOTORobeys command= 6localizes pain = 5withdraws (pain) = 4flexion (pain) = 3extension (pain) = 2none = 1
Assessing ABC’s We know how to assess the unresponsive More evaluation needed in responsive pt. Is patient speaking to you?
– A and B– Full sentences– 2 or 3 word
What are skin signs like? Cap refill?– C– Indicates perfusion
Establish Patient Rapport
People Skills Do what you can to make the patient comfortable Listen to the patient Make eye contact Base questions on the patient's complaint
– More to follow Mentally summarize before starting treatment Obtain consent
Decision point
Regardless if trauma or medical
Is patient critical?
Do they need rapid transport?
Identifying Priority Patients
Poor general impression
Unresponsive with no gag or cough reflexes
Responsive but unable to follow commands
Difficulty breathing Signs of poor
perfusion
Complicated childbirth
Uncontrolled bleeding
Severe pain Severe chest pain Inability to move any
part of the body
The Golden Hour
Medical vs. Trauma
Determination should come after initial assessment is finished.
Patients may have traumatic injuries caused by a medical reason.
Initially assume all patients have both medical and traumatic aspects to their condition.
Trauma Patients
With significant MOI Unresponsive or disoriented Extremely intoxicated Patients whose complaint cannot be
identified or understood• Proceed with rapid trauma assessment• Rapid transport• Consider ALS backup
Significant Mechanism of Injury
Ejection from vehicle Death in passenger compartment Fall greater than 15´-20´ Vehicle rollover High-speed collision Unresponsiveness or altered mental status Penetrating trauma to head, chest, or
abdomen
Auto vs auto
SAFETY observe/ask questions about mechanism Speed position of patient before accident
(driver, backseat, etc..) KO? restrained? airbag? Passenger space intrusion?
Auto vs pedestrian or bicycle/motorcycle
SAFTEY observe/ask questions about
mechanism helmet? KO? Injuries more likely to be severe
Rapid Physical Exam
60-90 seconds
head-to-toe exam– Significant trauma
patients– Unresponsive
medical patients
DCAP-BTLS
D Deformities
C Contusions
A Abrasions
P Punctures/ Penetrations
B Burns
T Tenderness
L Lacerations
S Swelling
Rapid Physical Exam (1 of 3)
Maintain spinal immobilization while checking patient’s ABCs.
Use DCAP BTLS Assess the head. Assess the neck. Apply a cervical spine
immobilization collar.
Rapid Physical Exam (2 of 3)
Assess the chest.
Assess the abdomen.
Assess the pelvis.
Assess all four extremities.
Rapid Physical Exam (3 of 3)
Roll the patient with spinal precautions.
Assess baseline vital signs and SAMPLE history.
Detailed Physical Exam
more in-depth only performed if time allows performed en route to the hospital have system - head to toe practice same way every time always check area before covering for our lab, rapid trauma assessment
and detailed physical exam are same (Head to Toe)
Focused History and Physical Exam (medical)
Medical history Baseline vital signs Physical exam
Focused History and Physical Exam (Trauma-no significant mechanism)
Assess the chief complaint.– Chest pain– Shortness of breath– Abdominal pain– Any pain associated with bones or
joints– Dizziness
Obtain baseline vital signs and SAMPLE history
SAMPLE SAMPLE History
S Signs and symptoms
A Allergies
M Medications
P Past medical history
L Last oral intake
E Events leading to the episode
Alternate
HAM– History– Allergies– Medications
Vital Signs
After rapid assessment, obtain baseline vital signs and a SAMPLE history.
Vital signs of stable patients should be reassessed every 15 minutes.
Vital signs of unstable patients should be reassessed every 5 minutes.
Focused Physical Exam
Investigate problems associated with chief complaint.
Examine abnormalities. Assess vital signs.
– Skins– Chest Auscultation
Make transportation decision. Document findings.
Assessing the Responsive Medical Patient
Ask general questions May not be obvious Use patient’s own words Multiple complaints?
Questions to ask: Chest pain
OPQRSTShortness of breath also?Medication?
OPQRST
O Onset P Provoking factors Q Quality of pain R Radiation / Region S Severity T Time / Treatment
Questions to ask: Shortness of breath
How long? Sudden or slow onset? Chest pain also? Chest auscultation
Questions to ask: Abdominal pain
OPQRST N/V Normal bowel movement & urination? GI bleed? FEMALES
– pregnant?– LMP, normal?
Assessing the Unresponsive Patient (Medical)
Perform a rapid medical assessment. Obtain baseline vital signs. Obtain SAMPLE history from family if
available. Provide emergency care and transport. Document findings.
Questions to ask: Altered level of consciousness
DERMAEIOU TIPSSudden or Slow?Ask bystanders
DERM
D - depth of consciousnessE - eyesR - respirations (abnormal patterns)M - motor function
AEIOU TIPS
A - alcohol, apnea, arrhythmia, anaphylaxis
E - epilepsy/environment I - insulin O - overdose U - uremia/underdose
AEIOU TIPS
T - trauma I - infectionP - psychogenicS - stroke
Questions to ask: Overdose - Poisonings
whathow long ago routeany other?
Questions to ask: Diabetes
Taken your medicine?Eaten normally?Slow or fast onset?
its a balance!
Questions to ask: Seizures
How long did it last?Fall?More than 1?How did it start
What is status epilepticus?
Questions to ask: Syncope
out how long? fall?chest pain? irregular heart beat?
Questions to ask: Shootings - a.k.a. GSW
SAFETY# shots heard type of gun (caliber)distanceother associated trauma?
Questions to ask: Stabbings - a.k.a. “cutting”
SAFETY type of knife? (size)associated trauma?
Questions to ask: Assaults
SAFETYhit with what?where?# of times?KO?
Questions to ask: Falls
trip & fall? or dizzy & fall?how far?how did they land?What did they land on?KO?
Ongoing Assessment
Is treatment improving the patient’s condition?
Has a problem gotten better? Worse?
Any newly identified problems?
Steps of the Ongoing Assessment
Repeat the initial assessment.
Reassess vital signs.
Repeat focused assessment.
Check interventions.
Documentation
Skin color, temperature, and moisture Initial assessment findings Baseline and subsequent vital signs
and SAMPLE history Circulation, sensation and movement in
all extremities Breath sounds
That’s all folks!!
questions?
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