1	Chapter 12 Patient Assessment
2	Objectives Identify components of scene size-up Identify priorities in each phase of assessment Outline steps in patient assessment Describe initial assessment findings that indicate life threat Discuss interventions for life threats
3	Objectives Identify steps of focused history and physical exam in the medical patient Identify steps of focused history and physical exam in the trauma patient List steps of detailed physical exam Describe ongoing assessments Distinguish priorities of care in medical versus trauma patients
4	Scenario You respond to a vehicle collision. On arrival, you see one car has crashed into a tree and appears to have very minor damage. The seatbelted driver is the only occupant and is confused and pale. The collapsed airbag surrounds the undamaged steering wheel. You see no visible trauma on the patient.
5	Discussion What potential hazards could there be on this scene? What is your general impression? Is this a trauma or a medical patient? What assessments will you need to perform? Does this patient need spinal immobilization?
6	Scene Size-Up Measure of scene and surroundings that provides valuable information to the emergency crew
7	Priorities in Scene Size-Up Scene safety Body substance isolation precautions Nature of incident Medical versus trauma Maximum potential number of patients Scene hazards
8	Priorities in Scene Size-Up Mass casualty plan, if indicated Additional resources Determine access routes and staging areas for responders Secure area as rapidly as possible Clear unnecessary people Begin triage (if needed)
9	Scene Safety May be dangerous even if seems safe Never enter potentially unsafe scene until it is known that it is safe to approach the patient Wait for law enforcement to secure scene, if necessary
10	Unsafe Scenes Must be made safe before patient care Crash and rescue scenes Toxic substances Crime scenes Unstable surfaces Violent/hostile environments Unstable structure Farm emergencies
11	Protective Clothing Personal protective equipment: Impact-resistant helmet with ear protection and chin strap Safety goggles with vents Lightweight, puncture-resistant turnout coat Slip-resistant waterproof gloves Boots with steel insoles and toe protection Self-contained breathing apparatus (SCBA)
12	Protection from Bloodborne Pathogens OSHA criteria for protection from bloodborne diseases Observe whenever there is a potential for contact with blood or body fluids Wear eye protection, gloves, gown, and mask if necessary
13	Patient Assessment Priorities Initial assessment Focused history and physical examination Detailed physical examination Ongoing assessment
14	Initial Assessment
15	General Impression of the Patient Determines priorities of care Based on: Assessment of environment Patient's chief complaint Determine if medical or trauma problem If injured, identify mechanism of injury If ill, identify nature of illness Patient’s age, gender, and race
16	Assess for Life-Threatening Conditions Systematic evaluation of: Level of consciousness Airway Breathing Circulation
17	Level of Consciousness Can be quickly assessed using the AVPU acronym: A = alert V = responds to verbal stimuli P = responds to painful stimuli U = unresponsive; no gag or cough reflex
18	Airway Patent or obstructed airway Assess patency: Can patient speak? Signs of airway obstruction or respiratory insufficiency (stridor, gurgling) Oral cavity for foreign objects
19	Airway Any condition that compromises the delivery of oxygen to body tissues is potentially life threatening and must be managed immediately
20	Airway Compromise Contributing factors Tongue, loose teeth, other foreign objects Epiglottitis Facial and oral bleeding Vomitus Soft tissue trauma to face and neck Facial fractures
21	Airway Compromise Management Manually or with adjunctive equipment If trauma suspected, take spinal precautions
22	Breathing Evaluate: Rate Depth Tidal volume Symmetry of chest movement
23	Breathing Expose chest wall and palpate for: Structural integrity Tenderness Crepitus Observe for accessory muscle use Musculature of the neck, chest, abdomen
24	Breathing Bilateral breath sounds Listen to patient talk Assess for other life-threatening respiratory abnormalities
25	Breathing—Management Supplement with high‑concentration oxygen If respirations ineffective, assist ventilation Ventilatory support may include: Synchronizing assisted ventilations with patient's respiratory efforts Interposing ventilations as needed to maintain adequate oxygenation
26	Breathing—Management If respirations are absent provide: Rescue breathing with barrier protection Positive pressure ventilation Bag-mask Endotracheal intubation Consider spinal precautions Use barrier protection with airway procedures
27	Circulation Head‑to‑toe visual survey to note and control severe bleeding Evaluate skin color, moisture, temperature
28	Pulse Evaluate for: Rate Rhythm Pulse location may indicate patient's systolic BP and perfusion status
29	Capillary Refill Normal = <2 sec Considered most reliable in children <12 y/o
30	Signs of Inadequate Circulation Altered level of consciousness Distended neck veins Pale, cool, diaphoretic skin Distant heart sounds Restlessness Thirst
31	Management If carotid pulse is absent, begin CPR and cardiac arrest protocols Control severe hemorrhage with direct pressure, elevation, use of pressure points Provide rapid stabilization and transportation to appropriate medical facility May include: IV fluids Other medications
32	Identify Priority Patients Poor general impression Decreased level of consciousness Unresponsive Difficulty breathing Shock (hypoperfusion) Complicated childbirth Chest pain with hypotension Uncontrolled bleeding Severe pain Multiple injuries
33	Focused H & P—Medical Overall condition and LOC dictate exam Identify: Chief complaint History of present illness Past medical history Current health status Perform physical exam Vital signs Emergency care provided based on signs and symptoms If patient unconscious: Rapid head-to-toe assessment
34	Focused H & P—Trauma Mechanism of injury Determine from bystanders and scene Rapid trauma physical examination Continued spinal immobilization Mental status assessment Inspect and palpate body for injuries Including posterior surfaces Baseline vital signs Patient history
35	Detailed Physical Exam Gather additional information Patient and injury specific Not all patients need detailed physical exam
36	Detailed Physical Exam Mental status Appearance and behavior Posture and motor behavior Speech and language Mood Thought and perceptions Insight and judgment Memory and attention
37	Detailed Physical Exam— General Survey Level of consciousness Signs of distress State of health Skin color and obvious lesions Height and build Sexual development Weight Posture, gait, and motor activity Dress, grooming, and personal hygiene Odors of breath or body Facial expression
38	Detailed Physical Exam Skin Head Eyes Ears Nose and sinuses Mouth and pharynx Neck Thorax and lungs Cardiovascular system Abdomen Genitalia Anus and rectum Peripheral vascular system Musculoskeletal system Nervous system Baseline vital signs
39	Ongoing Assessment Purpose Continue monitoring patient’s status en route to the hospital and provide treatment as necessary
40	Ongoing Assessment Components Repeat initial assessment Stable patient: every 15 minutes Unstable patient: every 5 minutes (minimum) Reassess mental status Reassess airway Monitor breathing for rate and quality Reassess circulation Reestablish patient priorities
41	Ongoing Assessment Reassess and record vital signs Changes in patient’s condition may require change in care or treatment Repeat focused assessment Assess interventions: Response to management Continuous assessment for “trends” Maintain or modify management plan
42	Care of Medical vs. Trauma Patients Medical patients Definitive care for medical patients can often be initiated in the prehospital setting
43	Care of Medical vs. Trauma Patients Trauma patients Definitive care usually given only at appropriate hospital Unstable patients should be ready for transport within 10 minutes of EMS arrival Limit field management to: Airway control, ventilatory support, spinal immobilization, major fracture stabilization IV fluid therapy en route to hospital
44	Conclusion In the prehospital environment, priorities of care must be established based on the patient assessment. These priorities include scene safety, recognition and stabilization of life-threatening conditions, and, if appropriate, rapid transport for definitive care.
45	Questions?