1. LESSON 11
SECONDARY ASSESSMENT

2. Introduction
With no immediate threats to life, obtain the history and conduct a secondary assessment
Obtain the patient’s vital signs and perform a physical examination
The secondary assessment reveals additional information and problems
Continue to reassess the patient to ensure treatment is effective and that the patient’s condition is not worsening

3. Patient History

4. Patient History Patient’s history is gained from patient or others
Begin by asking about the patient’s chief complaint
Although history focuses on specific injury or chief complaint, it should be complete
With responsive medical patients, you may take history before performing physical examination
With trauma patients and any unresponsive patient, perform physical examination first

5. Taking a History Talk to a responsive patient
With an unresponsive patient, talk to family members or others at the scene about what they know or saw
Look for medical alert insignia or other medical identification
In the home, look for medication bottles and a Vial of Life

6. Taking a History (continued)
With trauma patient, assess forces involved
When taking history of a responsive patient with a sudden illness, ask fully about the patient’s situation to learn possible causes
Look for clues in the environment

7. SAMPLE S = Signs and symptoms A = Allergies M = Medications
P = Pertinent past history
L = Last food or drink
E = Events

8. Additional Guidelines for History
If patient is unresponsive, ask family members or bystanders
Check scene for clues of what may have happened
Consider environment
Consider patient’s age
When additional EMS personnel arrive, give them information you gathered

9. Age Variations in History
When taking the history and performing the secondary assessment, consider the patient’s life stage
For pediatric patients:
Assess an infant’s pulse at brachial artery
Use capillary refill as an indicator of adequate blood flow in infants and children younger than 6
Use distracting measures and other actions to help gain the child’s trust
For geriatric patients:
Help the patient obtain eye glasses and hearing aids for improved communication
Accept that taking the history may take more time

10. Secondary Assessment
After the history, unless you are now providing critical patient care, continue patient assessment
Take the patient’s vital signs
Perform a physical examination

11. Vital Signs Some EMR check patient’s vital signs
Vitals signs assessed include:
Breathing rate, rhythm, depth and ease
Pulse rate, rhythm and strength
Skin color, temperature and condition
Pupil size, equality and reaction to light
Blood pressure

12. Importance of Vital Signs
Vital signs reveal additional information about condition
Changes in vital signs, from the baseline vital signs, are important and should be documented
Changes may show deterioration or improvement with treatment
Vital signs vary significantly among different individuals
Vital signs are affected by stress, activity and other variables

13. Normal Vital Signs Patient Normal Respiratory Rate at Rest
Normal Pulse Rate at Rest
Normal Blood Pressure (systolic/diastolic)
Infant
30-40
/ 56-70
Child
20-30
70-130
/ 50-80
Adult
12-20
60-100
/ 60-90

14. Assessing Respiration
Don’t tell a responsive patient that you are assessing breathing
Count respirations while holding wrist draped across chest as if taking a pulse
Observe or feel for the chest rising and falling (1 cycle = 1 breath)

15. Assessing Respiration (continued)
Count number of breaths in 30 seconds and multiply by 2
Note whether patient is making an effort to breathe, is short of breath or is using accessory muscles of neck and abdomen in breathing

16. Characteristics of Respiratory Distress
Gasping or wheezing
Very fast or slow respiratory rate
Very shallow or very deep breathing
Shortness of breath, difficulty speaking

17. Assessing Pulse Have a responsive patient sit or lie down
Take a radial pulse in an adult or child
If no radial pulse, take carotid pulse in an adult or brachial pulse in a child
Always take brachial pulse in an infant
Count the beats for 30 seconds and multiply by 2
Note strength of pulse (strong or weak)
Note rhythm of pulse (regular or irregular)

18. Characteristics of Possible Circulation Problem
Very fast or very slow pulse
Very weak or strong, bounding pulse
Very weak and fast pulse (thready pulse) may indicate shock
Irregular rhythm may indicate a cardiac problem
Unequal pulses at different sites

19. Assessing Skin Temperature and Condition
Assess skin temperature using back of hand on skin
Assess skin color
Assess skin moisture
In a young child, assess capillary refill

20. Skin Characteristics That May Indicate a Problem
Skin temperature
Unusual coloration
Skin condition
Capillary refill time >2 seconds may indicate shock or diminished blood flow

21. Assessing Pupils Assess size of patient’s pupils
Assess the pupils for equality
Assess reactivity to light

22. Assessing Pupils (continued)
Pupil characteristics that may indicate a problem:
Dilated or constricted pupils
Unequal pupils
Non-reactive pupils

23. Blood Pressure
When heart contracts, pressure is higher (systolic pressure)
Pressure falls lower when heart relaxes between beats (diastolic pressure)
Blood pressure is recorded as systolic pressure over diastolic pressure

24. Blood Pressure (continued)
Some EMRs are trained to take blood pressure
Blood pressure is force of blood pressing against arterial wall from heart’s pumping action
Blood pressure indicates level of perfusion

25. Skill: Measuring Blood Pressure by Auscultation

27. Repeated Blood Pressure
It is difficult to interpret blood pressure because of wide variation among individuals
Repeated measurements may show a possible trend in patient’s condition
A drop in blood pressure in shock usually develops as a late sign

28. Measuring Blood Pressure by Palpation
If you don’t have a stethoscope or the scene is noisy, measure systolic blood pressure by palpation
While palpating radial pulse, inflate cuff 30 mmHg beyond the point where you stop feeling pulse
While watching gauge, open valve to slowly deflate cuff
Note pressure when you feel radial pulse return
Record pressure as systolic pressure and include word ‘palpated’ (e.g., “130 palpated” or “130/P”)

29. Physical Examination
Unless you are caring for a life-threatening condition, perform a physical examination
Purpose is to find and assess additional signs and symptoms of illness or injury
Because patients are often anxious about being examined, provide emotional support

30. Physical Examination (continued)
Information gained from examination may help you care for patient and be of value to arriving EMS personnel
Complete rapid trauma assessment of unresponsive patient or a patient with a significant MOI
Perform focused physical examination of responsive medical patient or a trauma patient with only a minor injury

31. When Performing a Physical Examination
Allow responsive patient to remain in position he/she finds most comfortable
Ask responsive patient for consent to do physical examination
Don’t start with a painful area

32. When Performing a Physical Examination (continued)
Watch for facial expression or stiffening of body part
In responsive patient, begin with area of chief complaint and examine other body areas only as appropriate
With unresponsive patient, examine patient from head to toe in a systematic manner
If you find life-threatening problem at any time, treat it immediately

33. When Performing a Physical Examination (continued)
Sign: an objective observation or measurement such as warm skin or a deformed extremity
Symptom: a subjective observation reported by the patient, such as pain or nausea

34. Use Systematic Head-To-Toe Approach
Begin at head because injuries here are more likely to be serious than injuries elsewhere
With responsive children, begin at feet and work up body
Look and palpate for signs and symptoms throughout body – compare one side of body to other when appropriate

35. DOTS for Trauma Patients
D = Deformities
O = Open injuries
T = Tenderness (pain)
S = Swelling

36. DCAP-BTLS Memory Aid D = Deformities C = Contusions A = Abrasions
P = Punctures/Penetrations
B = Burns
T = Tenderness
L = Lacerations
S = Swelling

37. Check Head and Neck
Skull
Eyes
Ears
Nose
Breathing
Mouth
Neck

38. Check Chest Deformity? Wounds? Tenderness? Bleeding?
Use of accessory muscles?
Equal chest rise?

39. Check Abdomen
Rigidity?
Pain?
Bleeding?

40. Back
Unless head or spinal injury is suspected, roll patient onto side to examine back
If head or neck injury is suspected, don’t move patient but slide your gloved hand under back
Sweep entire lower back, looking at fingertips of your gloved hands for any bleeding
Treat any tenderness, swelling or deformity of lower part of spine as a sign of spinal injury and don’t move patient

41. Check Hips and Pelvis
Tenderness?
Instability?
Incontinence?
Priapism?

42. Check Lower Extremities
Bleeding? Asymmetry? Deformity? Pain?
Normal movement, sensation, temperature?
Circulation?

43. Check Upper Extremities
Bleeding? Deformity? Pain?
Medial alert identification?
Normal movement, sensation, temperature?
Circulation?

44. Reassessment
Continue to assess while awaiting additional EMS resources and giving care
Calm and reassure patient while reassessing breathing and circulation and repeating vital signs and physical examination
Repeat reassessments:
Every 15 minutes for a stable patient
Every 5 minutes for an unstable patient

45. Performing Reassessment
The primary assessment of responsiveness, breathing and circulation
Vital signs
The chief complaint

46. Importance of Reassessment
Check that your interventions are effective
Perform additional treatments as needed

47. Compare Reassessment Results to Baseline Status
Level of responsiveness
Airway maintenance
Adequacy of breathing (rate, depth, effort)
Adequacy of circulation (carotid or radial pulse; skin color, temperature and moisture)
Chief complaint (pain remains the same, getting worse or getting better)
Presence of new or previously undisclosed symptoms

48. Hand-Off Report
Give EMS hand-off report with detailed information about the patient’s:
Age and gender
Chief complaint
Responsiveness
Airway and breathing status
Circulation status

49. Hand-Off Report (continued)
Also include:
Vital signs and physical examination findings
Results of SAMPLE history
Interventions provided and the patient’s response to them
You may also complete a written report containing the same information