1. Class 9 (Exam Techniques; Focus, Rapid & Detailed, Ongoing Assessment & Spinal Immobilization) Ch8 (Partial), Ch30 (Partial) & Ch6 (Partial)

2. Patient Assessment Scene size-up Initial assessment Focused history and physical exam –Vital signs –History Detailed physical exam Ongoing assessment

3. Patient Assessment Process

4. Goals of the Focused History and Physical Exam Understand the circumstances surrounding the chief complaint. Obtain objective measurements. Perform physical exam.

5. Components of Focused History and Physical Exam Medical history Baseline vital signs Physical exam Order is situation dependent –Exam 1 st in trauma patients –Medical history 1 st in medical patients

6. Exam Types Focused Exam –Exam is “focused” on a specific part or problem in responsive medical patients or minor trauma injuries Rapid trauma exam –Fast head to toe exam on trauma patients with significant mechanism of injury Rapid medical exam –Fast head to toe exam on unresponsive medical patients. (Same technique as rapid trauma exam) Detailed exam –Slow, complete exam of the entire body. Done en-route to hospital if there is time

7. Focused Physical Exam Used to evaluate patient’s chief complaint Performed on: –Trauma patients without significant MOI –Responsive medical patients

8. Assessment Steps for Trauma Patients Without Significant MOI Focused assessment Baseline vital signs SAMPLE history Reevaluate transport decision

9. Responsive Medical Patients History of illness SAMPLE history Focused assessment Vital signs Reevaluate transport decision

10. Specific Chief Complaints Chest pain Shortness of breath Abdominal pain Pain associated with bones or joints Dizziness

11. Rapid Physical Exam 60-90 second head-to- toe exam Performed on: –Significant trauma patients –Unresponsive medical patients Identifies undiscovered conditions

12. Significant Mechanism of Injury Ejection from vehicle Death in passenger compartment Fall greater than 15'-20' Vehicle rollover High-speed collision Vehicle-pedestrian collision Motorcycle crash Unresponsiveness or altered mental status Penetrating trauma to the head, chest, or abdomen

13. Assessment Steps for Significant MOI Rapid trauma assessment Baseline vital signs SAMPLE history Reevaluate transport decision

14. Unresponsive Medical Patients Rapid medical assessment Baseline vital signs SAMPLE history Reevaluate transport decision

15. Detailed Physical Exam More in-depth exam based on focused physical exam –Do a focused exam on every body part Should only be performed if time and patient’s condition allows Usually performed en route to the hospital

16. The detailed exam is a focused exam of all body parts, starting at the head and proceeding to the feet. The focused exam is a detailed exam of a specific body part The rapid exam is a limited detailed exam of the entire body, starting at the head and proceeding to the feet If you learn the detailed exam, you also know how to do both the focused exam and a rapid exam.

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

18. Test Tip D.C.A.P.-B.L.S is textbook and will be on written exams so you need to learn it. However it is not generally used in the field nor is it general used on the practical skills test. Soft Tissue Injury (STI), Deformity, Crepitus is the preferred “general statement” for the practical physical exam and is what you would be looking for in a rapid physical exam. For a detailed physical exam, start looking for STI/Deformity/Crepitus and then examine the specific items for that body part

19. Exam Techniques Look Listen Feel Smell

20. Performing the Detailed Physical Exam (HEAD) Visualize and palpate using STI-Deformity-Crepitus. Ask about pain, visual changes or dizziness Look at the face. Inspect the area around the eyes and eyelids. Examine the eyes.

21. Performing the Detailed Physical Exam (HEAD) Pull the patient’s ear forward to assess for bruising. Use the penlight to look for drainage or blood in the ears.

22. Performing the Detailed Physical Exam (HEAD) Look for bruising and lacerations about the head. Palpate the zygomas.

23. Performing the Detailed Physical Exam (HEAD) Palpate the maxillae. Palpate the mandible.

24. Performing the Detailed Physical Exam (HEAD) Assess the mouth and nose for obstructions and cyanosis. Check for unusual odors.

25. Rapid Exam (HEAD) Faster and not as specific as the detailed. Palpate the cranium and the face as a whole The mandible, maxilla, zygomas, eyes, ears and nose are not treated as separate parts Eyes and nose can be checked later if there is time Check ears before spinal immobilization device hides them

26. Practical Exam Test Tip (HEAD) During the physical exam practical, you will need to do the exam and verbalize your exam to the evaluator. Start with the same general statement for each body part: “I am looking and feeling for Soft Tissue Injury, Deformity and Crepitus. Then examine the specifics for that body part. For the head examine and state that you are checking the maxillae, mandible zygomas, eyes, ears, nose and reevaluating the mouth.

27. Performing the Detailed Physical Exam (NECK) Look at the neck and ask about pain Palpate the front and the back of the neck. Look for distended jugular veins, tracheal shift and Sub-Q air Place a cervical collar on if needed

28. Practical Exam Tip (NECK) There is no difference between a rapid and a detailed neck exam. The reason is that the cervical collar will go on after the rapid exam thereby preventing a detailed exam later. Do it right the first time! Start the neck exam with “Soft Tissue Injury, Deformity, and Crepitus. The specifics for the neck exam is “JVD, Step-Offs, Sub-Q Air or Tracheal Shift” DO NOT PUT A C-COLLAR ON WITHOUT AN EXAM

29. Performing the Detailed Physical Exam (CHEST) Look & feel the chest for equal rise and fall, accessory muscle use, retractions, sucking chest wounds or paradoxical movement

30. Performing the Detailed Physical Exam (CHEST) Listen for breath sounds at the bases, apices and posterior side of the chest Ask about Chest Pain or Shortness of Breath

31. Practical Exam Test Tip (CHEST) There is little difference in the rapid and the detailed chest exam. The chest exam maybe completed during the B for Breathing portion of the initial assessment in both the real world as well as on the practical exam. Start with “Soft Tissue Injury, Deformity, and Crepitus Specific for the chest are “Equal rise and fall, Paradoxical movement/Flail Segments, Sucking Chest Wounds and Sub-Q Air.” Don’t forget to listen to breath sounds!

32. Performing the Detailed Physical Exam (ABDOMEN) Look at the abdomen for injury or distension Gently palpate all 4 quadrants of the abdomen. Ask about pain, nausea, vomiting and diarrhea

33. Practical Exam Test Tip (ABDOMEN) There is very little if any difference in the rapid and the detailed exams. Start with the general statement “Soft Tissue Injury, Deformity, and Crepitus” The specifics for the abdomen are “Distension, Rigidity, Guarding and Nausea/Vomiting

34. Performing the Detailed Physical Exam (PELVIS) Look for any signs of obvious injury, bleeding, or deformity. Press gently inward and downward on pelvic bones if there is no pain. Inspect the genitalia for incontinence to urine and stool and blood

35. Practical Exam Test Tip The only difference between the rapid and the detailed pelvic exam is the visualization of the genitalia in the detailed. Never palpate the genitalia! Start the practical exam with the general statement “Soft Tissue Injury, Deformity and Crepitus. Specific to the pelvis exam is “Checking the genitalia for bleeding or incontinence to urine or stool. Checking for stability by pressing down and in and on the pubic symphysis.

36. Performing the Detailed Physical Exam (EXTREMITIES) Inspect and palpate all four extremities. Check for motor function by having the patient move fingers and toes. Check for sensory function by asking the patient if they can feel you touching. Check distal circulation by checking for skin color, pulses, and capillary refill.

37. Practical Exam Test Tip (EXTREMITIES) All four extremities are done the same way. Make sure that you palpate all the way around the legs and arms. Start with the general statement “ Soft Tissue Injury, Deformity and Crepitus The specifics for the extremities are “Checking for motor, sensory and pulses/capillary refill” Note: On a medical patient check for bilateral swelling of the ankles/feet

38. Performing the Detailed Physical Exam (BACK) Feel for tenderness, deformity, and open wounds. Palpate and inspect the back of the head Carefully palpate from neck to pelvis. Posterior breath sounds Roll patient onto a long back board if needed.

39. Practical Exam Test Tip There is no difference between the rapid and the detailed back exams. The back must be checked as the patient is being placed onto a backboard. Do Not immobilize a patient to a backboard without examining the back first. Remember that the upper back is the back side of the chest. If you have a penetrating injury to the front of the chest, you need to immediately check the back of the chest. While you do that you can also check the entire posterior side of the patient. Check for Soft Tissue Injury, Deformity and Crepitus.

40. Detailed VS. Rapid Exam Tip The practical difference between a detailed exam and a rapid head-to-toe exam is state of mind. In the detailed you are really trying to look and feel to find every little scrape, cut, bruise and tender area. Because this takes extra time, it is usually done en- route to the hospital if you have the time In the rapid exam, your main focus is to quickly find (within 90 seconds) all the big, gross and obvious injuries and problems

41. Patient Assessment Process

42. Ongoing Assessment Is treatment improving the patient’s condition? Has an already identified problem gotten better? Worse? What is the nature of any newly identified problems?

43. Steps of the Ongoing Assessment Repeat the initial assessment. Reassess and record vital signs. Repeat focused assessment. Check interventions.

44. 30: Head and Spine Injuries

45. Stabilization of the Cervical Spine (1 of 3) Hold head firmly with both hands. Support the lower jaw. Move to eyes-forward position.

46. Stabilization of the Cervical Spine (2 of 3) Support head while partner places cervical collar. Maintain the position until patient is secured to a backboard.

47. Stabilization of the Cervical Spine (3 of 3) Do not force the head into a neutral, in-line position if: –Muscles spasm –Pain increases –Numbness, tingling, or weakness develop –There is a compromised airway or breathing problems.

48. Applying a Cervical Collar (1 of 2) One EMT-B provides continuous manual in-line support of the head. Measure the proper size collar.

49. Applying a Cervical Collar (2 of 2) Place the chin support snuggly under the chin. Wrap the collar around the neck. Ensure that the collar fits.

50. Backboards Short backboards –Used on patients found in a sitting position Long backboards –Provide full-body immobilization

51. Preparation for Transport: Supine Patients (1 of 2) Maintain in-line stabilization. Have the other team members position the immobilization device. Log roll patient. Examine the back for STI/Deformity/Crepitus or DCAP-BTLS

52. Preparation for Transport: Supine Patients (2 of 2) Secure patient to backboard. –Torso 1 st, Head last! Reassess pulse, motor, and sensory function in each extremity and continue to do so periodically.

53. Preparation for Transport: Sitting Patients (1 of 2) Maintain manual in-line stabilization. Apply a cervical collar. Place a short board behind patient. Position device around patient. Torso 1 st, Head last

54. Preparation for Transport: Sitting Patients (2 of 2) Turn patient and lower to long backboard. Secure short and long backboards together. Reassess the pulse, motor function, and sensation.

55. Preparation for Transport: Standing Patients Stabilize the head and neck and apply a cervical collar. Position board behind patient. Carefully lower the patient to the ground.

56. Helmet Removal (1 of 4) Is the airway clear and is the patient breathing adequately? Can airway be maintained and ventilations assisted with helmet in place? How well does the helmet fit? Can the patient move within the helmet? Can the spine be immobilized in a neutral position with the helmet on?

57. Helmet Removal (2 of 4) A helmet that fits well prevents the head from moving and should be left on, as long as: –There are no impending airway or breathing problems. –It does not interfere with assessment and treatment of the airway. –You can properly immobilize the spine.

58. Helmet Removal (3 of 4) Open the face shield. Prevent head movement. Partner places hands. Gently slip helmet off halfway.

59. Helmet Removal (4 of 4) Partner slides hands from occiput to back of head. Remove helmet. Stabilize spine. Apply cervical collar. Pad as needed.

60. Pediatric Needs Children may need extra padding to maintain immobilization. Children may need extra padding under the shoulders.

61. Pediatric Needs The Phoenix Fire Dept contacted several car seat manufacturers and they all said DO NOT DO THIS Follow the protocols of your employer

62. 6: Lifting and Moving Patients

63. When to Use Rapid Extrication Technique Vehicle or scene is unsafe. Patient cannot be properly assessed. Patient requires immediate care. Patient’s condition requires immediate transport. Patient is blocking access to another seriously injured patient.

64. Rapid Extrication (1 of 3) Provide in-line support and apply cervical collar.

65. Rapid Extrication (2 of 3) Rotate patient as a unit.

66. Rapid Extrication (3 of 3) Lower patient to the backboard.