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© 2011 National Safety Council 10-1 SCENE SIZE-UP AND PRIMARY ASSESSMENT LESSON 10
© 2011 National Safety Council 10-2 Introduction Patient assessment involves critical EMR skills Act quickly to ensure scene is safe, assess patient and care for immediate threats to life Care provided is based on patient assessment Assessment begins with the primary assessment
© 2011 National Safety Council 10-3 Scene Size-Up While going to scene, consider factors that may affect safety for you, bystanders and patient Dispatcher’s information may alert you to hazards or special precautions Begin scene size-up before you exit your vehicle and while approaching the patient
© 2011 National Safety Council 10-4 Scene Safety Observe for any hazards As you enter scene While approaching patient
© 2011 National Safety Council 10-5 Hazardous Materials Chemicals Biological agents
© 2011 National Safety Council 10-6 Vehicle Crash Hazards Traffic hazards Downed wires Risk of fire or explosion Unstable vehicles Extrication hazards Hazardous materials
© 2011 National Safety Council 10-7 Potential Violence Crime scenes Potentially violent patient or bystanders Guard dogs, wild animals
© 2011 National Safety Council 10-8 Environmental Dangers Unstable surfaces Water, ice Weather extremes
© 2011 National Safety Council 10-9 Hazards Within Structures Low-oxygen areas Toxic substances, fumes Risk of collapse Risk of fire or explosion
© 2011 National Safety Council Principles of Scene Safety Enter scene only if it is safe If unsafe, make it safe or stay away and request specialized resources Protect bystanders and other rescuers from hazards Protect patient from environmental threats
© 2011 National Safety Council Scene Management As you approach the patient, begin process of scene management Consider factors related to a medical or trauma patient Address hazards within the scene Consider the need for additional resources Implement standard precautions to prevent infection
© 2011 National Safety Council Trauma vs. Medical Patient Dispatch may tell you whether there is a trauma patient or a medical patient This focuses your attention on a mechanism of injury or the nature of the illness
© 2011 National Safety Council Mechanism of Injury With trauma patient, scene size-up includes evaluating for clues about mechanism of injury (MOI) MOI may suggest serious injury or presence of internal injuries
© 2011 National Safety Council Consider the Mechanism What specifically caused the injury? Was there an impact with a blunt or sharp object? What body area received the impact? What organs may be injured? How much force may have been involved? Might the force have been transferred from one body area to another?
© 2011 National Safety Council Examples of Mechanism of Injury Vehicle collision may cause head or spinal injuries Fall from a height may cause extremity fractures Blunt impact to abdomen may cause closed injury and internal bleeding Diving incident may cause spinal injury Gunshot may cause extensive internal damage not apparent from the appearance of the outside wound Fall forward onto a hand may transfer force up arm and cause shoulder dislocation
© 2011 National Safety Council Importance of Time Quickly consider MOI during scene size-up Do not delay patient assessment to examine scene in detail Consider MOI more fully while gathering history and performing physical examination
© 2011 National Safety Council Consider Nature of Illness Consider nature of illness during scene size-up Don’t stop to talk to family or bystanders until you are sure there is no immediate threat to life Observe patient’s position and demeanor for clues Use all your senses If patient is unresponsive, move immediately to primary assessment If patient is responsive, ask patient, family members or bystanders why EMS was called
© 2011 National Safety Council Number of Patients Determine how many patients are involved Observe for clues and ask those present if everyone is accounted for Be certain you know how many patients are involved Call for additional help immediately for multiple patients If more patients than responders, triage patients first
© 2011 National Safety Council Addressing Hazards Consider environmental factors as you size up scene Protect yourself and other responders Protect the patient Protect bystanders
© 2011 National Safety Council Additional Resources Scene size-up includes consideration of whether additional resources may be needed If resources not already en route, call dispatch immediately Describe injuries in detail, so an ALS ambulance can be sent if needed
© 2011 National Safety Council Additional Resources (continued) Consider these factors: -Number of patients and types and seriousness of injuries -Possible need for air transport -Potential for fire or explosion -Potential presence of hazardous materials -Need for extrication -Need for law enforcement or traffic control -Damage to power lines or other utilities
© 2011 National Safety Council BSI Precautions Put on medical examination gloves as you approach patient Observe scene and patient to determine whether to use other personal protective equipment: -Protective eyewear -Gown and mask -Turn-out gear Follow standard precautions
© 2011 National Safety Council Primary Assessment Performed when you reach patient to identify any immediate threats to life Rapid means to determine patient’s general condition and set initial priorities for care Begin with your initial impression of patient Check patient’s responsiveness, airway, breathing and circulation status Perform primary assessment of all patients after scene size-up If scene is safe, perform primary assessment before moving patient
© 2011 National Safety Council General Impression Is the patient ill or injured? Does patient’s appearance give clues about his or her condition? Are there signs of a serious problem? Note patient’s sex and approximate age
© 2011 National Safety Council Responsiveness You may notice immediately whether patient is responsive Responsive means a person is conscious and awake
© 2011 National Safety Council Responsiveness (continued) Patients who cannot talk may be able to move and thereby signal responsiveness
© 2011 National Safety Council Patients who cannot talk or move may be paralyzed but still able to respond with purposeful eye movements or other signs Responsiveness (continued)
© 2011 National Safety Council Assessing Responsiveness Begin by speaking to the patient; ask the patient what is wrong If patient isn’t speaking or moving, tap gently and shout, “Are you OK?” Be careful not to move patient in any way Always suspect a spinal injury and take steps to stabilize head and neck
© 2011 National Safety Council Unresponsiveness Unresponsiveness may be sign of life-threatening problem or may result from a less urgent problem Continue the primary assessment Unresponsiveness is considered life-threatening emergency In an unresponsive patient lying on the back, the tongue may block the airway
© 2011 National Safety Council Degree of Responsiveness Assessed with AVPU scale AVPU scale useful for noting changes in a patient’s responsiveness while providing care and for communicating this information Make mental note of level of responsiveness or write it down along with time A change in level of responsiveness generally indicates a serious condition
© 2011 National Safety Council Degree of Responsiveness (continued) AVPU Scale A = Alert V = Responds to Verbal stimuli P = Responds to Pain U = Unresponsive to all stimuli
© 2011 National Safety Council Responsiveness in pediatric patients -Infants and young children may respond differently from older children and adults -Look for age-appropriate responses -Assess unresponsive infant by flicking bottom of feet and noting response Degree of Responsiveness (continued)
© 2011 National Safety Council Assess Breathing While assessing for responsiveness, look for normal breathing A patient who can speak, cough or make other sounds is breathing and has a heartbeat Reflex gasping (agonal respirations) may be present just after cardiac arrest; do not confuse this with normal breathing Lack of breathing may be caused by cardiac arrest, obstructed airway or other causes If patient is not breathing normally, quickly move to next step and check for a pulse
© 2011 National Safety Council Assess Circulation In an unresponsive patient who is not breathing normally, check for circulation If patient’s heart has stopped or patient is bleeding profusely, vital organs are not receiving enough oxygen to sustain life Do not use more than 10 seconds to feel for the pulse unless a pulse is clearly found in that time, start CPR If the patient is responsive or breathing, the heart is beating
© 2011 National Safety Council Pulse Check In responsive adult or child, check radial pulse Note rate, rhythm and strength
© 2011 National Safety Council In an unresponsive adult, check carotid pulse (no longer than 10 seconds) Pulse Check (continued)
© 2011 National Safety Council In an unresponsive child, check either carotid pulse or femoral pulse In an infant, use the brachial pulse in the inside of the upper arm Pulse Check (continued)
© 2011 National Safety Council Pulse Check in Primary Assessment Do not take time to count pulse, note whether it is irregular, very slow or very fast signs that patient may not be stable Lack of pulse along with absence of normal breathing signifies heart has stopped or is not beating effectively enough to circulate blood If patient lacks a pulse and is not breathing normally, start CPR and call for an AED
© 2011 National Safety Council Inadequate Breathing A patient with a pulse may be breathing inadequately Inadequate breathing is characterized by diminished mental status and any of these: -Difficult or labored breathing -Wheezing or gurgling sounds with breathing -Pale skin (ashen skin in a dark-skinned patient) or a blue (cyanotic) color of the lips and nail beds -A respiratory rate in an adult slower than 10 or greater than 30 breaths a minute Give emergency care for a patient with a pulse who is breathing inadequately
© 2011 National Safety Council Check for Serious Bleeding Look for life-threatening bleeding Arterial bleeding usually most serious Bleeding from vein is generally slower
© 2011 National Safety Council Check for Serious Bleeding (continued) Don’t remove clothing to check for bleeding, but look for blood-saturated clothing and blood pooling During primary assessment, don’t address minor bleeding or wounds Control serious bleeding immediately with direct pressure
© 2011 National Safety Council Assess Circulatory Status Even with a pulse, circulation may be inadequate Inadequate oxygenation of vital organs results in life-threatening shock
© 2011 National Safety Council Signs of Inadequate Circulation Heart rate in an adult 100 Irregular pulse may be normal or abnormal Pale skin may indicate blood loss, shock or low body temperature Bluish skin may indicate an airway problem, poor ventilation or respiration, or poor blood flow Cool skin temperature may indicate low body temperature or shock Sweaty or wet skin may indicate shock, severe pain or physical exertion Slow capillary refill (>2 seconds) in children may indicate shock
© 2011 National Safety Council Treat Life Threats Found If patient is unresponsive to verbal stimulus, has a fast or slow heart rate, and has skin signs of shock, treat for shock after the primary assessment If patient has any life-threatening condition, treat it as soon as it is discovered If patient has no immediate threat to life, proceed to secondary assessment
© 2011 National Safety Council Primary Assessment of an Unresponsive Patient 1.Check for responsiveness and normal breathing. 2.If patient is unresponsive, call for more EMS resources. If unresponsive patient is not breathing normally, also call for an AED. 3.If patient is not breathing, check for a pulse for no longer than 10 seconds. If no pulse, start CPR. If a pulse, start ventilations. 4.If patient is breathing, check for severe bleeding, shock and other threats to life. 5.Care for any life-threatening conditions before continuing to check the patient and provide other care.
© 2011 National Safety Council Patient Priority Primary assessment determines whether a critical condition is present and what steps you need to take Unresponsiveness or any problem with the airway, breathing or circulation is a high priority Continue to reassess and treat life-threatening conditions while waiting for additional EMS resources Call EMS unit to update patient’s condition
© 2011 National Safety Council Report to EMS After the Primary Assessment Provide this information: -Number of patients -Patient age and gender -Patient’s condition -Patient’s level of responsiveness -Patient’s breathing and circulation status Ask responding unit their estimated time of arrival Continue to care for patient accordingly With stable patient, proceed to secondary assessment
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