1. Patient Assessment

2. Introduction
Patient assessment involves systematic evaluation or appraisal of the condition of the patient.
Needs critical First Responder skills
Act quickly to ensure scene is safe and care for immediate threats to life
Care provided is based on patient assessment

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

4. BSI Precautions Put on medical exam gloves as you approach patient
Observe scene/patient to determine whether to use other personal protective equipment:
Protective eyewear
Gown and mask
Turn-out gear
Follow standard precautions

5. Scene Safety Observe for any hazards As you enter the scene
While approaching the patient

6. Vehicle Crash Hazards Traffic hazards Downed wires
Risk of fire or explosion
Unstable vehicles
Hazardous materials

7. Potential Violence Crime scenes
Potentially violent patient or bystanders
Guard dogs, wild animals

8. Environmental Dangers
Unstable surfaces
Water, ice
Weather extremes
Hazards within Structures
Low-oxygen areas
Toxic substances, fumes
Risk of collapse
Risk of fire or explosion

9. Hazards Within Structures
Low-oxygen areas
Toxic substances, fumes
Risk of collapse
Risk of fire or explosion

10. Principles of Scene Safety
Enter scene only if it is safe
If unsafe, make it safe or stay away
Protect bystanders and other rescuers from hazards
Protect patient from environmental threats

11. Mechanism of Injury (MOI) Nature of Injury (NOI)
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?

12. Examples of Mechanism of Injury
Vehicle collision may cause head /spinal injuries
Fall from a height may cause extremity fractures
Blunt impact to abdomen may cause closed injury/ 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

13. Consider Nature of Illness
Consider nature of illness during scene size-up
Don’t stop to talk to family/bystanders until you are sure there is no immediate threat to life
Observe patient’s position/demeanor for clues
Use all your senses
If patient is unresponsive, move immediately to initial assessment
If patient is responsive, ask patient, family members, or bystanders why EMS was called

14. 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

15. Additional Resources Consider these factors:
Number of patients and types/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

16. Initial 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

17. General Impression Is the patient ill or injured?
What is chief complaint?
Does patient’s appearance give clues about his/ her condition?
Are there signs of a serious problem?
Note patient’s sex and approximate age

18. You may notice immediately whether patient is responsive
Responsive means a person is conscious and awake
Responsiveness

19. Patients who cannot talk may be able to move and thereby signal responsiveness

20. Patients who cannot talk/move may be paralyzed but still able to respond with purposeful eye movements or other signs
Responsiveness

21. Assessing Responsiveness
Begin by speaking to the patient:
If patient isn’t speaking or moving, tap gently and ask, “Are you okay?”
Be careful not to move patient in any way
Always suspect a spinal injury and take steps to stabilize head and neck

22. Unresponsiveness
Unresponsiveness may be sign of life-threatening problem or may result from a less urgent problem
Continue the initial assessment
Unresponsiveness is considered life-threatening emergency

23. 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

24. Degree of Responsiveness
AVPU Scale
A = Alert
V = Responds to Verbal stimuli
P = Responds to Pain
U = Unresponsive to all stimuli

25. Degree of Responsiveness continued
Responsiveness in Pediatric Patients
Infants/young children may respond differently from older children/adults
Look for age-appropriate responses
Assess unresponsive infant by flicking bottom of feet and noting response

26. ABCs identifies immediate life threats that must be corrected before patient assessment continues.
Checking the ABCs

27. A = Airway B = Breathing Checking the ABCs
After checking responsiveness, initial assessment continues by checking ABCs: C = Circulation
A = Airway B = Breathing
Checking the ABCs

28. Airway
Airway is route air moves from mouth and nose through pharynx to lungs
Airway may be blocked by a foreign body, swollen airway tissues, or tongue
Airway must be patent
Confirm that it is open
Take action to open it
Clear an obstruction

29. Airway continued
If patient is talking, crying, or coughing, the airway is open
Patient with weak, wheezing cough may have partially blocked airway

30. Opening the Airway
Open airway with head tilt–chin lift
or jaw thrust

31. Tilting head back, lift chin to move tongue away from opening of throat
Use your fingers, not your thumb, to lift chin
Do not press deeply into the soft tissues of chin
Ensure mouth stays open
Head Tilt–Chin Lift

32. Jaw Thrust
With possible spinal injury, lift jaw upward, using both hands
Jaw thrust is more difficult and fatiguing but is effective
If lips close, open lower lip with your gloved thumb
When in doubt, use jaw thrust
If jaw thrust does not open airway, switch to head tilt–chin lift method

33. Trauma or Vomiting
With head trauma/vomiting, inspect mouth for blood, loose teeth, vomit, or any other obstruction
Use a gloved finger or suction if needed to clear airway

34. Avoid Unnecessary Movement
Don’t immediately roll unresponsive person onto his/her back to open airway
Movement may cause additional injury
Determine whether airway is open by looking, listening, feeling for breathing without moving patient

35. Avoid Unnecessary Movement continued
Patient who is breathing has an open airway
Don’t move patient unless necessary
If cannot determine whether patient is breathing, move into supine position to open airway, check for breathing
Support head/neck when moving trauma patient

36. Breathing

37. Check Breathing In a responsive adult, check for adequate breathing
Inadequate Breathing
Difficult or labored breathing
Wheezing or gurgling sounds with breathing
Pale skin or a blue color of lips/nail beds
Respiratory rate ≤8 or ≥30 breaths/minute

38. Check for Breathing Look, Listen, Feel Look for rise and fall of chest
Listen for breathing
Feel for breath
Look, Listen, Feel

39. If No Breathing Detected
If no signs of breathing within 10 seconds, assume the person is not breathing
Lack of breathing may be caused by an obstructed airway or other causes
You must immediately give ventilations

40. Assessing a Child’s Breathing
It is difficult to assess a child’s adequacy of respiration
Check instead for presence/absence of breathing
Check the same as in an unresponsive adult

41. Circulation

42. Circulation After checking breathing, check for circulation
If patient’s heart has stopped or patient is bleeding profusely, vital organs are not receiving enough oxygen to sustain life
If patient is responsive or breathing, heart is beating

43. In responsive adult or child, check radial pulse
Pulse Check

44. In an unresponsive adult, check carotid pulse
Pulse Check

45. 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

46. Pulse Check in Initial 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 adequate breathing signifies heart has stopped or is not beating effectively enough to circulate blood
If patient lacks a pulse and is not breathing adequately, start CPR

47. Check for Serious Bleeding
Look for life-threatening bleeding
Arterial bleeding usually most serious
Bleeding from vein is generally slower
Don’t remove clothing to check for bleeding, but look for blood-saturated clothing and blood pooling
During initial assessment, don’t address minor bleeding or wounds
Control serious bleeding immediately with direct pressure

48. Skill: Initial Assessment of an Unresponsive Patient

49. Patient Priority
Initial 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

50. Report to EMS After the Initial Assessment
Provide this information:
Number of patients
Patient age and gender
Patient’s chief complaint
Patient’s level of responsiveness
Patient’s airway, breathing, and circulation status
Ask responding unit their estimated time of arrival
Continue to care for patient accordingly

51. Physical Exam

52. Physical Examination Follows the initial assessment
Question patient, family members, bystanders
Purpose is to find/assess signs/symptoms of illness or injury

53. Physical Examination continued
Information gained from exam and history 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 exam of responsive medical patient or a trauma patient with only a minor injury

54. When Performing a Physical Exam
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

55. When Performing a Physical Exam continued
Watch for facial expression/stiffening of body part
In responsive patient, begin with area of chief complaint and examine other body areas only as appropriate
With an unresponsive patient, examine patient from head to toe in a systematic manner

56. When Performing a Physical Exam Continued
A sign is an objective observation or measurement such as warm skin or a deformed extremity
A symptom is a subjective observation reported by the patient, such as pain or nausea

57. 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 the body.
Look and palpate for signs and symptoms throughout the body,
Compare one side of body to other when appropriate.

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

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

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

61. Check Chest
Deformity?
Wounds?
Tenderness?
Bleeding?
Even breathing?

62. Check Abdomen
Rigidity?
Pain?
Bleeding?

63. Back
Unless head/spinal injury is suspected, roll patient onto side to examine back
If head/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 a spinal injury and don’t move patient

64. Check Hips and Pelvis
Pain?
Deformity?

65. Check Lower Extremities
Bleeding? Deformity? Pain?
Normal movement, sensation, temperature?
Check Lower Extremities

66. Check Upper Extremities
Bleeding? Deformity? Pain?
Medial alert ID?
Normal movement, sensation, temperature?

67. Vital Signs
Some First Responders check patient’s vital signs in the physical examination
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

68. 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

69. Normal Vital Signs Patient Normal Respiratory Rate at Rest
Normal Pulse Rate at Rest
Normal Blood Pressure (systolic/diastolic)
Infant
/ 56-70
Child
/ 50-80
Adult
/ 60-90

70. 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 (one cycle equals one breath)

71. Assessing Respiration continued
Count number of breaths in 30 seconds and multiply by two
Note whether patient is making an effort to breathe, is short of breath, or is using abdominal muscles in breathing

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

73. 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 a brachial pulse in a child. Always take a brachial pulse in an infant
Count the beats for 30 seconds and multiply by two
Note strength of pulse (strong or weak)
Note rhythm of pulse (regular or irregular)

74. 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

75. 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

76. 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

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

78. Assessing Pupils Pupil Characteristics That May Indicate a Problem
Dilated or constricted pupils
Unequal pupils
Non-reactive pupils

79. Blood Pressure
Some First Responders are trained to take blood pressure
Blood pressure is force of blood pressing against arterial wall from heart’s pumping action

80. 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

81. Skill: Measuring Blood Pressure by Auscultation

83. 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

84. Measuring Blood Pressure by Palpation
If you don’t have a stethoscope or 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 the pressure when you feel radial pulse return
Record pressure as systolic pressure and include the word palpated (e.g., “130 palpated” or “130/Palp”)

85. Patient History

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

87. Taking a History Talk to a responsive patient
With an unresponsive patient, talk to family members or bystanders 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

88. 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

89. SAMPLE SAMPLE S Signs and symptoms A Allergies M Medications
P Previous problems
L Last food or drink
E Events
SAMPLE

90. 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

91. Ongoing Assessment

92. Ongoing Assessment
Continue to assess while awaiting additional EMS resources and giving care
Calm and reassure patient while reassessing ABCs and repeating physical examination
Repeat initial assessment:
Every 15 minutes for a stable patient
Every 5 minutes for an unstable patient

93. Performing the Ongoing Assessment
Reassess mental status
Maintain an open airway
Monitor breathing for rate and quality
Reassess pulse for rate and quality
Monitor skin color, temperature, and condition
Repeat the physical exam as needed

94. Importance of Ongoing Assessment
Check that your interventions are effective
Perform additional treatments as needed

95. 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

96. Hand-Off Report continued
Also include:
Physical exam 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