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Please be sure to view this page completely, this page is two pages in length and contains some very imformative information. ALS personnel should adapt to their skill level off of the same Patient Assessment Techniques as used by the BLS personnel. The next page not only will contain finishing comments of Patient Assessment, but will also contain some very important tables with explanations for SAMPLE, the AVPU Scale and more. Click the next button at the bottom of this page to view the second page of Patient Assessment. Please E-mail us with any suggestions!!







I. Scene Size-up/Assessment

A. Definition - an assessment of the scene and surroundings that will provide valuable information to the EMS crew:

B. Body substance isolation (BSI

1. Eye protection if necessary

2. Gloves if necessary

3. Gown if necessary

4. Mask if necessary


C. Scene safety:

1. Definition - an assessment to assure the safety and well-being of your crew.

2. Personal protection - Is it safe to approach the patient?

a. Crash/rescue scenes

b. Toxic substances - low oxygen areas

c. Crime scenes - potential for violence

d. Unstable surfaces: slopes, ice, water

3. Protection of the patient - environmental considerations.

4. Protection of bystanders - if appropriate, help the bystander avoid becoming a patient.

5. If the scene is unsafe, make it safe. Otherwise, do not enter.

D. Mechanism of injury/nature of illness:

1. Medical

a. Nature of illness (NOI) - determine from the patient, family or bystanders why EMS was activated.

b. Determine the total number of patients

1) If there are more patients than the responding unit can effectively handle, initiate a mass casualty plan.

(a) Obtain additional help prior to contact with patients: law enforcement, fire, rescue, ALS, utilities. You are less likely to call for help if involved in patient care.

(b) Begin triage

(c) If adequate resources are available at the scene, proceed to the initial assessment

2. Trauma

a. Mechanism of injury - determine from the patient, family or bystanders and inspection of the scene what the mechanism of injury is.

b. Determine the total number of patients

(1) If there are more patients than the responding unit can effectively handle, initiate a mass casualty plan.

(a) Obtain additional help prior to contact with patients. You are is less likely to call for help when involved in patient care.

(b) Begin triage

(2) If the responding crew can manage the situation, consider spinal precautions and continue care

E. Examples of hazards found at a medical scene:

1. Bloodborne pathogens

2. Instruments of violence

3. Family member interference

4. Needles

5. Steps and carpeting

6. Animals

Examples of hazards found at a trauma scene:

1. Bloodborne pathogens

2. Spills (hydrocarbons, chemicals)

3. Instruments of violence (guns, knives, clubs)

4. Electrical

5. Broken glass

6. Fire

7. Traffic and bystander interference

8. Environmental (terrain, gases, water)

A. General Impression of the Patient

1. Definition

a. The general impression is formed to determine priority of care and is based on the EMS crew's immediate assessment of the environment and the patient's chief complaint.

b. Determine if ill (medical) or injured (trauma). If injured, identify mechanism of injury

c. Age

d. Sex

e. Race

2. Assess patient and determine if the patient has a life threatening condition

a. If a life threatening condition is found, treat immediately

b. Assess nature of illness or mechanism of injury

B. Assess patient's mental status. Maintain spinal immobilization if needed.

1. Begin by speaking to the patient. You should state your names, tell the patient that you are emergency medical technicians, and explain that you are here to help.

2. Levels of mental status - (AVPU Scale)

a. (A)= Alert

b. (V)= Responds to Verbal stimuli

c. (P)= Responds to Painful stimuli

d. (U)= Unresponsive - no gag or cough

C. Assess the patient's airway status

1. Responsive patient - Is the patient talking?

a. If yes, assess for adequacy of breathing

b. If no, open airway

2. Unresponsive patient - Is the airway open?

a. Open the airway. Positioning of the patient is age and size specific

(1) For medical patients, perform the head-tilt chin-lift

(a) Clear

(b) Not clear - Clear the airway

(2) For trauma patients or those with unknown nature of illness, the cervical spine should be stabilized/immobilized and the jaw thrust maneuver performed

(a) Clear

(b) Not clear - Clear the airway

D. Assess the patient's breathing

1. If breathing is adequate and the patient is responsive, oxygen may be indicated.

2. All responsive patients breathing >24 or <8 should receive high flow oxygen.

3. If the patient is unresponsive and the breathing is adequate, open and maintain the airway and provide high concentration oxygen.

4. If the breathing is inadequate, open and maintain the airway, assist the patients breathing and utilize ventilatory adjuncts. In all cases oxygen should be used.

5. If the patient is not breathing, open and maintain the airway and ventilate using the appropriate airway adjunct. In all cases oxygen should be used.

E. Assess the patient's circulation

1. Assess the patient's pulse

a. The circulation is assessed by feeling for a radial pulse.

(1) In a patient one year old or less, palpate a brachial pulse

(2) If no radial pulse is felt, palpate carotid pulse

(a) If pulseless, medical patient > or = 12 years old, start CPR and apply automated external defibrillator (AED)

(b) Medical patient < 12 years old or < 90 lbs, start CPR.

(c) Trauma patient, start CPR

2. Assess if major bleeding is present. If bleeding is present, control bleeding

3. Assess the patient's perfusion by evaluating skin color, temperature and condition.

a. The patient's skin color is assessed by looking at the nailbeds, lips and eyes

(1) Normal - pink

(2) Abnormal conditions

(a) Pale

(b) Cyanotic or blue-gray

(c) Flushed or red

(d) Jaundice or yellow

b. Assess the patient's skin temperature by feeling the skin

(1) Normal - warm

(2) Abnormal skin temperatures

(a) Hot

(b) Cool

(c) Cold

(d) Clammy - cool & moist

c. Assess the patient's skin condition. This is an assessment of the amount of moisture on the skin.

(1) Normal - dry

(2) Abnormal - moist or wet

d. Assess capillary refill in infant and child patients under six (6) years old.

(1) Normal capillary refill is less than two seconds

(2) Abnormal capillary refill is greater than two seconds

Identify priority patients:

1. Poor general impression

2. Unresponsive patients - no gag or cough

3. Responsive, not following commands

4. Difficulty breathing

5. Shock (hypoperfusion)

6. Complicated childbirth

7. Chest pain with BP <100 systolic

8. Uncontrolled bleeding

9. Severe pain anywhere

G. Expedite transport of the patient. Consider ALS backup.

H. Proceed to the appropriate focused history and physical examination (trauma or medical)

III. Focused History and Physical Examination

A. Trauma

1. Perform rapid trauma assessment on patients with significant mechanism of injury to determine life threatening injuries. In the responsive patient, symptoms should be sought before and during the trauma assessment.

a. Continue spinal stabilization

b. Consider ALS request

c. Assess mental status

d. Inspect and palpate, looking and feeling for the following examples of injuries or signs of injury - DCAP-BTLS

(1) (D)= Deformities

(2) (C)= Contusions

(3) (A)= Abrasions

(4) (P)= Punctures/penetrations

(5) (B)= Burns

(6) (T)= Tenderness

(7) (L)= Lacerations

(8) (S)= Swelling

e. Assess the head, inspect and palpate for injuries, signs of injury, or crepitation

f. Assess the neck, inspect and palpate for injuries or signs of injury

(1) Jugular vein distension (JVD)

(2) Crepitation

g. Apply cervical spinal immobilization collar (CSIC)

h. Assess the chest, inspect and palpate for injuries or signs of injuries

(1) Paradoxical motion

(2) Crepitation

(3) Breath sounds in the apices, mid-clavicular line, bilaterally and at the bases, mid-axillary line, bilaterally

(a) Present

(b) Absent

(c) Equal

I. Assess the abdomen, inspect and palpate for injuries or signs of injury

(1) Firm

(2) Soft

(3) Distended

(4) Tender

(5) Rigid or Masses present?

j. Assess the pelvis, inspect and palpate for injuries or signs of injury. If no pain is noted, gently compress the pelvis to determine tenderness or motion.

k. Assess all four extremities, inspect and palpate injuries or signs of injury

(1) Distal pulse

(2) Sensation

(3) Motor function

l. Roll patient with spinal precautions and assess posterior body, inspect and palpate, examining for injuries or signs of injury

m. Assess baseline vital signs

n. Assess SAMPLE history

1) (S)= Signs and symptoms of present illness or injury

2) (A)= Allergies

3) (M)= Medications

4) (P)= Pertinent past history

5) (L)= Last oral intake: solid or liquid

6) (E)= Events leading to the injury or illness

2. For patients with no significant mechanism of injury, e.g., cut finger

a. Perform focused history and physical exam of injuries based on the components of the rapid assessment. The focused assessment is performed on the specific injury site.

b. Assess baseline vital signs

c. Assess SAMPLE history

B. Responsive Medical Patients

1. Assess history of present illness

2. Assess complaints and signs or symptoms

a. O-P-Q-R-S-T

(1) (O)= Onset

(2) (P)= Provocation

(3) (Q)= Quality

(4) (R)= Radiation

(5) (S)= Severity

(6) (T)= Time

b. Assess SAMPLE History

c. Perform rapid assessment

(1) Assess the head if necessary

(2) Assess the neck if necessary

(3) Assess the chest if necessary

(4) Assess the abdomen if necessary

(5) Assess the pelvis if necessary

(6) Assess the extremities if necessary

(7) Assess the posterior body if necessary

d. Assess baseline vital signs

e. Provide emergency medical care based on signs and symptoms in consultation with medical direction

C. Unresponsive Medical Patients

1. Perform rapid assessment

a. Assess the head

b. Assess the neck

c. Assess the chest

d. Assess the abdomen

e. Assess the pelvis

f. Assess the extremities

g. Assess the posterior aspect of the body

2. Assess baseline vital signs

3. Position patient to protect airway

4. Obtain SAMPLE history from bystander, family, friends prior to leaving

IV. Detailed Physical Exam (contains components of the former "secondary survey":

A. Patient and injury specific; e.g., cut finger would not require the detailed physical exam

B. Perform a detailed physical examination on the patient to gather additional information

1. As you inspect and palpate, look and/or feel for the following examples of injuries or signs of injury - DCAP-BTLS

a. (D)= Deformities

b. (C)= Contusions

c. (A)= Abrasions

d. (P)= Punctures/penetrations

e. (B)= Burns

f. (T)= Tenderness

g. (L)= Lacerations

h. (S)= Swelling

2. Assess the head, inspect and palpate for injuries or signs of injury

3. Assess the face, inspect and palpate for injuries or signs of injury.

4. Assess the ears, inspect and palpate for injuries and signs of injury, or drainage

5. Assess the eyes, inspect for injuries or signs of injury

a. Discoloration

b. Unequal pupils

c. Foreign bodies

d. Blood in anterior chamber

6. Assess the nose, inspect and palpate for injuries or signs of injury

a. Drainage

b. Bleeding

7. Assess the mouth, inspect for injuries or signs of injury

a. Teeth

b. Obstructions

c. Swollen or lacerated tongue

d. Odors

e. Discoloration

8. Assess the neck, inspect and palpate for injuries or signs of injury

a. Jugular vein distension

b. Crepitation

9. Assess the chest, inspect and palpate for injuries or signs of injury

a. Crepitation

b. Paradoxical motion

c. Breath sounds in the apices, mid-clavicular line, bilaterally and at the bases, mid-axillary line, bilaterally

(1) Present

(2) Absent

(3) Equal

10. Assess the abdomen, inspect and palpate for injuries or signs of injury

a. Firm

b. Soft

c. Distended

D. Tender

E. Rigid?

11. Assess the pelvis, inspect and palpate for injuries or signs of injury. If the patient does not complain of pain or is unresponsive, gently flex and compress the pelvis to determine stability.

12. Assess all four extremities, inspect and palpate for injuries or signs of injury

a. Distal pulses

b. Sensation

c. Motor function

d. Capillary Refill (CR

13. Roll with spinal precautions and assess posterior aspect of body, inspect and palpate for injuries and signs of injury

14. Reassess vital signs

V. Ongoing Assessment:

A. Repeat initial assessment. For a stable patient, repeat and record every 15 minutes, for an unstable patient, repeat and record at a minimum every 5 minutes.

1. Reassess mental status

2. Maintain open airway

3. Monitor breathing for rate and quality

4. Reassess pulse for rate and quality

5. Monitor skin color and temperature

B. Re-establish patient priorities

C. Reassess and record vital signs

D. Repeat focused assessment regarding patient complaint or injuries

E. Check interventions

1. Assure adequacy of oxygen delivery/artificial ventilation

2. Assure management of bleeding

3. Assure adequacy of other interventions