“It’s amazing what you can see when you look”

1. “It’s amazing what you can see when you look” Yogi Berra

2. Patient Assessment not a basic skill

3. do not diagnose the question is ... Do I have a critical patient?

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

5. Scene Size Up • Body Substance Isolation • Safety, Safety, Safety, Safety, ... • Mechanism of injury or • Nature of illness • # of patients • Need for additional resources • Need for extrication / spinal precautions

6. Body Substance Isolation • Assumes all body fluids present a possible risk for infection • Protective equipment • Latex or vinyl gloves should always be worn • Eye protection • Mask • Gown • Turnout gear

7. Scene Safety • Look for danger • Park in a safe area • Speak with law enforcement first if present. • The safety of you and your partner comes first! • Next is safety of patient(s) and bystanders. • Request additional resources.

8. Mechanism of Injury • Force body was exposed to • Chief complaint • Evaluate: • Amount of force applied • Length of time it was applied • Area involved

9. Nature of Illness • Search for clues • This is chief complaint • Gather information from the patient/bystanders • Observe the scene.

10. Chief Complaint • Most serious problem voiced by the patient • May not be the most significant problem present

11. Number of Patients • # of patients and condition. • Additional resources needed? • Triage to identify severity of each patient’s condition.

12. Additional Resources • Medical resources • Additional units • Advanced life support • Nonmedical resources • Fire suppression • Rescue • Law enforcement

13. Spinal Immobilization • Consider early during assessment. • Do not move without immobilization. • Err on the side of caution.

14. Initial Assessment • Develop a general impression • Assess mental status • Assess airway • Assess the adequacy of breathing • Assess circulation • Establish patient rapport • Identify patient priority

15. Develop a General Impression • As you approach the scene • Assessment of the environment • Patient’s chief complaint • Presenting signs and symptoms of patient • No vitals yet, only skin signs/cap refill

16. Assessing Mental Status • Checking responsiveness • Check for orientation

17. Checking Responsiveness • A - Alert • V - Verbal • P - Pain • U - Unresponsive

18. Checking Orientation • Person • Place • Time • Event

19. Glasgow Coma ScaleMore advanced LOC indicator • Eye • Verbal • Motor • point scale 15 - 3

20. GCS Eye Opening spontaneous = 4 to voice = 3 to pain = 2 none = 1

21. GCS VERBAL Oriented = 5 Confused = 4 Inappropriate words = 3 Incomprehensible sounds = 2 None = 1

22. GCS MOTOR obeys command = 6 localizes pain = 5 withdraws (pain) = 4 flexion (pain) = 3 extension (pain) = 2 none = 1

23. Assessing ABC’s • We know how to assess the unresponsive • More evaluation needed in responsive pt. • Is patient speaking to you? • A and B • Full sentences • 2 or 3 word • What are skin signs like? Cap refill? • C • Indicates perfusion

24. Establish Patient Rapport • People Skills • Do what you can to make the patient comfortable • Listen to the patient • Make eye contact • Base questions on the patient's complaint • More to follow • Mentally summarize before starting treatment • Obtain consent

25. Decision point • Regardless if trauma or medical • Is patient critical? • Do they need rapid transport?

26. Poor general impression Unresponsive with no gag or cough reflexes Responsive but unable to follow commands Difficulty breathing Signs of poor perfusion Complicated childbirth Uncontrolled bleeding Severe pain Severe chest pain Inability to move any part of the body Identifying Priority Patients

27. The Golden Hour

28. Medical vs. Trauma • Determination should come after initial assessment is finished. • Patients may have traumatic injuries caused by a medical reason. • Initially assume all patients have both medical and traumatic aspects to their condition.

29. Trauma Patients • With significant MOI • Unresponsive or disoriented • Extremely intoxicated • Patients whose complaint cannot be identified or understood • Proceed with rapid trauma assessment • Rapid transport • Consider ALS backup

30. Significant Mechanism of Injury • Ejection from vehicle • Death in passenger compartment • Fall greater than 15´-20´ • Vehicle rollover • High-speed collision • Unresponsiveness or altered mental status • Penetrating trauma to head, chest, or abdomen

31. Auto vs auto • SAFETY • observe/ask questions about mechanism • Speed • position of patient before accident (driver, backseat, etc..) • KO? • restrained? airbag? • Passenger space intrusion?

32. Auto vs pedestrian or bicycle/motorcycle • SAFTEY • observe/ask questions about mechanism • helmet? • KO? • Injuries more likely to be severe

33. Rapid Physical Exam • 60-90 seconds • head-to-toe exam • Significant trauma patients • Unresponsive medical patients

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

35. Rapid Physical Exam (1 of 3) • Maintain spinal immobilization while checking patient’s ABCs. • Use DCAP BTLS • Assess the head. • Assess the neck. • Apply a cervical spine immobilization collar.

36. Rapid Physical Exam (2 of 3) • Assess the chest. • Assess the abdomen. • Assess the pelvis. • Assess all four extremities.

37. Rapid Physical Exam (3 of 3) • Roll the patient with spinal precautions. • Assess baseline vital signs and SAMPLE history.

38. Detailed Physical Exam • more in-depth • only performed if time allows • performed en route to the hospital • have system - head to toe • practice same way every time • always check area before covering • for our lab, rapid trauma assessment and detailed physical exam are same (Head to Toe)

39. Focused History and Physical Exam (medical) • Medical history • Baseline vital signs • Physical exam

40. Focused History and Physical Exam (Trauma-no significant mechanism) • Assess the chief complaint. • Chest pain • Shortness of breath • Abdominal pain • Any pain associated with bones or joints • Dizziness • Obtain baseline vital signs and SAMPLE history

41. SAMPLE History • S Signs and symptoms • A Allergies • M Medications • P Past medical history • L Last oral intake • E Events leading to the episode

42. Alternate • HAM • History • Allergies • Medications

43. Vital Signs • After rapid assessment, obtain baseline vital signs and a SAMPLE history. • Vital signs of stable patients should be reassessed every 15 minutes. • Vital signs of unstable patients should be reassessed every 5 minutes.

44. Focused Physical Exam • Investigate problems associated with chief complaint. • Examine abnormalities. • Assess vital signs. • Skins • Chest Auscultation • Make transportation decision. • Document findings.

45. Assessing the Responsive Medical Patient • Ask general questions • May not be obvious • Use patient’s own words • Multiple complaints?

46. Questions to ask: Chest pain • OPQRST • Shortness of breath also? • Medication?

47. OPQRST • OOnset • P Provoking factors • Q Quality of pain • R Radiation / Region • S Severity • T Time / Treatment

48. Questions to ask:Shortness of breath • How long? • Sudden or slow onset? • Chest pain also? • Chest auscultation

49. Questions to ask: Abdominal pain • OPQRST • N/V • Normal bowel movement & urination? • GI bleed? • FEMALES • pregnant? • LMP, normal?

50. Assessing the Unresponsive Patient (Medical) • Perform a rapid medical assessment. • Obtain baseline vital signs. • Obtain SAMPLE history from family if available. • Provide emergency care and transport. • Document findings.