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Scene size up and initial assessment

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Scene Size-up and Patient Assessment

Scene Size-up and Patient Assessment

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  • 1. Patient Assessment
    Scene Size-up & Initial Assessment
  • 2. ObjectivesThrough this section we will learn:
    History and Physical exam for medical patients
    Detailed physical exams
    On-going assessments
    Documentation
    Pre-hospital Care Reports (PCR)
    Communications
    Scene safety and assessment
    Mechanism of Injury (MOI)
    Initial assessment
    SAMPLE history
    Rapid Trauma assessments
  • 3. Scene Size-up
    Size-up represents the very beginning of patient assessment. It requires the EMT-Basic to evaluate several aspects concerning the situation in a very short period of time. It is the essence in assuring the safety of the crew and the patient. This information may be obtained as part of dispatch, but should always be reassessed upon arrival at the scene. For some situations, size-up is an on-going process. As additional information is obtained, modification is performed to the size-up of the patient and the situation overall.
  • 4. Scene Size-up/Assessment
    Definition - an assessment of the scene and surroundings that will provide valuable information to the EMT-Basic.
  • 5. Body substance isolation (BSI) review
    Gloves
    Mask
    Gown
    Goggles
  • 6. Scene Safety
    Definition -an assessment to assure the safety and well-being of the EMT-Basic.
    YOU are always number 1! Take care of yourself first.
    Take caution on any scene that could potentially be violent or dangerous.
    Let Law Enforcement Secure before entering.
    Potentially dangerous scenes include:
    Attempted suicides
    Domestic Disputes
    Gun Shots / Stabbings
    Large gatherings of people (especially when alcohol is involved)
  • 7. Personal protection –
    Is it safe to approach the patient?
    Crash/rescue scenes
    Toxic substances - low oxygen areas
    Crime scenes - potential for violence
    Unstable surfaces: slope, ice, water, mud etc.
  • 8. Protection of the patient
    Environmental considerations
    Remember the patient has been in this environment for an unknown amount of time.
    Is it too hot or cold for the patient?
    Treat the patient accordingly
  • 9. Protection of bystanders
    If/when appropriate, help the bystander avoid becoming a patient.
    Bystanders will sometimes approach or enter dangerous areas and suddenly compound your problems by becoming a patient.
    Try to prevent this from happening!
  • 10. Scene safety
    If the scene is unsafe, make it safe.
    Law enforcement
    Fire department
    Haz-mat Teams
    Otherwise, DO NOT ENTER!
    Your job as an EMT is to treat the patient, let rescue, law enforcement, or the FD/Haz-mat teams bring you the patients.
  • 11. Mechanism of injury (Trauma) Nature of illness (Medical)
    Nature of illness (NOI) –
    This can be determined from the patient, family or bystanders
    Why EMS was activated.
    Shortness of breath
    Chest Pain
    Abdominal Pain
    Etc.
  • 12. Scene Size-up
    Determine the total number of patientsIf there are more patients than the responding unit can effectively handle, Obtain additional help prior to contact with patients:
    law enforcement, fire, rescue, ALS, utilities.
    The EMT is less likely to call for help if involved in patient care so make sure you call for help early.
  • 13. Scene Size-up (Cont.)
    If there are multiple patients you should begin triage
    If adequate resources are available at the scene, proceed to the initial assessment
  • 14. Mechanism of injury (Trauma)
    Mechanism of injury - determined from the patient, family or bystanders and inspection of the scene
    What is the mechanism of injury
    MOI Examples:
    Vehicle Crash
    Speed at impact?
    Rollover / Head-on / Rear End
    Fall
    How high and onto what?
    GSW / Stabbing
    What caliber gun?
  • 15. Initial Assessment
  • 16. General Impression of the Patient
    Definition: the general impression is formed to determine priority of care and is based on the EMT-Basic's immediate assessment of the environment and the patient's chief complaint.
    What is your initial response when you arrive?
    “We gotta go!”
    Or
    “What is going on here?”
  • 17. General Impression
    Determine if ill (medical) or injured (trauma).
    If injured, identify mechanism of injury.
    Remember that the MOI includes what caused the injury, how fast or far, where did it hit etc.
    General Impression includes determining:
    Approximate Age
    Sex
    Race
  • 18. Initial assessment
    Perform initial assessment on all patients after assuring scene and personal safety. If the scene is safe and the environment permits, perform the assessment prior to moving the patient. The initial assessment is a rapid means of assessing patient condition and priorities of care.
  • 19. Initial assessment
    Assess patient and determine if the patient has a life threatening condition
    If a life threatening condition is found, treat immediately
    Assess nature of illness or mechanism of injury
    Assess patient's mental status.
    Maintain spinal immobilization if needed.
  • 20. Initial Assessment
    Begin by speaking to the patient.
    EMT-Basics should state their name, tell the patient that they are emergency medical technicians, and explain that they are here to help.
    Levels of mental status - (AVPU)AlertResponds to Verbal stimuliResponds to Painful stimuliUnresponsive - no gag or cough
  • 21. Assess the patient's airway status
    Responsive patient - Is the patient talking or crying?
    If yes, assess for adequacy of breathing
    If no, open airway
    Unresponsive patient - Is the airway open?
    Open the airway.
    Positioning of the patient is age and size specific
  • 22. Airway
    For medical patients, perform the head-tilt chin-lift
    Is the airway Clear or Not clear
    If not clear they will have Noisy respirations such as:
    Crowing
    Audible wheezing
    Gurgling
    Snoring
    Stridor
    In this case you MUST Clear the airway
  • 23. Clearing the Airway
    Open the airway
    Suction the airway as needed
    Insert airway adjuncts to help maintain open airway
  • 24. Airway in Trauma Patients
    For trauma patients or those with unknown nature of illness, the cervical spine should be stabilized -immobilized and the jaw thrust maneuver performed
    Then ask yourself?
    Is the airway Clear or not clear
    If not clear you will have Noisy respirations
    Crowing
    Audible wheezing
    Gurgling
    Snoring
    Stridor
    In which case you MUST clear the airway.
  • 25. Clearing the Airway (Trauma)
    Open the airway with simultaneous spinal immobilization (Jaw-thrust)
    Suction the airway as needed
    Insert airway adjuncts to help maintain open airway
  • 26. Assess the patient's breathing (Responsive Patients)
    If breathing is adequate and the patient is responsive, oxygen may be indicated.
    All responsive patients breathing >24 or <8 should receive at a minimum, high flow oxygen (defined as a 15 LPM non-rebreather mask).
  • 27. Assess the patient’s breathing (Unresponsive patients)
    If the patient is unresponsive and the breathing is adequate, open and maintain the airway and provide high concentration oxygen.
    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.
  • 28. Non-Breathing Patients
    If the patient is not breathing, open and maintain the airway and ventilate using ventilatory adjuncts.
    In all cases oxygen should be used.
  • 29. Assess the patient's circulation
    Assess the patient's pulse
    The circulation is assessed by feeling for a radial AND carotid pulse simultaneously.
  • 30.
    • In a patient one year old or less, palpate a brachial pulse
  • Assess the patient’s Circulation (Pulseless patients)
    If pulseless, start CPR
    If Medical patient, apply automated external defibrillator (AED)
    Trauma patient, start CPR if consistent with state or local protocol
  • 31. Assessing Circulation
    Assess if major bleeding is present
    If bleeding is present, control bleeding
  • 32. Assess Skin for perfusion
    Assess the patient's perfusion by evaluating skin color, temperature and condition/texture.
    The patient's skin color is assessed by looking at the nailbeds, lips and eyes
    Normal Skin color is pink
    Abnormal conditions
    Pale
    Cyanotic or blue-gray
    Flushed or red
    Jaundice or yellow
  • 33. Skin (Color, Temperature, Texture/Condition)
    Assess the patient's skin temperature by feeling the skin
    Normal
    warm
    Abnormal skin temperatures
    Hot
    Cool
    Cold
    Clammy - cool & moist
  • 34. Skin
    Assess the patient's skin Texture/condition.
    This is an assessment of the amount of moisture on the skin.
    Normal –
    Dry
    Abnormal
    moist or wet
    Assess capillary refill in infant and child patients under six years old.
    Normal capillary refill is less than two seconds
    Abnormal capillary refill is greater than two seconds
  • 35. Identify priority patients
    Poor general impression
    Unresponsive patients - no gag or cough
    Responsive, not following commands
    Difficulty breathing
    Shock (hypoperfusion)
    Complicated childbirth
    Chest pain with BP <100 systolic
    Uncontrolled bleeding
    Severe pain anywhere
    When a “priority patient” has been identified, expedite transport of the patient and consider ALS backup
  • 36. Focused History and Physical Exam
    The focused history and physical exam is performed following the initial assessment and correction of immediate threats to life. The focused history and physical exam differs for medical and trauma patients. During this process, obtain additional information regarding the patient's condition. This assessment may be performed at the same location as the initial assessment, unless the scene or patient's condition requires movement. This assessment is the second hands-on approach to gain information to continue providing patient care.
  • 37. Focused History and Physical Exam Trauma
    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.
    Continue spinal stabilization
    Consider ALS request
    Assess mental status
  • 38. Trauma (Cont.)
    Inspect and palpate, looking and feeling for the following examples of injuries or signs of injury –
    DCAP-BTLSDeformitiesContusionsAbrasionsPunctures/penetrationsBurnsTendernessLacerationsSwelling
  • 39. HEAD
    Assess the head, inspect and palpate for injuries, signs of injury, or crepitation
  • 40. NECK
    Assess the neck, inspect and palpate for injuries or signs of injury
    Jugular vein distention (JVD)
    Crepitation
    Apply cervical spinal immobilization collar (CSIC)
    http://static.flickr.com/54/149117532_1e81d2162f_m.jpg
  • 41. CHEST
    Assess the chest, inspect and palpate for injuries or signs of injuries
    Paradoxical motion
    Crepitation
    Breath sounds in the apices, mid-clavicular line, bilaterally and at the bases, mid-axillary line,
    You are listening to see if the breath sounds are:
    Present
    Absent
    Equal
  • 42. ABDOMEN
    Assess the abdomen, inspect and palpate for injuries or signs of injury.
    You want to know if the abdomen is:
    Firm
    Soft
    Distended
  • 43. PELVIS
    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.
  • 44. EXTREMITIES
    Assess all four extremities, inspect and palpate injuries or signs of injury
    Assess each extremity for:
    Distal pulse
    Sensation
    Motor function
  • 45. POSTERIOR
    Roll patient with spinal precautions and assess posterior body, inspect and palpate, examining for injuries or signs of injury
  • 46. Baseline Vitals
    Assess baseline vital signs
    Assess SAMPLEhistory
    Signs and symptoms of present illness or injuryAllergiesMedicationsPertinent past historyLast oral intake: solid or liquidEvents leading to the injury or illness
  • 47. For patients with no significant mechanism of injury, e.g., cut finger
    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.
    Assess baseline vital signs
    Assess SAMPLE history
  • 48. Responsive Medical Patients
    Assess history of present illness
    Assess complaints and signs or symptoms
    Using O-P-Q-R-S-T
    O nsetP rovocationQ ualityR adiationS everityT ime
    Assess SAMPLE history
    Perform rapid assessment
  • 49. Responsive Medical (Cont.)
    Assess the head if necessary
    Assess the neck if necessary
    Assess the chest if necessary
    Assess the abdomen if necessary
    Assess the pelvis if necessary
    Assess the extremities if necessary
    Assess the posterior body if necessary
    Assess baseline vital signs
    Provide emergency medical care based on signs and symptoms in consultation with medical direction
  • 50. Unresponsive Medical Patients
    Perform rapid assessment
    Assess the head
    Assess the neck
    Assess the chest
    Assess the abdomen
    Assess the pelvis
    Assess the extremities
    Assess the posterior aspect of the body
    Assess baseline vital signs
    Position patient to protect airway
    Obtain SAMPLE history from bystander, family, friends prior to leaving 
  • 51. Sources:
    http://www.preparednesszone.com/images/triage_s2.jpg
    National Standard Curriculum EMT-Basic Refresher
    http://office.microsoft.com/en-us/clipart/default.aspx
    http://static.flickr.com/54/149117532_1e81d2162f_m.jpg