Alexander ch15 lecture

Copyright © 2017, 2012 Pearson Education, Inc. All Rights Reserved.
Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 15
Scene Size-Up and
Primary Assessment

• Applies scene information and patient assessment
findings (scene size-up, primary and secondary
assessment, patient history, and reassessment) to
guide emergency management.
Advanced EMT
Education Standard

1. Define key terms introduced in this chapter.
2. Use information from the scene size-up and initial
approach to the patient to formulate a general impression
of the nature and seriousness of the patient’s condition.
3. Use the primary assessment findings to identify
immediate threats to life.
4. Accurately assess a patient’s level of responsiveness
using the AVPU approach.
5. Determine whether a patient’s airway is patent.
Objectives (1 of 3)

6. Differentiate between adequate and inadequate
breathing.
7. Determine whether a patient has adequate circulation.
8. Integrate the use of manual airway maneuvers, simple
airway adjuncts, bag-valve-mask ventilations,
supplemental oxygen, CPR, defibrillation, and bleeding
control into the primary assessment.
9. Use the primary assessment findings to reevaluate the
general impression and determine the priority for patient
transport.
Objectives (2 of 3)

10.Use primary assessment findings to make a decision
about the next step in the assessment and management
of the patient.
11.Describe the processes of gaining and maintaining
control of the scene, teamwork, and reducing the
patient’s anxiety in preparation for obtaining the history
and assessing the patient.
Objectives (3 of 3)

• Two phases of patient assessment provide initial
information: scene size-up and primary
assessment.
– Build mental framework for patient assessment.
– Not just checklists of steps to be completed mindlessly
through repetition.
– Deliberate processes of collecting information; inform
decisions about further assessment and treatment.
Introduction (1 of 3)

• Scene size-up
– Scene safety
– Number of patients
– General nature of incident
– Additional resources

• Primary assessment
– Identify and correct life threats
– Airway, breathing, circulation, disability (ABCD)
– Complete rapid analysis
– Process completed within 30 seconds with many
observations made simultaneously

Think About It
• What is the next thing Eric should do?
• What should Kyle look for as he approaches
his patient?
• What equipment must each have to provide
patient care in the next few minutes?
• What decisions must they make within the first
few minutes?

Figure 15-1
Observe the scene to determine the mechanism of injury. (© Mark C. Ide/Science Source)

Scene Size-Up (1 of 5)
• Start collecting information before making
initial contact.
• Assess scene safety and determine the number
of patients.
– Decide on additional resources needed.
• Personal protective equipment (PPE) and
Standard Precautions needed.

• Determine mechanism of injury (MOI) or nature
of illness.
• MOI refers to the types and amount of energy
resulted in the injury.
• What are the five types of energy?

• Kinetic energy
– Blunt or penetrating injuries
• Blunt force injury
– Impact with object with high surface area and low
velocity (speed); does not penetrate body
• Penetrating trauma
– Surface area small; low velocity impact can result in
penetration

Table 15-1
Critical Mechanisms of Injury
 Complete or partial ejection in a motor vehicle collision (MVC)
 MVC that causes death to another occupant of the same vehicle
 Rollover mechanism in an MVC
 High-speed MVC
 Intrusion (damage) of > 12 inches into the passenger compartment of a vehicle, or vehicle
crush of > 18 inches at any point on the vehicle
 Pedestrian or bicyclist struck by a motor vehicle
 Motorcyclist involved in collision at > 20 mph
 Fall from a height > 20 feet
 Blast (explosion) trauma
 Penetrating trauma except distal to the elbow or knee
 Amputation or near-amputation proximal to the fingers or toes
 Trauma with burns
Source: CDC (Centers for Disease Control and Prevention). 2012. “Guidelines for Field Triage of
Injured Patients: Recommendations of the National Expert Panel on Field Triage, 2011.” Morbidity
and Mortality Weekly Report 61, no. 1:1–21. http://www.cdc.gov/mmwr/pdf/rr/rr6101.pdf

Table 15-2
Indications of Cervical-Spine Injury
 Penetrating injury to the head, neck, or torso
 Shallow-water diving injuries
 Pedestrian–vehicle injuries
 Motor vehicle collisions
 Motorcycle collisions
 Contact sport injuries
 Recreational vehicle (personal watercraft, all-terrain vehicle) injuries
 Hanging
 Falls from a height
 Electrical (including lightning) injuries
 Unresponsive trauma patient

• Assessment of MOI determines if cervical-spine
precautions are necessary
• Unresponsive
– Check pulse; if present, open airway using modified
jaw-thrust
– Check pulse; if no pulse, begin resuscitation efforts
• Responsive
– Determine level of responsiveness and adequacy
of ABCs

Figure 15-2
(B)
(B) a modified jaw-thrust maneuver.

• General impression
– Indication of how to approach primary assessment
• Don’t assume.
– look for clues about scene and patient.
• Listen for sounds; detect odors; use sense of
touch.
• Be cautious but confident; maintain order.

• Purpose
– Immediately identify and correct life-threatening
conditions
 Conditions that interfere with perfusion
 Airway, breathing, circulation, and disability (ABCD)
 Disability refers to neurologic disability
Primary Assessment (1 of 22)

• Patients who appear to be unresponsive and not
breathing or breathing ineffectively, check carotid
pulse before opening airway.
• Order is circulation, airway, and breathing (CAB).
• What is the most important step in resuscitation of
patients in cardiac arrest?

• Equipment to perform primary assessment
– Personal protective equipment
– Portable suction unit
– Simple airway adjuncts and additional airway devices
in scope of practice
– Automatic external defibrillator
– Bandages, dressings, and tourniquet

Figure 15-5
Cyanosis in the (A) conjunctiva, (B) mucosa, (C) fingernail beds, (D) circumoral area.

• Assessing General Appearance
– Determine age and sex
– Responsive or unresponsive
– Skin color
– Level of distress

• AVPU used to assess level of responsiveness.
– Alert (A)
– Responsive to verbal stimuli (V)
– Responsive to painful stimuli (P)
– Unresponsive to all stimuli (U)
• Glasgow Coma Scale (GCS) more specific way of
assessing level of responsiveness.

• Glasgow Coma Scale (GCS) score determined for
every patient.
– All information needed to determine GCS is available
from AVPU assessment.
– Mental status beyond level of responsiveness; includes
assessment of higher cognitive functions.

Table 15-3
Glasgow Coma Scale
BEST EYE OPENING RESPONSE
Spontaneous 4
To verbal command 3
To pain 2
No response 1
BEST VERBAL RESPONSE
Oriented and converses 5
Disoriented and converses 4
Inappropriate words 3
Incomprehensible sounds 2
No response 1
BEST MOTOR RESPONSE
Obeys verbal commands 6
Localizes pain 5
Withdraws from pain (flexion) 4
Abnormal flexion in response to pain (decorticate posturing) 3
Abnormal extension in response to pain (decerebrate posturing) 2
No response 1

• Decreased responsiveness
– Indication brain deprived of oxygen, circulation, or
glucose, or there is injury to brain.
• Other causes
– Drug overdose, toxic exposure, environmental
extremes, infection, endocrine or metabolic
derangements.

• Determine chief complaint.
• Observe for evidence that airway, breathing,
or circulation compromised.
• Some chief complaints make patients higher
priority for transport.

Table 15-4
Selected High-Priority Chief Complaints and
Presenting Problems
 Abdominal pain
 Acute nonmusculoskeletal back/flank pain in a patient > 60 years old
 Indications of GI bleeding (blood in vomit or stool)
 Other indications of internal bleeding (profuse hematuria or hemoptysis)
 Chest pain or discomfort in a patient > 35 years old
 Difficulty breathing/shortness of breath
 Dizziness in a patient > 65 years old
 Acute, severe headache
 Acute onset of neurologic deficit (slurred speech, facial droop, weakness, paralysis)
 Seizures
 Immersion/submersion incident (drowning)
 Electrocution or lightning strike
 Poisoning/overdose
 Syncope

• For unresponsive patients who are not breathing
normally, primary assessment changes to CAB
(circulation, airway, and breathing).
• If patient’s pulse is absent, begin resuscitation.
• Unresponsive patients who have pulse, proceed
to assessing airway.

• Assessing the airway
– Passageway between lungs and environment must
be open (patent).
– Without open airway, patient’s life in immediate
jeopardy from hypoxia.
 Use manual airway maneuvers and simple adjuncts.
– Nasopharyngeal airway or oropharyngeal airway

• Assessing the airway (continued)
– For decreased level of responsiveness, begin by
manually positioning airway.
– Look for rise and fall of the chest.
– Listen for air movement.
– Feel for movement of air.
– Air movement confirms that airway is open.

• Assessing the airway (continued)
– If inadequate air movement, ventilate patient using
bag-valve-mask device.
– Check that you have positioned head and neck
properly to open airway; attempt to ventilate.
– If not able to ventilate, manage patient for obstructed
airway.

• Risk to patient’s airway
– Decreased level of consciousness
 Relaxation of the muscles
 No gag reflex
 Increased risk of vomiting

• Abnormal breath sounds
– Snoring
– Stridor
– Gurgling
– Coughing

Figure 15-9
Assess the airway by looking for chest rise and fall, listening for air movement at the mouth
and nose, and feeling for air movement from the mouth and nose.

• Assessing breathing
– Indication of breathing status
 Level of responsiveness, skin color, level of distress, wheezing
or crackles (rales)
– Patients with respiratory distress, failure, and arrest
need immediate intervention.

Table 15-5
Signs of Inadequate Breathing
 Increased work of breathing/use of accessory muscles
 Noisy breathing (stridor, snoring, gurgling, wheezing, crackles)
 Decreased or absent air movement or breath sounds
 Apnea/respiratory arrest
 Ventilatory rate < 8 or > 30 per minute in an adult
 Irregular breathing
 Cyanosis

Figure 15-10
Look for indications of respiratory distress.

• Assessing breathing (continued)
– Normal breathing
 Effortless and quiet.
– Respiratory distress
 Working to breathe.
– Respiratory arrest
 Absence of breathing (apnea).
– Assess rate, depth, rhythm, effort of patient’s breathing.
– Listen for abnormal breathing noises.

• Assessing breathing (continued)
– Nonrebreather mask or nasal cannula
– Patients with inadequate or absent breathing, assist
with a bag-valve-mask
– Continuous positive airway pressure (CPAP)

Table 15-6
Indications for Administration of Oxygen
 Cardiac or respiratory arrest
 Respiratory distress or respiratory failure
 Any patient requiring assisted ventilations
 SpO2 less than 95 percent
 Inadequate tidal volume
 Respiratory rate < 8 or > 30
 Patient has an altered mental status/decreased level of responsiveness
 Patient complains of difficulty breathing/shortness of breath
 Other medical conditions that can cause hypoxia, such as seizures, stroke, overdose,
toxic inhalation, and wheezing
 Signs and symptoms of shock or severe internal or external bleeding
 Major or multiple trauma

• Assessing circulation
– Alert, good skin color, no significant bleeding: patient
has adequate circulation
– Unresponsive patients, check carotid pulse before
opening airway
– Good perfusion indicated by dry, warm skin without
pallor (paleness)

Figure 15-12
Use direct pressure to control bleeding.

Figure 15-13
A tourniquet is used to control bleeding proximal to the knee or elbow when direct pressure
cannot control it.

• Assessing circulation (continued)
– Search for and control significant external bleeding
with direct pressure.
– Use tourniquet according to your protocol.
– ABCDE
 (E) expose patients with significant trauma to check
for bleeding.

• Patient care decisions
– Scene size-up and primary assessment information
to make decisions
 Further assessment
 Treatment
 Transport

• Patient care decisions (continued)
– Patient deceased
 not candidate for resuscitation because of presumptive signs
of death or presence of DNR order
– Patient not critical
 needs additional assessment and treatment
– Patient critical
 immediate intervention may improve situation
 must be packaged and transported without delay

Table 15-7
Signs of Presumptive Death
 Decapitation or midsection transection of the body
 Decomposition
 Dependent lividity (discoloration of the body as blood pools from the effects of gravity)
 Severe charring of the body
 Rigor mortis (rigidity of muscles)

Table 15-8
High-Priority Findings in the Primary Assessment
 Poor general impression (cyanosis, pallor, obvious major bleeding or injuries, obvious
respiratory distress, diaphoresis, or other indications of serious illness or injury)
 Cardiac or respiratory arrest
 Decreased level of responsiveness/altered mental status
 Compromised or obstructed airway
 Inadequate breathing
 Signs of inadequate perfusion (absent or weak pulse; bradycardia or tachycardia;
pale, cool, diaphoretic skin)
 Significant external bleeding or suspected internal bleeding

• Primary assessments compared
– You cannot overlook any part of scene size-up or
primary assessment.
– Steps may vary depending on the situation.
– Use prescribed approach, common sense, flexibility,
and concern for the best interest of the patient.

Scan 15-1 (1 of 5)
The Primary Assessment Process—Responsive Patient
1. To direct the primary assessment, first perform a scene size-up to determine
scene safety, the nature of the situation, the number of patients, and the need for
additional resources.

Scan 15-1 (2 of 5)
2. Note the patient’s general appearance, such as skin color, obvious injuries, level of
distress, and level of responsiveness.

Scan 15-1 (3 of 5)
3. Look and listen for evidence of airway problems, such as struggling to breathe, noisy
breathing, and cyanosis.

Scan 15-1 (4 of 5)
4. Assess the patient’s breathing, looking and listening for signs of difficulty breathing.

Scan 15-1 (5 of 5)
5. Check the patient’s circulation.

Scan 15-2 (1 of 5)
Primary Assessment—Unresponsive Patient with a Pulse
1. To direct the primary assessment, first perform a scene size-up to determine
scene safety, the nature of the situation, the number of patients, and the need for
additional resources.

Scan 15-2 (2 of 5)
2. Note the patient’s general appearance, such as skin color, obvious injuries, and level of
distress. Check the patient’s level of responsiveness.

Scan 15-2 (3 of 5)
3. Position the patient and check the airway. Use a head-tilt/chin-lift maneuver for patients
without suspected spine injury. Use a modified jaw-thrust maneuver to open the airway
if spine injury is suspected. If needed, use suction and a basic airway adjunct to maintain
an open airway.

Scan 15-2 (4 of 5)
4. Assess the patient’s breathing by looking and listening for signs of difficulty breathing.

Scan 15-2 (5 of 5)
5. Check the rate and quality of the pulse. Control obvious hemorrhage.

Think About It
• Key phases of the assessment
– Scene size-up
– Primary assessment
– Secondary assessment
– Reassessment

• Primary assessment findings can change;
reassess
– General appearance
– Level of responsiveness
– Airway, breathing, or circulation
• Document patient’s initial condition, interventions
implemented, and effects of interventions.
Reassessment and Documentation

Chapter Summary (1 of 5)
• Scene size-up and primary assessment performed
on every patient.
– Determine MOI or nature of illness
– Form general impression
– Responsive or unresponsive
– Skin color

• Assess patient’s level of responsiveness.
• If unresponsive, immediately check carotid pulse.
• If pulseless, begin chest compressions.
• If pulse present, proceed with assessing airway
and breathing.
• Problems with airway, breathing, and circulation
• Obtain chief complaint

• For patients with decreased level of
responsiveness
– Ensure airway is open
– Assess adequacy of patient’s breathing
– Use bag-valve-mask device with supplemental oxygen
If breathing is inadequate

• Assess patient’s pulse.
• Check for significant external bleeding.
– Control bleeding with direct pressure.
– If necessary, use tourniquet.
– Expose patient if indicated.

• Determine priority for transportation.
• Reassess primary assessment findings.
• Document initial and subsequent assessment
findings.

Alexander ch15 lecture

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Alexander ch15 lecture

Similar to Alexander ch15 lecture (20)

More from corynava00

More from corynava00 (15)

Recently uploaded

Recently uploaded (20)

Alexander ch15 lecture