Chapter 13 Initial Assessment. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation....

Chapter 13Initial Assessment

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© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved

Overview

The Initial Assessment Steps of the Initial Assessment Determine Priority

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The Initial Assessment

The initial assessment is designed to rapidly find life-threatening problems

Every patient gets an initial assessment, due to the fact that every patient might have a life-threatening problem

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Steps of the Initial Assessment

Scene size-up Use appropriate standard

precautions (PPE) Airway, breathing, and circulation

(ABCs) are the focus

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General appearance– Form a general impression of the status of the

patient (can be done in the first 15 seconds of observation)• Does the patient appear to be awake? • Does the patient appear to be very ill or

very uncomfortable?• Does the problem seem to be related to a medical

illness or to a traumatic injury?


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General appearance– General impression is the

“look test”– When you first look at the

patient, does he look sick?


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Mental status– A: Alert– V: Verbal– P: Pain– U: Unresponsive

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Mental status: A (alert)– If the patient’s eyes are open and she appears

to be aware of the crew approaching, then the patient is referred to as alert

– Alert to:• Person, place, and time• Abbreviated as A/Ox3 (alert and oriented times three),

referring to person, place, and time

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Mental status: V (verbal)– If the patient opens her eyes when spoken to

but closes them again when not spoken to, she is considered to be responsive to voice or verbal stimuli

– Difference between “alert” and “responsive to voice” is the need to provide verbal stimuli to keep the patient awake and interactive

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Mental status: P (pain)– If the patient does not respond to loud verbal

stimuli, the next appropriate action would be to attempt to awaken her with physical stimuli• Start with a firm tap on the shoulder• If this doesn’t work, try a sternal rub

– The objective of the EMT is not to cause pain– Do not use unorthodox techniques that can harm

the patient!

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Mental status: U (unresponsive)– If no response is elicited by verbal or painful

stimuli, the patient is truly unresponsive– The unresponsive patient is truly ill and requires

rapid interventions

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The Initial Assessment

Watch this clip on using AVPU for assessment of mental status

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Stop and Review

How is mental status assessed? What is the purpose of the

general impression?

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Airway– Once the general impression is formed and the

level of consciousness determined, address the state of patient’s airway

– If the patient is awake and alert, the airway is most likely maintained without difficulty

– Observe patient’s effort to breathe and speak – If air is moving in and out without difficulty and

patient is speaking, airway is considered open and patent

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Airway– Awake but cannot speak? Continue to further

assess airway– Drooling is also a sign that patient is having

difficulty with the airway– The less responsive the patient becomes, the

more likely the airway will not be maintained on its own

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Airway– An unresponsive patient is a significant cause for

concern; the airway needs to be supported– Methodical approach to managing a patient’s

airway• Open• Assess• Suction

– Remember: without an airway you have no patient. It’s all about airway, airway, airway!

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Breathing– Check to see if there is any breathing at all

• Look (for chest rise and fall)• Listen (for air movement)• Feel (for air movement)

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Breathing– If no breathing, establish effective ventilations– If patient is breathing, assess breathing adequacy

by determining respiratory rate– For a rate of 10–28, give supplemental oxygen by

non-rebreather mask– Assist ventilations using a BVM with 100% oxygen

if:• Patient is breathing but it is too fast or too slow, is of

inadequate depth, or requires marked effort

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Breathing– Other conditions should prompt the EMT to put

on high-flow oxygen by non-rebreather mask• Examples: Chest or abdominal pain, difficulty

breathing, or any signs and symptoms of shock

– Never withhold oxygen from a patient who needs it!

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Breathing– Look

• Expose chest to inspect for obvious wounds or uneven breathing

• Open chest wounds should be immediately covered with an occlusive dressing– Stabs, gunshot wounds; also referred to as sucking

chest wounds• Broken ribs can cause a flail chest segment

• Flail chest segments move in the opposite direction of the rest of the chest wall

• This is called paradoxical movement

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Breathing– Listen

• Use a stethoscope to evaluate the effectiveness of air movement

• Listen just below the clavicles and at their midpoint• Listen to both lungs• Auscultate for clear bilateral breath sounds • Compare both sides. Diminished or no air movement on

one side indicates the potential for a significant injury

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Sound Potential Diagnosis

Absent Complete airway obstruction

Diminished (volume of sound) Collapsed lung (pneumothorax)

Wheezing (whistling sound) Air moving through narrow lowerairways (asthma or partial airwayobstruction)

Crackles (or rales) Fluid in smaller airways (heart failure)

Rhonchi (rumbling sound) Fluid in larger airways (bronchitis)

Abnormal Breath Sounds

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Breathing– Feel

• Feel for any deformity or crepitation in the chest; use two hands to press on both sides of the chest wall and sternum

• Tenderness in the chest wall is suggestive of a rib fracture

• Crepitus should be noted– Crepitus is the sensation of air under the skin, similar

to Rice Krispies popping under the fingertips

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Circulation– Assess for a pulse

• Check radial first; if present, the EMT can assume that patient has enough blood pressure to supply blood to that peripheral site • Pulse should be checked in the brachial site for

children less than one year• Check strength, rate, and regularity• If radial is not present, move directly to the carotid; blood

pressure is assumed to be quite low• If no pulse after 5–10 seconds, start CPR!

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Circulation– Assess for bleeding

• Check for life threatening bleeding• If the amount of bleeding seems life

threatening, the EMT should immediately control it

• Minor or small amounts of bleeding should not be treated at this time

• Focus on life threatening external and interal bleeding only!

• Check skin temperature, condition, and color

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Circulation– Circulatory support

• CPR• Control of severe bleeding• Trendelenburg position• Consider military anti-shock trousers (MAST) or

pneumatic anti-shock garment (PASG)

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Determine Priority

Ask the following to determine priority:– On the basis of the initial assessment, does the

patient have any life threatening problems that require immediate, rapid transport to the hospital?

– Do the EMTs need to arrange for an ALS intercept or aeromedical transport?

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Determine Priority

Load and go—high priority:– Poor general impression– Decreased level of consciousness– Responsive but not following commands– Difficulty breathing– Shock (evidence of hypoperfusion)– Complicated childbirth– Chest pain– Uncontrolled bleeding– Severe pain anywhere

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Determine Priority

Low priority—stay and play– If a patient is identified as low priority and

does not have any immediate life threatening problems, the EMT must continue in the assessment of the patient

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Stop and Review

What are three methods to determine whether a patient is breathing?

Where do you check pulse in patients less than one year old?

Chapter 13 Initial Assessment. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation....

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Transcript of Chapter 13 Initial Assessment. © 2005 by Thomson Delmar Learning,a part of The Thomson Corporation....