Patient Assessment Without Review Questionsv2

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    Patient Assessment

    UCLA Center for Prehospital Care

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    Count the White Shirt Passes

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    Patient Assessment and

    Management Model

    Scene size-up

    Primary Assessment (Initial assessment ) CriticalManagement and Transport Decisions

    Secondary Assessment

    Focused history and physical: Unresponsive Medical / Major TraumaPatient

    Focused history and physical: Responsive Medical / Minor Trauma Patient

    Detailed physical exam Management of specific Problems or Injury

    Reassessment (Ongoing assessment)

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    Scene Size-up & Primary

    Assessment

    Why to find potential life threats

    When - upon arrival, pts condition changes, after

    interventions

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    Scene Size-up

    Assess for:

    Personnel / Patient Safety with BSI Environmental hazards

    Number of patients

    Mechanism of injury Additional resources / special equipment

    Need for extrication / spinal immobilization

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    Scene Size-up

    Assess for:

    Personnel / Patient Safety with BSI

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    Safety to include the use ofPersonal Protective Equipment

    (PPE)

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    Safety to include the use ofPersonal Protective Equipment

    (PPE)

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    Scene Size-up

    Assess for:

    Environmental hazards

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    Scene Size-up

    Assess for:

    Number of patients

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    Scene Size-up

    Assess for:

    Mechanism ofinjury

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    Scene Size-up

    Assess for:

    Mechanism ofinjury

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    Scene Size-up

    Assess for:

    Mechanism ofinjury

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    Scene Size-up

    Assess for:

    Mechanism ofinjury

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    Scene Size-up

    Assess for:

    Mechanism ofinjury

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    Scene Size-up

    Assess for:

    Mechanism ofinjury

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    Scene Size-up

    Assess for:

    Mechanism ofinjury

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    Scene Size-up

    Assess for:

    Mechanism ofinjury

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    Scene Size-up

    Assess for:

    Mechanism ofinjury

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    Scene Size-up

    Assess for:

    Additional resources / special equipment

    Need for extrication / spinal immobilization

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    Scene Size-up

    Assess for:

    Personnel / Patient Safety with BSI Environmental hazards

    Number of patients

    Mechanism of injury

    Additional resources / special equipment

    Need for extrication / spinal immobilization

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    Primary Assessment

    General impression

    Life-threatening conditions

    Patient Rapport

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    Primary Assessment

    Assess/manage:

    AVPU/Spinal Considerations Orientation as appropriate (Person, Place,

    Time, Event)

    Airway

    Breathing

    Circulation

    pulses

    skin signs

    obvious bleeding

    Intervene whenevernecessary!!!

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    Primary Assessment

    Disability/Deformity:

    Altered mental status

    Obvious neurological deficits

    Abnormal body presentation (posture)

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    Subtle Signs of Hypoxia

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    Primary Assessment

    Determine:

    Chief complaint / problem

    Big Sick vs. Little Sick.

    Make a transport decision

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    Initial Contact / Primary Assessment

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    Initial Contact / Primary Assessment

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    Initial Contact / Primary Assessment

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    Initial Contact / Primary Assessment

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    Initial Contact / Primary Assessment

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    Secondary Assessment

    Two approaches based on patients chief complaint: responsive medical / minor trauma

    unresponsive medical / major trauma

    To Include: Neuro Exam if ALOC

    History of chief complaint (OPQRST, AEIOUTIPS)

    History of patient (SAMPLE)

    Vital signs

    Detailed or pertinent physical exam

    Reassessment

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    The goal is to identify the life threatening injuries thatcaused the disturbance or loss of function found

    during the primary assessment . Airway, breathing, circulation, or acute change in mental

    status

    Use inspection, palpation, auscultation, and thesmell of certain odors to help you uncover thesefindings.

    Head to Toe, Rapidly

    Rapid Assessment

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    Deformities

    C

    A

    P

    B

    T

    L

    S

    Use of the DCAP-BTLS mnemonicwill help you recall important

    indications of trauma

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    D

    Contusions

    A

    P

    B T

    L

    S

    DCAP BTLS

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    D

    C

    Abrasions

    P

    B T

    L

    S

    DCAP BTLS

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    D

    C

    A

    Punctures &

    Penetrations

    B T

    L

    S

    DCAP BTLS

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    D

    C

    A

    P

    Burns

    T

    L

    S

    DCAP BTLS

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    D

    C

    A

    P

    B

    Tenderness

    L

    S

    DCAP BTLS

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    D

    C

    A

    P

    B

    T

    Lacerations

    S

    DCAP BTLS

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    D

    C

    A

    P

    B T

    L

    Swelling

    DCAP BTLS

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    Rapid Assessment

    http://localhost/var/www/apps/conversion/tmp/scratch_2/Rapid%20Trauma%20Assessment.mov

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    Detailed / Pertinent Physical Exam

    Head

    Neck

    Chest

    Abdomen

    Pelvis

    Legs

    Arms

    Back

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    Physical Exam - Head

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    Physical Exam - Head

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    Physical Exam - Head

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    Physical Exam - Head

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    Physical Exam - Head

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    Physical Exam - Neck

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    Physical Exam - Neck

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    Physical Exam - Neck

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    Physical Exam - Chest

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    Physical Exam - Chest

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    Physical Exam - Abdomen

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    Physical Exam - Abdomen

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    Physical Exam - Pelvis

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    Physical Exam - Legs

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    Physical Exam - Legs

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    Physical Exam - Arms

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    Physical Exam - Arms

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    Physical Exam - Back

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    Detailed Body Check

    http://localhost/var/www/apps/conversion/tmp/scratch_2/Detailed%20Physical%20Exam.mov

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    Reassessment

    Repeat initial assessment

    Repeat relevant portion of thefocused exam

    This is repeated:

    Every 5 minutes for priority patients

    Every 15 minutes for stable patients

    Evaluate response to treatment

    Compare results to baseline


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