Scene Size-up

• How you prepare for a specific situation
• Begins the moment you are dispatched
• Includes:
• Dispatch information
• Inspection of the scene
• Identify hazards, safety concerns, mechanisms of Injury (MOI), Nature of illness
• # of patients
• Additional Resources that may be needed

BSI

Assumes that all body fluids pose a threat of Infection

• Wear PPE to reduce personal risk of injury or illness
• Protective gloves and eye protection are always indicated
• Eye protection and masks - blood or fluids may become airborne by coughing of splattering

Scene Safety

• Personal Protection:
• Oncoming Traffic
• Unstable surfaces
• Leaking fluids
• Broken utility poles and downed wires
• Aggravated or hostile bystanders
• Smoke or Fire
• Toxic materials
• Crash or rescue scenes and unstable elements (unsecured vehicles, placards)
• Violence and Crime Scenes

Making an Unsafe Scene Safe

• May not be able to enter a scene safely
• Request the appropriate assisstance
• If a scene become unsafe - extricate yourself and patient ASAP

Consider Mechanisms of Injury

(MOI)

• MOI - with traumatic injury, the body has been exposed to some force or energy that has resulted in temporary injury, permanent damage, or death
• Evaluate:
  • Amount of Force Applied
  • Length of time the Force was Applied
  • Areas of the Body that are Involved

• Blunt Trauma:
  • Force of the Injury occurs over a broad area
  • Skin is not usually broken
  • Tissues and Organs below the area of impact may be damaged
• Penetrating Trauma:
  • Force of the Injury occurs at a small point of contact between the skin and the object
  • Skin is broken - carries high potential for infection

• Search for clues regarding how the incident occurred
• Determine general type of illness (Patient's Chief Compaint)
• Talk with the patient, family, bystanders
• Open/spilled medication bottles
• Poisonous substances
• Unsanitary Living Conditions
• Strong Odors
• Hissing Sounds

Importance of MOI & NOI

• MOI may Include:
  • Motor Vehicle Crashes
  • Assaults
  • Stabbing or Gun Shot Wounds
• NOI may Include:
  • Seizures
  • Heart Attack
  • Diabetic Problems
  • Poisoning

Determine the Number of Patients

• To Determine the need for additional Resources
• Establish Incident Command
• Triage
  • Based on the severity of each patient's condition
  • Establish Treatment and Transport

Consider Additional Resources

• BLS units may be all that is required
• ALS units for:
  • severe injuries
  • Complex Medical Problems
  • Dependent on available Resources

• Fire Department
• High Angle Resue
• Hazardous Materials Management
• Complex Extrication from Motor Vehicle Crashes
• Water Rescue
• Swift Water Rescue
• Search & Rescue Teams

• How many patient's are there?
• What is the nature of the condition?
• Who contacted EMS?
• Does the scene pose a threat to you, your patient, or others?

• If an Injury is Suspected - Consider early C-Spine Immobilization
• If uncertain - Err on the side of caution

Initial Assessment

• Includes:
• A visual Assessment
• Gathering Information as you approach the patient
• Make sure the patient sees you coming
• Note whether the patient is moving or still
• Note Odors (chemical or smoke)
• Place yourself at the patient's level for
  • Their comfort
  • Less threatening

Introduce Yourself and Ask Permission to Treat

• Tell the who you are - how I'd like to be addressed
• What you are doing
• What Their Name is - How they'd like to be addressed
• Use their name frequently
• Obtain Consent - treatment for unresponsive patients is implied

Determine Chief Complaint

• The most serious thing that the patient is concerned about - usually expressed in their own words (symptoms) 
• Something may be observable (signs)
• May not be the most serious thing that is wrong
• Gives a Point of Reference to begin
• Helps narrow down MOI or NOI

• Evaluating how a person was injured may help you predict the types of injuries the person may have
• The assessment process begins by assuming that all patients may have both medical and trauma aspects to their condition
• Obtain general impressions of the patient before focusing on specific concerns - "The Big Picture"

Assess Mental Status

Responsiveness

AVPU

Alert

• Alert - patients eye open spontaneously as you approach
• Aware of you and responsive to the environment
• Patient appears to follow comands
• Eyes visually track people

• The patient's eyes do not open spontaneously
• Patient's eyes do open to verbal stimuli
• Patient is able to respond in some meaningful way when spoken to

• The patient does not respond to your questions
• Moves or cries out in response to a painful stimulus

• The patient does not respond spontaneously
• The patient does not respond to verbal stimuli
• The patient does not respond to painful stimuli
• The patient usually have no cough or gag reflex and lack the ability to protect their airway
• Assume the worst and treat

• For the patient who is alert and responsive to verbal stimuli evaluate orientation
• Orientation tests mental status by checking the patient's memory and thinking ability

• Person - the patient is able to remember his/her name 
• Place - the patient is able to identify his/her current location
• Time - the patient is able to tell you the current year, month, and approximate date 
• Event - the patient is able to describe what happened (MOI, NOI)

• Person and place (if the patient is at home) evaluate long-term memory
• Place and time (when asking year or month) evaluate intermediate memory
• Time evaluates short-term memory (when asking approximate date and event)

• If the patient knows these facts the patient is said to be alert and fully oriented or
• alert and oriented to person, place, time, and event
• If a patient does not know these facts, he/she is considered less than fully alert

• head trauma
• hypoxia
• hypoglycemia
• stroke
• cardiac problems
• drug use

• Rapidly complete the initial assessment
• Provide high-flow supplemental oxygen
• consider spinal immobilization if trauma suspected
• Initiate Transport

• Watch and listen to how a patient speaks
• Stridor suggests a partially occluded airway caused by swelling
• High-Pitched crowing sounds indicate partial airway obstruction from a foreign body

• Immediately assess airway (esp. their tongue)
• Signs of obstruction:
• Obvious Trauma, blood, or obstruction
• Noisy Breathing, such as snoring, bubbling, gurgling, crowing, or abnormal sounds
• Extremely shallow or absent breathing

• Important to consider spinal precautions
• Airway management and spinal immobilization must be performed simultaneously
• Consider placing the patient in Recovery Position

Assess Breathing

• Make sure the patients airway is open
• Make sure the patient's breathing is:
• Present
• Adequate
• Administer oxygen to patient's having:
  • Difficulty Breathing
  • Breathing Inadequately
• Positive Pressure Ventilations - patient's who are: 
  • apneic
  • Breathing too slowly
  • Breathing too shallow

• Observe how much effort is required to breathe
• Signes of inadequate breathing:
  • Use of accessory muscles
  • Nasal Flaring and see-saw breathing (children)
  • 2 - 3-Word Dyspnea
    • Patient who can only speak 2 - 3 word without pausing to take a breath

• Does the patient appear to be choking?
• Is the respiration rate too fast or too slow?
• Are the patient's respirations shallow or deep?
• Is the patient cyanotic?
• Do you hear abnormal sounds when listening to the patient's lungs?
• Is the patient moving air into and out of the lungs on both sides?

• Place the head of the stethoscope on the skin of the upper anterior chest at the midclavicular line and listen to 1 - 2 breathes
• Repeat on opposite side
• Inadequate breathing:
  • Decreased or absent sounds on 1 side
  • Decreased rise and chest fall on one side

• Fowler's Postion (if no spinal injury concerns) - sitting up at about 90^o
• Oxygen should be delivered using a non-rebreathing mask at 15L/min

Assess Circulation

Pulse

• Present and adequate
• Radial artery or carotid artery (if you can't find radial)
• AED if no pulse is palpable (patient's older than 8 & weighing more than 55 lbs.)
• AED pediatric for ages 1 - 7
• If pulse, but no breathing -
  • Ventilations at least 12 breaths/min -adults
  • Ventilations at least 20 breaths/min infant or child
• If pulse is lost - use CPR and AED if indicated

Infant: 1 month to 1 year = 100 - 160 beats/min

Toddler: 1 to 3 years = 90 - 150 beats/min

Preschooler: 3 - 6 = 80 - 140 beats/min

School-age: 6 - 12 = 70 - 120 beats/min

Adolescent: 12 - 18 = 60 -100 beats/min

• After determining if a pulse is present:
• Determine adequacy:
  • Rate 
  • Rhythm
  • strength

Assess and Control External Bleeding

Signs of Blood Loss

• Active bleeding from wounds and/or evidence of bleeding such as blood on clothes or near the patient
• Steady flow of blood - indicates large vein
• Spurting blood flow - indicates large artery
• Periodic checks by lightly running your gloved hand over the patient from head - to - toe

1)  Apply direct pressure with gloved hand, then sterile gauze over the wound

2)  Elevate

3)  Apply direct pressure over arteial pressure points

Assess Perfusion

• One of the most important and most readily accessible ways of evaluating circulation
• A lack of perfusion (hypoperfusion) will result in hypoxia of the brain, lugs, heart, and kidneys
• In most cases hypoperfusion is caused by shock
• Assessed by evaluating:
  • Skin Color
  • Temperature
  • Moisture

Assess Perfusion

Skin Color

• Pink - normal color
• Deeply Pigmented Skin - look at:
  • Fingernail  beds
  • Sclera (whites of the eyes)
  • Conjunctiva (linings of the eyelids)
  • Mucus Membranes
• Alert if skin is:
  • Cyanotic
  • Flushed
  • Pale
  • Jaundice

• Alert if:
  • cool
  • Clammy
• With poor perfusion - body pulls blood away from the surface of the body and diverts it to the core

• Assess the presence of moisture
• Skin is normally dry
• Cool, cold, moist, or clammy skin = shock 

• Most accurate in children under 6
• Capillary refill may be slowed by:
  • Patient's age
  • Exposure to cold (hypothermia)
  • Frozen tissue (frostbite)
  • Vasoconstriction
  • Injury to bone and muscles of the extremities

Identify Priority Patients and Make Transport Decisions

• High Priority patients should be transported immediately - Including:
  • Difficulty breathing
  • Poor General Impression
  • Unresponsive with no gag or cough reflexes
  • Severe Chest Pain, esp if Systolic BP < 100 mm Hg
  • Pale Skin, or signs of poor perfusion

• Transport Immediately if:
  • Complicated childbirth
  • Uncontrolled Bleeding
  • Responsive, but unable to follw commands
  • Severe Pain in any part of the body
  • Inability to move any part of the body

• You may need 60 - 90 seconds to identify injuries that must be protected during packaging and loading for transport
• Golden Hour - time from injury to definitive care, during which the treatment of shock and traumatic injuries should occur.  
• After the 1st 60 mins., body has increasing difficulty compensating for shock and traumatic injuries
• Aim to Assess, stabilize, package, and begin transport within 10 mins.

• Some patients benefit by remaining on scene and receiving continuing care:
• Older patients with chest pain - administer nitroglycerin - wait for ALS transport
• May need to rendezvous with ALS to hasten transport

Focused History & Medical Exam

• Help to identify specific problems and Chief Complaint
• 3 components to meet the Goals:
  • Evaluation of Patient's Medical History
  • Obtaining Base-Line Vital Signs
  • Performing a Physical Exam Base on Patient's Complaint Or - case of critical patient (MOI or NOI)

• Understand the specific circumstances surrounding the chief complaint:
• What key factors were associated with the event?
• Does the MOI put the patient at high risk for serious injuries?

• Obtain objective measurements:
  • Do measurements validate the seriousness of the patient's condition?
  • How well is the patient dealing with injury or illness?

• Direct Further Physical Exam:
  • What clues help to identify the problem?

Focused History and Physical Exam

• Obtain SAMPLE (general medical history)
• OPQRST (focused history of a specific problem)
• Obtain Baseline Vital Signs

2 Types of Physical Exams

• Rapid Physical Exam
• Focused Physical Exam

Rapid Physical Exam

DCAP-BTLS

• Quick Head-to-toe Exam looking for:
  • Deformities
  • Contusions
  • Abrasions
  • Punctures/Penetrations
  • Burns
  • Tenderness
  • Lacerations
  • Swelling

• Access the head, looking and feeling for DCAP-BTLS and Crepitus (a grating or grinding sensation caused by fractured bone ends or joints rubbing together; also air bubbles under the skin that produce a crackling sound or crinkly feeling)

• Assess the neck, looking and feeling for DCAP-BLTS, jugular venous distention, tracheal deviation, and creitus
• In trauma patients - apply a cervical spinal immobilization device

• Assess the chest, looking and feeling for DCAP-BTLS, paradoxical motion, and crepitus
• Listen to breath sounds on both sides of the patient's lungs

• Assess the abdomen, looking and feeling for DCAP-BTLS, rigidity (firm or soft), and distention

• Assess the pelvis, looking and feeling for DCAP-BTLS
• If there is no pain, gently compress the pelvis downward and inward to look for tenderness or instability

• Assess all 4 extremities, looking and feeling for DCAP-BTLS
• Assess bilaterally for distal pulses, motor, and sensory function

• Assess the back and buttocks, looking and felling for DCAP-BTLS
• In all trauma patient's you should maintain in-line stabilization of the spine while rolling the patient on his/her side in 1 motion

Focused Physical Exam

• Specific assessment techniques to evaluate the patient's chief complaint
• Generally focuses on the location or body system related to the chief complaint
• Only the relevant steps for the patient will be done

• Inspect for abnormalities of the head, neck, and cervical spine
• Gently palpate the head and back of the neck for any pain, deformity, tenderness, crepitus, and bleeding
• Ask a responsive patient if he/she feels any pain or tenderness
• Check the neck for signs of trauma, swelling, or bleeding
• Palpate the neck for subcutoneous emphysema, as well as any abnormal lumps or masses

• In patients where spinal injury is not suspected:
• Inspect for pronounced or distended jugular veins with the patient sitting at a 45^o angle

• Inspect, visualize, and palpate over the chest area for injury or signs of trauma, including bruising, tenderness, or swelling
• Watch for both sides of the chest to rise and fall together
• Normal breathing signs, Including
  • retractions or paradoxical motion
• Feel for crepitus
• Palpate the chest for subcutaneous emphysema
• Auscultate breath sounds

• Inspect the abdomen for any obvious injuries, bruising, or tenderness
• Palpate both the front and back of the abdomen
• Evaluate for tenderness and bleeding

• Inspect for cuts, bruises, swelling, obvious injuries, bleeding, or deformity
• If the patient reports no pain, gently press downward and inward on the pelvic bones

• Inspect for cuts, bruises, swelling, obvious injuries, and bleeding
• Palpate along extremity for deformities
• Check pulses and motor sensory function

Focused Physical Exam

Extremities

Step 6

Pulse

• Check the distal pulses on the foot (dorsalis pedis or posterior tibial) and wrist (radial)
• Check circulation
• Evaluate skin color in the hands or feet

• Evaluate sensory function in the extremities by:
  • Asking the patient to close his/her eyes
  • Gently squeeze or pinch a finger or toe
  • Ask the patient to identify what you are doing

• Feel the back for tenderness, deformity, and open wounds
• Carefully palpate the spine from the neck to the pelvis for tenderness or deformity
• Look under the clothes for obvious injuries, including bruising and bleeding

Assessing Common Chief Complaints

Chest Pain

• Look for trauma to the chest and listen for breath sounds
• Obtaining a pulse, BP, and respiratory rate
• Evaluate the skin

• Look for signs of airway obstruction
• Look for trauma to the neck or chest
• Listen carefully to breath sounds, noting abnormalities
• Measure respiratory rate, chest rise and fall (tidal volume), and effort
• Carefully evaluate pulse, BP, and skin condition

• Look for trauma to the abdomen or Distention
• Palpate the abdomen for tenderness, rigidity, and patient guarding

• Expose the site and evaluate the pulse, motor, and sensory function adjacent to and below the affected area
• Assess Range of Motion - ask patient how much he/she can move the extremity or joint
• Never force a painful movement

• Evaluate the level of consciousness and orientation to determine the patient's ability to think
• Evaluate speech for clarity
• Inspect the head for trauma
• Pulse, BP, skin - may indicate hypoperfusion of the brain

Physical Exam Techniques

Inspection

• Looking for a patient's abnormalities
• Swelling in a lower extremity may indicate an acute injury or chronic illness

• Touching or feeling the patient for abnormailities
• At times gentle and at other times firmer to help you identify what hurts

• The process of listening to sounds the body makes using a stethoscope

Steps in a Focused History and Physical Exam

• It wil always have 3 components:
  • Baseline Vitals - what's happening inside the body
  • Rapid or Focused Physical Exam - What's happening outside the
  • SAMPLE - helps make sense of Baseline Vitals and SAMPLE to guide treatment

• Ejection from a vehicle
• Death of another occupant of the vehicle
• Any fall equal to or greater than the patient's height, esp. if the head strikes a firm surface first, or simultaneously with torso
• Vehicle Rollover
• High-speed collision
• Vehicle-pedestrian collision
• Motorcycle or bicycle crash
• Unresponsive or altered mental status following trauma
• Penetrating trauma to the head, chest, or abdomen

Steps in a Focused History and Physical Exam

Trauma Patient With a Significant MOI

Rapid Trauma Assessment

• Taking 60 - 90 seconds to identify obvious and hidden injury
• 1^st - Identify and Treat hidden life treats that were not apparent on the initial assessment
• 2^nd - Better know how to prepare the patient for packaging and rapid transport

Steps in a Focused History and Physical Exam

Trauma Patient With a Significant MOI

• Take Baseline Vitals
• SAMPLE History
• Reevaluate Transport Decision

Steps in a Focused History and Physical Exam

Trauma Patient With No Significant MOI

• Focused Trauma Assessment Based on Chief Complaint
• Baseline Vitals
• SAMPLE History
• Reevaluate Transport Decision

Focused History & Physical Exam

History of Illness

• If time:
  • Take time to sit down and make the patient comfortable
  • Listen to develop an increased understanding of the patient's condition
  • Don't jump to conclusions
  • Chief complaint may not be obvious
  • Stay Flexible
  • Assess and Treat the patient's problem vs the dispatcher's report
  • Ask patient, family member, or bystander

• The more signs and symptoms you are able to gather, the better
• Attempt to record the chief complaint in a few of the patient's own words
• Note if the information comes from someone other than the patient

• OPQRST
• SAMPLE History
• Focused Medical Exam
• Key is to:
  • Emphasize priorities
  • Focus on the Region of the Problem
  • Focus on the Physiological System Involved

Focused Medical Assessment to Unresponsive Medical Patients

Rapid Medical Assessment 60 - 90 seconds

Baseline Vitals

• SAMPLE History - while packaging the patient for transport from family or bystanders, or environment:
  • Drug paraphernalia - OD
  • Medical Identification Device
  • Patient medication labels
• Reevaluate Transport decision

Detailed Physical Exam

While in Transit (usually)

• Goal: Further define the problems
• Should never delay transport

1. Return to the initial assessment if a potentially life-threatening condition is identified 
2. Stay focused on the ABCs
3. Perform Spinal Immobilization if neck or back pain or abnormality in sensation or movement is identified
4. Modify any treatment that is under way on the basis of new information
5. Provide treatment for problems identified
6. Provide transport or call ALS backup

Perform the Detailed Physical Exam

• Organized by body region
• Inspect and palpate to find the Evidence of Injury utilizing DCAP-BTLS

• Step 1:
  • Look at the face for obvious lacerations, bruises, or deformities
• Step 2:
  • Examine the area around the eyes and eyelids
• Step3:
  • Examine the eyes for redness and for contact lenses
  • Assess the Pupils using a pen light

• Step 4:
  • Look behind the patient's ear to assess for bruising (Battle's Sign)
• Step 5:
  • Use a penlight to look for drainage of spinal fluid or blood in the ears
• Step 6:
  • Look for bruising and lacerations about the head
  • Palpate for tenderness, depressions of the skull, and deformities

• Step 7:
  • Palpate the zygomas for tenderness or instabiity
• Step 8:
  • Palpate the maxillae
• Step 9:
  • Palpate the mandible
• Step 10:
  • Assess the mouth and nose for cyanosis, foreign bodies (loose teeth, dentures), bleeding, lacerations, or deformities

• Step 11:
  • Check for unusual odors on the patient's breath
• Step 12:
  • Look at the neck for obvious lacerations, bruises, and deformities
• Step 13:
  • Palpate the front and the back of the neck for tenderness and deformity

• Step 14:
  • Look for distended jugular veins (not necessarily significant when patient's are lying down)
• Step 15:
  • Look at the chest for obvious signs of injury before you begin palpation.
  • Watch chest movement with respirations

• Step 16:
  • Gently palpate over the ribs to elicit tenderness
  • Avoid pressing over obvious bruises or fractures
• Step 17:
• Listen for breath sounds over the midaxillary and midclavicular lines

• Step 18:
  • Listen at the bases of the apices of the lungs
• Step 19:
  • Look at the abdomen and pelvis for obvious lacerations, bruises, and deformities
• Step 20: 
  • Gently palpate the abdomen for tenderness ( tense = 'Rigid')

• Step 21:
  • Gently compress the pelvis from the sides to assess tenderness
• Step 22:
  • Gently press the iliac crests to elicit instability, tenderness, or crepitus

• Step 23:
  • Inspect all extremities for lacerations, bruises, swelling, deformities, and medic alert anklets or bracelets
  • Assess distal pulses and motor and sensory function
• Step 24:
  • Assess the back for tenderness or deformities

Ongoing Assessment Steps

Every 15 minutes for Stable patients

Every 5 minutes for Unstable patients

• Performed while in transit
• To answer the following questions:
  • Is treatment improving the patient's condition?
  • Has an already identified problem gotten better or worse?
  • What is the nature of any newly identified problems?

Ongoing Assessment Step 1

• Repeat the initial assessment
  • Reassess Mental Status
  • Maintain an open Airway
  • Monitor the patient's Breathing
  • Reassess Pulse Rate and Quality
  • Monitor Skin Color and Temperature
  • Reestablish patient priorities

• Step 2:
  • Reassess and Record Vital Signs
• Step 3:
  • Repeat your focused assessment regarding patient complaint or injuries, including questions about the patient's medical history

• Check Interventions
  • Ensure adequacy of oxygen delivery/srtificial ventilation
  • Ensure management of bleeding
  • Ensure adequacy of other interventions