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š EMS Patient Assessment Overview
Brief Overview
This note covers pre ā hospital patient assessment and was created from an uploaded audio. It walks through scene sizeāup, primary and secondary assessments, vitalāsign techniques, and transport decisionāmaking.
Key Points
Scene safety, hazard identification, and scene sizeāup. Primary assessment steps: airway, breathing, circulation, and rapid neurological checks. Detailed vitalāsign acquisition, neurovascular evaluation, and bloodāpressure methods. Criteria for transport priority, reassessment intervals, and documentation cues.
Patient Assessment Overview
Five main parts of the assessment process
- Scene size ā up
- Primary assessment
- History taking
- Secondary assessment
- Reassessment Definition: A sign is an objective finding you can observe or measure; a symptom is a subjective condition reported by the patient. The order may change based on patient condition and environment. Effective assessment requires organization and the integration of multiple signs and symptoms to form a field impression.
Scene Size Up š§
Purpose & Continuous Situational Awareness
Initial evaluation of scene conditions, then maintain awareness throughout the call.
Situational awareness = constant attention to surroundings and potential risks.
Safety Considerations
Definition: Scene sizeāup ā the evaluation of the environment, hazards, and resources before and during patient contact to ensure safe and effective operations. Weapons may be ordinary objects (screwdriver, hammer). Secure or remove access, then position yourself between patient and potential danger. If the scene is unsafe, retreat or stage at a safe location until additional resources arrive.
Mechanism of Injury vs. Nature of Illness
Hazard Type Examples Mitigation Physical Uneven surfaces, ice, mud, water, traffic Use highāvisibility vest, secure footing, position vehicle safely Environmental Cold, snow, rain, heat, humidity Dress appropriately, provide patient with similar protection Biohazard Blood, bodily fluids Apply standard precautions (gloves, eye protection) Chemical Hazardous material release (^) Call hazāmat team, wear protective suit if needed Electrical Downed power lines Keep distance, request utility assistance Violence Weapons, angry bystanders, gang activity Position between patient and danger, request lawāenforcement assistance Aspect Mechanism of Injury (Trauma) Nature of Illness (Medical) Source External physical force (e.g., fall, motorāvehicle Internal physiological problem (e.g., asthma,
Soap & water preferred; alcohol ā based sanitizer acceptable when water unavailable. Perform before and after patient contact.
Glove Management
Do not touch face or bare skin with contaminated gloves. Change gloves if they become soiled or after each patient.
Eye & Respiratory Protection
Standard eyewear often insufficient; use splash ā guarded goggles. Upgrade to N95 or higher respirator if airborne disease is suspected (e.g., tuberculosis, COVIDā19).
Post ā Exposure Procedure
Follow agency protocol for reporting, testing, and prophylaxis if an exposure occurs. Primary Assessment š
Forming the General Impression
Observe age, sex, race, level of distress, overall appearance as you approach. Introduce yourself (e.g., āHi, Iām Sam, EMT with the fire departmentā) and ask the chief complaint. The patientās response provides early clues to consciousness, airway, breathing, and circulation.
AVPU Scale ā Level of Consciousness
Definition: AVPU assesses consciousness based on response to stimuli. Level Stimulus Typical Response A ā Awake Spontaneous Eyes open, aware, follows commands V ā Verbal Voice Opens eyes or speaks when spoken to; may moan
Use appropriate stimulus (verbal ā louder ā painful) if needed; avoid excessive force on the spine.
Immediate Life ā Threat Checks
- Uncontrolled External Bleeding Look for gushing, soaking through clothing, or pooled blood. Control before proceeding with other assessments.
- Airway ā Ensure patency; check for obstructions.
- Breathing ā Observe chest rise, listen for abnormal sounds.
- Circulation ā Assess pulse, skin color, temperature. Priority: Treat any identified lifeāthreatening condition immediately (e.g., massive bleeding > all other steps). Unresponsive Patient Assessment š Unresponsive patient ā a patient who does not respond spontaneously, to verbal cues, or to painful stimuli. Absence of cough or gag reflex means the airway cannot be protected without assistance.
Painful Stimulus Technique
Common pressure points P ā Pain Painful stimulus (e.g., trapezius pinch) Moves or cries out U ā Unresponsive No response to any stimulus No movement or verbal response Location How to apply Sternum (midāline) Firm thumb pressure downward Posterior edge of mandible (lower jaw) Pinch with thumb and index finger Trapezius (upper neck) Strong but brief squeeze
Airway obstruction ā any blockage that prevents adequate airflow into the lungs, leading to inadequate perfusion.
Signs of Airway Compromise
No speech/cry in a conscious patient ā severe obstruction. Noisy breathing (snoring, gurgling, stridor). Visible trauma, blood, vomitus, foreign body. Tongue sagging in an unconscious patient.
Technique Selection
Adjuncts ā oral or nasal airway can be placed after the airway is opened. Suction ā remove blood, vomitus, or secretions if needed. If airway cannot be secured promptly, stop the primary assessment and focus on airway clearance. Breathing Assessment š« Breathing adequacy ā the ability of the lungs to provide sufficient oxygenation and carbonādioxide removal.
Quick Evaluation Questions
- Is the patient breathing?
- Is the effort adequate? (see effort indicators below)
- Is the patient hypoxic? ā target SpOā > 94 %. Patient Condition Preferred Maneuver When to Use Unresponsive with potential trauma Jaw thrust (maintains Cāspine) Immediately after scene safety and before any headātilt Unresponsive without trauma Head tilt ā chin lift If jaw thrust ineffective or trauma ruled out Obstruction by foreign body Abdominal thrusts (Heimlich) or chest compressions (infants) When the patient cannot cough or expel the object
Normal vs. Abnormal Breathing
Normal ā quiet, effortless, speech without pauses. Labored ā use of accessory muscles, retractions, noisy respirations. Indicators of Increased Work of Breathing
Respiratory Rate Thresholds
> 28 breaths/min with distress ā consider positive ā pressure ventilation. < 8 breaths/min or absent breathing ā start ventilations immediately.
Interventions
Positive ā pressure ventilation (bagāvalveāmask) with appropriate airway adjunct. Oxygen administration if SpOā < 94 % despite adequate breathing. Reāevaluate airway if breathing deteriorates during the assessment. Circulation Evaluation š Circulation ā the movement of blood supplying oxygen and nutrients to vital organs.
Pulse Assessment
Indicator Description Speech pattern Twoātoāthreeāword dyspnea ā patient stops after 2ā3 words to breathe. Posture Tripod (leaning forward on hands) or sniffing (upright, head thrust). Accessory muscle use Sternocleidomastoid, pectoralis major, abdominal muscles. Pediatric signs Nasal flaring, intercostal/subcostal retractions, seesaw breathing. Patient Preferred Site Technique Responsive (ā„ 1 yr) Radial (wrist) Light pressure with index + middle fingers.
Rapid exam ā a swift, focused headātoātoe survey (ā 90 s) to uncover additional lifeāthreatening injuries after the primary assessment. Maintain spinal stabilization throughout the exam; logāroll the patient in one motion if immobilization is required. Determining Transport Priority š Transport priority ā classification (high, medium, low) based on identified life threats and the need for rapid definitive care. Step Area Key Checks 1 Head Look/feel for decapitated BTLS, assess pupils 2 Neck JVD, tracheal deviation, spinal stepāoff 3 Chest Wall movement, crepitus, equal rise, breath sounds 4 Abdomen Rigidity, distension, firmness 5 Pelvis Gentle compression for tenderness/instability (if no pain) 6 Extremities Distal pulses, motor & sensory function 7 Back & buttocks Visual/palpation for BTLS; maintain ināline spinal stabilization when logārolling High ā Priority Indicators Unresponsive Severe difficulty breathing
The āgolden hourā concept underscores that definitive care should begin within the first hour after major trauma to maximize survival. Transport Decision & Prioritization š Transport decision ā choosing whether to stay onāscene for definitive care or to move the patient toward definitive care, based on the patientās condition, resource availability, distance, and protocols. Key factors influencing the decision:
- Patient condition ā highāpriority patients (e.g., uncontrolled bleeding, airway compromise) require rapid transport.
- Availability of advanced help ā request ALS if not already en route; consider a rendezvous if ALS is farther away.
- Distance to destination ā longer transports may allow more onāscene interventions (e.g., splinting an isolated fracture for pain relief).
- Local protocols ā adhere to agencyāspecific guidelines for scene time vs. transport time. Primary assessment reminder ā identification and treatment of airway, breathing, and circulation threats should be completed as quickly as possible before deciding on transport. Reassessment timing Stable patients ā vitals every 15 min until arrival at the ED. Unstable patients ā vitals every 5 min (or more frequently as needed). Uncontrolled hemorrhage Altered level of consciousness Severe chest pain Pale, cool, clammy skin (signs of shock) Complicated childbirth Severe pain in any region
Remember: Do not delay transport for a detailed history when the patient is unstable.
OPQRST ā Pain & Symptom Exploration
Adaptability: OPQRST can be applied to dyspnea, nausea, or other nonāpain symptoms by substituting appropriate descriptors.
SAMPLE ā Comprehensive History Mnemonic
Events Leading to Incident Mechanism of injury, symptom onset, activities prior to collapse Letter Prompt Example Question O ā Onset When did it start? What were you doing? āWhat were you doing when the pain began?ā P ā Provocation/Palliation What makes it better or worse? āDoes movement change the pain?ā Q ā Quality How would you describe it? āIs it sharp, dull, crushing?ā R ā Region/Radiation Where is it? Does it spread? āWhere do you feel the pain? Does it move?ā S ā Severity Rate 0ā10. āOn a scale of 0 to 10, how bad is the pain?ā T ā Timing Duration, frequency, pattern. āHas the pain been constant or intermittent?ā Letter Focus Sample Question S ā Signs & Symptoms What happened at onset? āWhat signs did you notice when it started?ā A ā Allergies Any known allergies? Reactions? āAre you allergic to any medications or foods?ā M ā Medications Current meds, dosage, timing. āWhat medicines have you taken today?ā
Document pertinent negatives (symptoms the patient does not have) as they help narrow differential diagnoses. Critical Thinking in Assessment š§ Critical thinking ā the active process of gathering, evaluating, and synthesizing information to make sound clinical decisions, avoiding ācookbook medicine.ā
1. Gathering
Observe scene, ask openāended questions, note nonāverbal cues. Anticipate barriers: uncooperative patients, unconsciousness, language differences.
2. Evaluating
Compare gathered data against expected patterns. Example: fluālike symptoms in cold weather plus a broken heater ā consider carbon monoxide poisoning.
3. Synthesizing
Integrate validated information into an actionable plan (e.g., continue primary assessment, request hazāmat, evacuate occupants). Avoid ācookbook medicine.ā Adapt the algorithm to each unique scene. Sensitive Topics & Special Populations š
Alcohol & Drug Use
P ā Pertinent Past History Medical, surgical, trauma, family. āDo you have a history of heart disease?ā L ā Last Oral Intake When/what was last eaten; for women, LMP. āWhen was your last meal? When was your last period?ā E ā Events Leading Up Circumstances surrounding the incident. āWhat were you doing before you felt ill?ā
Documentation should capture observed behavior, patient statements, and any safety concerns. Communication Strategies for Difficult Interactions š£
Silence
Possible meanings: Processing information, fear, language barrier, or hidden chief complaint. Tactics:
- Use closed ā ended yes/no questions.
- Observe nonāverbal cues (facial expression, posture).
- Allow pause; reassure the patient you are listening.
Over ā Talkative Patients
Potential causes: Caffeine, stimulants, anxiety, psychiatric conditions. Control technique: Gently redirect with āLetās focus on the main problemā¦ā Summarize key points and ask, āIs there anything else you want to add?ā
Multiple Symptoms
Intoxication Slurred speech, agitation, impaired coordination Expect unreliable history; monitor for airway compromise Crying Tears, sobbing, possible panic Speak softly, maintain eye contact, reassure Depression Hopelessness, low energy, possible suicidal ideation Listen without judgment; note any plan or intent Confusing Behavior Disorientation, incoherent speech Consider hypoxia, stroke, metabolic derangements; reassess mental status Limited Cognitive Ability Inability to answer complex questions Use simple language, rely on caregivers for history Cultural Challenges Language barriers, differing health beliefs Use interpreter services, respect cultural norms
Prioritization: Treat as a triage scenario ā address the most lifeāthreatening complaint first. Documentation: List each symptom; note which prompted EMS dispatch.
Anxiety & Panic
Physical manifestations: Pallor, diaphoresis, tachypnea, dizziness. Management: Validate feelings (āItās normal to feel scaredā). Perform rapid assessment to rule out physiologic emergencies.
Anger & Hostility
Safety first: Keep a clear escape route, never be alone with a potentially violent patient. De ā escalation: Speak calmly, use a soft tone, avoid confrontational language.
Intoxicated Patients
Unreliable history: Treat the patient as if you have limited information; focus on objective findings. Safety: Anticipate sudden aggression; maintain a safe distance and have backup ready.
Crying & Emotional Distress
Approach: Soft voice, gentle touch if appropriate, maintain eye contact. Goal: Reassure, obtain necessary clinical information, and avoid further distress.
Depression & Suicidal Ideation
Screening: Ask directly, āAre you thinking about harming yourself?ā Action: If risk is present, activate mentalāhealth crisis protocol and arrange rapid transport.
Confusing Behavior
Differential includes: Hypoxia, stroke, hypoglycemia, medication side effects. Action: Secure airway, obtain glucose reading, assess neurological status (AVPU).
Cognitive Limitations
Hearing Impairments
Speak slowly and face ā to ā face; keep the stethoscope in the patientās ears while speaking to amplify your voice. Written communication (paper & pen) is often the most reliable; ask āyes/noā questions. For patients with a hearing aid, ask them to turn it on; otherwise, repeat key information verbally. Basic sign language (e.g., āyes,ā āno,ā āpainā) can bridge gaps in urgent situations.
Visual Impairments
Announce your arrival and describe each action (āIām moving your blanket nowā). Preserve the original layout of objects; replace anything you move to its prior spot. Explain positioning before lifting, rolling, or transporting the patient. Use glasses if the patient wears them; ask them to put them back on before visual assessment. š Secondary Assessment Secondary assessment ā a systematic physical examination performed after lifeāthreatening problems have been addressed, aimed at uncovering hidden injuries or additional causes of distress.
General Approach
4 Employ gestures or visual aids ā point to body parts, demonstrate actions. (^5) Access interpreters ā phoneābased, mobile apps, or onāsite bilingual staff. Notify the receiving hospital in advance. 6 If no interpreter is available, enlist a trusted family member while remaining mindful of privacy and accuracy.
Conduct at the scene if the patient is stable; otherwise, continue in the ambulance. Choose full head ā to ā toe or focused exam based on chief complaint and mechanism of injury.
Inspection, Palpation, Auscultation
DECAP ā BTLS Mnemonic
Technique What to Do Tools/Notes Inspection Visually scan for bruises, swelling, deformities, odors, and any abnormal skin changes. No equipment required; maintain eyeālevel with patient. Palpation Use fingertips for texture & consistency; back of hand for temperature. Compare bilaterally whenever possible. Gentle for superficial structures; firmer pressure for deeper tissues. Auscultation Listen with a stethoscope for breath sounds, heart tones, and blood flow (e.g., BP auscultation). Ensure the diaphragm contacts skin; avoid clothing over the area. Letter Structure Abnormal Finding to Look For D Deformities Angulation, visible displacement E Ecchymosis (bruising) New vs. old, pattern of injury C Contusions Soft tissue swelling, tenderness A Abrasion Skin integrity loss P Puncture Entry wound, possible foreign body B Burns Depth, size, location
