Initial Assessment


The EMT quickly assesses the patient's major body systems to identify life-threatening problems, initiate interventions, identify priority patients, and determine whether immediate transportation is necessary. Common priority patients include:

 
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  • general impression of a very sick patient.
  • unresponsive - no gag or cough.
  • responsive, not following commands.
  • difficulty breathing.
  • shock (hypoperfusion).
  • complicated childbirth.
  • chest pain with blood pressure < 100 systolic.
  • uncontrolled bleeding.
  • severe pain anywhere.

The EMT gathers information simultaneously from all senses during the examination. Logical steps, based on the life-threatening potential of each step are:

 

A- Airway

B- Breathing or Ventilation

C- Circulation or Perfusion

D- Disability or Mental Function

E- Expose the patient for the rapid focused physical examination and detailed examination, then protect the patient from the environment

 

 

A general impression of the patient is formed from the scene size-up and quick physical overview. It is further refined by the patient's reaction. Some patients are so ill that immediate transportation is crucial and cannot wait for arrival of ALS. In some cases, ALS may be able to rendezvous en route. The EMT should identify themselves to all patients and provide reassurance that they are there to help. 

A - If the patient is talking or screaming, the airway is obviously open. Quiet patients may indicate lack of breathing or inability to breath. A noisy airway generally indicates a problem with breathing. Positioning an unresponsive patient on their back may result in total or partial airway obstruction by the tongue or aspiration of vomit, blood, or saliva. If the airway problem is not corrected by the first intervention, the EMT should try another intervention. Immediate transport should be made if airway interventions do not work. Airway assessment and potential interventions include:

B - Breathing is the process of moving air into and out of the lungs. Respiration is the physiologic process of moving oxygen into the cells where it is metabolized and eliminating the waste product of this metabolism (carbon dioxide). The patient's ability to talk is an indicator of adequate breathing. A person who appears to be out of breath and speech is broken and choppy is in need of intervention. Rapid assessment of breathing involves listening, looking, and feeling the chest (front and back). 

Click on image to open PDF and enlarge. 

Click on image to open PDF and enlarge. 

If the patient has a breathing problem, the EMT must intervene and continue trying a different intervention until one works. Breathing assessment and potential interventions are listed below.

Click on image to open PDF and enlarge

Click on image to open PDF and enlarge

As a general rule, a ventilation rate of greater than 24 breaths per minute should be managed with supplemental oxygen to the lungs. A ventilation rate of 30 or more breaths per minute should be managed by assisting ventilation in addition to the supplemental oxygen.

C - If no pulse can be felt at any location, the EMT should ensure that the rest of the patient's condition supports the assessment. Consider all the possible reasons why no pulse is felt and begin interventions and assessment steps to correct this problem. If a pulse and respiration are truly absent, begin cardiopulmonary resuscitation and incorporate the use of an automated external defibrillator. Immediately start transportation and arrange for ALS rendezvous as appropriate.

If there is no pulse found on the extremities but is found on more central parts of the body, this indicates poor perfusion secondary to a problem with the circulatory system (heart, vascular system or blood volume). Assess for major external bleeding and intervene to control bleeding. Transport immediately if bleeding cannot be controlled.

The next step is to evaluate perfusion. Adequate perfusion means well oxygenated blood is getting to all tissues and organs. Major bleeding, internal or external, results in decreased perfusion. Since hypoperfusion cannot be seen, the EMT must rely on indications such as pulse, skin color, capillary refilling time, skin temperature, and/or decreased level of consciousness. The patient with poor perfusion and hypoxia of the brain may act combative or intoxicated, or may have a decreased level of consciousness, the EMT must attribute this to some cause or condition that can be corrected. The correct intervention by the EMT is supplemental oxygen. The cause will be determined at the hospital.

The capillary refill test may be helpful in evaluating perfusion. This test may be influenced by cold weather or other medical conditions not related to the event. It may be a less useful test for adults than for infants or children. Capillary refill can be performed on any skin surface, finger nail, or toe nail. The EMT presses on the patient's skin or nail with a finger, which pushes the blood from the capillaries in the skin or nail bed. When the EMT releases their finger, the patient's skin or nail bed will be pale due to blood being moved out of the capillaries. The EMT then counts seconds until the area returns to its previous color. Normal is considered two seconds or less.

D - The EMT should use the AVPU system to quickly determine the patient's level of consciousness. A cervical spine injury should be suspected for any patient with an altered level of consciousness.


Mental Status

The patient's level of consciousness is assessed to determine if the patient is awake, alert, or confused. The AVPU system is used to determine the patient's state of consciousness.

A-Alert and awake; aware of person, place, time, condition, etc.

V-Responds to verbal stimuli

P-Responds to painful stimuli; does not respond to verbal stimuli

U-Unconscious; does not respond to verbal or painful stimuli


Review Questions:

1. What factors would you take into account in forming a general assessment of a patient?

2. Explain how to assess a patient's mental status using the AVPU levels of consciousness.

3. Explain how to assess airway, breathing, and circulation during the initial assessment.

4. What interventions would you take for possible problems with airway, breathing, and circulation?

5. What is meant by the term priority decision?

6. What special interventions would you use in the following cases?

  • if a patient has suffered multiple traumas
  • if a patient is unresponsive

 

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