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Paramedic Care: Principles & Practice
Fourth Edition
Volume 3: Patient Assessment
CHAPTER
7
Patient
Assessment
in the Field
Standard
• Assessment
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Competency
• Integrate scene and patient assessment
findings with knowledge of
epidemiology and pathophysiology to
form a field impression.
• This includes developing a list of
differential diagnoses through clinical
reasoning to modify the assessment
and formulate a treatment plan.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• Patient assessment: problem-oriented
evaluation of patient; establishing
priorities of care.
• Patient's condition determines
components you use; how to use them.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• Proficiency in performing patient
assessment will determine your ability
to deliver highest quality of prehospital
advanced life support (ALS).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Scene Size-Up
• First stage of every emergency call.
• Ensure safe environment.
• Take necessary precautions for
personal protection.
• Determine what resources needed.
• Locate all patients.
• Assess mechanism of injury (MOI) or
nature of medical illness.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Primary Assessment
• Determine whether patient “looks dead
or doesn't look dead.”
• If patient looks dead, quickly assess
responsiveness and breathing.
• If pulse absent, begin chest
compressions immediately.
• If patient shows signs of life, conduct
primary assessment (ABC).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Primary Assessment
• Steps of Primary Assessment
– Form general impression
– Stabilize cervical spine as needed
– Assess baseline mental status
– Assess airway
– Assess breathing
– Assess circulation
– Assign priority
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Manually stabilize the head and neck on first patient contact.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Primary Assessment
• Should take less than 1 minute, unless
you intervene with lifesaving measures.
• Do not delay transport for detailed
assessments and procedures.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Vital signs, followed by focused history
and physical exam.
• Based on primary assessment and
patient's chief complaint.
• Includes monitoring technology.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Types of Patients
– Major trauma patient with significant
injury or altered mental status
– Minor trauma patient with isolated
injury
– Responsive medical patient
– Unresponsive medical patient
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• The Major Trauma Patient
– Primary assessment.
– Rapid secondary assessment.
– Package patient.
– Rapid transport to emergency
department.
– Perform reassessment and treatments
en route.
– MOI could be life-threatening.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Predictors of Serious Internal Injury
– Fall from more than 20 feet
– Automobile crash with intrusion
– Ejection from vehicle
– Death in same passenger compartment
– Automobile–pedestrian collision
– Automobile–bicycle collision
– Motorcycle crash
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• MOIs can result from seat belts, air
bags, child safety seats.
• Look for hidden internal injuries.
• Physical signs of trauma confirm index
of suspicion.
• If in doubt, transport patient to medical
facility without delay; always best to
err on side of precaution.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment
– To identify all other life-threatening
conditions.
– Assess patient systematically; avoid
tunnel vision.
– Maintain spinal immobilization
throughout rapid trauma exam.
– Reconsider decision to transport; things
can change unexpectedly.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment
– Assess mental status using AVPU
mnemonic.
– Compare findings with baseline mental
status from initial assessment.
– Pay special attention to head, neck,
chest, abdomen, pelvis.
– Major concern: internal injuries beneath
superficial wounds.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment
– Deformities, contusions, abrasions,
penetrations, burns, tenderness,
lacerations, swelling.
– Assess head for injuries and crepitus.
– Simple scalp laceration can cause lifethreatening hemorrhage.
– Altered mental status and abnormality
in structure of skull: serious emergency.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment
– Inspect and palpate neck for injuries
and crepitus; significant blood loss
quickly.
– Examine jugular veins for abnormal
distention.
– Inspect and palpate trachea.
– Inspect and palpate neck for
subcutaneous emphysema.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment
– Palpate posterior neck for evidence of
spinal trauma.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–1
Rapid Secondary Assessment—
The Head and Neck
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–1 Rapid Secondary Assessment—The Head and Neck
7-1a The first step in the rapid secondary assessment is to palpate the head.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–1 Rapid Secondary Assessment—The Head and Neck
7-1b Periodically examine your gloves for blood.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–1 Rapid Secondary Assessment—The Head and Neck
7-1c Inspect and palpate the anterior neck. Pay particular attention to tracheal deviation and subcutaneous
emphysema.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–1 Rapid Secondary Assessment—The Head and Neck
7-1d Inspect and palpate the posterior neck. Note any tenderness, irregularity, or edema.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment
– Look for signs of acute respiratory
distress.
– Quickly inspect and then palpate chest.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment
– Be careful when palpating ribs; look for
erythema caused by impact to ribs.
– Suspect major damage to underlying
organs, especially vascular structures,
when ribs broken.
– Observe for equal, symmetrical,
effortless chest rise.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment
– Flail chest greatly reduces air
movement.
– Inspect patient's chest and back for
open wounds.
– Seal any open wounds with occlusive
dressing; tape dressing on three sides.
– Auscultate both lungs quickly at
midaxillary line for air movement.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–2 Rapid Secondary Assessment—The Chest
7-2c Seal any sucking chest wound with tape on three sides.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment
– Tension pneumothorax: life-threatening
condition.
– Inspect and palpate abdomen for
injuries and crepitus.
– Note areas of bruising and guarding.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–2
Rapid Secondary Assessment—
The Chest
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–2 Rapid Secondary Assessment—The Chest
7-2a Palpate the clavicles.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–2 Rapid Secondary Assessment—The Chest
7-2b Stabilize a flail chest.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–2 Rapid Secondary Assessment—The Chest
7-2c Seal any sucking chest wound with tape on three sides.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–2 Rapid Secondary Assessment—The Chest
7-2d Perform needle decompression to relieve tension pneumothorax if authorized.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment
– Inspect and palpate abdomen for
injuries and crepitus.
– Note areas of bruising and guarding.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment
– Bruising over umbilicus (Cullen's sign).
– Bruising over flanks (Grey Turner's
sign).
– Both signs indicate intraabdominal
hemorrhage; immediate transport to
medical facility for surgery.
– Test for rebound tenderness.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment
– Examine pelvis for injuries and crepitus;
stable pelvic ring.
– Evaluate pelvic ring at iliac crests and
symphysis pubis.
– Immobilize pelvis before transport to
prevent movement and possible
circulatory catastrophe.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–3 Rapid Secondary Assessment—The Chest
7-3a Assess the integrity of the pelvis by gently pressing medially on the pelvic ring.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment
– Inspect and palpate all four extremities
for injuries and crepitus.
– Splint fractures en route to hospital.
– Evaluate distal neurovascular function.
– Inability to feel and move both legs
indicates complete spinal cord
disruption.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–3 Rapid Secondary Assessment—The Chest
7-3f Assess distal sensation and motor function.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment
– Diminished sensation, paresthesias, or
diminished motor ability indicates partial
disruption.
– Weakness or disability on only one side
of body suggests brain injury due to
stroke or head injury.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–3
Rapid Secondary Assessment—
The Pelvis and Extremities
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–3 Rapid Secondary Assessment—The Chest
7-3a Assess the integrity of the pelvis by gently pressing medially on the pelvic ring.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–3 Rapid Secondary Assessment—The Chest
7-3b Compress the pelvis posteriorly.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–3 Rapid Secondary Assessment—The Chest
7-3c Palpate the legs.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–3 Rapid Secondary Assessment—The Chest
7-3d Palpate the arms.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–3 Rapid Secondary Assessment—The Chest
7-3e Palpate the dorsalis pedis pulse to evaluate distal circulation in the leg.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–3 Rapid Secondary Assessment—The Chest
7-3f Assess distal sensation and motor function.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• Rapid Secondary Assessment
– Check for MedicAlert tags.
– Log-roll patient onto side to inspect
posterior body; note tenderness in
spinal area.
– History: chief complaint, history of
present illness, past history, current
health status.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Inspect and palpate the posterior body.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• SAMPLE History
– Symptoms
– Allergies
– Medications
– Pertinent past medical history
– Last oral intake
– Events leading up to the incident
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• The Minor Trauma Patient
– Isolated injury; no significant MOI; no
signs of systemic involvement.
– Does not require extensive history or
comprehensive physical exam.
– Ensure hemodynamic status via primary
assessment.
– Secondary assessment on specific
isolated injury.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• The Responsive Medical Patient
– History takes precedence over physical
exam.
– Physical exam: identifies signs of
medical complications rather than
injury.
– Conscious, alert patients can tell you
about their illness.
– Chief complaint: pain, discomfort, or
dysfunction; patient requested help.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Begin treatment while you assess your responsive medical patient.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• The Responsive Medical Patient
– Present problem: circumstances
surrounding chief complaint.
– Follow acronym OPQRST–ASPN.
– Past medical history: insights into chief
complaint and field diagnosis.
– Family/social history: history of serious
disease may be “red flag” in the case.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• OPQRST–ASPN
– Onset
– Provocation/Palliation
– Quality
– Region/Radiation
– Severity
– Time
– Associated Symptoms
– Pertinent Negatives
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• The Responsive Medical Patient
– Review of systems: system-by-system
list of questions more specific than
those asked during basic history.
– Begin focused physical exam based on
information elicited from patient.
– Cardiac chest pain/respiratory distress,
altered mental status, acute abdomen.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• The Unresponsive Medical Patient
– Begin with primary assessment.
– Rapid head-to-toe exam.
– Brief history from family or friends.
– Airway protected.
– Assess head, neck, chest, abdomen,
pelvis, extremities, posterior aspect of
body.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Secondary Assessment
• The Unresponsive Medical Patient
– Assess baseline vital signs.
– Perform additional tests.
– Consider unresponsive patient unstable.
– Expedite transport to hospital.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Reassessment
• Patient condition can change suddenly.
• Reassess mental status, airway
patency, breathing adequacy,
circulation, any deterioration.
• Every 15 minutes for stable patients.
• Every 5 minutes for unstable patients.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–4
Reassessment
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–4 Reassessment
7-4a Reevaluate the ABCs.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–4 Reassessment
7-4b Take all vital signs again.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–4 Reassessment
7-4c Perform your focused assessment again.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Procedure 7–4 Reassessment
7-4d Evaluate your interventions' effects.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Reassessment
• Mental Status
– Recheck mental status by performing
AVPU exam frequently during transport.
– Falling level of response indicates direct
or indirect brain pathology.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Reassessment
• Airway Patency
– Can change instantly.
– Endotracheal intubation best way to
secure airway in patients with no gag
reflex.
– Be prepared for the worst.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Reassessment
• Breathing Rate and Quality
– Sudden increase in rate or respiratory
effort suggests deterioration.
– Subtle increases in respiratory rate can
suggest developing problem.
– Decrease in rate and effort could mean
treatments are effective.
– Requires constant reevaluation.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Reassessment
• Pulse Rate and Quality
– Rising pulse rate: shock, hypoxia,
cardiac dysrhythmia.
– Falling rate: terminal stage of shock or
rise in intracranial pressure.
– Sudden change in rate or regularity:
cardiac dysrhythmia.
– Loss of peripheral pulses:
decompensating shock.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Reassessment
• Skin Condition
– Reflects body's hemodynamic status.
– Reevaluate skin color, temperature,
condition.
• Transport Priorities
– Depending upon patient status, you
may need to either upgrade or
downgrade transport decision.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Reassessment
• Vital Signs
– Reassessing vital signs reveals trends.
– Reevaluate critical patients every 5
minutes.
• Secondary Assessment
– Repeat focused assessment as chief
complaint dictates.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Reassessment
• Effects of Interventions
– Know expected therapeutic benefits of
interventions; evaluate whether they
worked.
• Management Plans
– Evaluate whether care is working.
– If not, consider another management
plan.
– Be flexible to change course of action.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Clinical Decision Making
• Critical Thinking
– Form concept
– Interpret data
– Apply principles
– Evaluate results
– Reflect on incident
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Clinical Decision Making
• Form a Concept
– Assess general environment and
immediate surroundings.
– Conduct initial assessment.
– Chief complaint, history of present
illness, past history, current health
status.
– Conduct focused physical exam.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Clinical Decision Making
• Interpret the Data
– Consider all data.
– Determine most common and
statistically probable conditions that fit
patient's initial presentation.
– Differential field diagnosis.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Clinical Decision Making
• Apply the Principles
– Devise management plan that covers all
contingencies.
• Evaluate the Results
– Reassess patient's condition and effects
of protocol interventions.
– Determine whether treatment improving
patient's condition and status.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Clinical Decision Making
• Reflect on the Case
– Discuss field diagnosis and care with
emergency physician.
– Compare field diagnosis with physician's
diagnosis.
– Conduct run critique with your crew.
– With every patient contact, your
experience grows and clinical judgment
improves.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Patient assessment is key to providing
effective prehospital emergency
medical care.
• Primary assessment, secondary
assessment, vital signs, reassessment.
• Primary assessment: identify and treat
life-threatening airway, breathing,
circulation problems.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Secondary assessment: identify signs
and symptoms surrounding chief
complaint.
• Problem-oriented approach; easily
modified to match patient's clinical
situation.
• Reassessment: reevaluate patient for
changes in status en route to hospital.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Trauma patient with significant MOI:
primary assessment, rapid secondary
assessment, rapid transport.
• Patient with isolated, minor trauma:
physical exam focused on particular
problem or area.
• Responsive medical patient: primary
and secondary assessment; focused on
chief complaint, vital signs.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Unresponsive medical patient: primary
assessment; rapid secondary
assessment and rapid transport.
• You will be expected to use clinical
judgment when deciding which
assessment tools to use.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.