The scene assessment:
The scene assessment begins as you approach the address or location of the emergency call. On pulling up to the scene, assess for EMCAP:
Environment: Where is the incident occurring? Are there any obvious hazards present? Does the environment present logistical problems?
Mechanism: Is this a trauma call, a medical emergency, or are we unsure?
Casualties present: How many patients appear to be present?
Additional resources: Do you need another unit? Are Police or Fire needed?
PPE/BSI: What protective equipment might be needed for this call?
The scene assessment is a quick first glance risk assessment, and is intended to allow EMS personnel to perform their duties in a safe and effective manner.
The General Impression:
Sometimes called the doorway impression or the first look, the general impression is a quick interpretation of the perceived degree of patient distress. This allows us to determine if we can take our time or if we need to move quickly. The general impression consists of:
Apparent level of consciousness: Is the patient awake or not?
Positioning: Are they sitting, standing, lying down, tripodding, etc?
Work of breathing: What is the visible respiratory effort noted?
Skin colour and condition: Is the patient sweaty, pale, jaundiced, or perfusing well?
This first impression allows us to have an idea of how sick the patient is.
The Primary Survey
Affectionately referred to as the ABCs of emergency care, the primary survey is THE MOST IMPORTANT part of initial and ongoing patient care. It is here we identify and correct the things that will IMMEDIATELY kill our patient. The primary assessment consists of the following:
Massive hemorrhage management: If there is obvious profuse bleeding present (Life threatening bleeding such as visible arterial spray), it must be addressed and corrected first.
C-Spine precautions: If the mechanism of injury suggests possible spinal trauma, cervical spine must be stabilized with a collar.
Level of awareness: Is the patient ALERT, alert to VERBAL, rousable to PAIN, or UNRESPONSIVE, AVPU.
Airway: Is the airway both PATENT and PROTECTED? Do you need to suction, sweep or place an adjunct?
Breathing: Is the patient breathing? Is there evidence of respiratory distress (Apply oxygen) or respiratory failure (Assist ventilation with a BVM).
Circulation: Are distal and carotid pulses present? What is skin colour and condition? Is capillary refill 2 seconds or less?
When the primary survey has been initiated, it cannot be stopped or moved on from until life threats to the ABCs are corrected.
Following the primary survey, the type of assessment that will occur is determined by the type of patient you are dealing with. There are essentially 4 types of patients:
THE MAJOR TRAUMA PATIENT: The major trauma patient is an individual with a significant MOI, and obvious or potential trauma affecting multiple body systems. Immediately following the primary assessment, these patients should receive a RAPID TRAUMA SURVEY; a head to toe physical assessment, identifying trauma life threats and correcting them prior to moving the patient. History taking takes a back seat here as time is critical, and ultimately these patients need to be off scene and en-route to a trauma centre within 10 minutes of patient contact.
THE MINOR TRAUMA PATIENT: These are the patients we can take more time with. These individuals have one or more minor injuries, such as localized fractures, minor bleeding, or blunt trauma with a less significant MOI. Here we perform a focused exam on the area of injury, and we have time to deal with minor injuries prior to leaving scene.
THE UNRESPONSIVE MEDICAL PATIENT: This is difficult because the patient cannot tell you what happened. Following the primary survey, a rapid head to toe medical exam should be completed to look for clues and rule out trauma. If bystanders or family are present, a history can be obtained concurrently with the physical examination. Vitals should be obtained including a blood glucose and 12 lead ECG. Attempt to rule out life threats and determine a cause if possible. If a cause can be corrected on scene, do so (ie: narcan or dextrose), otherwise we are transporting these patients for definitive investigation at the hospital.
THE RESPONSIVE MEDICAL PATIENT: This is probably our easiest patient to treat, because they can often tell us what is wrong. Following the primary survey, we complete a history and physical examination of the patient based on the complaint stated. We treat what can be dealt with on scene and then transport.
Next, lets break down the primary survey, the rapid trauma survey, and history taking/The secondary survey.
The primary survey:
I Like to use the LOA (C)ABC format.
LOA: If the patient is alert and awake on arrival, we can consider them to be ALERT. If the patient is unresponsive until prompted verbally they are alert to VERBAL. If it takes a painful stimulus such as a trap squeeze or sternal rub to wake the patient, they are alert to PAIN. If none of this works, they are said to be UNRESPONSIVE. It is also during assessment of LOA that manual cervical spine stabilization should occur if a traumatic mechanism of injury is known or suspected.
(C) or Circulation in reference to massive hemorrhage: If profound hemorrhage is noted, it needs to be addressed as per local protocols. This may include direct digital pressure, tourniquets, or hemostatic dressings, and even potentially TXA.
Airway: If the patient is speaking clearly, it can be assumed the airway is patent. If the patient is unresponsive or has facial trauma, we need to ensure the airway is patent AND protected. This may mean that we need to suction secretions, manually position using a head-tilt-chin-lift, or a modified-jaw-thrust in the case of traumatic mechanism of injury. If the patient is unable to maintain the airway, we can utilize BLS adjuncts such as an OPA or NPA (except in head trauma), or an advanced airway such as a supraglottic airway or ET Tube to secure it.
Breathing: If a patient can speak full sentences without effort, and has no evidence of distress, we can assume breathing to be adequate. However, if the patient has evidence of respiratory distress, such as accessory muscle use, tachypnea,cyanosis, or audible wheezing, there is an issue with oxygenation and we need to apply supplemental oxygen in the form of a nasal cannula, hi-ox mask, or NRB. If the patient is struggling to breath and appears exhausted from the effort, or LOA has begun to deteriorate, the patient is entering respiratory failure, which requires ventilatory assistance with a BVM; the same is true for the apneic patient.
Circulatory status: We assess the radial pulse to ensure distal circulation is intact, noting rate, rhythm and strength, and a central pulse at the carotid. We can also perform bilateral pulse checks to ensure equality. Additionally we want to assess skin colour and condition. This gives us a picture of the patient's general perfusion status. In compromised perfusion states (SHOCK) we may want to consider having our partner start an IV as soon as able.
THE RAPID TRAUMA SURVEY:
The RTS is a head-to-toe assessment where we expose the patient and seek out life threatening traumatic injuries, correcting them as they are found.
Head: Assess for Contusions, Lacerations, Abrasions, Penetrations, Swelling, Deformity, Tenderness, instability, Crepitus (CLAPSD-TIC). Check pupils, and look for Ottorhea, rhinorhea, peri-orbital ecchymosis, or mastoid bruising.
Neck: Observe for tracheal deviation (at the sternal notch), or JVD (may be normal if patient is supine). Assess for CLAPSD-TIC, and feel the C-Spine for Point tenderness, instability, crepitus, or step deformity.
Chest: Assess for CLAPSD-TIC, Subcutaneous emphysema, Open chest wounds, paradoxical movement, and auscultate breath sounds for any diminished or absent air entry. Secure sucking chest wounds with chest seal. For Flail chests, provide PPV with a BVM an secure the segment with a bulky dressing or 500ml saline bag secured to the site (prevents movement of the segment which can cause other injuries) DO NOT WRAP THE CHEST CIRCUMFERENTIALLY.
Abdomen: Observe for CLAPSD-TIC, Palpate for tenderness, asymmetry, rigidity, or distension. Look pulsations, scars, discolouration (Grey-Turner or Cullen signs), or masses. Note eviscerations if present and address them following the completion of the RTS.
Pelvis: Palpate medially for stability. If pelvis is unstable, secure it NOW with a sheet wrap or pelvic binder if available.
Femurs: Palpate for stability. If Fracture is noted, address it following the completion of the rapid trauma survey.
Lower limbs and upper extremities: Assess for CLAPSD-TIC. Assess CSM is all 4 limbs.
Back: Palpate the spine and observe for CLAPSD-TIC.
Once the RTS is complete, roll the patient onto a backboard and move them to the ambulance. Once inside Vital signs, and a detailed head-to-toe exam can be completed concurrently with transport to a trauma centre. All other interventions can be done en-route. The exception to this rule is impaled objects, which need to be stabilized in place prior to moving the patient. IV cannulation, Sager splints, and minor dressings all can wait until you are moving toward a trauma surgeon.
HISTORY TAKING AND FOCUSED SECONDARY SURVEY:
In the case of minor trauma or responsive medical patients, we have time to utilize our patient history for the purpose of accurate field diagnosis and treatment of problems within our scope. The History taking portion of the assessment follows this format:
History of present illness (HPI)
Past medical history
Current medications
Allergies
Last ins and outs
History of present illness: The acronym I like to use is SOCRATES, which can be shortened to SOCATE for non-pain-related complaints. SOCRATES stands for:
S- Site or symptom: Why did the patient call? Has this happened before?
O- Onset: When did the problem start? Was the onset sudden or gradual? What was the patient doing when it started?
C- Character: How does the patient describe the problem or pain?
R- Radiation: In the case of pain, is it localized or does it radiate?
A- Associated symptoms: What other problems is the patient having that may be related?
T- Timing: Is the problem or pain constant or does it come and go?
E- Exacerbating factors: What makes the pain or problem worse? What makes it better? Has the patient taken any steps to address the problem themselves?
S- Severity: For pain, how bad is it on a 0-10 scale?
Past medical history: A good catch-all phrase is: Do you have any problems with your heart, your lungs, any history of diabetes, epilepsy, stroke, or cancer?
Medications: What medications is the patient currently on? Any recent changes? Are they taking them as prescribed?
Allergies: Does the patient have known allergies?
Last ins and outs: Is the patient eating and drinking normally? Are they peeing and pooping normally?
The focused secondary examination: This is a physical assessment of the systems associated with the patient's chief complaint. The assessments will vary, but could include, inspection, palpation, percussion, and auscultation, as well as stroke assessment, neurological exams, 12-lead ecg, blood glucometry, etc.
Once you have performed your history and physical examination, and incorporated findings from vital signs, you should be able to identify a probable cause within your differential, and utilize the correct treatment protocols to address the issue.
Patient assessment is as much an art as it is a science, and everyone develops their own methodology. I have presented what I do, every patient, every time. If this is helpful, use it, and feel free to tweak it to suit your needs.
Kommentare