Advanced Assessment Guide:
Prehospital patient assessment is designed to be versatile and allow the paramedic to use rapid and focused examination to look for life threatening conditions and to determine appropriate treatments in the field. While all paramedic students at the PCP level are trained in rapid assessment and history taking, it is in these areas that skills often require development once students enter practical placements. The purpose of this guide is to allow the student to review and reference advanced patient care assessments for use in professional practice.
The General impression:
The general impression of the patient is meant to describe what the paramedic sees immediately upon approaching the patient. This is a “quick look” assessment that provides valuable information as to the degree of distress the patient may be in. It takes time to develop, and comes with practice. The General impression examines the following areas:
The patient's apparent level of consciousness: Is the patient awake? Are they tracking your movements? Do they acknowledge your presence in any way?
The patient's body positioning: Are they upright/supine/prone/seated/tripoding? Are all of thier limbs positioned appropriately? Are all of thier extremities attached?
The patient's apparent work of breathing: Are they breathing at a regular rate? Are they in obvious distress?
The patient's skin colour and apparent condition: Are they pale/cyanotic/diaphoretic?
This quick look test takes 3-5 seconds and gives us an idea of just how “sick” or “not sick” the patient may be.
The Primary Survey:
In the primary survey we want to look for and correct any life threats to the patient's main body systems; namely the airway, breathing, or circulation. The primary survey takes the following generally accepted format:
LOA/C-Spine: Here we want to determine if the patient needs C-Spine management and apply it if indicated. We also use this time to determine the patient's level of awareness. Are they alert, alert to verbal, alert to pain, or unresponsive?
X: X stands for “Exsanguinating hemorrhage”. In other words, does the patient have a massive external hemorrhage present? If so, we obviously need to correct this immediately, using BLS treatment.
Airway: We need to assess the patient's airway for patency, and determine if the patient can protect the airway themselves. If there are secretions or debris in the airway, clear them with suction and manual removal. If the patient is unable to maintain the airway, we need to consider using an adjunct such as an OPA or NPA. A supraglottic airway may also be considered for a patient who is GCS 3.
Breathing: Is the patient breathing spontaneously? Is the rate and rhythm adequate to support life? If the patient is in respiratory distress, we need to consider oxygen. If the patient is in respiratory failure (RR <10) we need to look at ventillation.
Circulation: We assess for peripheral and central pulses, as well as skin condition and capillary refill. We can anticipate the potential need for IV therapy here.
Disability: Now that we know the patient's general LOA, we can determine how impaired it may be. Is the patient oriented to person, place, time, and event?
Exposure: What areas do we need to expose in order to further assess the patient? If they are wearing 4 layers, or covered in blankets, we need to remove this. In the case of a Major Trauma Patient, we would now perform a RAPID TRAUMA SURVEY.
The Secondary Assessment:
The Secondary Assessment/Survey consists of obtaining a history, and vitals, and performing physical assessments based on the nature of the patient's complaint. A general template would be as follows:
History of Present Complaint | The HPC/HPI takes the following format depending upon whether the patient is complaining of pain, or another medical concern:
|
Past Medical History | A good general line of questioning is: “Do you have any problems with your heart, your lungs, any history of diabetes, epilepsy, stroke, or cancer?” |
Current Medications | Ask for a medication list or the bottles for the medications they currently take. |
Allergies | We really are only concerned with medication allergies, not so much environmental allergies. |
Last ins/outs | Has the patient been eating and drinking normally? Have they had any changes in bowel or bladder habits? When did they last eat or drink anything? |
Physical Examination | The physical examination will be dependant upon the patient's chief complaint. For an unresponsive patient, we will likely do a head to toe, however for a patient with abdominal pain, we would focus our exam on the affected areas (abdomen, chest, and back, with a possible assessment of the lower limbs). |
The review of systems:
Having generally discussed the primary and secondary assessments, lets focus on the physical examination. This is the meat and potatoes of advanced assessment, and it is here that we can formulate and narrow our differnetial diagnosis. Not all of these assessments are performed on every patient, however, varying combinations of exams are utilized based on the patient's chief complaint. For ease of understanding, assessments have been divided between medical and trauma.
Head and Neck:
Medical Examination: With regard to the medical examination of a patient, in the absence of trauma, we may assess the following:
Pupils for size, equality, reactivity to light, and accomodation response
Photophobia
Visual fields, for any deficits, or the presence of nystagmus, or deviation
Facial muscles for any asymmetry or droop
Speech for slurring or inapropriate or absent responses
Pain in the head or neck
Abnormal sensations of smell, taste, or auditory activity (tinnitis or deafness)
Abnormal masses, lesions, or rashes
The airway for angioedema
The patient's level of orientation and GCS
Trauma examination: In the setting of head injury, we want to assess:
The airway for any broken teeth, blood, or other secretions or debris.
The patient's level of awareness and orientation.
The skull for contusions, lacerations, abraisions, penetrating wounds, or Battle signs (Ottorhea, rhinorrhea, peri-orbital ecchymosis or mastoid bruising).
The facial bones for any evidence of deformity.
Pupils for PERLA
Any visual disturbances
The cervical spine for point tenderness, instability, crepitus, or step deformity.
The presence of pain
The chest and back:
Medical examination: We want to assess for;
Symmetrical expansion of the chest/thorax
The presence of any pain in the chest or back
Dyspnea, cough, or any other audible adventitious sounds
Accessory muscle use
Auscultate anterior and posterior lung fields noting air entry, wheezes, crackles, pleural rubs, or rhonchi
The back for any abnormalities
We may wish to perform 12-lead ecg
Trauma examination: We need to assess for;
Pain
contusions, lacerations abraisions, penetrations, subcutaneous emphysema, tenderness, instability, crepitus, or deformity
Symmetry of chest expansion
Audible and auscultated lung sounds
Open chest or back wounds
Paradoxical chest wall movement
Sternal bruising that may suggest cardiac or pulmonary contusions (we may wish to perform 12-lead ecg)
Check the spine for anatomical deformity
The Abdomen:
Medical examination: Due to the presence of multiple organ systems, abdominal assessment can be difficult. What follows is an overview of the myriad of things to assess for.
Assess for visible pulsations, scars, discolouration, distension, or masses
Palpate 4 quadrants, or 9 regions based on complaint
Consider assessments for Murph's Sign, or pain at McBurney's point in the settings of suspected cholecystitis or appendicitis
Assess for pain
In the presence of pain above the umbilicus, perform 12-lead ecg
Assess for the presence of nausea, vomiting, diarrhea, or changes in urination
Assess for changes in appetite
Ask about blood in the urine, stool, or vomit
Trauma examination:
Pain
Tenderness, asymmetry, rigidity, distension
ClAPS, TICS
Cullen's and Grey-Turner's signs
Penetrating trauma or eviscerations
The pelvis:
Medical examination: We generally don't perform assessment of the pelvis physically/visually unless an obstetrical patient states they feel an urge to push, or that there is something felt there. We can however ask:
Changes in bladder habits
Changes in bowel habits
Blood in the urine or stool
If there is bleeding, how much do we estimate it was
Obstetrical questions regarding contractions, amniotic fluid, blood, mucous plugs etc.
Pain
Trauma examination: In trauma, we are very concerned about the pelvis because a fracture here has the potetial to cause laceration of one or more arteries. The pelvic cavity itself can contain up to 2000cc of blood, so we want to be very careful not to overlook it.
Assess for instability medially
If the pelvis is suspected to have an unstable (open book) fracture, we need to secure it immediately with a sheet wrap or pelvic binding device.
Assess for pedal pulses and cap refill bilaterally before and after any splinting.
Assess for visible blood in the groin area.
Assess for pain
The extremities:
Medical examination: Assessment of the extremities, medically, involves looking for Circulation, Sensation, and Movement. We are trying to identify:
Pallor
Pulselessness
Paralysis
Paresthesia
Cool extremities
Cap refill
Range of motion
Pain
Grips bilaterally and pedal strength bilaterally
Drift
Gait and/or ataxia of movements
Trauma examination: In traumatic extremity injury, we are assessing for threats to life or limb. Our primary concerns are the identification of:
Gross bleeding
Extremity fracture, particularly of the femurs or the humoral bones
CSM
Cap refill
ROM
System Specific assessment:
The Neurological system:
We assess the neurological system, looking at both the central and peripheral nervous systems and attempting to identify neuro-deficits.
Beginning with the head, we need to look for:
GCS
LOA (Allert and oriented to what?)
Facial symmetry
Pupils
Visual fields for movement, disturbances, or deficits
Nystagmus
vertigo or dizziness
drowsiness
Speech for slurring or inapropriate responses
abnormal tastes, smells or sounds
Object recognition
Next we assess the peripheral nervous system, looking for:
Extremity deficits in grip or strength
Ataxic movements
Paresthesia or paralysis
Pain
Drift
Diminished or absent sensation
Tremor
If the setting permits, we can assess for reflexes
The key point of the neurological examination is to allow us to consider possible diagnoses to include in our differential, and thus determine appropriate treatments and destination for the patient.
The cardiovascular system:
In the setting of a patient with possible cardiac complaints, we need to assess:
Pain (SOCRATES/OPQRST)
Hemodynamic status
Distal perfusion
Dizziness, weakness
Nausea
Dyspnea
Headache
Pallor
Diaphoreses
Is the pain reproducible?
Is the pain Pleuritic?
Are there other symptoms such as fever or cough present
Auscultate the lungs for rales, wheezes, or rhonchi
Perform 3 lead and 12-lead ecg to look for arrhythmia, ST-elevation or depression, or conduction blocks
Much of this assessment can be done through questioning, however physically assessing for reproducible pain is important, as “chest pain” is a vague and non-specific symptom with a wide differential. We want to be wary of PAPPA; our deadly causes of chest pain.
P: Pulmonary embolism
A : Acute coronary syndrome/MI
P: Pneumothorax
P: Pericarditis
A: Aortic dissection
The respiratory system:
Respiratory assessment involves first identifying respiratory failure and correcting it. If a patient appears to be struggling to breath, or suddenly begins to slow respirations and decrease in responsiveness, we need to initate PPV with BVM. In settings of mild to moderate dyspnea, we assess for the following:
Auscultate the lungs for wheezes, rales, rhochi, diminished or absent breath sounds
Assess SPO2 and ETCO2
Look for pallor or cyanosis
Assess rate, volume, and rhythm of respirations
Ask about the presence of cough, fever, or chills
Identify any obvious odours that might indicate DKA (not everyone can)
Look for accessory muscle use
Look at patient positioning
Consider the possible involvement of other systems as well
The gastrointestinal/genitourinary systems:
Assessment of the GI/GU system involves a mix of questioning and physical examinations in order to identify underlying etiologies that may be responsible for the patient's chief complaint. Consider assessment of the following:
Pain
Nausea/vomiting/diarrhea
The presence of blood in the vomit, urine, or stools
If there is oral or rectal bleeding, attempt to determine upper vs lower GI source (Coffee ground emesis, frank rectal bleeding, melena, etc)
Changes in urination (dysuria, anuria, frequency, urgency, foul odours, cloudy or dark urine)
Palpate the abdomen in 4 quadrants or 9 regions
Consider assessment for Murphy's sign or palpation of McBurny's point
Assess for rebound tenderness
Consider auscultation for bowel sounds
Identify masses, or pulsations
Identify any distension or discolouration
The Obstetrical examination:
For a patient with known or suspected pregnancy, assess for:
Due date or the patient's last known menstrual period
Determine the patient's Gravida and Para
Ask about the patient's pre-natal care, and the presence of any problems with the current or previous pregnancies. Do they know if they are GBS positive?
Assess for any pain or contractions. If contractions are present, how far apart are they and what is thier duration?
Has the patient had any vaginal discharge or bleeding? Has the patient's water broken?
Palpate uterine height
Perform full set of vitals including blood glucose and ecg monitoring
If the patient is in active labour, determine if they have an urge to push, or if they feel a presenting part. At this point only would we inspect the vaginal opening for bloody show or crowning
Pediatric Patient Assessment:
Pediatric patients are a different animal. Children have anatomical and physiological differences that are significant in terms of identifying potential serious conditions.
Children compensate for hypovolemia by increasing heart rate.
Heart rate is largely controlled by respiration and oxygenation
Due to lower blood volume and smaller size, children compensate very well, right up until they don't.
Fever is a major cause of pediatric seizure in otherwise healthy patients.
Pediatric SVT is a thing, and we need to be aware of it.
We don't have a lot of medications that pediatric patients can take.
Assessment of pediatric patients follows the pediatric assessment triangle:
Appearance
Work of breathing
Circulation
When approaching a pediatric patient, use your general impression to gather information. Be wary of any pediatric patient who appears:
Lethargic
Pale
Has laboured breathing (nasal flaring in very young children)
Has slow or shallow breathing
Is involved in a trauma with a serious/high-energy MOI but appears otherwise “fine”
When approaching infants or todlers, consider the TICLS acronym:
T: Tone
I: Interactivity
C: Consolability
L: Look or gaze
S: Speech or cry
If possible, assess pediatric patient's with a parent present, or holding them. Assess from toe-to-head, leaving invasive or uncomfortable procedures until the end of your examination. Let children play with your equipment and become comfortable with it. Always explain what you are doing; don't surprise them, and DO NOT lie to them.
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