SCENE SIZE-UP AND PRIMARY ASSESSMENT

1. LESSON 10 SCENE SIZE-UP AND PRIMARY ASSESSMENT

2. Introduction • Patient assessment involves critical EMR skills • Act quickly to ensure scene is safe, assess patient and care for immediate threats to life • Care provided is based on patient assessment • Assessment begins with the primary assessment

3. Scene Size-Up • While going to scene, consider factors that may affect safety for you, bystanders and patient • Dispatcher’s information may alert you to hazards or special precautions • Begin scene size-up before you exit your vehicle and while approaching the patient

4. Scene Safety Observe for any hazards • As you enter scene • While approaching patient

5. Hazardous Materials • Chemicals • Biological agents

6. Vehicle Crash Hazards • Traffic hazards • Downed wires • Risk of fire or explosion • Unstable vehicles • Extrication hazards • Hazardous materials

7. Potential Violence • Crime scenes • Potentially violent patient or bystanders • Guard dogs, wild animals

8. Environmental Dangers • Unstable surfaces • Water, ice • Weather extremes

9. Hazards Within Structures • Low-oxygen areas • Toxic substances, fumes • Risk of collapse • Risk of fire or explosion

10. Principles of Scene Safety • Enter scene only if it is safe • If unsafe, make it safe or stay away and request specialized resources • Protect bystanders and other rescuers from hazards • Protect patient from environmental threats

11. Scene Management • As you approach the patient, begin process of scene management • Consider factors related to a medical or trauma patient • Address hazards within the scene • Consider the need for additional resources • Implement standard precautions to prevent infection

12. Trauma vs. Medical Patient • Dispatch may tell you whether there is a trauma patient or a medical patient • This focuses your attention on a mechanism of injury or the nature of the illness

13. Mechanism of Injury • With trauma patient, scene size-up includes evaluating for clues about mechanism of injury (MOI) • MOI may suggest serious injury or presence of internal injuries

14. Consider the Mechanism • What specifically caused the injury? • Was there an impact with a blunt or sharp object? • What body area received the impact? What organs may be injured? • How much force may have been involved? • Might the force have been transferred from one body area to another?

15. Examples of Mechanism of Injury • Vehicle collision may cause head or spinal injuries • Fall from a height may cause extremity fractures • Blunt impact to abdomen may cause closed injury and internal bleeding • Diving incident may cause spinal injury • Gunshot may cause extensive internal damage not apparent from the appearance of the outside wound • Fall forward onto a hand may transfer force up arm and cause shoulder dislocation

16. Importance of Time • Quickly consider MOI during scene size-up • Do not delay patientassessment to examine scene in detail • Consider MOI more fully while gathering history and performing physical examination

17. Consider Nature of Illness • Consider nature of illness during scene size-up • Don’t stop to talk to family or bystanders until you are sure there is no immediate threat to life • Observe patient’s position and demeanor for clues • Use all your senses • If patient is unresponsive, move immediately to primary assessment • If patient is responsive, ask patient, family members or bystanders why EMS was called

18. Number of Patients • Determine how many patients are involved • Observe for clues and ask those present if everyone is accounted for • Be certain you know how many patients are involved • Call for additional help immediately for multiple patients • If more patients than responders, triage patients first

19. Addressing Hazards • Consider environmental factors as you size up scene • Protect yourself and other responders • Protect the patient • Protect bystanders

20. Additional Resources • Scene size-up includes consideration of whether additional resources may be needed • If resources not already en route, call dispatch immediately • Describe injuries in detail, so an ALS ambulance can be sent if needed

21. Additional Resources (continued) • Consider these factors: • Number of patients and types and seriousness of injuries • Possible need for air transport • Potential for fire or explosion • Potential presence of hazardous materials • Need for extrication • Need for law enforcement or traffic control • Damage to power lines or other utilities

22. BSI Precautions • Put on medical examination gloves as you approach patient • Observe scene and patient to determine whether to use other personal protective equipment: • Protective eyewear • Gown and mask • Turn-out gear • Follow standard precautions

23. Primary Assessment • Performed when you reach patient to identify any immediate threats to life • Rapid means to determine patient’s general condition and set initial priorities for care • Begin with your initial impression of patient • Check patient’s responsiveness, airway, breathing and circulation status • Perform primary assessment of all patients after scene size-up • If scene is safe, perform primary assessment before moving patient

24. General Impression • Is the patient ill or injured? • Does patient’s appearance give clues about his or her condition? • Are there signs of a serious problem? • Note patient’s sex and approximate age

25. Responsiveness • You may notice immediately whether patient is responsive • Responsive means a person is conscious and awake

26. Responsiveness (continued) • Patients who cannot talk may be able to move and thereby signal responsiveness

27. Responsiveness (continued) • Patients who cannot talk or move may be paralyzed but still able to respond with purposeful eye movements or other signs

28. Assessing Responsiveness • Begin by speaking to the patient; ask the patient what is wrong • If patient isn’t speaking or moving, tap gently and shout, “Are you OK?” • Be careful not to move patient in any way • Always suspect a spinal injury and take steps to stabilize head and neck

29. Unresponsiveness • Unresponsiveness may be sign of life-threatening problem or may result from a less urgent problem • Continue the primary assessment • Unresponsiveness is considered life-threatening emergency • In an unresponsive patient lying on the back, the tongue may block the airway

30. Degree of Responsiveness • Assessed with AVPU scale • AVPU scale useful for noting changes in a patient’s responsiveness while providing care and for communicating this information • Make mental note of level of responsiveness or write it down along with time • A change in level of responsiveness generally indicates a serious condition

31. Degree of Responsiveness(continued) AVPU Scale A = Alert V = Responds to Verbal stimuli P = Responds to Pain U = Unresponsive to all stimuli

32. Degree of Responsiveness(continued) • Responsiveness in pediatric patients • Infants and young children may respond differently from older children and adults • Look for age-appropriate responses • Assess unresponsive infant by flicking bottom of feet and noting response

33. Assess Breathing • While assessing for responsiveness, look for normal breathing • A patient who can speak, cough or make other sounds is breathing and has a heartbeat • Reflex gasping (agonal respirations) may be present just after cardiac arrest; do not confuse this with normal breathing • Lack of breathing may be caused by cardiac arrest, obstructed airway or other causes • If patient is not breathing normally, quickly move to next step and check for a pulse

34. Assess Circulation • In an unresponsive patient who is not breathing normally, check for circulation • If patient’s heart has stopped or patient is bleeding profusely, vital organs are not receiving enough oxygen to sustain life • Do not use more than 10 seconds to feel for the pulse  unless a pulse is clearly found in that time, start CPR • If the patient is responsiveor breathing, the heart is beating

35. Pulse Check • In responsive adult or child, check radial pulse • Note rate, rhythm and strength

36. Pulse Check (continued) • In an unresponsive adult, check carotid pulse (no longer than 10 seconds)

37. Pulse Check (continued) • In an unresponsive child, check either carotid pulse or femoral pulse • In an infant, use the brachial pulse in the inside of the upper arm

38. Pulse Check in Primary Assessment • Do not take time to count pulse, note whether it is irregular, very slow or very fast  signs that patient may not be stable • Lack of pulse along with absence of normal breathing signifies heart has stopped or is not beating effectively enough to circulate blood • If patient lacks a pulse and is not breathing normally, start CPR and call for an AED

39. Inadequate Breathing • A patient with a pulse may be breathing inadequately • Inadequate breathing is characterized by diminished mental status and any of these: • Difficult or labored breathing • Wheezing or gurgling sounds with breathing • Pale skin (ashen skin in a dark-skinned patient) or a blue (cyanotic) color of the lips and nail beds • A respiratory rate in an adult slower than 10 or greater than 30 breaths a minute • Give emergency care for a patient with a pulse who is breathing inadequately

40. Check for Serious Bleeding • Look for life-threatening bleeding • Arterial bleeding usually most serious • Bleeding from vein is generally slower

41. Check for Serious Bleeding(continued) • Don’t remove clothing to check for bleeding, but look for blood-saturated clothing and blood pooling • During primary assessment, don’t address minor bleeding or wounds • Control serious bleeding immediately with direct pressure

42. Assess Circulatory Status • Even with a pulse, circulation may be inadequate • Inadequate oxygenation of vital organs results in life-threatening shock

43. Signs of Inadequate Circulation • Heart rate in an adult <60 or >100 • Irregular pulse may be normal or abnormal • Pale skin may indicate blood loss, shock or low body temperature • Bluish skin may indicate an airway problem, poor ventilation or respiration, or poor blood flow • Cool skin temperature may indicate low body temperature or shock • Sweaty or wet skin may indicate shock, severe pain or physical exertion • Slow capillary refill (>2 seconds) in children may indicate shock

44. Treat Life Threats Found • If patient is unresponsive to verbal stimulus, has a fast or slow heart rate, and has skin signs of shock, treat for shock after the primary assessment • If patient has any life-threatening condition, treat it as soon as it is discovered • If patient has no immediate threat to life, proceed to secondary assessment

45. Primary Assessment of an Unresponsive Patient • Check for responsiveness and normal breathing. • If patient is unresponsive, call for more EMS resources. If unresponsive patient is not breathing normally, also call foran AED. • If patient is not breathing, check for a pulse for no longer than 10 seconds. If no pulse, start CPR. If a pulse, start ventilations. • If patient is breathing, check for severe bleeding, shock and other threats to life. • Care for any life-threatening conditions before continuing to check the patient and provide other care.

46. PatientPriority • Primary assessment determines whether a critical condition is present and what steps you need to take • Unresponsiveness or any problem with the airway, breathing or circulation is a high priority • Continue to reassess and treat life-threatening conditions while waiting for additional EMS resources • Call EMS unit to update patient’s condition

47. Report to EMS After the Primary Assessment • Provide this information: • Number of patients • Patient age and gender • Patient’s condition • Patient’s level of responsiveness • Patient’s breathing and circulation status • Ask responding unit their estimated time of arrival • Continue to care for patient accordingly • With stable patient, proceed to secondary assessment