2. National EMS Education
Standard Competencies
Assessment
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.
3. National EMS Education
Standard Competencies
Scene Size-up
• Scene safety
• Scene management
− Impact of the environment on patient care
− Addressing hazards
− Violence
− Need for additional or specialized resources
− Standard precautions
− Multiple patient situations
4. National EMS Education
Standard Competencies
Primary Survey
• Primary survey for all patient situations
− Initial general impression
− Level of consciousness
− ABCs
− Identifying life threats
− Assessment of vital functions
• Begin interventions needed to preserve life.
• Integration of treatment/procedures needed
to preserve life
5. National EMS Education
Standard Competencies
History Taking
• Determining the chief complaint
• Investigation of the chief complaint
• Mechanism of injury/nature of illness
• Past medical history
• Associated signs and symptoms
• Pertinent negatives
6. National EMS Education
Standard Competencies
History Taking (cont’d)
• Components of the patient history
• Interviewing techniques
• How to integrate therapeutic communication
techniques and adapt the line of inquiry
based on findings and presentation
7. National EMS Education
Standard Competencies
Secondary Assessment
• Performing a rapid full-body exam
• Focused assessment of pain
• Assessment of vital signs
• Techniques of physical examination
• Respiratory system
− Presence of breath sounds
8. National EMS Education
Standard Competencies
Secondary Assessment
• Cardiovascular system
• Neurologic system
• Musculoskeletal system
9. National EMS Education
Standard Competencies
Secondary Assessment
Techniques of physical examination for all
major
• Body systems
• Anatomic regions
Assessment of
• Lung sounds
10. National EMS Education
Standard Competencies
Monitoring Devices
• Obtaining and using information from
patient monitoring devices including (but not
limited to):
− Pulse oximetry
− Noninvasive blood pressure
− Blood glucose determination
− Continuous ECG monitoring
− 12-lead ECG interpretation
− Carbon dioxide monitoring
− Basic blood chemistry
11. National EMS Education
Standard Competencies
Reassessment
• How and when to reassess patients
• How and when to perform a reassessment
for all patient situations
12. National EMS Education
Standard Competencies
Medicine
Integrates assessment findings with principles
of epidemiology and pathophysiology to
formulate a field impression and implement a
comprehensive treatment/disposition plan for
a patient with a medical complaint.
13. National EMS Education
Standard Competencies
Medical Overview
Assessment and management of a
• Medical complaint
Pathophysiology, assessment, and
management of medical complaints to
include:
• Transport mode
• Destination decisions
14. Introduction
• One of the most important skills you will
develop is the ability to assess a patient.
− Combines a number of steps:
• Assessing the scene
• Obtaining chief complaint and medical history
• Performing a secondary assessment
− Process leads to:
• Differential diagnosis
• Working diagnosis
15. Introduction
• Your job is to quickly:
− Identify your patient’s problem(s).
− Set your care priorities.
− Develop a patient care plan.
− Execute your plan.
16. Sick Versus Not Sick
• Determine whether the patient is sick or not
sick.
− If the patient is sick, determine how sick.
• Every time you assess a patient:
− Qualify whether your patient is sick or not sick.
− Quantify how sick the patient is.
17. Establishing the Field
Impression
• A determination of what you think is the
patient’s current problem
− You must be able to communicate and ask
the right questions.
• Be a “detective.”
• Ask increasingly relevant questions.
− Develop your own style.
18. Is This Medical or Trauma?
• Medical patients
− Identify chief complaint and sift through medical
history.
• Trauma patients
− Medical history may have less impact
− Requires a modified approach
20. Scene Size-up
• Looking around and evaluating the overall
safety and stability of the scene
− Safe and secure access into the scene
− Ready egress out of the scene
− Specialty resources needed
21. Scene Safety
• Ensure the safety and well-being of your
EMS team and any other responders.
− If the scene is not safe, do what is necessary to
make it safe.
− Requires constant reassessment
23. Scene Safety
• Ensure that your team can safely gain
access to the scene and the patient.
− Consider a snatch and grab.
• Establish a safe perimeter to keep
bystanders out of harm’s way.
24. Scene Safety
• Be wary of toxic
substances and
toxic
environments.
− Proper body and
respiratory
protection is a
must.
Courtesy of Tempe Fire Department.
26. Scene Safety
• Environment risks
include:
− Unstable surfaces
− Snow and ice
− Rain
• Consider stability of
structures around you.
• Ensure safety of
bystanders next.
Courtesy of James Tourtellotte/U.S. Customs & Border Control.
27. Mechanism of Injury or Nature
of Illness
• Mechanism of injury (MOI)
− Forces that act on the body to cause damage
• Nature of illness (NOI)
− General type of illness a patient is experiencing
28. Mechanism of Injury or Nature
of Illness
• Multiple patients or obese patients may
warrant additional resources.
− Multiple patients must be triaged.
− Be familiar with specialized resources.
− Assess the need for spinal motion restriction.
30. Standard Precautions
• Treat all patients as potentially infectious.
− Wear properly sized gloves.
− Wear eye protection.
− Wear a HEPA or N95 mask.
− Wear a gown.
− Err on side of caution.
31. Standard Precautions
• Personal protective equipment (PPE)
− Clothing or equipment that provides protection
from substances that pose a health/safety risk
• Steel-toe boots
• Helmets
• Heat-resistant outerwear
• Self-contained breathing apparatus
• Leather gloves
33. Primary Survey
• You may use three exam techniques:
− Inspection
− Palpation
− Auscultation
34. Primary Survey
• Form a general impression.
− Based on initial presentation and chief
complaint
− Make conscious, objective, and systematic
observations.
− Is the patient in stable or unstable condition?
− Is the patient sick or not sick?
35. Primary Survey
• Observe level of consciousness.
• Decide whether to implement spinal motion
restriction procedures.
• Determine your priorities of care.
• Identify age and sex of the patient.
36. Primary Survey
• Treat life threats as you find them.
− What additional care is needed?
− What needs to be done on scene?
− When to initiate transport?
− Which facility is most appropriate?
• Assess mental status by using AVPU
process.
37. Assess the Airway
• Is airway open and patent?
• Crying or talking indicates airway adequacy.
• Move from simple to complex:
− Position
− Obstruction
38. Assess the Airway
• Possibility of spine injury determines how to
open airway:
− Head tilt–chin lift maneuver in medical patients
− Jaw-thrust maneuver in trauma patients
• Mechanical means requires an airway
adjunct.
• If patient cannot maintain airway, use more
invasive technique.
39. Assess Breathing
• Is the patient breathing?
− If not, you must breathe for him or her.
− If so, is he or she breathing adequately?
• Expose chest and inspect for injuries.
• Consider minute volume.
− Respiratory rate multiplied by the tidal volume
inspired with each breath
40. Assess Breathing
• Also consider:
− Breathing rate
− Work of breathing
− Chest rise and fall
− Lung sounds
41. Assess Circulation
• Perform full-body scan.
− Look for major hemorrhage or life-threatening
injury.
− Check for pulse.
− Evaluate the skin.
42. Assess Circulation
• Assess and control external bleeding.
− Perform rapid exam to identify any major
external bleeding.
− Venous bleeding is characterized by steady
blood flow.
− Arterial bleeding is characterized by a spurting
flow of blood.
− For unresponsive patients, sweep for blood by
running gloved hands from head to toe.
43. Assess Circulation
• Palpate the pulse.
− Count the number of beats in 30 seconds and
multiply by 2.
• Normal pulse rate for adults is 60–100 beats/min.
• Bradycardia: Rate less than 60 beats/min
• Tachycardia: Rate higher than 100 beats/min
44. Assess Circulation
• Quality
− Normal pulse is easy to feel.
− Weak pulse is thready.
− Bounding indicates hypertension.
• Rhythm
− Normal rhythm is regular.
− Irregular: Beats come early or late, or are
skipped
• Report your findings.
47. Restoring Circulation
• If a patient has inadequate circulation:
− Restore or improve circulation.
− Control severe bleeding.
− Improve oxygen delivery to the tissues.
48. Restoring Circulation
• If you cannot feel a pulse, begin CPR until
an AED or manual defibrillator is available.
− Follow standard precautions.
− Evaluate cardiac rhythm of any patient in
cardiac arrest.
− Oxygen delivery is improved through the
administration of supplemental oxygen.
49. Assess the Patient for
Disability
• Perform a neurologic evaluation.
− A mini-neurologic exam includes:
• AVPU scale and pupils (eg, size, equality,
reactivity to light)
• A quick assessment for neurologic deficits
• Glasgow Coma Scale (GCS)
50. Assess the Patient for
Disability
• Assess for any gross neurologic deficits.
− Have the patient move all extremities.
− Assess for motor strength and weakness.
− Assess grip strength.
− Assess for loss of sensation.
51. Expose Then Cover
• Visually inspect areas being examined.
• You cannot assess what you cannot see!
− Proper exposure of areas being examined is
essential to the physical examination process.
52. Make a Transport Decision
• Identify priority patients.
− Do only what is necessary at the scene and
handle everything else en route.
53. Priority Patients
• Include:
− Patients receiving
CPR
− Hypoperfusion or
shock
− Complicated
childbirth
− Chest pain w/ systolic
BP < 100 mm Hg
− Uncontrolled bleeding
− Multiple injuries
− Poor general
impression
− Unresponsive
patients
− Difficulty breathing
− Hypoxia not
corrected in 1–2
minutes
− Suspected AMI w/
ECG showing
STEMI
− Suspected stroke
55. History Taking
• Gain information about the patient and the
events surrounding the incident.
• Ask open-ended questions.
• Avoid leading questions.
• Ask age-appropriate questions.
• Be patient.
56. Patient Information
• Name and chief complaint are the most
important pieces.
• Obtain other information in whatever order
is most conducive to good patient care and
most convenient.
59. Communication Techniques
• Introduce yourself and partner.
• Identify your service and certification level.
• Be familiar with the cultural groups in your
area.
− Any issues that could lead to misunderstanding
• Ask about feelings.
62. Dealing With Sensitive Topics
• Social history
− Not typically gathered in prehospital setting
− However, provides valuable information about
overall health and helps to identify risk factors
for various disease processes
64. Dealing With Sensitive Topics
• Sexual history
− Talk to the patient in private.
− Keep your questions focused.
− Do not interject opinions or biases.
− Treat with compassion and respect.
66. Handling Physical Attraction to
Patients
• It is never appropriate for a clinician to act
on feelings of attraction to a patient.
• If a patient becomes seductive or makes
sexual advances, firmly make it clear that
your relationship is professional.
• Keep someone else in the room at all times.
68. Protecting the Patient’s
Privacy
• Interview patients in a private setting.
• Obtain information that patient may be
reluctant to share.
• Do not hesitate to ask nonessential
personnel to leave the room or to step back.
69. Gathering Information From
Third Parties
• If patients can’t provide information, other
sources on scene may need to be used.
• The further from primary source, the greater
the chance of inaccuracies.
− Family and friends often filter information.
− They may be able to describe the patient’s chief
complaint, history, and possibly current health
status.
70. Gathering Information From
Third Parties
• Law enforcement personnel and bystanders
can also provide information.
• For routine transfers, take a few moments
to review transfer paperwork.
− Learn about the patient’s medical history.
− Consider reliability of this paperwork.
71. Cultural Competence
• Common barriers to communication:
− Race
− Ethnicity
− Age
− Gender
− Language
− Education
− Religion
− Geography
− Economic status
72. Cultural Competence
• Respect ideas and beliefs.
• Consider dietary practices.
• Obtain consent.
• Provide best possible care for all patients.
• Research prevalent groups in your area.
• Remember the importance of manners.
73. Cultural Competence
• Facilitating cross-cultural communication
− Identify an interpreter.
• Consider using closed-ended questions.
• Remind interpreter that information is
confidential.
− Use a certified medical interpreter if possible.
− Consider manners, hand gestures, and body
language.
74. Special Challenges in History
Taking
• Overly talkative
patients
• Silence
• Anxious patients
• Depression
− Situational
− Chronic
• Anger and hostility
− Don’t take it
personally.
− Be attentive to
risks.
− Retreat and call
police if needed.
75. Special Challenges in History
Taking
• Confusing history or bizarre behavior
− Consider medical causes.
• Sensory or developmental challenges
− Limited education or intelligence
− Hearing loss, low vision, or blindness
76. Managing Age-Related
Considerations
• Pediatric patients
− Include child in the history-taking process.
− Be sensitive to the fears of the parents.
− Pay attention to the parent-child relationship.
77. Managing Age-Related
Considerations
• Pediatric patients (cont’d)
− Tailor your questions to the age of the child.
• Neonates/infants: Maternal history and birth
history
• 3 to 5 years: Performance in school
• Adolescent: Risk-taking behaviors, self-esteem
issues, rebelliousness, drug and alcohol use, and
sexual activity
− Gather an accurate family history.
78. Managing Age-Related
Considerations
• Geriatric patients
− Present a variety of medical and traumatic
conditions not seen in other patients
− Accommodate sensory losses.
− Patients tend to have multiple problems.
• May have multiple chief complaints
• May take a multitude of medications
79. Managing Age-Related
Considerations
• Geriatric patients (cont’d)
− Symptoms may be less dramatic.
− Consider including a functional assessment.
• Assessment of mobility
• Upper extremity function
• Activities of daily living
80. Responsive Medical Patients
• Chief complaint
− Reason someone called 9-1-1
− Should be recorded in patient’s own words
− Determine patient’s alertness.
− Ask about events to begin elaborating on chief
complaint.
− Look for clues on scene.
81. Responsive Medical Patients
• History of illness
− OPQRST
• Onset
• Provocation
• Quality
• Region/radiation/
referral
• Severity
• Time
− SAMPLE
• Signs and
symptoms
• Allergies
• Medications
• Pertinent past
history
• Last oral intake
• Events that led to
injury or illness
82. Responsive Medical Patients
• “What made you call 9-1-1?”
• If the patient’s behavior is inappropriate,
consider:
− Hypoxia
− Medical issue
− Low blood glucose or hypothermia
− Psychiatric emergency
− Drug or alcohol ingestion
83. Responsive Medical Patients
• Current health status
− Made up of unrelated pieces of information
− Ties together past history with history of current
event
− Focuses on environmental and personal habits
84. Responsive Medical Patients
• Current health status (con’d)
− Examples of questions to ask:
• What prescription medicines do you take?
• Are you allergic to anything?
• Do you drink beer, wine, or cocktails?
• Do you smoke?
− Decide which items to explore.
85. Responsive Medical Patients
• Family history
− Helps establish patterns and risk factors for
potential diseases
− Information should be related to the patient’s
current medical condition.
86. Responsive Medical Patients
• Social history
− Patient’s occupation may indicate possible toxic
exposures.
− Environment indicates lifestyle and chronic
exposures.
− Travel history may be relevant.
− Questions regarding diet may be appropriate.
87. Responsive Medical Patients
• Past medical history
− Should include:
• Current medications and dosages
• Allergies
• Childhood illnesses
• Adult illnesses
• Past surgeries
• Past hospitalizations and disabilities
88. Responsive Medical Patients
• Past medical history (cont’d)
− Patient’s emotional affect provides insight into
overall mental health.
− Determine whether the patient has ever
experienced the problem.
• A new problem or condition is best considered
serious until proven otherwise.
90. Trauma Patients
• Life-threatening MOIs
− Falls
• Greater than 20
feet for adults
• Greater than 10
feet for children
− High-risk motor
vehicle crash
• Intrusion
• Ejection
• Death of another
occupant
• Vehicle-pedestrian
collision
• Motorcycle/ATV
crash
94. Review of Body Systems
• General symptoms
− Ask questions regarding:
• Fever
• Chills
• Malaise
• Fatigue
• Night sweats
• Weight variations
95. Review of Body Systems
• Skin, hair, and nails
− Rash, itching, hives, or sweating
• Musculoskeletal
− Joint pain, loss of range of motion, swelling,
redness, erythema, and localized heat or
deformity
96. Review of Body Systems
• Head and neck
− Severe headache or loss of consciousness
− Eyes and ears
• Ask about visual acuity, blurred vision, diplopia,
photophobia, pain, changes in vision, and flashes
of light.
• Ask about hearing, loss, pain, discharge, tinnitus,
and vertigo.
97. Review of Body Systems
• Nose, throat, and mouth
− Sense of smell, rhinorrhea, obstruction,
epistaxis, postnasal discharge, and sinus pain
− Sore throat, bleeding, pain, dental issues,
ulcers, and changes to taste sensation
98. Review of Body Systems
• Endocrine
− Enlargement of the thyroid gland
− Temperature intolerance
− Skin changes
− Swelling of hands and feet
− Weight changes
− Polyuria, polydipsia, polyphagia
− Changes in body and facial hair
99. Review of Body Systems
• Chest and lungs
− Dyspnea and chest pain
− Coughing, wheezing, hemoptysis, and
tuberculosis status
− Previous cardiac events
− Pain or discomfort
− Orthopnea, edema, and past cardiac testing
100. Review of Body Systems
• Hematology and lymph nodes
− History of anemia, bruising, and fatigue
− Tender and enlarged lymph nodes
101. Review of Body Systems
• Gastrointestinal
− Ask about:
• Appetite and general digestion
• Food allergies and intolerances
• Heartburn, nausea and vomiting, diarrhea
• Hematemesis
• Bowel regularity, changes in stool, flatulence,
• Jaundice
• Past GI evaluations and tests
− Consider GI bleeding and urinary habits.
102. Review of Body Systems
• Genitourinary
− Ask about sexually transmitted diseases.
− For women ask:
• If menstrual cycle is regular
• When last period was
• If she has dysmenorrhea
• When last sexual intercourse was
• Whether she has had multiple partners
• What kind of contraception she uses
• Whether she has ever been pregnant
103. Review of Body Systems
• Genitourinary
− For men:
• Ask about erectile dysfunction, fluid discharge,
and testicular pain.
• When most recent sexual encounter was
• If they use condoms
• About the characteristics of any discharge or
lesions
104. Review of Body Systems
• Neurologic
− Seizures or syncope, loss of sensation,
weakness in extremities, paralysis, loss of
coordination or memory, and muscle twitches
− Facial asymmetry
− If you suspect stroke or TIA, use appropriate
stroke scale.
105. Review of Body Systems
• Psychiatric
− Depression, mood changes
− Difficulty concentrating
− Anxiety, irritability
− Sleep disturbances, fatigue
− Suicidal or homicidal tendencies
106. Critical Thinking
• Goal of assessment:
− Figure out most likely reason for patient’s chief
complaint and how best to address it.
• Five aspects of critical thinking:
− Concept formation
− Data interpretation
− Application of principles
− Reflection in action
− Reflection on action
107. Clinical Reasoning
• Combines knowledge of anatomy,
physiology, pathophysiology, and patient’s
complaints
• Pay attention to signs or symptoms that are
inconsistent with working diagnosis.
− Differential diagnosis—a working hypothesis of
the nature of the problem
109. Secondary Assessment
• Process by which quantifiable, objective
information is obtained from a patient about
his or her overall state of health
− Consists of two elements:
• Obtaining vital signs
• Performing a systematic physical exam
110. Secondary Assessment
• Prehospital setting may determine how
secondary assessment is performed.
• Identifying abnormalities requires direct
hands-on experience.
• Factors in starting exam:
− Stability of patient
− Chief complaint
− History
− Communication ability
111. Secondary Assessment
• Not every aspect will be completed in every
patient.
• Factors to consider:
− Location
− Positioning of the patient
− The patient’s point of view
− Maintaining professionalism
112. Physical Exam of Priority
Patients
• The physical exam performed depends on
patient needs.
• If traditional physical exam isn’t possible, a
rapid full-body scan may be required.
− A 60- to 90-second nonsystematic review and
palpation of the patient’s body
− Inspect the soft tissue, look for open or closed
wounds, and palpate for pain or tenderness.
114. Assessment Techniques
• Percussion
− Striking surface of the body, typically where it
overlies various body cavities
− Detects changes in the densities of the
underlying structures
115. Assessment Techniques
• Auscultation
− Listening with a stethoscope
− Requires:
• Keen attention
• Understanding of what “normal” sounds like
• Lots of practice
117. Vital Signs
• Pulse
− Assess rate, presence, location, quality,
regularity
− To palpate, gently compress an artery against a
bony prominence.
• Count for 30 seconds and multiply by 2.
• Check for central pulse in unresponsive patients.
119. Vital Signs
• Respiration
− Assess rate by inspecting the patient’s chest.
− Quality
• Pathologic respiratory patterns or rhythms
• Tripod positioning, accessory muscle use,
retractions
− Rate should be measured for 30 seconds and
multiplied by 2 for pediatric patients.
121. Vital Signs
• Blood pressure
− Product of cardiac output and peripheral
vascular resistance
• Systolic pressure
• Diastolic pressure
− Measured using a cuff
− Ideally should be auscultated
122. Vital Signs
• Temperature
− When measuring the tympanic membrane
temperature:
• External auditory canal must be free of cerumen.
• Position the probe so the infrared beam is aimed
at the tympanic membrane.
• Wait 2–3 seconds until temperature appears.
129. Physical Examination
• Terms to describe
the degree of
distress:
− No apparent
distress
− Mild
− Moderate
− Acute
− Severe
• Terms to describe
the general state
of a patient’s
health:
− Chronically ill
− Frail
− Feeble
− Robust
− Vigorous
130. Full-Body Exam
• A systematic head-to-toe examination
• Patients who should receive:
− Sustained a significant MOI
− Unresponsive
− Critical condition
131. Focused Exam
• Performed on patients who have sustained
nonsignificant MOIs and are responsive
• Focus on the immediate problem.
132. Mental Status
• For any patient with a “head” problem,
assess and palpate for signs of trauma.
− Assess the patient in four areas:
• Person
• Place
• Day of week
• The event
133. Mental Status
• Use the Glasgow Coma Scale
− Assigns point value for eye opening, verbal
response, and motor response
• General appearance
• Speech and language patterns
• Mood
• Thoughts and perceptions
• Information relevant to thought content
• Insight and judgment
• Cognitive function (attention and memory)
134. Skin
• Perhaps the quickest and most reliable way
to assess overall distress
• Serves three major functions:
− Transmits information from the environment to
the brain
− Protects the body from the environment
− Regulates the temperature of the body
136. Skin
• Pallor: Poor red blood cell perfusion to the
capillary beds
• Vasoconstriction: Indicated by pale skin
• Cyanosis: Low arterial oxygen saturation
• Mottling: Severe hypoperfusion and shock
137. Skin
• Ecchymosis: Localized bruising or blood
collection within or under the skin
• Turgor: Relates to hydration
• Skin lesions: May be only external evidence
of a serious internal injury
138. Hair
• Examine by inspection and palpation.
− Note:
• Quantity
• Distribution
• Texture
• Recent changes in growth or loss of hair
146. Ears
• Involved with hearing, sound perception,
and balance control
• Includes:
− Outer portion
− Middle portion
− Inner portion
147. Ears
• Assess for:
− Changes in hearing perception
− Wounds
− Swelling
− Drainage
• Assess mastoid process of the skull for
discoloration and tenderness.
149. Nose
• Look for:
− Asymmetry
− Deformity
− Wounds
− Foreign bodies
− Discharge or bleeding
− Tenderness
− Evidence of respiratory distress
150. Throat
• Evaluate mouth, pharynx, and neck.
− Prompt assessment is mandatory in patients
with altered mental status.
− Assess for a foreign body or aspiration.
• Be prepared to assist with manual techniques
and suction.
151. Throat
• Mouth
− Lips
− Symmetry
− Gums
− Look for cyanosis around the lips.
• Inspect airway for obstruction.
152. Throat
• Tongue
− Size
− Color
− Moisture
• Maxilla and
mandible
− Integrity
− Symmetry
• Oropharynx
− Discoloration
− Pustules
− Unusual odors on
the breath
− Fluids that might
need suctioning
− Edema and
redness
155. Cervical Spine
• Indications for spinal immobilization:
− Tenderness on palpation of spinal column
− Complaint of pain in spine
− Altered mental status
− Inability to communicate effectively
− GCS of less than 15
− Evidence of a distracting injury
− Paralysis or other neurologic deficit or complaint
156. Cervical Spine
• Inspect and palpate.
− Stop exam if pain, tenderness, or tingling
results.
− Assess range of motion when there is no
potential for serious injury.
• Passive exam
• Active exam
157. Chest
• Contains lungs, heart, and great vessels
• Three phases of exam
− Chest wall exam
− Pulmonary evaluation
− Cardiovascular assessment
158. Chest
• Check for:
− Symmetry
− Respiratory effort
− Signs of obstruction
− General shape of the chest wall
− Signs of abnormal breathing
− Chest deformities
− Tenderness or crepitus
162. Chest
• Are sounds:
− Dry or moist?
− Continuous or intermittent?
− Course or fine?
• Are breath sounds diminished or absent?
− In a portion of one lung or entire chest?
− If localized, assess transmitted voice sounds.
163. Cardiovascular System
• Circulates blood throughout the body
• Blood flows through two circuits:
− Systemic circulation
− Pulmonary circulation
166. Cardiovascular System
• Splitting: Events on the right of the heart
usually occur later than those on the left.
− Creates two discernible sounds
• Korotkoff sounds: Related to blood pressure
− There are five (first and fifth are significant):
• First: Thumping of the systolic
• Fifth: Disappears as the diastolic pressure drops
below that created by the blood pressure cuff
167. Cardiovascular System
• Use the point of maximum impulse (PMI) to
assess apical pulse.
• Bruit: Abnormal “whoosh”-like sound
− Turbulent blood flow through narrowed artery
• Murmur: Abnormal “whoosh”-like sound
− Turbulent blood flow around a cardiac valve
− Graded by range of intensity from 1 to 6
168. Cardiovascular System
• Arterial pulses are an expression of systolic
blood pressure.
− Palpable where artery crosses bony
prominence
• Venous pressure tends to be low.
− Assess extremities for signs of obstruction or
insufficiency.
169. Cardiovascular System
• Jugular venous distention (JVD)
− With penetrating left chest trauma, may indicate
cardiac tamponade
− With pedal edema, consider heart failure.
− Note how much distention is present.
170. Cardiovascular System
• An older patient’s ability to compensate for
cardiovascular insult may be compromised.
− Arterial atherosclerosis and diabetes
− Medications, such as for high blood pressure
171. Cardiovascular System
• Pay attention to arterial pulses.
• Obtain blood pressure and repeat.
− Note history and class of hypertension.
172. Cardiovascular System
• Palpate and auscultate carotid arteries.
• For a suspected heart problem, assess:
− Pulse
− Skin
− Breath sounds
− Baseline vital signs
− Extremities
175. Abdomen
• Abdomen contains:
− Almost all of the organs of digestion
− Organs of the urogenital system
− Significant neurovascular structures
• Peritoneum: Well-defined layer of fascia
made up of parietal and visceral peritoneum
− Intraperitoneal organs
− Extraperitoneal organs
176. Abdomen
• Three basic mechanisms produce pain
− Visceral pain
− Inflammation
− Referred pain
177. Abdomen
• Orthostatic vital signs (tilt test)
− Blood pressure and pulse are taken in the
supine and sitting or standing positions.
− Determines extent of volume depletion
• If volume-depleted, there is not enough
circulating blood to push into core circulation.
178. Abdomen
• Orthostatic vital signs (tilt test) (cont’d)
− Generally considered positive if:
• Decrease in systolic pressure
• Increase in diastolic pressure of 10 mm Hg
• Increase in pulse rate by 20 beats/min
179. Abdomen
• For inspection:
− Make patient comfortable.
− Proceed in systematic fashion.
• Abdomen can be described as:
− Flat
− Rounded
− Protuberant (bulging out)
− Distinguish from obesity
− Scaphoid
− Pulsatile
180. Abdomen
• Ascites
− Fluid within the peritoneal cavity
− Abdomen may appear markedly distended
− A visible or palpable fluid wave may be evident
− Shifting dullness to percussion
• Bluish discoloration in periumbilical area
(Cullen sign) or along flanks (Grey Turner
sign)
− Indicates ruptured ectopic pregnancy or acute
pancreatitis
181. Abdomen
• Auscultation
− May have limited utility in prehospital setting
− Setting must be quiet to hear bowel sounds.
− Differentiating normal from abnormal can be
challenging.
− Practice on healthy people.
− Note presence or absence of bowel sounds.
182. Abdomen
• Palpation
− Palpate each quadrant gently but firmly.
• Should appear soft without tenderness or
masses.
− Guarding: Contraction of abdominal muscles
− Rebound tenderness: Pain upon release
− Abdominal rigidity: Peritoneal irritation and
guarding
− Less discrete (localized) guarded tenderness
may indicate a more visceral problem.
183. Abdomen
• Palpation (cont’d)
− To palpate the liver:
• Place left hand behind patient, parallel to right
11th and 12th ribs.
• Place right hand on right abdomen below rib
cage.
• Ask patient to take a deep breath.
• Try to feel the liver edge.
184. Abdomen
• Palpation (cont’d)
− To palpate the gallbladder:
• Use same technique as for liver.
• Response indicating pain may mean possible
inflammation.
• When patient takes deep breath, move fingers
under liver edge.
185. Abdomen
• Palpation (cont’d)
− To palpate the spleen:
• With left hand, reach over and around patient.
• Press forward lower left rib cage and adjacent
soft tissues.
• With right hand below costal margin, press
toward the spleen.
186. Abdomen
• Aortic aneurysm
− May be seen pulsating in the upper midline
− Do not palpate an obvious pulsatile mass.
• Hernia
− Place patient in supine position and raise the
head and shoulders.
• Bulge of hernia will usually appear.
188. Female Genitalia
• Limited and discreet assessment
− Reasons to examine include:
• Life-threatening hemorrhage
• Imminent delivery in childbirth
− Assessment includes:
• Palpating the bilateral inguinal regions
• Palpating the hypogastric region
189. Female Genitalia
• Reasons for pain on palpation include:
− Ectopic pregnancy
− Complications of third trimester pregnancy
− Nonpregnant ovarian problems
− Pelvic infections
191. Male Genitalia
• Limited exam with partner present.
− Assess for bleeding, injury, or fracture.
− Note inflammation, discharge, swelling, or
lesions.
− Priapism: Prolonged erection
− Look for evidence of urinary incontinence.
192. Anus
• Distal orifice of the alimentary canal
• Often evaluated at same time as genitalia
• Examined in limited circumstances
− Keep patient draped.
− Partner should be present.
• Assess for need of bleeding control or
another intervention.
− Examine sacrococcygeal and perineal areas.
193. Musculoskeletal System
• Joints: Areas where bone ends abut each
other and form a kind of hinge
• Skeletal muscles: Used to flex and extend
joints
− Joints become more vulnerable to injury, stress,
and trauma as they age.
194. Musculoskeletal System
• Common injuries:
− Fractures
− Sprains
− Strains
− Dislocations
− Contusions
− Hematomas
− Open wounds
195. Musculoskeletal System
• Note:
− Structure and
function
− Limitation or pain
in range of motion
− Bony crepitance
− Inflammation or
injury
− Obvious deformity
− Diminished
strength
− Atrophy
− Asymmetry
− Pain
196. Musculoskeletal System
• Problems with the shoulders can often be
determined by noting posture.
− Assess:
• Sternoclavicular joint
• Acromioclavicular joint
• Subacromial area
• Bicipital groove
197. Musculoskeletal System
• Assess range of motion:
− Ask patient to raise arms above the head.
− Have patient demonstrate external rotation and
abduction.
− Perform internal rotation.
203. Peripheral Vascular System
• Perfusion occurs in the peripheral
circulation.
− Diseases of the peripheral vascular system are
often seen in patients with other underlying
medical conditions.
204. Peripheral Vascular System
• During assessment, pay attention to upper
and lower extremities.
− Signs of acute or chronic vascular problems
205. Peripheral Vascular System
• Assessment
− Inspect upper extremities.
− Five Ps of acute arterial insufficiency:
• Pain
• Pallor
• Paresthesias
• Paresis
• Pulselessness
206. Peripheral Vascular System
• Assessment (cont’d)
− Palpate epitrochlear and axillary lymph nodes.
− Inspect lower extremities.
− Palpate lower extremities.
− Note temperature of feet and legs.
− Attempt to palpate edema.
− Palpate superficial inguinal lymph nodes.
207. Spine
• Consists of 33 individual vertebrae
• Inspect the back.
− Lordosis
− Kyphosis
− Scoliosis
210. Spine
• Range of motion:
− Check passively first, then actively.
− If any pain or tingling is elicited, stop the exam
and immobilize the spine.
211. Nervous System
• Nervous system is divided into:
− Voluntary nervous system
− Involuntary (autonomic) nervous system
• Sympathetic
• Parasympathetic
212. Nervous System
• Reflexes
− Involuntary motor response to specific sensory
stimuli
− Primitive reflexes
− Babinski reflex test may be used to check
neurologic function.
• Do not perform on a patient with lower-extremity
injuries.
213. Nervous System
• Neurologic exam
− Mental status
(AVPU)
− Cranial nerve
function
− Distal motor
function
− Distal sensory
function
− Deep tendon
reflexes
• Mental status
exam
− COASTMAP
• Consciousness
• Orientation
• Activity
• Speech
• Thought
• Memory
• Affect (mood)
• Perception
214. Nervous System
• Cranial nerve examination
− Determines presence and degree of disability
− Can be performed in less than 3 minutes
216. Nervous System
• Check sensory function.
− Assess primary and cortical sensory functions.
− Evaluate deep tendon reflexes.
217. Nervous System
• Results of the neurologic exam
− Delirium
• Consistent with an acute sudden change in
mental status
− Dementia
• Representative of deterioration of cognitive
cortical functions
218. Secondary Assessment of
Unresponsive Patients
• After ruling out trauma, position in recovery
position.
− If trauma, position in neutral alignment.
• Perform a thorough assessment of the body
and look for signs of illness.
219. Secondary Assessment of
Unresponsive Patients
• Perform at least two sets of vital signs.
− Should include:
• Auscultated blood pressure
• Accurate pulse and respiratory rates
• Patient’s temperature
• Consider unresponsive patients to be in
unstable condition.
220. Secondary Assessment of
Trauma Patients
• Two classifications of trauma patients:
− Isolated injury
− Multisystem trauma
• “High visibility factor”
− Do not become distracted by obvious but non–
life-threatening injuries.
221. Secondary Assessment of
Trauma Patients
• Patient who is unresponsive or has altered
mentation is considered high risk.
• Perform rapid exam.
− When time and condition permit, perform
physical examination.
222. Recording Secondary
Assessment Findings
• Should be orderly and concise
• Document using the forms recommended
by your medical director.
− Note:
• Objective signs
• Pertinent negatives
• Similar relevant information
223. Limits of the Secondary
Assessment
• Not everything can be discovered in the
secondary assessment.
• Keep total time in field to a minimum.
• Evaluation by trained physician coupled
with laboratory and radiographic studies
may be needed for a definitive diagnosis.
228. Monitoring Devices
• Blood glucometer
− Can obtain reading in two ways in the field:
• From the hub of an IV catheter
• From a finger stick
− Most take only a few seconds.
− Should be calibrated regularly
229. Monitoring Devices
• Cardiac biomarkers
− Used to assess presence of damage to cardiac
muscle
− May take several hours following a myocardial
infarction for the cardiac biomarkers to become
elevated
230. Monitoring Devices
• Other blood tests
− Basic and complete metabolic profile (CHEM 7
and CHEM 12)
− Brain natriuretic peptide (BNP) test
− Arterial blood gases
232. Reassessment
• Stable patients should be reassessed every
15 minutes.
• Unstable patients should be reassessed
every 5 minutes.
233. Reassessment of Mental
Status and the ABCDEs
• Compare LOC with baseline assessment.
• Review the airway.
• Reassess breathing, circulation, pulse.
234. Reassessment of Patient Care
and Transport Priorities
• Have you addressed all life threats?
• Do priorities need to be revised?
• Is initial transport decision appropriate?
• Obtain another complete set of vital signs
and compare with expected outcomes.
− Priority patients: Minimum three sets
235. Reassessment of Patient Care
and Transport Priorities
• Look for trends.
• Revisit patient complaints.
• Document all of your findings.
