When you arrive at the scene of an emergency, after ensuring the safety of yourself and others, you must quickly determine whether the patient has any life-threatening injuries or conditions by conducting a primary assessment. This includes assessing any life-threatening bleeding, mechanism of injury, the chief complaint, level of responsiveness, airway, breathing, breathing quality, circulation, circulatory emergencies, deformity, disability, environmental exposure, and everyone else. Once the primary assessment has been complete on everyone, and everyone has been removed from any hazardous environmental exposures, you can begin your secondary assessment. The secondary assessment includes assessing and documenting vital signs, conducting a thorough physical examination, interviewing the patient for a SAMPLE History, treating any secondary injuries and illnesses, monitoring what happened and when, clearing the spine, and creating a rescue plan. You must also check to ensure that the ABC’s are present at least every 5 minutes for an unstable patient (a patient with a life-threatening condition), or every 10 minutes for a stable patient. This check is just to confirm that the ABCs haven’t changed.
This assessment model may be modified depending on the situation. For example, a responsive patient may complain of an ankle injury. In this case, a full head-to-toe assessment is probably unnecessary, unless you have a reason to suspect that additional injuries or conditions may be present.
These steps should be conducted in this order help to ensure your safety and that of the patients and bystanders. They will also increase the patients’ chance of a positive outcome.
Scene Size-Up. Before you approach the patients:
As you approach the patients:
Life Threatening Bleeding. Once you reach the patient:
Chief Complaint. The chief complaint is the injury or condition that the patient verbally identifies as the most serious. If the patient is unresponsive, the chief complaint is unresponsiveness.
If the patient has a Positive Mechanism of Injury, tell them to remain still as you are concerned about their spine. The checklist for a positive mechanism of injury are as follows:
“Please remain still. I am concerned about your spine”
“What happened? How do you feel? My name is _____. I am trained in _____. Can I help you?”
“I am going to hold your head still. I am placing a reminder under your chin and on your head to remind you to remain still.”
Awake (Level of Responsiveness). A patient’s LOR can be identified using the AVPU scale. The letters A, V, P, and U each refer to a stage of awareness – Alert, Verbal, Painful, and Unresponsive.
Airway. Open and check for a clear airway.
Breathing. Open the airway and check breathing – chin-lift/head-tilt. Look, listen, feel for 5 seconds.
If the patient is not breathing or experiencing agonal respirations (not breathing adequately, associated with cardiac arrest and presented as sporadic, gasping breaths, or snorting, gurgling, moaning, or laboured breathing), begin with two rescue breaths to get oxygen into the lungs.
Breathing Quality. If the patient is choking, wheezing, gasping, or breathing too fast/slow, proceed to Chapter 4 – Immediate Life Threats – Airway Management and Respiratory Emergencies.
a) Life Threatening Bleeding. Begin with a rapid body survey (RBS) to look for life-threatening bleeding. Stop life-threatening bleeding first (see Chapter 4 – Immediate Life Threats – Bleeding Control).
An RBS should check the patient in the following order: head, neck, chest, abdomen, pelvis, legs/feet, arms/hands, and back. Palpate each of these areas, checking your gloves for blood or other bodily fluids. If you see any bodily fluids on your gloves, expose and examine the area of origin before proceeding. If you discover the need for a critical intervention, pause the RBS and perform the intervention before continuing the survey
b) Pulse. If the patient is unconscious and not breathing, check for pulse. You must determine whether the patient’s heart is beating.
The method of assessing pulse is different for infants than for adults and children. If an adult or child is responsive, check their pulse using the radial artery. If the adult or child is unresponsive, check the pulse at one of the carotid arteries in the neck.
If no pulse is detected after a maximum of 10 seconds, start the CPR/AED protocol (see Chapter 4 – Immediate Life Threats – Circulatory Emergencies).
c) Pulse Oximetry (SpO2). Pulse oximetry is a non-invasive method used to measure the percentage of oxygen saturation in the blood. The reading is taken by a pulse oximeter, which measures the percentage of hemoglobin that is saturated with oxygen. The reading is taken as a percentage of hemoglobin saturated with oxygen. Pulse oximeters also measure the patient’s pulse.
Pulse oximetry should be applied whenever a patient’s oxygenation is a concern, for example:
Note: Smokers who are breathing room air can have oxygen saturation of around 94 to 96%. People with chronic lung disease may have oxygen saturations as low as 90% on room air, even when they are not ill.
Circulatory Emergencies. If the patient is presenting signs and symptoms of an Myocardial Infarction (heart attack), or stroke, start the protocol for Circulatory Emergencies. (Chapter 4 – Immediate Life Threats – Circulatory Emergencies).
Signs and symptoms of an MI include:
Signs and symptoms of a stroke include:
Perform a quick head-to-toe physical exam to note any areas that may need treatment.
Perform a quick hands, feet, and spine physical exam to note any loss of circulation.
Log Roll Checklist:
Environment Exposure. Log roll patient onto pad and protect them from the elements. (See log roll checklist – continued)
Log Roll Checklist – Continued:
Transport Decision. Now that basic life support has been provided, you must decide whether the patient requires immediate transport. If so, the patient is considered to be in the rapid transport category (RTC). A patient with a life-threatening condition will fall into the RTC. Examples of RTCs include:
Everyone Else. Check on others in the group who may require attention. Share your transport decision to others of your patient. Assign tasks to others in the group.
Once you have made a decision about transport, you can begin gathering more information through a secondary assessment.
The secondary assessment begins with the following three steps, and can be performed in any order.
If the patient is experiencing pain of any kind, use OPQRST to ask the patient to accurately describe the pain (See below, in the SAMPLE figure).
1. Interview the patient and bystanders
2. Check vital signs
Continue to inflate the cuff for another 20 mmHg beyond this point. Slowly reduce the pressure in the cuff by releasing the valve slowly. Allow the cuff to deflate at a rate of about 2 mmHg per second. Continue to feel for the radial pulse as the cuff deflates. The point at which the pulse returns is the approximate systolic blood pressure by palpation. Using this method, the systolic pressure found is about 10-20 mmHg less than systolic pressure found by auscultation. This blood pressure reading is expressed such as 130/P (P = Palpation. Once you know the approximate systolic pressure, quickly deflate the cuff. Record the systolic pressure and whether the patient was sitting or lying down.
Next, locate the brachial pulse. Place the earpieces of the stethoscope in your ears and the diaphragm over the brachial pulse. Apply the cuff as for palpation (or leave it in place after performing palpation) and inflate the cuff to 20 mmHg above the approximate systolic blood pressure.
Slowly deflate the cuff at a rate of about 2 mmHg per second. As you deflate the cuff, listen carefully for the pulse. The point at which the pulse is first heard is the systolic pressure.
As the cuff deflates, the sound of the pulse will fade. The point at which the sound disappears s the diastolic pressure. release the remaining air quickly. Record the blood pressure such as 130/80 and whether the patient was sitting or lying down.
3. Do a head-to-toe physical examination. This involves inspection, auscultation, and palpation. Do not waste time on this if a life-threatening condition exists. Maintain patient’s dignity. Explain to the patient what you are doing, and direct them to keep still. If you encounter a painful area, have the patient characterise using OPQRST.
Wounds and Illness Treatment. Following the above three steps, treat all secondary injuries and illnesses (see links below):
Monitor What and When. Record what injuries and treatments were done and when.
Clear Spine (if applicable) or Immobilize the Patient. Clear spine or immobilize the patient using the workflow diagram below. Techniques for spinal motion restriction are described in Chapter 1: Principles and Practices – Reaching, Positioning, and Extricating Patients.
Create Rescue Plan. See Chapter 1: Principles and Practices – Reaching, Positioning, and Extricating Patients.