4-3 PATIENT ASSESSMENT AT THE SCENE

LEARNING OBJECTIVE: Recognize the assessment sequence for emergency medical care in the field, and identify initial equipment and supply needs.

Patient assessment is the process of gathering information needed to help determine what is wrong with the patient. Assessments that you conduct in the field (at the emergency scene) or during transport are known as a field assessments.

Field assessments are normally performed in a systematic manner. The formal processes are known as the primary survey and the secondary survey. The primary survey is a rapid initial assessment to detect and treat life-threatening conditions that require immediate care, followed by a status decision about the patient’s stability and priority for immediate transport to a medical facility. The secondary survey is a complete and detailed assessment consisting of a subjective interview and an objective examination, including vital signs and head-to-toe survey. (Both types of surveys will be discussed in more detail later in this chapter.)

BEFORE ARRIVAL AT THE SCENE

Before or during transit to an emergency scene, you may learn about the patient’s illness or injury.

Although this information could later prove to be erroneous, you should use this time to consider what equipment you may need and what special procedures you should use immediately upon arrival.

ARRIVAL AT THE SCENE

When you arrive at an emergency scene, you need to start gathering information immediately. First, make sure the scene is safe for yourself, then for the patient or patients. Do not let information you received before your arrival form your complete conclusion concerning the patient's condition. Consider all related factors before you decide what is wrong with the patient and what course of emergency care you will take.

You can quickly gain valuable information as to what may be wrong with the patient. Observe and listen as you proceed to your patient. Do not delay the detection of life-threatening problems. Be alert to clues that are obvious or provided to you by others. Some immediate sources of information may come from the following:

PRIMARY SURVEY

As stated earlier, the primary survey is a process carried out to detect and treat life-threatening conditions. As these conditions are detected, lifesaving measures are taken immediately, and early transport may be initiated. The information acquired before and upon your arrival on the scene provides you with a starting point for the primary survey. The primary survey is a “treat-as-you-go” process. As each major problem is detected, it is treated immediately, before moving on to the next.

During the primary survey, you should be concerned with what are referred to as the ABCDEs of emergency care: airway, breathing, circulation, disability, and expose.

As soon as the ABCDE process is completed, you will need to make what is referred to as a status decision of the patient’s condition. A status decision is a judgment about the severity of the patient’s condition and whether the patient requires immediate transport to a medical facility without a secondary survey at the scene. Ideally, the ABCDE steps, status, and transport decision should be completed within 10 minutes of your arrival on the scene.

SECONDARY SURVEY

The object of a secondary survey is to detect medical and injury-related problems that do not pose an immediate threat to survival but that, if left untreated, may do so. Unlike the primary survey, the secondary survey is not a “treat-as-you-go” process. Instead, you should mentally note the injuries and problems as you systematically complete the survey. Then you must formulate priorities and a plan for treatment.

The secondary survey for a patient who presents with medical illness is somewhat different from that of an injured patient. Usually the trauma assessment is about 20 percent patient interview and 80 percent physical exam. On the other hand, the medical assessment is 80 percent patient interview and 20 percent physical exam. Both the physical exam and patient interview should always be done for all medical and trauma patients.

NOTE

Remember, if the patient’s condition deteriorates, it may not be possible to complete the secondary survey before starting to transport the patient.

Subjective Interview

The subjective interview is similar to the interview physicians make before they perform a physical examination. The main objective of the interview is to gather needed information from the patient. Other objectives of the interview are to reduce the patient’s fear and promote cooperation. Whenever possible, conduct the subjective interview while you are performing the physical examination.

Relatives and bystanders at the emergency scene may also serve as sources of information, but you should not interrupt interviewing the patient to gather information from a bystander. If the patient is unconscious, you may obtain information from bystanders and medical identification devices while you are conducting the physical examination.

When conducting a patient interview, you should take the following steps:

  1. Place yourself close to the patient. Position yourself, when practical, so the patient can see your face. If at all possible, position yourself so that the sun or bright lights are not at your back. The glare makes it difficult for the patient to look at you.
  2. Identify yourself and reassure the patient. Identify yourself and maintain a calm, professional manner. Speak to the patient in your normal voice.
  3. Learn your patient’s name. Once you learn the patient’s name, you should use it during the rest of your interview. Children will expect you to use their first name. For military adults, use the appropriate rank. If civilian, use “Mr.” or “Ms.” unless they introduce themselves by their first name.
  4. Learn your patient’s age. Age information will be needed for reports and communications with the medical facility. You should ask adolescents their age to be certain that you are dealing with a minor. With minors, always ask how you can contact their parent or guardian. Sometimes this question upsets children because it intensifies their fear of being sick or injured. Be prepared to offer comfort and assure children that someone will contact their parents or guardians.
  5. Seek out what is wrong. During this part of the interview, you are seeking information about the patient’s symptoms and what the patient feels or senses (such as pain or nausea). Also, find out what the patient’s chief complaint is. Patients may give you several complaints, so ask what is bothering them most. Unless there is a spinal injury that has interrupted nerve pathways, most injured individuals will be able to tell you of painful areas.
  6. Ask the PQRST questions if the patient is experiencing pain or breathing difficulties.
  1. Obtain the patient’s history by asking the AMPLE questions.

Objective Examination

The objective examination is a comprehensive, hands-on survey of the patient’s body. During this examination, check the patient’s vital signs and observe the signs and symptoms of injuries or the effects of illness.

When you begin your examination of the patient, you should heed the following rules:

  1. Obtain the patient’s consent (if the patient is alert).
  2. Tell the patient what you are going to do.
  3. Always assume trauma patients have a spinal injury, especially unconscious trauma patients, unless you are certain you are dealing with a patient free from spinal injury (e.g., a medical patient with no trauma).

HEAD-TO-TOE SURVEY.—The head-to-toe survey is a systematic approach to performing a physical examination. This survey is designed so nothing important is missed during the examination of the patient. There maybe variations in the head-to-toe survey depending on local guidelines. Traditionally, the examination is started with the head. However, most medical authorities now recommend that the neck be examined first in an effort to detect possible spinal injuries and any serious injury to the trachea that may lead to an airway obstruction.

During the head-to-toe survey, you should:

The head-to-toe survey may appear to be a long process, but as you practice the procedure you will find that it can be done injust a few minutes. All necessary personal protective equipment, such as exam gloves and eye protection, should be worn during your examination.

Begin the survey by kneeling at the side of the patient’s head. Quickly take an overview of the patient’s body (i.e., general appearance, demeanor, behavior, skin color and characteristics, etc.), then perform the 26 steps described in the following sections.

Step 1.—Check the cervical spine for point tenderness and deformity. To perform this procedure, gently slide your hands, palms up, under both sides of the patient’s neck. Move your fingertips toward the cervical midline. Check the back of the neck from the shoulders to the base of the skull. Apply gentle finger pressure. A painful response to this pressure is point tenderness.

If there are signs of possible spinal injury, such as midline deformities, point tenderness, or muscle spasms, stop the survey and provide stabilization of the head and neck.

NOTE

If a rigid cervical collar is to be applied, make sure you have examined the posterior, anterior, and sides of the neck before applying the collar.

Step 2.—Inspect the anterior neck for indications of injury and neck breathing. This procedure consists of exposing the anterior neck to check for injury and to detect the presence of a surgical opening (stoma) or a metal or plastic tube (tracheostomy). The presence of a stoma or tracheostomy indicates the patient is a neck breather. Also, if you have not already done so in the primary survey, check for a medical identification necklace. A necklace may state the patient has a stoma or tracheostomy.

Look for signs of injury, such as the larynx or trachea deviated from the midline of the neck, bruises, deformities, and penetrating injuries. Also, check for distention of the jugular vein. If the jugular vein is distended, there may be an airway obstruction, a cervical spine injury, damage to the trachea, or a serious chest injury. All of these conditions require immediate medical care.

After the anterior neck is inspected and if a spinal injury is suspected, apply a rigid cervical or extrication collar. If the patient is unconscious, assume the patient has a spinal injury.

Step 3.—Inspect the scalp for wounds. Use extreme caution when inspecting the scalp for wounds. Pressure on the scalp from your fingers could drive bone fragments or force dirt into wounds. Also, DO NOT move the patient’s head, as this could aggravate possible spinal injuries. To inspect the scalp, start at the top of the head and gently run your gloved fingers through the patient’s hair. If you come across an injury site, DO NOT separate strands of the hair. To do this could restart bleeding. When the patient is found lying on his back, check the scalp of the back of the head by placing your fingers behind the patient’s head. Then slide your fingers upward toward the top of the head. Check your fingers for blood. If a spinal or neck injury is suspected, delay this procedure until the head and neck have been immobilized. Furthermore, if you suspect a neck injury, DO NOT lift the head off the ground to bandage it.

NOTE

You may find upon inspection that the patient is wearing a hairpiece or wig. Hairpieces and wigs may beheld in place by adhesive, tape, or permanent glue, so DO NOT remove them unless you suspect profuse bleeding. Attempting removal may aggravate injury or restart bleeding.

Step 4.—Check the skull and face for deformities and depressions. As you feel the scalp, check for depressions or bony projections. Visually examine facial bones for signs of fractures. Unless there are obvious signs of injury, gently palpate the cheekbones, forehead, and lower jaw.
 
Step 5.—Examine the patient’s eyes. After examining the face and scalp, move back to a side position. Begin your examination of the eyes by looking at the patient’s eyelids. Do not open the eyelids of patients with burns, cuts, or other injuries to the eyelid(s). Assume there is damage to the eye and treat accordingly. If eyelids are not injured, have patients open their eyes. To examine the eyes of unconscious patients, gently open their eyes by sliding back the upper eyelids. Keep in mind, pressure applied to the eyelid may cause further injury. When the eye has been opened, visually check the globe of the eye.
 
Step 6.—Check the pupils for size, equality, and reactivity. Using a penlight or flashlight, examine both eyes. Note pupil size and if both pupils are equal in size. Also, see if the pupils react to the beam of light. Note a slow pupil reaction to the light. Look for eye movement. Both eyes should move as a pair when they observe moving persons or objects.

NOTE

Check unconscious patients for contact lenses. Prompt removal of contact lenses is recommended. If removal of the lens is impractical, close the patient's eyes so the contact lenses stay lubricated.

Table 4-1 lists pupil characteristics you may encounter and the possible causes of abnormalities.

Table 4-1.—Listing of Pupil Characteristics and the Possible Cause of Abnormality

PUPIL
CHARACTERISTICS
POSSIBLE CAUSE OF
ABNORMALITY
Dilated and unresponsive
Cardiac arrest
Influence of drugs (e.g., LSD and amphetamines)
Constricted and unresponsive
Central nervous system disease or disorder
Influence of narcotics (e.g., heroin, morphine, or codeine)
Unequal
Stroke
Head injury
Lackluster (dull) and pupils do not appear to focus
Shock
Coma
Step 7.—Inspect the inner surfaces of the eyelids. If there is no obvious injury to the eye, gently pull the upper lid up and the lower eyelid down, and check the color of the inner surface. Normally, the inner surfaces of the eyelids are pink. However, with blood loss they become pale; with jaundice, the surface is yellow. The inner surface of the eyelid is an excellent location to detect cyanosis (skin discoloration due to lack of oxygen), especially for patients with dark skin pigmentation. Cyanosis is denoted by a blue color.

Step 8.—Inspect the ears and nose for injury and the presence of blood or clear fluids. Without rotating the patient’s head, inspect the ears and nose for cuts, tears, or burns. Use a penlight to look in the ears and nose for blood, clear fluids, or bloody fluids. Blood in the ears and clear fluids (cerebrospinal fluid) in the ears or nose are strong indicators of a skull fracture. Also, check for bruises behind the ears, commonly referred to as Battle’s sign. Bruises behind the ears are strong indicators of skull fracture and cervical spine injury. Burned or singed nasal hairs indicate possible burns in the airway.

Step 9.—Inspect the mouth. Look inside the mouth for signs of airway obstruction that may not have been observed during the primary survey (e.g., loose or broken teeth, dentures, and blood). When you inspect the mouth, remember not to rotate the patient’s head.

Step 10.—Smell for odd breath odors. Place your face close to the patient’s mouth and nose and note any unusual odors. A fruity smell indicates diabetic coma or prolonged vomiting and diarrhea; a petroleum odor indicates ingested poisoning; and an alcohol odor indicates possible alcohol intoxication.

Step 11.—Inspect the chest for wounds. Expose the chest. For unconscious and trauma patients, you should completely remove clothing to expose the chest. (Try to provide as much privacy as possible for patients.) Look for obvious chest injuries, such as cuts, bruises, penetrations, objects impaled in the chest, deformities, burns, or rashes. If puncture or bullet wounds are found, check for exit wounds when inspecting the back.

Step 12.—Examine the chest for possible fracture. Before you begin examining the chest for fractures, warn the patient that the examination may be painful. Begin your examination by gently feeling the clavicles (collarbones). Next, feel the sternum (breastbone). Then examine the rib cage by placing your hands on both sides of the rib cage and applying gentle pressure. This process is known as compression. If the patient has a fracture, compression of the rib cage will cause pain. Finally, slide your hands under the patient’s scapulae (shoulder blades) to feel for deformities or tenderness.

Point tenderness, painful reaction to compression, deformity, or grating sounds indicate a fracture. If air is felt (like crunching popcorn) or heard (crackling sounds) under the skin, this indicates that at least one rib is fractured or that there is a pneumothorax (punctured lung). You may also observe air escaping the chest cavity and the wound when the patient has a punctured lung.

Step 13.—Check for equal expansion of the chest. Check chest movements and feel for equal expansion by placing your hand on both sides of the chest. Be alert to sections of the chest that seem to be “floating” (flail chest) or moving in a direction opposite to the rest of the chest during respiration.

Step 14.—Listen for sounds of equal air entry. Using a stethoscope, listen to both sides of the anterior and lateral chest. The sounds of air entry will usually be clearly present or clearly absent. The absence of air movement indicates an obstruction, injury, or illness to the respiratory system. Bubbling, wheezing, rubbing, or crackling sounds may indicate the patient has a medical problem or a trauma-related injury.

Step 15.—Inspect the abdomen for wounds. Look for obvious signs of injury (e.g., abdominal distension, cuts, bruises, penetrations, open wounds with protruding organs (evisceration), or burns) in all four quadrants and sides.

Step 16.—Palpate the abdomen for tenderness. Look for attempts by the patient to protect his abdomen (e.g., patient drawing up the legs). Gently palpate the entire abdomen. If the patient complains of pain in an area of the abdomen, palpate that area last. Do not palpate over an obvious injury site or where the patient is having severe pain. While palpating the abdomen, check for any tight (rigid) or swollen (distended) areas. Performing abdominal palpation is important because tender areas do not normally hurt until palpated. Note if pain is localized, general, or diffused.

Step 17.—Feel the lower back for point tenderness and deformity. Gently slide your hands under the void created by the curve of the spine. Apply gentle pressure to detect point tenderness or any deformities.

NOTE

This examination of the lower back may be performed later, when the patient’s entire back is exposed in preparation to being placed on a backboard or stretcher.

Step 18.—Examine the pelvis for injuries and possible fractures. Examine the pelvic area for obvious injuries. Next, gently slide your hand down both sides of the small of the patient’s back and apply compression downward and then inward to check the stability of the pelvic girdle. Note any painful responses or deformities. If a grating sound is heard, the injury may involve the hip joint, or the pelvis may be fractured.

Step 19.—Note any obvious injury to the genital region. Look for obvious injuries, such as bleeding wounds, objects impaled in the area, or burns. Also, check for priapism in male patients. Priapism is a persistent erection of the penis often brought about by spinal injury or certain medical problems, such as sickle cell crisis.

Step 20.—Examine the lower extremities. DO NOT move, lift, or rearrange the patient’s lower extremities (legs and feet) before or during the examination as further injury to the patient may occur. Check for signs of injury by inspecting each limb, one at a time, from hip to foot. Rearrange or remove clothing and footwear to observe the entire examination site. Pants should be removed in a manner that does not aggravate injuries. Cutting along the seams to remove pants is the best method. If the injury is not obvious, remove the shoe(s) and palpate any suspected fracture sites for point tenderness. Before palpating the site, warn the patient that this examination may cause pain. Before the patient is moved, all suspected or known fractures should be stabilized (with splints, traction splints, or the like).

Step 21.—Check for a distal pulse and capillary refill. To make sure there are no circulatory problems in the legs or feet, check the distal pulse and capillary refill. The distal pulse is a pulse taken at the foot or wrist. It is called distal because the pulse is located at the distal end of the limb. The distal pulse of the foot, also referred to as pedal pulse, may be taken at either of two sites: the posterior tibial pulse (located behind the medial ankle) or the dorsalis pedis pulse (located on the anterior surface of the foot, lateral to the large tendon of the great toe).

You should compare the quality of the pulses in each lower limb. Absence of a distal pulse usually indicates that a major artery supplying the limb has been pinched or severed. This condition may be caused by a broken or displaced bone end or a blood clot. An absent or weak distal pulse may also result from splints or bandages being applied too tightly.

Check capillary refill by squeezing a toe (usually, the big toe) with your thumb and forefinger. The skin and nail where pressure is applied should blanch (lighten). When you release the pressure, the color (blood) should return immediately. If it takes more than 2 seconds for the color to return, capillary refill is considered delayed.

NOTE

After splints or bandages are applied, check capillary refill to make sure circulation has not been impaired.

Step 22.—Check for nerve function and possible paralysis of the lower extremities (conscious patient). Check the lower extremities of conscious patients for nerve function or paralysis. First, touch a toe and ask the patient which toe it is. Do this to both feet. If the patient cannot feel your touch or if the sensations in each foot are not the same, assume that nerve damage in the limb or a spinal injury has occurred.

If sensations appear normal and no injuries are present, have the patient wave his feet. Finally, ask the patient to gently press the soles of his feet against your hand. The inability of the patient to perform any of these tasks indicates the possibility of nerve damage. When nerve damage is suspected, assume the patient has a spinal injury.

Step 23.—Examine the upper extremities for injury. Check for signs of injury to the upper extremities (arms and hands) by inspecting each limb, one at a time, from clavicle to fingertips. Rearrange or remove items of clothing to observe the entire examination site. Check for point tenderness, swelling, or bruising. Any of these symptoms may indicate a fracture. Immobilize any limb where a fracture is suspected.

Step 24.—Check for a distal pulse and capillary refill. To make sure the circulation to the upper extremities has not been compromised, confirm distal (radial) pulse. Initial check of radial pulse was performed during the primary survey. Check capillary refill of fingers or palm of hand (see step 21 for procedure). If there is no pulse or if capillary refill is delayed, the patient may be in shock or a major artery supplying the limb has been pinched, severed, or blocked.

Step 25.—Check for nerve function and possible paralysis of the upper extremities (conscious patient). Check the upper extremities of conscious patients for nerve function or paralysis. Have the patient identify the finger you touch, wave his hand, and grasp your hand. Do this to both hands. If the patient cannot feel your touch or the sensations in each hand are not the same, assume nerve damage in the limb or a spinal injury has occurred.

WARNING

Be alert for a rapid onset of difficult breathing or respiratory arrest. These conditions may occur to patients who have sustained a cervical injury.

Step 26.—Inspect the back and buttocks for injury. If there is no indication of injury to the skull, neck, spine, or extremities, and you have no evidence of severe injury to the chest or abdomen, gently roll the conscious patient as a unit toward your knees and inspect the surface of the back for bleeding or obvious injuries. The back surface may be inspected prior to positioning the patient for transport or delayed until the patient is transferred to a spineboard or other immobilization device.

VITAL SIGNS.

Vital signs (which generally are taken after primary, secondary, and head-to-toe surveys have been completed) include taking the patient’s pulse, respiration, blood pressure, and temperature. Depending on local protocols, the patient’s level of consciousness as well as eye pupil size and reactivity may be recorded with vital signs. Skin characteristics, such as temperature, color, and moistness or dryness, can also be conveniently determined at this time.

Pulse.—When taking a patient’s pulse, you should be concerned with two factors: rate and character. For pulse rate, you will have to determine the number of beats per minute. Pulse rate is classified as normal, rapid, or slow. A normal pulse rate for adults is between 60 to 80 beats per minute. Any pulse rate above 100 beats per minute is rapid (tachycardia), while a rate below 60 beats per minute is slow (bradycardia).

NOTE

An athlete may have a normal at-rest pulse rate between 40 and 50 beats per minute. This is a slow pulse rate, but is not an indication of poor health.

Pulse character is the rhythm and force of the pulse. Pulse rhythm is evaluated as regular or irregular. When intervals between beats are constant, the pulse is regular, and when intervals are not constant, the pulse is described as irregular. Pulse force refers to the pressure of the pulse wave as it expands the artery. Pulse force is determined as full or thready. A full pulse feels as if a strong wave has passed under your fingertips. When the pulse feels weak and thin, the pulse is described as thready.

The pulse rate and character can be determined at a number of points throughout the body. The most common site to determine a patient’s pulse is the radial pulse. The radial pulse (wrist pulse) is named after the radial artery found in the lateral aspect of the forearm.

Respiration.—Respiration is the act of breathing. A single breath is the complete process of breathing in (inhalation) followed by breathing out (exhalation). When observing respiration in connection to vital signs, you should be concerned with two factors: rate and character.

Respiration rate is the number of breaths a patient takes in 1 minute. The rate of respiration is classified as normal, rapid, or slow. The normal respiration rate for an adult at rest is 12 to 20 breaths per minute. A rapid respiration rate is more than 28 respirations per minute, and a slow respiration rate is less than 10 breaths per minute. A rapid or slow respiration rate indicates the patient is in need of immediate medical attention and should be transported to a medical treatment facility as soon as possible.

Respiration character includes rhythm, depth, ease of breathing, and sound. Respiration rhythm refers to the manner in which a person breathes. Respiration rhythm is classified as regular or irregular. A regular rhythm is when the interval between breaths is constant, and an irregular rhythm is when the interval between breaths varies.

Respiration depth refers to the amount of air moved between each breath. Respiration depth is classified as normal, deep, or shallow.

Ease of breathing can be judged while you are judging depth. Ease of breathing may be judged as labored, difficult, or painful.

Sounds of respiration include snoring, wheezing, crowing (birdlike sounds), and gurgling (sounds like breaths are passing through water).

You should count respirations as soon as you have determined the pulse rate. Count the number of breaths taken by the patient during 30 seconds and multiply by 2 to obtain the breaths per minute. While you are counting breaths, note the rhythm, depth, ease of breathing, and sounds of respiration.

Blood Pressure.—The measurement of the pressure blood exerts against the wall of blood vessels is known as blood pressure. The pressure created in the arteries when the heart pumps blood out into circulation (heart beat) is called the systolic blood pressure. The pressure remaining in the arteries when the heart is relaxed (between beats) is called the diastolic blood pressure. The systolic pressure is always reported first and the diastolic pressure second (e.g., 120 over 80).

Blood pressure varies from one person to another and is measured with a stethoscope and a sphygmomanometer (BP cuff). Low blood pressure (hypotension) is considered to exist when the systolic pressure falls below 90 millimeters of mercury (mm Hg) and/or the diastolic falls below 60. “Millimeters of mercury” refers to the units of the BP cuff’s gauge. High blood pressure (hypertension) exists once the pressure rises above 150/90mm Hg. Keep in mind that patients may exhibit a temporary rise in blood pressure during emergency situations. More than one reading will be necessary to determine if a high or low reading is only temporary. If a patient’s blood pressure drops, the patient may be going into shock. You should report major changes in blood pressure immediately to medical facility personnel.

Temperature.—Body temperatures are determined by the measurement of oral, rectal, axillary (armpit), and aural (ear) temperatures. In emergency situations, taking a traditional body temperature may not be indicated, so a relative skin temperature may be done. A relative skin temperature is a quick assessment of skin temperature and condition. To assess skin temperature and condition, feel the patient’s forehead with the back of your hand. In doing this, note if the patient’s skin feels normal, warm, hot, cool, or cold. At the same time, see if the skin is dry, moist, or clammy. Also check for “goose pimples,” indicating chills.