UNIT ONE: Assessment & Triage
The importance of patient assessment cannot be overemphasized. EMTs must master and be
comfortable with the patient assessment process. Patient assessment is used, to some degree,
in every patient encounter. EMTs develop and perfect their own assessment techniques as they
complete their education and gain experience in the field. The assessment process is divided
into five main parts:
l. Scene size-up
2. Primary assessment
3. History taking
4. Secondary assessment
5. Reassessment
Although the steps of the
l. Scene size-up
When you are alerted for an emergency call, your dispatcher will provide you with some basic
information about the situation that requires your assistance. Your scene size-up begins here.
The scene size-up is how you prepare for a specific situation. From the moment you are called
into action until you finally reach your patient, you must consider a variety of things that will
have an impact on how you begin to care for your patient. The scene size-up includes dispatch
information and must be combined with an inspection of the scene to help you ensure safety
and identify hazards, safety concerns, and the number of patients you may have, as well as
additional resources you might need to safely and effectively care for the patient.
During your prehospital assessment you may be tempted to categorize your patient
immediately as a trauma or medical patient. Remember, the fundamentals of a good patient
assessment are the same despite the unique aspects of trauma and medical care. If an
unconscious patient is found at the bottom of a ladder, did he fall off the ladder, strike his
head, and become unconscious or did he experience a medical problem that caused him to fall
off the ladder and then lose consciousness? Early in the assessment, it can be difficult to
identify with absolute certainty whether the problem is of a traumatic or medical origin.
Although further assessment is needed to come to a conclusion, considering
1
UNIT ONE: Assessment & Triage
the mechanisrn of injury (MOI) or nature of illness (NOI) early will help you prepare for the rest
of your assessment.
II. Primary assessment
The primary_ assessment has a single, critical, all-important goal to identify and initiate
treatment of immediate or potential life threats. The patient's vital signs (level of
consciousness; airway, breathing, and circulation [ABCs]) will determine the extent of your
treatment at the scene. Vital signs are the key signs that are used to evaluate the patient's
condition. Always give priority to the patient's level of consciousness and ABCs to ensure
lifesaving treatment from here you will be able to determine the priority of patient care and
transport.
Form a General Impression:
Anytime you meet someone new, you form an initial general impression about that person.
Forming an Initial general impression of your patient is a similar process, but it helps to focus
your attention toward life threatening problems. The initial general impression is formed to
determine the priority of care and is based on your immediate assessment of the patient. This
includes noting things such as the person's age, sex, race, level of distress, and overall
appearance. You may anticipate different problems depending on the parent’s age, sex, and
race. A woman reporting abdominal pain, for example, may have more serious implications
than a man with the same complaint because of the complexity of the female reproductive
system. Write any important information down because it will be difficult to remember minor
details later. You should think of your initial general impression as a visual assessment,
gathering information as you approach the patient. As you approach, make sure that * the
patient sees you coming to avoid surprising the patient or causing the patient to turn to see
you, possibly making any injuries worse. Note the patient’s position and whether the patient
is moving or still. After you introduce yourself, you should ask the patient about the chief
complaint. Assess the patient’s skin color and condition as you begin. For example, is the
patients skin pink, pale, gray, or cyanotic? Is it dry clammy, or diaphoretic? The patient may
direct you to a wound on his or her leg or demonstrate an airway problem by creating
2
UNIT ONE: Assessment & Triage
abnormal sounds when breathing. If a life-threatening problem is found, it should be treated
immediately Determine whether your patient's condition is stable, stable but potentially
unstable, or unstable.
Assess Level of Consciousness
The patient's level of consciousness (LOC) is considered a vital sign because it can tell a great
deal about the patient's neurologic and physiologic status. The brain requires a constant supply
of oxygen and glucose to function properly in the primary assessment, you need to ascertain
only the gross LOC by determining which of the following categories best fits your patient:
1-Conscious with an unaltered LOC
2-Conscious with an altered LOC
3-Unconscious
When a patient is conscious with an altered LOC, it may indicate that inadequate perfusion and
oxygenation or a chemical or neurologic problem is adversely affecting the brain and its ability
to function. Your assessment of a patient who is unconscious should focus initially on problems
with airway, breathing, and circulation, which are critical life threats, and then identify other
emergency care that the patient may need. Sustained unconsciousness should warn you that a
critical respiratory, circulatory, or central nervous system problem or deficit may exist, and you
must assume that the patient has a potentially critical injury or potentially life-threatening
condition. Therefore, after rapidly assessing the patient and providing emergency treatment,
you should package the patient and provide rapid transport to the hospital.
The AVPU scale is a rapid method of assessing the patient's level of consciousness using one
of the following four terms:
A ...Awake and Alert
V... Responsive to Verbal stimuli
P... Responsive to Pain
U.. Unresponsive
Assess the Airway
As you move through the steps of the primary assessment, you must always be alert for signs of
airway obstruction. Regardless of the cause, a mild or severe airway obstruction will result in
inadequate or absent air flow into and out of the lungs. To prevent permanent damage to the
3
UNIT ONE: Assessment & Triage
brain, heart, and lungs, or even death, you must determine if the airway is open (patent) and
adequate.
Assess Breathing
A patients breathing status is directly related to the adequacy of his or her airway. Once you
have made sure the patient's airway is open, make sure the patient's breathing is present and
adequate. A patient who is breathing without assistance is said to have spontaneous
respirations or spontaneous breathing. When assessing breathing, you must obtain the
following information:
 Respiratory rate
 Rhythm, regular or irregular
 Quality/character of breathing
 Depth of breathing
Oxygen should always be administered to patients who are having difficulty breathing, but it
may also be provided to patients who are breathing adequately. Positive-pressure ventilations
should be performed for patients who are apneic or whose breathing is too slow or too shallow.
lf a patient seems to develop difficulty breathing after your primary assessment, you should
immediately reevaluate the airway. lf the airway is open and breathing is present and
adequate, you should consider Administering supplemental oxygen. If breathing is present and
inadequate (the normal rate is 12 to 20 breaths/min in adults) because respirations are too fast
(generally more than 20 breaths/min), too shallow, or too slow (generally fewer than 12
breaths/min), you should administer supplemental oxygen. When respirations exceed 24
breaths/min or are fewer than 8 breaths/min, you should consider providing positive pressure
ventilations with an airway adjunct. Remember that air exchange is the critical issue, not the
number of breaths.
.Assess Circulation:
Assessing circulation helps you to evaluate how well blood is circulating to the major organs,
including the brain, lungs, heart, kidneys, and the rest of the body A variety of problems can
impair circulation, including blood loss, shock, and conditions that affect the heart and major
blood vessels. Circulation is evaluated by assessing the pulse rate, pulse quality, and pulse
rhythm. You will also need to identify external bleeding and evaluate the skin.
4
UNIT ONE: Assessment & Triage
Assess and Control External Bleeding:
Perform a rapid scan of the patient to identify any major external bleeding. in some cases, blood loss
can be very rapid and can quickly result in shock or even death. Therefore, this step demands your
immediate attention. Signs of blood Loss include active bleeding from wounds and./or evidence of
bleeding such as blood on the clothes or near the patient. Serious bleeding from a large vein may be
characterized by steady blood flow. Bleeding from an artery is characterized by a spurting flow of
blood. When you evaluate an unconscious patient, do a sweep for blood quickly and lightly by running
your gloved hands from head to toe, pausing periodically to see if your gloves are bloody. Controlling
external bleeding is often very simple. Initially, direct pressure with your gloved hand and soon
thereafter a sterile bandage over the wound will control bleeding in most cases. This direct pressure
stops the bleeding and helps the blood to coagulate, or clot naturally Most often, bleeding can be
adequately controlled by using direct pressure, along with elevating the extremity if bleeding is from
the arms or legs. When direct pressure and elevation are not successful, you should apply a tourniquet.
Identify and Treat Life Threats:
Many conditions present an immediate threat to life, and key to your role as an EMT is to
determine if a life threat is present and, if so, to quickly address it. In many situations, there is a
process the body takes when reacting to a life threat. Lifesaving interventions begin with you
opening the airway. Airway patency is your number one priority Assess the patients breathing,
and initiate ventilations in patients who have inadequate respirations or a respiratory rate
greater rhan24 or less than 8 breaths/min.
Perform a Rapid Scan
You will need to take 60 to 90 seconds and perform a rapid scan of the patient's body to
identify injuries that must be managed and\or protected immediately this is not a systematic or
focused physical examination. Perform a Rapid Scan You will need to take 60 to 90 seconds and
perform a rapid scan of the patient's body to identify injuries that must be managed and\or
protected immediately This is not a systematic or focused physical examination.
Determine Priority of Patient care and Transport
As you complete your primary assessment, you have to make some decisions about patient
care and transport. The rapid scan will assist you in determining transport priority. Would you
consider your patient a high, medium, or low priority for transport? Priority designation is used
5
UNIT ONE: Assessment & Triage
to determine if your patient needs immediate transport will tolerate a few more minutes on
scene. Patients with any of the following conditions are examples of high priority
Patients and should be transported immediately:
 . Difficulty breathing
 Poor general impression
 Unresponsive with no gag or cough reflex
 Severe chest pain
 Pale skin or other signs of poor perfusion
 Complicated childbirth
 Uncontrolled bleeding
 Responsive but unable to follow commands
 Severe pain in any area of the body
 In ability to move any part of the body
Protecting the patients spine and identifying fractured extremities are integral parts of
packaging for transport. lf a spinal injury is suspected or the MOI is significant enough to cause
a possible injury consider spinal immobilization early. If you are unsure if spinal immobilization
is necessary always err on the side of caution and immobilize the patient. These injuries can be
made worse if you neglect to assess and treat them before moving the patient. Recognizing
the need to transport serious trauma patients is of such importance that you may hear
colleagues refer to the Golden Period. This refers to the time from injury to definitive care,
during which treatment of shock and traumatic injuries should occur because survival potential
is best. After the first 60 minutes, the body has increasing difficulty in compensating for shock
and traumatic injuries For this reason, you should spend as little time as possible on scene with
patients who have sustained significant or severe trauma. Aim to assess, stabilize, package, and
begin transport to the appropriate facility within 10 minutes (often referred to as the "Platinum
I0")
III-History taking
History taking provides detail about the patient’s chief complaint and an account of the
patients signs and symptoms. It is important to document all of the information. on gathered
during this phase of the assessment process. This includes demographic information, past
medical history, and current health status of the patient. Be sure to document the following
information:




Date of the incident
All times of assessments and interventions
Patient's age
Patient's sex
6
UNIT ONE: Assessment & Triage
 Patient's race
 Past medical history including any pertinent information about the patient’s condition,
such as medical problems, traumatic injuries, and surgeries
 Patient's current health status, including diet, medications, drug use ,Living
environment and hazards, physician visits for immunizations or testing, and family
history.
IV-secondary assessment:
The purpose of the secondary assessment is to perform a systematic physical examination of
the patient. The physical examination may be a systematic head-to toe, full-body scan or a
systematic assessment that focuses on a certain area or region of the body, often determined
through the chief complaint. Circumstances will dictate which aspects of the physical
examination will be used. The following are guidelines on how and what to assess during
a physical examination:
 Inspection. Inspection is simply looking at your patient for abnormalities. This is done
by looking for anything that may indicate a problem. For example, swelling in a lower
extremity may indicate an acute injury or a chronic illness.
 Palpation. Palpation describes the process of touching or feeling the patient for
abnormalities. At times palpation is gentle, and at other times it is firmer and will help
you to identify where the patient has pain. Your fingertips are best suited for detecting
texture and consistency, while the back of your hand is best suited for noting
temperature.
 Auscultation. Auscultation is the process of listening to sounds the body makes by using a
stethoscope. For example, when measuring a patient's blood pressure, you listen to the
flow of blood against the brachial artery with the head of the stethoscope.This is
auscultation of a blood pressure. The mnemonic DCAP-BTLS will help remind you what to
look for when inspecting and palpating various body regions. Each area of the body is
evaluated for the following:
 Deformities
 Contusions
 Abrasions
7
UNIT ONE: Assessment & Triage
 Punctures/penetrations
 Burns
 Tenderness
 Lacerations
 Swelling
Assess Vital Signs Using the Appropriate Monitoring Device
 Pulse Oximetry :Pulse oximetry is a newer assessment tool that is used to evaluate the
effectiveness of oxygenation. The pulse oximeter is a photoelectric device that monitors the
Oxygen saturation of hemoglobin.
 Noninvasive Blood Pressure Measurement : The sphygmomanometer, or blood pressure
cuff, is used in the measurement of the patient's blood pressure. electronic measurement,is
another method of obtaining blood pressure readings on patients.
 End-Tidal Carbon Dioxide: Capnography is a noninvasive method that can quickly and
Efficiently provide information on a patient's ventilator status. Circulation. and metabolism.
It can be used as a secondary tool during the confirmation of endotracheal intubation or the
effectiveness of ongoing CPR. End-tidal co, is the partial pressure or maximal concentration
of CO2, at the end of an exhaled breath, which is expressed as a percentage of co2, or
millimeters of mercury The normal range is 35 to 45 mm Hg, or 5 % to 6 % co2. When co, is
absent when measured by capnography, it may indicate the endotracheal tube is in the
wrong position or there is an absence or decrease in the level of co, in the lungs, possibly
from cardiac arrest, ineffective CPR, or shock. When cardiac output increases, the end-tidal
co2, measurement will provide information on the adequacy of ventilations and circulation.
Systematically Assess the Patient- Full-Body Scan:
The full-body scan is a systematic head-to-toe examination. The goal of this process is to
identify hidden injuries or identify causes that may not have been found during the 60- to 9Osecond rapid scan that took place during the primary assessment. Any patient who has
sustained a significant MOl, is unconscious, or is in critical condition should receive this type of
examination. An unconscious patient is unable to tell you what is wrong; therefore, this
type of examination may give you clues to identify the problem.
8
UNIT ONE: Assessment & Triage
V-Reassessment:
Is performed at regular intervals during the assessment process, and its purpose is to identify
and treat changes in a patient's condition.
Reassessment should take Place:
 every 5 minutes for patients in unstable condition
 every 15 minutes for patients in stable condition
9