First Responders
Dr. Abdul-Monim Batiha
Assistant Professor
Critical Care Nursing
Philadelphia university
Patient Assessment
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Scene assessment
Primary survey
Secondary Survey
Reporting of data
Scene Assessment
Make a quick assessment of the overall situation at an
accident scene. Concentrate on the big “big picture.”
Consider three things:
• Environment
• Hazards
• Mechanism of injury
Look for anything that may threaten your safety and the safety of
others, such as downed power lines, falling rocks, traffic, fire,
smoke, etc.
Do not move a casualty unless he or she is in immediate
danger, If you must move the casualty, do so as quickly as
possible.
Mechanism Of Injury
The mechanism of injury can alert you to the
possibility that certain types of injuries may
be present. For example, fractured bones are
usually associated with falls and motor
vehicle accidents, burns with fires, and soft
tissue injuries with gunshot wounds.
Remember, however, that for every obvious
injury, there may be a number of hidden
ones.
Primary Survey
The primary survey is conducted once dangers at the scene have
been neutralized. It is the first step in the physical assessment
and consists of the following:
• Check of level of consciousness (LOC) as you approach the
patient.
• Check of DABC (Delicate spine, Airway, Breathing, and
Circulation)
• Rapid body survey (RBS) for external blood loss and
deformities
While conducting the primary survey, you may discover lifethreatening emergencies such as obstructed airways, respiratory
difficulties, external bleeding, and obvious shock. Treat these
problems immediately.
For your protection, wear disposable gloves whenever you
might be handling blood, body fluids, or secretions.
Perform A Primary Survey
To perform a primary survey, you must be able to do the following:
• Assess level of consciousness (LOC) using the AVPU method.
• Manage a delicate spine.
• Open and maintain the airway.
– Clear obstructions from the patients mouth.
– Open the airway.
– Correctly use an oral airway for unconscious.
– Suction the mouth cavity if required.
– Place unconscious patients and patients with compromised
airways in the recovery position and monitor breathing.
Continued
• Assess and manage the patient’s breathing.
– Determine when a patient is not breathing adequately.
– Use a pocket mask to ventilate patients with inadequate
breathing.
– Ventilate an infant using a pocket mask, connected to oxygen,
and mouth-to-mask ventilation's.
– Use the bag-valve-mask-oxygen reservoir unit to ventilate
patients with inadequate breathing.
• Assess and manage the patients circulation.
• Perform a rapid body survey (RBS).
– Perform a rapid body survey.
– Give oxygen at high flow (10 L/min) with a standard face
mask.
– Describe the pathophysiology of hypoxic drive and the
management of a COPD patient.
Assess Level of Consciousness (LOC)
• Check for LOC as you approach the patient.
• The A,V,P,U method is a short and simple way to
assess the LOC:
A - patient is Alert
V - patient responds to Verbal stimuli
P - patient responds to Pain
(Use a trapezoidal squeeze to administer a painful stimulus.)
U - patient is Unresponsive to verbal and painful
stimuli
A change in the level of consciousness is the first sign
of a brain injury or other serious medical conditions.
Manage A Delicate Spine
Always assume that the patient has a neck or spine
injury(delicate spine). You may rule it out after considering
the mechanism of injury, bur always check for a delicate
spine if the patient must be moved.
If you suspect that the patient has a delicate spine, do the
following:
• Approach the patient from the head.
• Tell the patient, “If you can hear me, don’t move.”
• Stabilize the head in the position found.
• Do not move the patient unless absolutely necessary to
maintain an an open airway.
When using the various grips remember to use the principles
of STABLE to UNSTABLE
Open and Maintain The Airway
Airway management involves three things:
• Opening the airway
• Maintaining the open airway
• Helping the patient breathe effectively (ventilation)
Look, listen, and feel for the movement of air at the mouth
and/ or nose. After an injury, a patient’s airway may
become closed or blocked by teeth, the tongue, or foreign
objects. “check for 5 seconds”
Continued
Before taking steps to open the airway, make sure you have ruled out
a delicate spine or protected the neck. The technique you use will
depend on whether or not the mechanism of injury indicates a
delicate spine.
To manage the airway, you must be able to do the following:
• Clear obstructions from the patient's mouth.
• Open the airway.
• Correctly use an oral airway for unconscious patients.
• Suction the mouth cavity if required.
• Place unconscious patients and patients with compromised
airway in the recovery position and monitor breathing.
Clear Obstructions From The Patient’s
Mouth And Throat.
Make sure your patient’s airway is clear before
trying to open it. Remove foreign materials such
as broken teeth, vomitus, fluid and mucus before
attempting any further treatment. Use a crossedover finger technique to open the patient's mouth,
and do a visual check.
Crossed-over Finger Technique
Opening The Airway
Open the airway after clearing foreign materials form the
mouth. The tongue can easily act as a lid, closing down
onto the back of the throat and making breathing
impossible. To open your patient’s airway, you must lift
the tongue up and off the back of the throat.
NO NECK INJURY:
• Use the Head-Tilt/Chin-Lift Method
Do not use this procedure on any patient with neck or spinal
injuries.
NECK INJURY SUSPECTED:
• Use the jaw thrust or modified jaw thrust
If you suspect a neck injury, take care not to move the neck.
Head-Tilt/Chin-Lift
Modified Jaw Thrust Method
Oral Airways
Once the airway passage is clear and open, you must
keep it open, especially if the patient is
unconscious and cannot do it himself or herself.
The oral airway (oropharyngeal airway), a hard
plastic tube, is the ideal tool for this. Inserted
correctly, it prevents the tongue from falling back
and blocking the airway.
Oral Airways For Unconscious Patients
Moving Patients
A general principle for First Responders is that patients
should be cared for in the position found. This principle is
based on the assumption that certain conditions or injuries
(such as a neck fracture in an unconscious patient) can be
hidden so that it is missed during initial assessment, and
unnecessary movement may make the situation worse.
However, there are three situations in which you, the First
Responder, will have to move the patient:
• Repositioning the patient to manage immediate ABC’s.
• Moving patients as quickly as possible out of hazardous
areas.
• Rescuing and transporting patients.
Repositioning The Patients To Manage
Immediate ABC’s
Many patients are found in unusual or difficult positions. It
may be necessary to move them in order to effectively
assess or manage their ABC’s.
If you must move a patient, follow these principles:
• Moves are best done with the help of two or more people.
• Although managing the ABC’s is always a priority, try to
minimize movement during urgent repositioning.
• Movement of the neck and spine is potentially more
dangerous than moving an extremity.
• In an awake patient, increased pain with movement should
limit your repositioning.
Positioning The Patient
In most cases, positioning of the patient is determined by
patient comfort. If possible, the patient should be left in the
position found. However, if moving the patient results in
better patient care, consider the following options:
• Semi-sitting
– Shortness of breath; obese patients; chest pain.
• Supine
– Suspected neck injuries; patient with no radial pulse; hip fractures.
• 3/4 Prone or Recovery Position
– All unconscious patients with no neck injury.
– All patients with airway problems that cannot be controlled by
suctioning.
Suction
Suctioning the mouth cavity is another procedure used to keep
the airway clear. Secretions and other debris are removed by
applying negative pressure through a hollow tube. If you do
not remove the debris, you may force it into the patient’s
lungs during ventilation.
Assess And Manage The Patient’s Breathing
A patient may be breathing on his or her own but not doing so
adequately. Do not wait for respiratory arrest before
ventilating the patient.(below 10, and over 30).
To assess and manage the patient’s breathing, you must be
able to do the following:
• Determine when a patient is not breathing adequately.
• Use a pocket mask to ventilate patients with inadequate
breathing.
• Ventilate an infant using pocket mask, connected oxygen,
and mouth-to-mask ventilation's.
• Use the bag-valve-mask-oxygen reservoir unit to ventilate
patients with inadequate breathing.
Determine When A Patient Is Not Breathing Adequately
A patient is not breathing adequately if he or she has fewer
than 10 respirations per minute and/ or shows some or all
of the following signs of hypoxia (low oxygen level in the
blood):
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agitation
irritability
drowsiness
headache
decreased level of consciousness
rapid pulse
labored breathing
abdominal breathing
bluish skin color
irregular heartbeat
BVM
The bag-valve-mask-oxygen reservoir (BVM) unit
allows you to ventilate a patient by moving
enriched, oxygenated air into the lungs and
removing carbon dioxide.
The unit consists of the following:
• oxygen reservoir
• a bag
• a non-return valve(to prevent rebirthing)
• an anesthetic-type mask of various sizes (the
pocket mask may also be used with this unit)
• an inlet for oxygen delivery
Circulation - Radial Pulse
Circulation - Carotid Pulse
Causes of Cardiac Arrest
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heart attack
electric shock
drowning
asphyxiation
sensitivity reaction
Compression Rates
• One person adult CPR: 15 compressions 2 ventilation
• Two person adult CPR: 5 compressions 1 ventilation
• One person child CPR: 5 compressions 1 ventilation
• Two person child CPR: 5 compressions 1 ventilation
• One person infant CPR: 5 compressions 1 ventilation
Perform A Rapid Body Survey
(RBS).
The rapid body survey will help you to locate and
expose injury sites, stabilize fractures, and control
bleeding.
You should be able to accomplish the following:
• Perform a rapid body survey.
• Give oxygen at high flow (10 L/min) with a
standard face mask.
• Describe the pathophysiology of hypoxic drive
and the management of a COPD patient.
Rapid Body Survey
Check for bleeding, deformity, and your patient’s response to
pain by systematically running your hands over and under
the following:
• head and neck
• chest and abdomen
• back
• lower extremities
• upper extremities
You should take no more than 30 seconds to perform a
rapid body survey. It should be interrupted only long
enough to provide intervention for life-threatening
injuries.
Oxygen Flow Rates
• 5 Litres per minute
– COPD Patients (No Trauma)
• 10 Litres per minute
– All trauma patients
– Medical emergencies
• 15 Litres per minute
– Smoke and/ or gas inhalation
– Carbon monoxide poisoning
Oxygen Delivery Masks
Bag-Valve-Mask (BVM)
– Assist patients patients with inadequate respiration's.
– Hyperventilate unconscious patients with head injuries.
Pocket Mask
– CPR-on-the-move.
– Infant ventilation's.
– when resuscitation from BVM does not create an effective seal.
Non-Rebreather Mask
– Victims of smoke and/ or gas inhalation.
– Victims of carbon monoxide poisoning
Full Face Mask
– Patients with adequate respiration's.
Oxygen
As a first responder, you should use a standard face
mask to give oxygen at 10 L/min to:
• All trauma patients
• All medical patients except those with a history of
chronic obstructive pulmonary disease (COPD)
Oxygen therapy for the non-traumatic COPD
patient is 5 L/min through a standard adult oxygen
mask. But at a 10 L/min flow for traumatic COPD
patient’s.
COPD Patients
In normal people, the breathing reflex is triggered by high
level of carbon dioxide (CO2) in the blood. Patients with
emphysema, chronic bronchitis, and chronic asthma may
have a condition know as Chronic Obstructive Pulmonary
Disease (COPD). They retain CO2 and thus have a
chronically high level of this gas. Their breathing reflex is
triggered only when the oxygen level in their blood is low.
This mechanism is known as hypoxic drive. By giving
COPD patients oxygen, you may suppress their breathing
reflex.
Give the patient with COPD, 5 L/min through a standard
adult oxygen mask. Closely monitor the patient’s
respiratory rate, depth, and volume. Assist the patient’s
ventilation's if necessary.
Perform A Secondary Survey
The purpose of a secondary survey is to identify
problems that, while not immediately lifethreatening, may threaten the patient’s survival if
left undetected.
The secondary survey consists of the:
• Medical history (chief complaint and history of
chief complaint)
• Vital signs (LOC, pulse, respiration's, and skin
colour and temperature)
• Head-to-toe physical examination (if time permits)
The information you gather here will be vital for the patient’s
later care. You should be able to report it accurately and
concisely to ambulance personnel when they arrive.
Chief Complaint
The chief complaint is what the patient says is wrong
with him or her. Record and report it using the
patient’s own words. This will help you avoid
interpreting what was said, which may obscure or
change the nature of the problem.
Most chief complaints are characterized by pain or
abnormal function. Find out what is bothering the
patient most. For example, a victim of a motor
vehicle accident may have an obvious leg fracture
but his chief concern may be,”I can’t breath.” This
may help you discover an unsuspected chest
injury.
History Of The Chief Complaint
The history of the chief complaint examines the
chief complaint in greater detail. Get a description
of the events that caused the chief complaint. If
pain is the chief complaint, use the PQRST
method to help you organize your questioning.
Ask the following:
• Position of the pain.
• Quality of the pain.
• Does the pain Radiate?.
• Severity of the pain.
• Timing of the pain.
P - Position
– Where is it located? Can you point to it?
Q - Quality
– What does it feel like? Is it sharp, dull, throbbing, or crushing?
R - Radiation
– Does it radiate anywhere? or Does it stay in one place or move
around? Does anything relieve it? What makes it worse?
S - Severity
– How would you rate the pain on a scale of 1 to 10
– (10 being the worst)?
T - Timing
– When did it start? What brought it on? Have you had it before?
How long does it last?
Guidelines When Interviewing A Patient
• Allow the patient to answer in his or her own words.
• Avoid suggesting answers. (“What provoked the pain?”
Not “Does the pain come after exertion?”)
• Use open-ended questions. Avoid asking questions that can
be answered with yes or no.
• To pinpoint responses, give the patient alternatives. (Does
the pain stay in one place or does it move around?)
• Reassure the patient frequently.
Vital Signs
Baseline vital signs are one of the most
important aspects of patient assessment.
They are taken after the primary survey and
the medical history. Based on them,
ambulance personnel and receiving hospital
staff can tell whether or not the patient’s
condition is deteriorating.
As a First Responder you should record the following:
• LOC (using the AVPU method)
• Skin - colour, condition and temperature
• Pulse - rate, rhythm, and strength
• Respiration's - rate, rhythm, and volume (quality)
Monitor the LOC, take the pulse, and count the respiration's
every five minutes.
Check whether the patient’s skin is:
• cool or warm
• moist or dry
• pale or normal in colour
• condition
Recording And Reporting Data
Recording and reporting data is the last major component of
the patient assessment model. Your report will help guide
the ambulance personnel and hospital staff in treating the
patient.
Report your findings orally to responding ambulance
personnel. Your oral report should include the following:
• Mechanism of injury
• Chief complaint
• History of chief complaint
• LOC, pulse, respiration's, and skin colour and temperature
• Treatment given
• All relevant physical findings
Follow up your oral report with a completed copy of the First Responder
Report. (within 24 hours of the incident)
Manage An Unconscious Medical Patient
Assess And Manage Victims Of A Heart Attack
Manage A Patient Experiencing A Heart Attack
Assess and Manage Victims of Respiratory Emergency
People experience difficulty breathing for many reasons.
Some conditions that cause respiratory distress are:
• Asthma - spasms occurring in the airways of the
lungs, causing wheezes.
• Pneumonia - infection of the lungs.
• Bronchitis - inflammation of the bronchi in the
lungs.
• Emphysema - a chronic decrease in the lung’s
ability to expel air due to cell damage
If respiratory distress is not relived, respiratory failure
and respiratory arrest may follow.
Signs and Symptoms of Respiratory Distress
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Laboured, Noisy Breathing
Irregular Rate, Rhythm, and depth of breathing
Unusual Pulse Rate and Character
Flaring Nostrils
Pursed Lips
Numbness or Tingling in Hands ands And Feet
Blue or Grey Lips, Skin, or Nail Beds
Confusion, Hallucinations
Desire to Lean Forward
Manage A Patient Experiencing A
Respiratory Emergency
Assess and Manage Stroke Victims
• Strokes are sudden brain damage caused by
blocked or ruptured arteries. A severe stroke
may cause death; less severe one may
impair certain bodily functions. Because
each of the two hemispheres in the brain
controls the opposite side if the body,
damage in one hemisphere causes weakness
or paralysis in the opposite side of the body.
Signs and Symptoms of a Stroke
• Change in level of mental
ability
• Decreased consciousness
• Change in personality
• Trouble understanding
speech
• Convulsions
• Severe headache
• Loss of vision, or dimness
• Pupils unequal in size
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Drooping mouth, eyelids
Inability to speak
Respiratory distress
Loss of bladder or bowel
control
• Nausea and/ or vomiting
• Paralysis or weakness on
one or both sides of the
body(face, arm, or leg)
• Rapid, strong pulse
Manage a Patient Experiencing a Stroke
Do the following:
• Maintain an open airway and provide O2 .
• Keep the patient at rest.
– Turn an unconscious patient 3/4 prone onto the
affected side.
– Place a conscious patient in the position with
head and shoulders slightly elevated to relieve
pressure on the brain.
Continued
• Protect the patient from injury when being
lifted or moved or during convulsions.
• Do not allow the patient to become
overheated.
• Do not give the patient anything by mouth.
Assess and Manage Patients With Seizures
A seizure is a sudden change in sensation, behavior,
muscle activity, or level of consciousness. It is not
a disease but a symptom of an underlying
problem.
The most common cause of seizure is epilepsy.
Epileptic have recurrent seizures, but the cause is
not always known. Focal seizures begin with
convulsive movements in one part of the body.
Generalized seizures may begin suddenly and
spread rapidly.
Continued
Other causes of seizures are:
• head trauma
• infection and high fever
• tumors
• hypoglycemia (too little sugar or too much
insulin)
• stroke
• poisoning
Signs and Symptoms of a
Generalized Seizure
• The patient has sudden loss of consciousness and
collapses.
• The patient’s body stiffens.
• Convulsions occur, jerking all parts of the body.
• Breathing is laboured.
• There is frothing at the mouth.
• After convulsions, the patient's body relaxes
completely.
• The patient becomes conscious, but is very tired
and confused.
Manage A Patient Experiencing A Seizure
• Place the patient on the floor or ground if the patient is not
already down.
• Check the patient’s ABCs. Intervene if necessary to maintain an
open airway or to ventilate the patient. If an oral airway is not
tolerated, do not force any other objects between the patient’s
teeth while the seizure is going on.
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Administer high flow O2 at 10 L/ min.
Loosen tight clothing.
Do not hold the patient during the convulsions.
Protect the patient from injury and from onlookers. Remove any
potentially harmful objects.
• After the seizure, turn the patient on his or her side (3/4/ prone
recovery position).
• If the seizure resulted from high fever, cool the patient by
removing excess clothing.