S
R
J
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P ATIENT A SSESSMENT T RAUMA
I am taking appropriate BSI precautions.
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* Takes or verbalizes appropriate body substance isolation precautions (CRITICAL CRITERIA)
* Assess scene safety (CRITICAL CRITERIA)
Determine mechanism of injury
Determine number of patients
Assess need for additional help
Take cervical spine precautions as necessary
Verbalizes general impression of patient
I am determining if the scene is safe.
I am determining the mechanism of injury.
I am determining the number of patients.
I am determining the need for additional help.
I am taking/directing appropriate c-spine precautions.
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Determines responsiveness/level of consciousness
Determines chief complaint
Identify apparent life threats
* Assess airway/initiate appropriate airway management (CRITICAL CRITERIA)
* Assess breathing/initiate appropriate oxygen therapy (CRITICAL CRITERIA)
* Assess circulation
(CRITICAL CRITERIA)
* Assess and control severe bleeding
(CRITICAL CRITERIA)
Assess skin signs
State priority of patient for transport
I observe an approximately ___ year old male/female patient who appears to be in mild/moderate/severe distress (determine one and state it).
E YES O PEN /A WAKE
: “Hello, my name is _________ and I am an EMT. I am going to take care of you. What is your name?
How old are you?”
I have determined the patient is awake and alert (if eyes are open but patient seems confused, state it).
E YES C LOSED : Determine responsiveness using:
A lert - V erbal - P ainful - U nresponsive
“What seems to be the problem?”
I am identifying and managing apparent life threats.
I F P ATIENT S PEAKS T O Y OU : I have determined the airway is patent.
I F P ATIENT D OES N OT S PEAK O R I S U NCONSCIOUS : I am assessing the airway for patency.
I am assessing breathing for: adequate rate & tidal volume, labored or easy.
At this time, I would initiate oxygen therapy if appropriate.
(specify the device and appropriate flow rate)
I am assessing for presence of a pulse at the carotid artery
(unconscious pt.) or radial artery (conscious pt.), assessing approximate rate, strength, and regularity.
I am assessing for and controlling severe bleeding.
I am assessing the skin for color, temperature and moisture.
At this time I have determined the patient is low or high priority
(select one)
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I will obtain a baseline Blood Pressure, Pulse and Respirations.
Skins signs have already been noted. Pupils will be noted in
Detailed Physical.
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Rev 11/04

(Otherwise, moves to rapid trauma assessment.)
*S
- Signs and symptoms
(assess history of present injury).
I am observing for obvious trauma and questioning the patient about their complaints.
*A -
Allergies
Is the patient allergic to foods or medications?
*M -
*P -
*L -
Medications
Past pertinent medical history
Last oral intake
Does the patient take any medications? (prescribed/nonprescribed, vitamins, herbal remedies, birth control pills, illegal drugs).
Do they have history of other medical conditions such as diabetes, high blood pressure, cardiac or breathing problems, seizures?
When and what did the patient last eat? or drink?
What were you doing right before this happened today? *E -
Event(s) leading to present injury.
*O, P, Q, R, S, T
(as pertinent)
Place an “X” in the box if the student performs an appropriate physical exam while stating the appropriate findings.
BOLD items make up the Rapid Trauma Assessment
Italicized items make up the Detailed Trauma Assessment
D eformities, C ontusions, A brasions, P unctures/penetrations, B urns, T enderness,
L acerations, S welling
Head
Face
Eyes
Ears
Nose
Mouth
Neck
Chest
Abdomen
Pelvis
Legs
Arms
Back
Manages secondary injuries and wounds appropriately
( verbalizes).
I am examining the head for DCAP BTLS + scars
I am examining the face for DCAP BTLS + equality of facial
muscles
I am examining the eyes for size, equality, reactivity to light + color, pink-moist conjunctiva .
I am examining the ears for DCAP BTLS, drainage .
I am examining the nose for DCAP BTLS, drainage, singed nostrils, flaring, + foreign body.
I am examining the mouth for DCAP BTLS, loose/broken teeth, blood + mucus, foreign body, pink & moist soft tissue.
I am examining the neck for DCAP BTLS, jugular vein distention, tracheal deviation, accessory muscle use + medical alert necklace, scars, stoma.
I am examining the chest for DCAP BTLS, chest rise, subcutaneous emphysema, paradoxical movement, breath sounds + scars.
I am examining the abdomen for DCAP BTLS, distention, rigidity, guarding + scars
I am examining the pelvis for DCAP BTLS + incontinence of urine.
I am examining the legs for DCAP BTLS, distal circulationsensation-motor function, equal pulses bilaterally + capillary refill, scars, track marks, medical alert jewelry.
I am examining the arms for distal DCAP BTLS, CSM, equal pulses bilaterally + capillary refill, scars, track marks, medical alert bracelet/necklace.
I am examining the back for DCAP BTLS, paradoxical chest movement + scars.
I would perform or delegate the following interventions.
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2 Rev. 11/04

Obtain second set of vital signs and compare to baseline I would record second set of vital signs and compare with the first set.
* = CRITICAL CRITERIA
(Must Perform to Pass)
TOTAL POINTS (41 pts.)
PASSING: 80% = (33 pts.)
Start Time: _________ Date: ____________
Stop Time: _________
Student’s Name: ____________________________________________________________
Evaluator’s Name: __________________________________________________________
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Abdominal Distention (abdomen)
Accessory Muscle Use (neck & chest)
Pink Moist Conjunctiva (eyes)
Guarding (abdomen)
Incontinence of Urine (pelvis)
Jugular Vein Distention (neck)
Nasal flaring (nose)
Paradoxical Movement (chest & Back)
Patent Airway (mouth)
Abdominal Rigidity (abdomen)
Singed Nares (nose)
Stoma (neck)
Subcutaneous Emphysema (chest & back)
Tracheal Deviation (neck)
Swelling of the abdomen. Can be caused by bleeding or trapped air.
Contraction of the muscles of the neck, chest and abdomen. Indicative of moderate to severe respiratory distress.
The area around the eye that is visible when the lower eyelid is pulled down.
When a patient tightens the abdominal muscles during palpation.
Loss of bladder control.
Abnormally bulging neck veins. May be indicative of heart failure.
Indicative of moderate to severe respiratory distress.
When a section of ribs in the chest or back moves opposite from the normal movement of breathing.
Open and clear airway.
A stiff or tight abdomen when the patient is at rest. May be indicative of abdominal trauma/bleeding.
Burning and/or soot around the nostrils. May be indicative of inhalation of hot air and smoke.
Hole in anterior neck where patient breathes from.
Air that has become trapped beneath the skin.
Typically secondary to severe chest trauma.
Movement of the trachea away from the midline of the neck. Indicative of severe chest trauma.
3 Rev. 11/04