MOTLOW STATE COMMUNITY COLLEGE
EMT-IV
PATIENT ASSESSMENT - TRAUMA
Evaluator states: “You are to demonstrate an appropriate assessment of a trauma patient. Check your equipment and
let me know when you are ready to begin. You have ___ minutes to complete your assessment and will be notified
when you have two minutes remaining.”
DETERMINE PROPER BSI
* Takes or verbalizes appropriate body substance
isolation precautions
SCENE SIZE UP
* Assess scene safety
Determine mechanism of injury
Determine number of patients
Assess need for additional help
*Take cervical spine precautions as necessary
INITIAL ASSESSMENT
Verbalizes general impression of patient
Determines responsiveness/level of consciousness
Determines chief complaint/Identify life threats
* Assess airway and breathing
* Assess circulation
* State priority of patient for transport
DECIDE IF FOCUSED OR RAPID
ASSESSMENT IS IN ORDER
OBTAIN BASELINE VITAL SIGNS
ACTION/VERBAL RESPONSE
POINTS
I am taking appropriate BSI precautions.
(1)
ACTION/VERBAL RESPONSE
I am determining if the scene is safe.
I am determining the mechanism of injury.
I am determining the number of patients.
If additional help is necessary, request ALS intercept.
I am taking/directing appropriate c-spine precautions.
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ACTION/VERBAL RESPONSE
I observe an approximately ___ year old male/female patient who
appears to be in mild/moderate/severe distress (determine one
and state it).
EYES OPEN/AWAKE: “Hello, my name is _________ and I am
an EMT. I am going to take care of you. Ask only questions you
know the answer to for LOC determination!
EYES CLOSED: Determine responsiveness using:
Alert - Verbal - Painful - Unresponsive
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What is the problem/Are there potential life threats ?
Opens airway/Assesses the airway for patency/Corrects PRN
Inserts and/or initiates appropriate adjunct(s) (w/ 02?)
Assesses rate/rhythm/quality
Manages injury which may compromise respiration/ventilation
Assesses and controls major bleeding
Assesses pulse for rate/rhythm/quality (peripheral vs central)
Assesses skin color/condition/temp
*Treat for shock as indicated!
At this time I have determined the patient is low or high priority
(select one)
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RAPID ASSESSMENT=High priority pts. Quick head to toe scan
to reveal life threats missed in initial assessment.(See below)
FOCUSED ASSESSMENT=Low priority pts. Fully evaluates
C/C. (See below)
You already have a general idea of BP/HR/RR, now get a
definitive set of VS. Do this in ambulance for RTA.
(1)
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Obtain SAMPLE hx while pt is conscious if possible. (Don’t skip the RTA to perform)
I am observing for obvious trauma and questioning the patient
S - Signs and symptoms
about their complaints.
(assess history of present injury).
(1)
Total
Is the patient allergic to foods or medications?
A - Allergies
M - Medications
P - Past pertinent medical history
L - Last oral intake
E - Event(s) leading to present injury.
O, P, Q, R, S, T (as pertinent)
DETAILED PHYSICAL EXAMINATION
*Perform only after ABC’s and life threats
corrected!!
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?
BOLD items make up the Rapid Trauma Assessment
Italicized and BOLD items make up the Focused/Detailed Trauma
Assessment
Deformities, Contusions, Abrasions, Punctures/penetrations, Burns, Tenderness,
Lacerations, Swelling
Head
Face
I am examining the head for DCAP BTLS/crepitus + 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, crepitus, + accessory muscle use,
breath sounds with stethoscope, medical alert necklace, scars
,subcutaneous emphysema, stoma.
I am examining the chest for DCAP BTLS, = chest rise or
paradoxical movement, breath sounds, crepitus, + accessory
muscle use, subcutaneous emphysema, scars.
I am examining the abdomen for DCAP BTLS, distention,
rigidity, guarding +scars
I am examining the pelvis & genitalia for DCAP BTLS if no
pelvic pain press down & in to check for stability +
incontinence of urine.
I am examining the legs for DCAP BTLS & CMS + scars, track
marks, medical alert jewelry.
Eyes
Ears
Nose
Mouth
Neck
Chest
Abdomen
Pelvis
Legs
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Arms
I am examining the arms for distal DCAP BTLS & CSM, +
scars, track marks, medical alert bracelet/necklace.
Back
I am examining the back, posterior legs, and buttocks for
DCAP BTLS, + scars. paradoxical movement
I will perform or delegate the following interventions to be
completed at this time.
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Manages secondary injuries and wounds appropriately
(verbalizes).
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ONGOING ASSESSMENT
Obtain subsequent set of vital signs and compare to
baseline and other ongoing assessments
I would obtain subsequent set of vital signs and compare with the
previous sets and treat accordingly.
TOTAL POINTS (40 pts.)
* = CRITICAL CRITERIA
Start Time: _________
Stop Time: _________
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(1)
Key Terms
Abdominal Distention (abdomen)
Swelling of the abdomen. Can be caused by
bleeding or trapped air.
Accessory Muscle Use (neck & chest)
Contraction of the muscles of the neck, chest
and abdomen. Indicative of moderate to severe
respiratory distress.
Pink Moist Conjunctiva (eyes)
The area around the eye that is visible when the
lower eyelid is pulled down.
Guarding (abdomen)
When a patient tightens the abdominal muscles
during palpation.
Incontinence of Urine (pelvis)
Loss of bladder control.
Jugular Vein Distention (neck)
Abnormally bulging neck veins. May be
indicative of heart failure.
Nasal flaring (nose)
Indicative of moderate to severe respiratory
distress.
Paradoxical Movement (chest & Back)
When a section of ribs in the chest or back
moves opposite from the normal movement of
breathing.
Patent Airway (mouth)
Open and clear airway.
Abdominal Rigidity (abdomen)
A stiff or tight abdomen when the patient is at
rest. May be indicative of abdominal
trauma/bleeding.
Singed Nares (nose)
Burning and/or soot around the nostrils. May
be indicative of inhalation of hot air and
smoke.
Stoma (neck)
Hole in anterior neck where patient breathes
from.
Subcutaneous Emphysema (chest & back)
Air that has become trapped beneath the skin.
Typically secondary to severe chest trauma.
Tracheal Deviation (neck)
Movement of the trachea away from the
midline of the neck. Indicative of severe chest
trauma.
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