Alert – the patient’s eyes open spontaneously as you approach, and the patient appears aware of you
and responsive to the environment. The patient appears to follow commands, and the eyes visually
Responsive to verbal stimulus – the patient’s eyes do not open spontaneously. However, the patient’s
eyes do open to verbal stimuli, and the patient is able to respond in some meaningful way when
spoken to.
Responsive to pain – the patient does not respond to your questions but moves or cries out in
response to painful stimulus. There are appropriate and inappropriate methods of applying painful
stimulus based a great deal on personal preference. Be aware that some methods may not give an
Unresponsive – the patient does not respond spontaneously or to verbal or painful stimulus. These
patients usually have no cough or gag reflex and lack the ability to protect their airway. If you are in
doubt about whether a patient is truly unresponsive, assume the worst and treat appropriately.
The most common test evaluates a patient’s ability to remember four things:
Time – the patient is able to tell you the current year, month, and approximate date
Mental status may be difficult to evaluate in children. First determine whether the child is alert. Even infants
should be alert to your presence and should follow you with their eyes. Ask the parent whether the child is
behaving normally, particularly in regards to alertness. Most children older than 2 years should know their
name and the names of their parents and siblings. Evaluate mental status in school – age children by asking
Responsive patients
Patients of any age who are talking and crying have an open airway
Watching and listening to how patients speak, particularly those with respiratory problems, may
provide important clues about the adequacy of their airway and the status of their breathing.
High pitched crowing sounds may indicate a partial airway obstruction form a foreign body
A conscious patient who cannot speak or cry most likely has a complete airway obstruction
If you identify an airway problem, stop the assessment process and obtain a patent airway, this may be
as simple as positioning the patient so the air moves in and out easier or a complex as abdominal
If you patient has signs of respiratory difficulty or is not breathing you should immediately take
Unresponsive patient:
With an unresponsive patient or a patient with a decreased level of consciousness, you should
If it is clear then you can continue your assessment, if the airway is not clear, your next priority is to
open it using the head tilt chin lift or jaw thrust maneuver.
Airway obstruction in an unconscious patient is most commonly due to relaxation of the tongue
Dentures, blood clots, vomitus, mucus, food, or other foreign objects may also create an obstruction.
breathing is quiet)
The body will not have the necessary oxygen needed to survive if the airway is not managed quickly
and efficiently. Remember that airway positioning depends on the age and size of you patient.
Spinal considerations:
Trauma patients, those who are conscious or unconscious, should be stabilized to protect their spine.
Conscious or unconscious medical patients, however may have fallen and have a potential for a spinal
injury.
It is important for you to consider spinal precautions during scene size up and evaluate the MOI and
Thousands of deaths per year occur from airway obstruction following acute alcohol intoxication or
drug overdose. Generally, these patients vomit while lying on their backs and cannot protect their
airway because of a severely decreased level of consciousness. Never leave anyone who has passed
out unattended. If the person cannot be continually monitored, place the patient prone or on their side,
not supine
Assess breathing:
Look, listen, and feel for the presence of breathing and then assess the adequacy of breathing
Remember the goal of your initial assessment is to identify and treat airway, breathing, and circulation
Nasal flaring and see saw breathing in pediatric patients indicate inadequate breathing
As you assess the patient’s breathing you should ask yourself the following questions:
o Is the patient moving air into and out of the lungs on both sides
Any patient with a decrease level of consciousness, respiratory distress, or poor skin color should also
If there is no risk of spinal injury, the patient should remain in a comfortable position that supports
breathing; this is usually sitting up with the legs dangling or even a high fowler’s position
Assessing the 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
Circulation is evaluated by assessing the rate and quality of the pulse, identifying external bleeding
Our first goal in assessing circulation is to determine if the patient’s pulse is present and adequate.
Assess the pulse by feeling the radial artery at the distal end of the forearm.
If a pulse cannot be felt at eth radial artery, check the carotid artery in the neck.
If you cannot palpate a pulse in an unresponsive patient, begin CPR
If the patient has a pulse but is not breathing, provide ventilations at a rate of at least 12 breaths/min
You can feel the pulse of a child at the carotid artery, as in an adult. However, palpating the pulse in an
infant may present a problem. Because an infant’s neck is often very short and fat, and its pulse is
often quiet fast, you may have a hard time finding the carotid pulse. Therefore, in infants younger than
1 year, you should palpate the brachial artery to assess the pulse. normal pulse rates for children are:
Adult normal resting rate should be between 60 and 80, but could be as much as 100 beats per minute
in geriatric patients
Pediatrics generally the younger the patient, the faster the pulse rate.
The actual number of pulsations per minute is not as important as obtaining a sense of whether the rate
With practice you can develop a sense for pulse rate without actually counting the pulsations. This will
help you speed up your initial assessment and allow you to focus on finding potentially life
threatening problems
A pulse too slow or too fast may change decisions related to transporting your patient
If it is difficult to feel or irregular, the patient may have problems with his circulatory system.
Therefore, this step demands your immediate attention as soon as the patient’s airway is patent and
The direct pressure stops the bleeding and helps the blood to coagulate or clot naturally
When direct pressure and elevation are not successful, you may apply pressure directly over arterial
pressure points
Assess Perfusion:
Assessing the skin is one of the most important and most readily accessible ways of evaluating
circulation
A lack of perfusion or hypo perfusion will result in hypoxia of the brain, lungs, heart and kidneys.
Color:
Skin color depends on pigmentation, blood oxygen levels, and the amount of blood circulating
Deeply pigmented skin may hid skin color changes that result from injury or illness
You should look for changes in color areas of the skin that have less pigment:
Normal skin color, particularly of the conjunctiva and mucous membrane, is pinkish
o Flushed (red)
o Pale (white)
o Jaundice (yellow)
Temperature:
The skin has many functions, it helps maintain the water content of the body, acts as insulation and
protection from infection, and also plays a role in regulating body temperature by changing the
Poor perfusion, the body pulls blood away from the surface of the skin and diverts it to the core of the
body
A good indication in your initial assessment of hypo perfusion and inadequacy of circulatory system
function (shock)
Condition:
Assessing the skin condition of the skin is really assessing the presence of moisture on the skin
Skin that is cool or cold, moist, or clammy suggests shock (hypo perfusion)
These characteristics are important findings in your initial assessment because hypo perfusion can lead
Capillary Refill:
Although capillary refill is a quick and delivery general way to evaluate perfusion, it is important to
remember that other conditions, not related to the body’s circulation, may also slow capillary refill.
Conditions include, but are not limited to the patient’s age as well as exposure to a cold environment:
o Hypothermia
o Frozen tissue (frostbite)
o Vasoconstriction
Injuries to bones and muscles of the extremities may cause local circulatory comprise resulting in
hypo perfusion of an extremity rather than hypo perfusion of the body in general
As complete your assessment you have to make a decision about patient care
Patients with any of the following conditions are examples of high priority patients and should be
transported immediately:
o Difficulty breathing
o Severe chest pain, especially when the systolic blood pressure is less than 100 mm Hg
o Complicated childbirth
o Uncontrolled bleeding
o Severe pain in any area of the body inability to move any part of the body
60-90 seconds to identify injuries that must be protected during packaging and loading for transport
Protecting the patient’s spine and identifying fractured extremities are an integral part of packaging for
transport
Recognizing the need to transport serious trauma patients is of such IMPORTANCE that you may
After the first 60 minutes the body has increasing difficulty in compensating for shock and traumatic
injuries
Assess, stabilize, package, and begin transport to the appropriate facility within 10 minutes after
arrival on scene whenever possible ( a difficult or complex extrication may obviously limit
possibilities)
Some patients may benefit from remaining on scene and receiving continuing care.
ALS should be called for if not already en route to the scene, and depending on the travel distance, can
Facts:
o EMS intervention
Focused history and physical exam will help you to identify specific problems
It is based on the patient’s chief complaint (what happened to this patient) and has the following goals:
o Understand the specific circumstances surrounding the chief complaint. What key factors were
associated with the event? Does the mechanism of injury put the patient at high risk for serious
injuries?
o Obtain objective measurements of the patient’s condition. Do these measurements validate the
seriousness of this patient’s condition? How well is the patient dealing with his or her injury or
illness?
o Direct further physical examination. What physical clues help us to identify problems?
Focused history and physical exam has three components to meet these goals:
o An evaluation of the patient’s medical history, obtaining baseline vital signs, performing a
physical exam based on the patient’s complaint, or in the case of critical patient, the MOI or NOI.
o SAMPLE history (general medical history using the mnemonic)
o OPQRST
o If the patient is stable, you should reassess vital signs every 15 minutes until you reach the
emergency department
o If the patient is unstable you should reassess at a minimum of every 5 minutes, look at your
This exam generally focuses on the location or body system related to the chief complaint
The goal of a focuses assessment is to focus your attention on the immediate problem.
medical patient.
o pelvis
o posterior body
suggestions for assessing some common chief complaints, remember that you will also be assessing
o Chest pain- looks for trauma to the chest and listens for breath sounds.
o Shortness of Breath – look for signs of airway obstruction, as well as trauma to the neck or chest.
o Abdominal pain – look for trauma to the abdomen distention. Palpate the abdomen for tenderness,
think.
DCAP BTLS will help remind you what to look for when inspecting and palpating various body
regions.
Crepitus is the grating or grinding that is often felt or heard when two ends of a broken bone rub
together
Subcutaneous emphysema bleeding as well as a cracking sound produced by air bubbles under the
skin.
It is particularly important to assess the neck before covering it with a cervical collar
Also, in patients where spinal injury is not suspected, inspect for pronounced or distended jugular
Patients who are sitting up suggest a problem with blood returning to the heart.
Report and record your finding carefully
Inspect, visualize, and palpate over the chest area for injury or signs of trauma, including bruising,
tenderness, or swelling.
Watch both sides of the chest to rise and fall together with normal breathing
Retractions – when the skin pulls in around the ribs during inspiration
Paradoxical motion – when only one section of the chest rises on inspiration while another area of the
chest falls
Retractions indicate the patient has some condition, usually medical that is impairing the flow of air
Paradoxical motion is associated with a fracture of several ribs (flail) causing a section of the chest to
Palpate the chest for subcutaneous emphysema, especially in cases of severe blunt chest trauma.
First remember that you can almost always hear a patient’s breath sounds better from the patient’s
back
Auscultate over the upper lungs (apices), the lower lungs (bases), and over the major airways
Place the diaphragm of the stethoscope firmly against the skin to hear the breath sounds
Abdomen:
Inspect the abdomen for any obvious injuries, bruising ,and bleeding
Palpate both the front and back of the abdomen, evaluating for tenderness and bleeding
As you palpate the abdomen, use the terms “firm,” “soft,” “tender,” or “distended”
Do not palpate obvious soft tissue injuries, and be careful not to palpate too firmly
Pelvis:
If the patient reports no pain, gently press downward and inward on the pelvic bones
Do not rock the pelvis; this motion may result in motion of an unstable spine
Injuries to the pelvis and surrounding abdomen may bleed profusely, so continue to monitor the
patient’s skin color and vital signs and be sure to give supplemental oxygen to minimize the effects of
shock
Extremities:
o Pulses check the distal pulses on the foot and wrist. Also check circulation, noted skin color.
o Motor functions ask the patient to wiggle his or hers fingers or toes. Inability to move a single
extremity can be the result of a bone, muscle, or nerve injury. An inability to move several
o Sensory function – ask the patient to close his or hers eyes. Gently squeeze or pinch a finger or
toe, and ask the patient to identify what you are doing. Inability to feel sensation in the extremity
Posterior:
Remember that significant mechanisms of injury for adults and children may include the following:
o Any fall equal to or greater than the patient’s height, especially if the head strikes a firm surface
Taking 60 to 90 seconds to identify both hidden and obvious injuries will help you in two ways
A good baseline set of vital signs will be useful as you continue to monitor changes in the patient’s
condition
SAMPLE History:
Trauma patient with a significant MOI, the patient’s history is not as critical as performing a rapid
If transport is not yet under way, consider transporting the patient at this time
Focused Trauma Assessment Based on Chief Complaint, after evaluating the MOI of your trauma
patient, you determine the patient has sustained only minor trauma
Obtain the patient’s pulse, respirations, and blood pressure and assess the patient’s pupils and skin
Sample History:
SAMPLE history should be gathered to determine whether a medical problem may have caused the
trauma
Mnemonic OPQRST
The patient response to questions about the chief complaint drives your assessment of the history of
Be careful not to jump to conclusions regarding the chief complaint because of what you have seen or
Chief complaint may not be obvious; it may even be different than the dispatched complaint.
Don’t forget if the patient cannot tell you the complaint due to language barriers, hearing barrier or
SAMPLE History:
Remember to do these
Consider
SAMPLE History
physical exam and to possibly identify the cause of complaints that were not identified during the
You must simply ask and answer one question: “What additional problems can be identified through a
This exam is more in depth examination that builds on the focused history and physical exam portion
of your assessment.
o Wheezing
o Congested – rhonchi
o Crowing – stridor
Abdomen :
o Tenderness
o Guarding
Ongoing Assessment:
o Repeat your focused assessment regarding patient complaint or injuries, including questions about
o Check interventions