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Initial Assessment
The initial assessment is designed to help the Emergency Medical Responder
detect all immediate threats to life.
Immediate life threats typically involve the patients ABCs, and each is
corrected as it is found.
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Focused History and Physical Exam (Secondary Survey)
A focused history and physical exam should be performed after the initial
assessment. It is assumed that the life-threatening problems have been
found and corrected. If you have a patient with a life-threatening problem
that requires intervention (i.e. CPR) you may not get to this component. The
main purpose of the focused history and physical is to discover and care for
a patient's specific injuries or medical problems.
S - Signs/symptoms
A - Allergies
M - Medications
P - Pertinent past medical history
L - Last oral intake
E - Events leading to the illness or injury
Pupils - Check pupils for size, equality, and reaction to light. Constricted
pupils in a mass casualty event are highly suggestive of nerve
agent/organophosphate toxicity.
Head - Check the scalp for cuts, bruises, swellings, and other signs of
injury. Examine the skull for deformities, depressions, and other signs of
injury. Inspect the eyelids/eyes for impaled objects or other injury.
Determine pupil size, equality, and reactions to light. Note the color of the
inner of the inner surface of the eyelids. Look for blood, clear fluids, or
bloody fluids in the nose and ears. Examine the mouth for airway
obstructions, blood, and any odd odors.
Chest - Examine the chest for cuts, bruises, penetrations, and impaled
objects. Check for fractures. Note chest movements a look for equal
expansion.
Lower Back - Feel for point tenderness, deformity, and other signs of injury
Pelvis - Feel the pelvis for injuries and possible fractures. After checking the
lower back, slide your hands from the small of the back to the lateral wings
of the pelvis. Press in and down at the same time noting the presence of
pain and/ or deformity
The focused physical exam of the responsive medical patient is usually brief.
The most important information is obtained through the patient history and
the taking of vital signs. Focus the exam on the body part that the patient
has the complaint about.
Head
Is headache present
Are the pupils are the pinpoint, dilated, asymmetrical in size
Are the conjunctiva injected, draining,
Does the patient complain of eye pain, photophobia or blurring of
vision
Is salivation, drooling, and/or rhinorrhea present
Is nasal flaring present
Note skin color - i.e. is the patient cyanotic
Note the smell of the patients breath
Is the patients throat sore, red
Neck
Is stridor present
Are the muscles in the neck "pulling"
Chest/Lungs
Heart/Circulation
Abdomen
Pelvis
Neurological
What is the patient's mental status? Is he (she) seizing?
Is the patient dizzy?
Did syncope occur?
Was there sudden collapse
Does he (she) have muscle twitching?
Skin
Response:
Do they respond when you ask them: Are you alright? or if you say: Open your
eyes!
No: If they dont respond, pinch their ear lobe or gently shake their shoulders,
or with a child - tap their shoulder, and with a baby - tap their foot. If they still
dont respond, then you can presume theyre unresponsive and move on to the
next stage Airway. Someone whos unresponsive should always take priority
so you should treat them first and as quickly as possible.
Yes: If they respond by making eye contact with you or some gesture then you
know that theyre responsive and you can move on to the next stage Airway.
Airway:
Is their airway open and clear?
No:
o Responsive: If theyre responsive, treat them for conditions that may be
blocking their airway, such as choking. Only move on to the next stage
Breathing once their airway is open and clear.
o Unresponsive: If theyre unresponsive, tilt their head and lift their chin to
open their airway. Only move on to the next stage Breathing once their
airway is open and clear.
Yes: If their airway is open and clear, move on to the next stage Breathing.
Breathing:
Are they breathing normally? You need to look, listen and feel to check theyre
breathing.
No:
o Responsive: If theyre conscious, treat them for whatever is stopping them
breathing, for example, an obstructed airway. Then go to the next stage
Circulation
o Unresponsive: If theyre unresponsive and not breathing, call 999/112 for
an ambulance, or get someone else to call if possible, and start giving chest
compressions and rescue breaths CPR cardiopulmonary resuscitation. If
this happens you probably wont move on to the next stage as the casualty
needs resuscitation.
Yes: If they are breathing normally, move on to the next stage circulation.
Circulation:
Are there any signs of severe bleeding?
Yes: If theyre bleeding severely, control the bleeding with your gloved fingers,
dressing or clothing, call 999/112 for an ambulance and treat them to reduce the
risk of them going into shock.
No: If they arent bleeding, and youre sure you have dealt with any life-
threatening conditions, then you can move on to the Secondary Survey, to check
for any other injuries or illnesses.
History
Event history
Ask them to describe exactly what happened leading up to them feeling unwell or
injuring themselves.
You can ask other people near the scene too and also look for clues. For
example, if theyve had a car accident the impact on the car will help you work
out what type of injury they could have.
Medical history
Then, ask them to tell you their medical history. Use the word AMPLE to
remember all the things you need to ask them:
Allergy do they have any allergies?
Medication are they taking any regular or prescribed medication?
Previous medical history did they already have any conditions?
Last meal when did they last eat something?
Event history what happened?
Symptoms
Ask them to give you as much detail as possible about how they feel. Listen
carefully to what they say and make notes, if possible.
Here are they key questions to ask them:
Can they feel any pain?
Can they describe the pain, e.g. is it constant or irregular, sharp or dull?
What makes the pain better or worse?
When did the pain start?
Signs
Check the casualty over from head to toe, using all your senses look, listen,
feel and smell.
You may have to loosen, open, cut away or remove clothing. Ask their
permission to do this and make sure youre sensitive and discreet.
Make a note of any minor injuries as you go. Only return to these when you have
finished checking the whole body, to make sure you dont miss any more serious
injuries.