AAOS Emergency Care and Transportation of the Sick and Injured Eleventh Edition

assessment process
scene size-up
primary assessment
history taking
secondary assessment
a subjective condition that the patient feels and tells you about
an objective condition that you can observe about the patient
scene size-up
ensure scene safety
number of patients
mechanism of injury/nature of illness
additional resources
need for c spine/extraction
mechanism of injury (MOI)
how traumatic injury occurred
motor vehicle crashes, assaults, stabbings or gunshot wounds
nature of illness (NOI)
the general type of illness the patient is experiencing;
seizures, heart attacks, diabetic problems, poisonings
personal protective equipment (PPE)
clothing or specialized equipment that provides protection to the wearer
standard precautions
protective measures that have traditionally been developed by the CDC for use in dealing with objects, blood, body fluids, etc (also universal precautions)
incident command system
a system implemented to manage disasters and mass-casualty incidents in which section chiefs, including finance, logistics, operations and planning, report to the incident commander
the process of sorting patients based on the severity of each patient’s condition
primary assessment
single goal is to identify and initiate treatment of immediate or potential life threats
vital signs
the key signs that are used to evaluate the patient’s condition; respirations, pulse, blood pressure, level of consciousness, and skin characteristics
general impression

overall initial impression that determines the priority for patient care

based on 1) patient’s surroundings, 2) mechanism of injury, 3) signs and symptoms, and 4) chief complaint

level of consciousness (LOC)
conscious with an unaltered LOC
conscious with an altered LOC
the circulation of blood within an organ or tissue
the way in which a patient responds to external stimuli, including verbal stimuli, tactile stimuli, and painful stimuli
A – the patient is awake
V – the patient responds to verbal stimulation
P – the patient responds to painful stimuli
U – the patient is completely unresponsive
AVPU scale
tests mental status by checking patient’s memory and thinking ability
person, place, time and event
alert and oriented x 4
person, place, time and event
regular in size
react to light
a brassy, crowing inspiratory, harsh, high-pitched sound, prominent on inspiration, often heard without a stethoscope, may indicate airway obstruction in the neck or upper part of the chest
signs of airway obstruction
obvious trauma, blood or other obstruction
noisy breathing such as snoring, bubbling, gurgling, crowing
extremely shallow or absent breathing
spontaneous respirations
breathing that occurs with no assistance
respiration ratio
active inhalation phase:passive exhalation phase
breath sounds
an indication of air movement in the lungs, usually assessed with a stethoscope
breathing assessment
respiration rate
rhythm, regular or irregular
quality/character of breathing
depth of breathing
respiratory rates
adults and adolescents 12-20 breaths/minute
children 15-30 breaths/minute
infants 25-50 breaths/minute
to listen to sounds within an organ with a stethoscope
normal breath sounds
clear and quiet during inspiration and expiration
wheezing breath sounds
suggest obstruction of lower airways, high pitched whistling sounds most prominent on expiration
wet breath sounds/rattling may indicate cardiac failure, also called crackles, usually on both inspiration and expiration
congested breath sounds may suggest the presence of mucus in the lungs, low pitched, noisy sounds most prominent on expiration
tidal volume
a measure of the depth of breathing and is the amount of air in milliliters that is moved into or out of the lungs during one breath
shallow respirations
little movement of the chest wall
movements in which the skin pulls in around the ribs during inspiration
accessory muscles
the secondary muscles of respiration
neck muscles, chest pectoralis major muscles, and the abdominal muscles
use of these for respiration is a sign of inadequate breathing
nasal flaring
indicates inadequate breathing
two- to three-word dyspnea
speaking only two or three words without pausing to take a breath
tripod position
common posture that indicates a patient is trying to increase airflow
sitting and leaning forward on outstretched arms with head and chin thrust slightly forward
sniffing position
common posture seen in children that indicates a patient is trying increase airflow
patient sits upright with the head and chin thrust slightly forward, appears to be sniffing
labored breathing
breathing that requires visibly increased effort; characterized by grunting, stridor, and use of accessory muscles
signs of respiratory distress
agitation, anxiety, restlessness
stridor, wheezing
accessory muscle use
mild tachycardia
nasal flaring, seesaw breathing, head bobbing
signs of respiratory failure
lethargy, difficult to arouse
tachypnea with periods of bradypnea or agonal respirations
inadequate chest rise/poor excursion
inadequate respiratory rate or effort
diminished muscle tone
ventilation rate
10 breaths/minute for adults
12 breaths/minute for children
infant pulse range
100 – 160 beats/minute
toddler pulse range
90 – 150 beats/minute
preschool pulse range
80 – 140 beats/minute
school age pulse range
70 – 120 beats/minute
adolescent pulse range
60 – 100 beats/minute
adult pulse range
60 – 100 beats/minute
adult pulse rate greater than 100 beats/minute
adult pulse rate less than 60 beats/minute
membrane lining the eyelids, covers the exposed surface of the eye
bluish skin color that occurs when a patient has low levels of oxygen in the blood
indicates liver disease or dysfunction, patient’s skin and sclera turn yellow
normally white portion of the eye
skin that is wet, bathed in sweat
assessment of skin

color, temperature, moisture

in infants and small children, skin color is assessed on the palms and soles

capillary refill
a test that evaluates distal circulatory system function by squeezing blood from an area (nail bed) and watching the speed of its return after releasing the pressure
more reliable indicator of cardiovascular stress in children than in adults
a condition in which the internal body temperature falls below 95F after exposure to a cold environment
damage to tissues as the result of exposure to cold, frozen or partially frozen body parts are frostbitten
narrowing of a blood vessel, such as with hypoperfusion or cold extremities
to form a clot to plug an opening in an injured blood vessel and stop bleeding
rapid scan
60 to 90 seconds to identify injuries that must be managed immediately
assess head, neck, chest, abdomen, pelvis, extremities, back and buttocks


For rapid scan during physical exam

high priority patients
difficulty breathing
poor general impression
unresponsive with no gag or cough reflex
severe chest pain
pale skin or other signs of poor perfusion
complicated childbirth
uncontrolled bleeding
responsive but unable to follow commands
severe pain in any part of the body
inability to move any part of the body
Golden Period
the time from injury to definitive care treatment of shock and traumatic injuries is most critical and potential for survival is best
history taking
a step within the patient assessment process that provides detail about the patient’s chief complaint and an account of the patient’s signs and symptoms
obtain SAMPLE history
chief complaint
the most serious thing that the patient is concerned about
Signs and symptoms
Pertinent past medical history
Last oral intake
Events leading up to injury or illnessTo gather past medical history

Provocation or palliation
Severity on a scale of 1-10
For pain assessment
pertinent negatives
any sign or symptom that commonly accompanies a particular condition but is absent. Negative findings that warrant no care or intervention, record these to indication a thorough and complete examination and history were performed
secondary assessment
step within the patient assessment process in which a systematic physical examination of the patient is performed. The examination may be a systematic full-body scan or a systematic assessment that focuses on a certain area or region of the body, often determined through the chief complaint
a grating or grinding sensation caused by fractured bone ends or joints rubbing together, also air bubbles under the skin that produce crackling sounds or crinkly feeling
pulse oximetry

photoelectric device that monitors oxygen saturation of hemoglobin in the capillary beds

used to evaluate effectiveness of oxygenation

a noninvasive method that can quickly and efficiently provide information on a patient’s ventilatory status, circulation and metabolism. measures partial pressure of CO2
end-tidal CO2
the amount of CO2 present in exhaled breath
colorimetric devices
capnometer or end-tidal CO2 detectors are devices that use a chemical reaction to detect the amount of CO2 present in expired gases by changing colors
the use of a capnometer, a device that measures the amount of expired CO2
full-body scan
a systematic head-to-toe examination that is performed during the secondary assessment to identify hidden injuries and causes that may not have been found during the rapid scan, performed on a patient who has sustained a significant mechanism or injury, is unconscious, or is in critical condition
focused assessment
performed on patients who have sustained nonsignificant MOIs or on responsive medical patients, based on the chief complaint
blood pressure
the pressure of circulating blood against the walls of the arteries
systolic pressure
the increased pressure that is caused along the artery with each contraction of the ventricles and the pulse wave that it produces
diastolic pressure
the residual pressure that remains in the arteries during the relaxing phase of the heart’s cycle
lower than normal blood pressure
higher than normal blood pressure
normal systolic blood pressure range
adults 90 to 140
children 80 to 110
infants 50 to 95
involuntary muscle contractions of the abdominal wall in an effort to protect an inflamed abdomen, a sign of peritonitis
subcutaneous emphysema
air bubbles under the skin
paradoxical motion
only one section of the chest rises on inspiration while another area of the chest falls, motion is the opposite of normal motion during breathing, associated with fracture of ribs
performed at regular intervals during the assessment process, identify and treat changes in a patient’s condition
reassess patient
every 5 minutes for patients in unstable condition
every 15 minutes for patients in stable condition
reassessment steps
1) repeat the primary assessment
2) reassess vital signs
3) reassess the chief complaint
4) recheck interventions
5) identify and treat changes in the patient’s condition
examine by touch
When examining abdomen, you should palpate for:
Guarding, tenderness and rigidity
physical examination
Inspection, palpation, auscultation
methods to control external bleeding
direct pressure, tourniquet, elevation
causes of decreased blood pressure
Loss of blood or its fluid components
Loss of vascular tone and sufficient arterial constriction to maintain necessary arterial pressure even without any actual fluid or blood loss
A cardiac jumping problem
response to decreased blood pressure
Increased heart rate and constriction of arteries
normal blood pressure is maintained and there is decreased blood flow to skin and extremities
respiratory infection
patient coughs up thick, yellowish or greenish sputum
decreased blood flow through organs
indicated by skin that is cool, clammy and pale
Breathing assessment questions
Choking? Respiratory rate too fast/too slow? Respirations shallow/deep? Is patient cyanotic? Abnormal sounds when listening to lungs? Is patient moving air into and out of lungs on both sides?
Questions to determine if additional resources are needed
1) How many patients?
2) Nature of their conditions
3) Who contacted EMS?
4) Scene pose threat to you, patient and others?
Sign of respiratory distress is seen MOST commonly in pediatric patients
seesaw breathing
bleeding under the skin (bruising)
A solid swelling of clotted blood within the tissue

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