BLS - F. Patient Assessment - Physical Assessments
From Paramedipedia - Ontario Paramedic Standards
- The Paramedic will:
- 1. Handle the patient gently. Minimize patient movement and manipulation.
- 2. Immediately on patient contact, perform the primary survey:
- Quickly note the patient’s general appearance, degree of distress.
- Ensure manual C-spine protection if trauma is obvious, suspect or unknown.
- Assess airway patency, breathing, circulation and level of consciousness and identify critical findings; look for and if possible, quickly expose obvious or suspect external hemorrhage and injury sites; use the AVPU mnemonic to assess the level of consciousness - Alert, responds to Voice, responds to Pain; Unresponsive.
- Upon identification of absent/inadequate airway, breathing or circulation (ABCs) immediately perform appropriate interventions to establish, improve and/or maintain the ABCs and to control external wound hemorrhage (see BLS - Section G - Patient Management).
- 3. Complete the primary survey within 2 minutes unless major problems are encountered, e.g. persistent airway obstruction, cardiac arrest.
- 4. Determine the need for rapid transport ("load and go") after completion of the primary survey, i.e. obvious/impending instability of the patient’s respiratory, cardiovascular and/or neurologic status, or the potential for instability is high, based on assessment.
- 5. Initiate rapid transport for all patients who meet "load and go" criteria as specified in the BLS - Load and Go Patients Standard. Perform further assessment and management enroute.
- 6. If a patient is determined to be stable after the primary survey, perform further assessments at scene, or transport patient and perform enroute.
- 7. Initiate cardiac monitoring for the following types of calls:
- VSAs (exception - "obvious" death as discussed in BLS - Patients with Vital Signs Absent (Transportation) Standard); respiratory arrest; severe respiratory distress;
- unconscious/decreased level of consciousness;
- collapse; syncope;
- chest pain; shortness of breath;
- CVA; post-ictal patients;
- overdose (unless known to be a non-toxic ingestion);
- major or multiple trauma;
- near-drowning/scuba diving incidents;
- hypothermia; heat exhaustion/heat illness;
- abnormal vital signs e.g. RR <8-10/minute or >28-30/minute; BP <90; HR >l20 or <60/minute, or alterations in rhythm patterns;
- if requested by sending staff (for inter-facility transfers).
- 8. Unless contraindicated (see specific standards), cover the patient with a blanket after the primary survey, or at the latest, after the secondary survey. Blanket before or during the primary survey if indicated, e.g. severe shock; environmental conditions exacerbating heat loss; the need for privacy.
- 9. Expose body parts only as required to perform appropriate assessments and management. Attempt to maintain the patient’s comfort and privacy. If exposure (and assessment) is limited due to the patient’s condition, document specific reasons for omissions when completing the Ambulance Call Report, e.g. need to keep patient movement to a minimum, prevent heat loss, institute cooling, control shock, etc., or, ensure that routine documentation clearly reflects the situation at scene.
- 10. Perform the following secondary survey physical assessments:
- elicit history (if not already done);
- take vital signs;
- respiratory rate, rhythm and volume;
- skin colour, condition (wet/dry), temperature;
- pulse rate, rhythm and volume;
- blood pressure by auscultation; blood pressure by palpation if constrained by very short transport time, e.g. 5 minutes or less and/or active management of serious illness or injury e.g. primary survey critical findings/interventions;
- pupillary size, equality and reactivity where indicated (see specific standards);
- baseline Glasgow Coma Score where indicated (see specific standards);
- perform complete head to toe assessment or a limited head to toe assessment based on history, patient’s condition and/or scene observations;
- if indicated, perform trauma assessments in medical patients, and medical assessments in trauma patients;
- if a limited head to toe assessment is done, ensure inclusion of minimum assessments detailed in this manual for specific categories of illness or injury.
Unless major and/or multiple problems are encountered, the secondary survey should be completed in 5 minutes or less.
- 11. If the secondary survey is conducted at scene, make a second transport decision upon completion, or sooner if the patient becomes unstable during the secondary survey. Initiate rapid transport for identified "load and go" problem(s); perform further assessment and management enroute. If the patient is deemed stable and circumstances permit, perform further management interventions at scene, prior to transport.
- 12. Formulate a working assessment after the primary and/or secondary survey. List and prioritize problems, i.e. according to their impact on the patient’s current condition.
For routine (return priority Code 2) inter-facility transfers, assessments can generally be limited to the primary survey and vital signs. If transport time is short e.g. 5 minutes or less, blood pressure recording may be limited to systolic blood pressure by palpation only, or omitted at the paramedic’s discretion.