Hi all and welcome to another blog. When teaching a standard provide first aid course, we cover your primary survey (also called an emergency action plan or basic life support flow chart) in a decent amount of depth. But due to time restraints, we only briefly touch on the secondary survey. If you do the more advanced courses (such as Advanced First Aid and Remote First Aid), we go into the secondary survey in a lot more depth. So for this blog, I thought I would go through all the patient assessment tools that you the first aider might require. Some of these might be a bit more thorough and in-depth than what you need, but hey, it’s better to have too much knowledge than not enough!
Your initial survey when you come across a casualty, DRSABCD, is familiar to all who do a first aid course. This is a systematic approach you take each and every time you come across a patient, regardless of where you find them. It helps you by not forgetting stuff, getting you hurt, or getting your patient hurt. It looks like this:
Danger – to you, your bystanders and your casualty. Always looking for hazards.
Response – talk and touch. Talk loudly, if they don’t respond, touch (i.e. painful stimuli).
Send – for help (Triple Zero – 000 or 112 from mobile phones anywhere in the world so long as there is mobile service available) and send for a defibrillator (every minute delaying the application of a defibrillator reduces the chances of survival by 10%).
At this point, you should have a quick look for any dangerous bleeding. If you recognise that there is, you should immediately stop it with sustained direct pressure or a tourniquet before proceeding.
Airway – make sure the airway is clear of obstructions, then open the airway by tilting the head back.
Breathing – look, listen and feel to see if the patient is breathing normally
CPR – if the patient is not responsive and not breathing (or not breathing normally), immediately commence cardiopulmonary resuscitation by doing 30 compressions and 2 breaths at a rate of 100 – 120/min, or about 2/second.
Defibrillation – apply a defibrillator as soon as possible to your patient.
After conducting the primary survey, if the patient responds to us, it is now time to figure out what is actually wrong with them. Because if they respond verbally, there is absolutely no need at this stage to check airways or breathing (because they’re talking to us) and we certainly don’t need to do CPR just yet. The secondary survey consists of two parts – visual assessment and verbal questioning. The visual component is the ‘head to toe’ physical assessment and the verbal component is basic medical questioning using the ‘SAMPLE’ acronym. Here is how these are done:
Head to Toe physical assessment
After gaining consent and informing the patient of what we’re about to do, the head to toe assessment gives us the opportunity to gather a lot of information. We are looking for signs that things aren’t right (a sign being something we can see). One thing to keep an eye out for when doing a head to toe assessment is to look for any medical alert jewellery. This can be in the form of bracelets, dog tags, necklaces, pendants, anklets. Most will be engraved with the relevant information, however some now contain a QR code that can be scanned allowing access to a secure URL with the patients information.
When conducting a head to toe assessment, it is literally that – start at the head and work your way down to the toes. At each stage, you’re wanting to do two things: inspect and palpate (you can also auscultate if you have a stethoscope, but that’s a bit above your standard first aid level of training). So, let’s do a head to toe assessment now:
Head – inspect for any bleeding and obvious deformity. Check the ears for blood, fluid or bruising. Check the eyes for reactivity to light and equal size pupils. Check the nose for bleeding or deformity. Check the mouth for missing teeth, clench their teeth (to see if the top meets the bottom) and anything blocking the airway. Listen to them speaking for any hoarseness or other abnormalities. Palpate the skull, feeling for any soft boggy areas or crepitus.
Neck – inspect for any bruising, bleeding or deformity. If trained, palpate for a carotid pulse.
Chest – inspect for equal rise and fall, paradoxical movement (normally, when you breath in and out your chest rises and falls respectively. With paradoxical movement, you breath in and your chest falls, breath out your chest rises. This is indicative of a flail chest injury.), bleeding, bruising, accessory muscle use (think asthma). Palpate for tenderness and crepitus.
Abdomen – inspect for bruising, bleeding, penetrating injuries, distention, priapism (spinal injury). Palpate for pain/tenderness, guarding, rigidity, rebound tenderness (this is when you push down, no pain, release suddenly and they have pain).
Pelvis – inspect for bruising, bleeding and deformity. Palpate for tenderness along the bone, but DO NOT SPRING THE PELVIS (i.e. push down on both sides of the pelvis. If they have a pelvic fracture, this will make things a whole lot worse).
Arms and legs – inspect for bleeding, bruising, deformity, range of motion. Palpate for strength/weakness, sensation/touch/temperature, pulses, crepitus.
Back – inspect for bleeding, bruising, deformity. Palpate for pain/tenderness.
Now that we’ve had a good look at our patient, they may have identified some pain when you’ve done your inspecting and palpating. It’s important to really question your patient about their pain as this can provide a lot of valuable information. The acronym (or mnemonic) that we use for pain assessment is OPQRST.
Onset – Find out what the patient was doing when the pain started (were they active, sitting down, did they just have an argument, stressful event) and if they believe that has contributed. Find out whether the pain has come on suddenly, gradually, or has been a part of a long-term chronic illness/condition.
Provocation – Ask the patient what makes it worse – movement, palpation, positioning or if it’s like that when at rest. You can also ask if there is anything that makes it better – position, movement, rest.
Quality – Ask either an open-ended question (can you describe the pain to me?) or a leading question (is the pain sharp, dull, crushing, stabbing, burning, tearing, etc). Ask if it is constant, intermittent or comes in waves.
Radiation – Ask the patient to point with one finger where the pain originates from. You can then ask the patient if the pain radiates (extends) anywhere (e.g. chest pain – does it radiate down the arms, up the neck to the jaw, to the shoulder blades, to the top of the stomach).
Severity – Ask the patient to describe the pain on a scale of zero to ten, with zero pain being no pain at all, through to ten being the worst possible pain. You can ask the patient to compare it to previous injuries or be imaginative (ten is like getting your arm ripped off…). For little kids, it’s hard to determine, so you can use the Wong-Baker faces scale as an indicator.
Timing – Ask the patient how long it has been going for. You can also ask if it has changed since the onset (better, worse, new/different symptoms), if they’ve had this before.
Treatment – This is a good time to ask if the patient has taken any medication themselves or have done anything to help themselves with the pain.
Finally, it’s time to drill down and get some sort of medical history from your patient. You can do this by doing a SAMPLE survey, yet another acronym/mnemonic we use in first aid. Let’s have a look at this one:
Signs and Symptoms – You’ve got this by doing your head to toe assessment. Symptoms are something that the patient needs to describe to you, so ask! Do you feel sick? Is there any pain?
Allergies – Good information to know as it might explain the state of your casualty. It will also help for any medication that might be given by you (e.g. Aspirin) or the paramedics.
Medications – Find out what medication they are taking. You can also check to see if they have taken the medication they’re supposed to be taking! Good information for you and for responding paramedics.
Past medical history – Ask the patient what medical conditions they have. Asthma, diabetes, epilepsy? Any recent surgery? Anxiety, depression?
Last ins and outs – Find out when the patient last ate and drank. If they have had any alcohol or illicit substances. Find out when they last went for a pee (how long ago; was it clear/dark yellow; did it sting; did it smell; was their blood in it?), when they last went for a poo (hard/soft/runny; how long ago; was their blood in it?). For females, ask if they’re bleeding down below. If they are, question if it’s their normal menstrual cycle. If not, question if there is a chance that they might be pregnant (could indicate miscarriage, ectopic pregnancy). It’s a lot of prying we are doing, but the information we get can greatly assist in getting a good solid diagnosis from our patient.
Events leading up to – Ask the patient what they were doing in the minutes/hours/days prior to you treating them. This can help narrow down a diagnosis, because some signs and symptoms can be attributed to a number of conditions.
There are a number of other assessments we can do in our secondary survey as well, such as mental status assessment, respiratory assessment, neurological assessment, perfusion status assessment and Glasgow Coma Scale. But that would see this blog post triple in size. The above is more than sufficient for providing a good solid patient assessment which can then nail down a diagnosis.
In wrapping up, hands on learning is a great way of solidifying and confirming your knowledge. Book in to one of our provide first aid courses to get the basics at any of our three locations (Coomera, Biggera Waters or Mermaid Beach). But if you want a lot more exposure to good solid patient assessments (as well as some excellent training), consider taking part in either our advanced first aid or remote first aid courses held regularly at Biggera Waters. Of course, if you have the numbers, we can come to you as well. Just give us a call at our head office on 07 5572 5299 or visit us at www.paradisefirstaid.com.au to make a booking. Stay safe folks and thanks for reading.