Patient Examination and Injury Assessment Principles

When providing emergency care, an effective patient examination and injury assessment is critical to identifying life-threatening conditions and determining appropriate treatment. This assessment follows a structured approach to ensure rapid, organized, and effective patient care.

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1. The Three Phases of Patient Assessment

The assessment process is divided into three primary phases:

1. Primary Assessment (Initial Evaluation)
   • Identify life-threatening conditions and initiate immediate interventions.
2. Secondary Assessment (Focused or Head-to-Toe Examination)
   • Conduct a detailed evaluation of the patient’s injuries and medical conditions.
3. Ongoing Assessment (Reassessment)
   • Monitor changes in the patient’s condition and adjust treatment as needed.

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2. Phase 1: Primary Assessment (Life-Threatening Issues)

This phase is focused on identifying and addressing immediate life threats using the ABCDE approach:

A. Airway (A)

• Is the airway open and clear?
• If not, perform:
  • Head tilt-chin lift (if no spinal injury suspected)
  • Jaw thrust maneuver (if spinal injury suspected)
• Suction if needed to remove obstructions.

B. Breathing (B)

• Is the patient breathing adequately?
• Look for:
  • Chest rise and fall
  • Breath sounds
  • Signs of respiratory distress (gasping, wheezing, cyanosis)
• If absent, provide rescue breaths or assist with bag-mask ventilation.

C. Circulation (C)

• Is the patient’s heart beating?
• Check:
  • Pulse (Carotid for adults, Brachial for infants)
  • Skin color, temperature, and moisture
  • Major bleeding
• If no pulse, start CPR and apply an AED.
• Control life-threatening bleeding with direct pressure, tourniquets, or hemostatic dressings.

D. Disability (D)

• Assess neurological function using the AVPU scale:
  • A – Alert
  • V – Responds to verbal stimuli
  • P – Responds to painful stimuli
  • U – Unresponsive
• Check pupil response and signs of head injury.

E. Exposure & Environment (E)

• Remove clothing to identify hidden injuries.
• Prevent hypothermia by covering the patient if necessary.

Decision Point

• Based on findings, determine:
  • Is immediate transport necessary?
  • Does the patient need CPR, airway intervention, or bleeding control?
  • Are additional resources needed (paramedics, trauma team)?

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3. Phase 2: Secondary Assessment (Detailed Examination)

Once life-threatening conditions are stabilized, conduct a more thorough evaluation.

A. SAMPLE History

Gather patient history using the SAMPLE method:

• S – Signs and Symptoms
• A – Allergies
• M – Medications
• P – Past medical history
• L – Last oral intake
• E – Events leading up to the injury/illness

B. Head-to-Toe Physical Examination

Perform a detailed physical assessment to identify additional injuries.

1. Head and Neck

• Check for:
  • Deformities, swelling, bruising
  • Unequal pupils
  • Bleeding or fluid from the nose/ears (possible skull fracture)
  • Neck stiffness or bruising (possible spinal injury)

2. Chest

• Check for:
  • Bruising, punctures, or abnormal movement
  • Listen for lung sounds (wheezing, crackles, absence of breath sounds)
  • Flail chest (broken ribs causing uneven chest movement)

3. Abdomen

• Check for:
  • Rigidity, tenderness, or bruising (possible internal bleeding)
  • Pulsating masses (possible abdominal aortic aneurysm)

4. Pelvis

• Check for:
  • Pain, instability, or deformity (pelvic fractures can cause severe bleeding)

5. Extremities

• Check for:
  • Deformities, swelling, or open fractures
  • Circulation (pulse, capillary refill)
  • Sensation and movement (possible nerve damage or spinal injury)

6. Spine & Back

• Check for:
  • Pain, tenderness, or deformity along the spine
  • Log-roll the patient carefully if necessary

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4. Phase 3: Ongoing Assessment (Monitoring)

• Reassess vital signs every 5 minutes (for unstable patients) or 15 minutes (for stable patients).
• Monitor for changes in breathing, pulse, and consciousness.
• Adjust treatments as needed (e.g., assist ventilation, manage shock).
• Communicate updates to EMS or hospital staff if transferring care.

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5. Special Considerations in Injury Assessment

A. Shock Management

• Recognize signs of shock:
  • Pale, cool, clammy skin
  • Rapid pulse, low blood pressure
  • Altered mental status
• Treatment:
  • Lay patient flat
  • Control bleeding
  • Keep warm and provide oxygen

B. Spinal Injury Precautions

• Assume spinal injury if trauma is significant.
• Immobilize the neck using a cervical collar.
• Use a log-roll technique for movement if necessary.

C. Pediatric and Geriatric Assessment

• Children: Have faster heart rates and recover quickly but deteriorate rapidly.
• Elderly: May have hidden medical conditions affecting injury response.

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6. Common Mistakes to Avoid

1. Failing to check the airway first – Always prioritize breathing and circulation.
2. Skipping the head-to-toe assessment – Hidden injuries can be life-threatening.
3. Moving a suspected spinal injury too quickly – Improper handling can cause paralysis.
4. Not reassessing the patient regularly – Conditions can worsen rapidly.

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Conclusion

A structured patient examination and injury assessment ensures rapid identification of life-threatening conditions and appropriate emergency response. By following the ABCDE approach, gathering a SAMPLE history, and performing a thorough head-to-toe assessment, you improve the chances of positive patient outcomes.

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