10 Assessment Tips for EMTs
The EMT exam evaluates your ability to assess patients quickly and formulate a treatment plan even if you don’t have all the information yet. You can adopt certain assessment approaches that can rapidly identify signs that identify life-threatening situations or serious medical conditions.
Look at the Whole Patient
As an EMT student, it’s easy to get hung up on one finding. For example, you may see a test question where the respiratory rate is 10. Based on this single finding, you may be tempted to choose an answer that provides supplemental oxygen using a nonrebreather mask.
But if the patient is also described as being altered, with shallow respirations, a slow heart rate, and cool, cyanotic skin, a breathing rate of 10 is probably inadequate and the patient requires manual ventilation.
Look at the big picture. Pull all the findings together before making a decision.
Assess the ABCs before anything else
What will kill your patient faster than anything else is compromise to the airway, breathing difficulty, or poor circulation (you guessed it: the ABCs).
If something is affecting the ABCs, fix it before moving on.
Decide whether to oxygenate or ventilate
If the patient is having trouble breathing, make sure you understand the patient’s mental status before you decide whether to oxygenate or ventilate:
Oxygenate: If she is alert or able to follow your commands, her body is compensating for whatever the problem is. Supplemental oxygen via a nasal cannula or a nonrebreather mask may help to relieve the respiratory distress.
Ventilate: If she is altered or unresponsive, she may be in respiratory failure and decompensating. You need to ventilate with a bag-valve mask and oxygen to ensure she has adequate tidal volume to push oxygen into the bloodstream.
In general, the problem lies within the three parts of the cardiovascular system:
Heart problems: Myocardial infarction, myocardial contusion, cardiac tamponade
Pipe problems: Sepsis, anaphylaxis, spinal injury
Fluid problems: Dehydration or major bleeding
As with breathing difficulty, there are two levels of shock:
Compensated: The patient is alert or follows commands, his breathing rate and pulse are elevated, his skin is pale and cool to the touch, and his blood pressure is normal or even high.
Decompensated: The patient is altered or unresponsive, his breathing rate and pulse are really fast or slow, his skin is pale or cyanotic and cold or clammy to the touch, and his blood pressure is falling or low.
Search for the signs of Beck’s triad
Beck’s triad refers to cardiac tamponade, where the space between the heart and its pericardium fills with fluid or blood.
This fluid compresses the heart chambers, which in turn makes it difficult for the heart to pump blood. Systolic blood pressure falls. At the same time, the pressure around the heart causes diastolic pressure to rise. This is called a narrowing pulse width or pressure.
The rising pressure causes the neck veins to bulge under the skin, or jugular venous distention. The fluid surrounding the heart makes it difficult to hear lung sounds; they become more muffled. Tie all of these findings together, and you have Beck’s triad: narrowing pulse width, jugular venous distension, and muffled heart sounds.
There’s not much for prehospital treatment; the patient will likely want to sit up to relieve the pain. Maintain oxygen saturation levels and transport as soon as possible.
Check for Cushing’s triad
When the brain is injured from trauma, it does what any other tissue does — it swells. But the skull keeps it from becoming bigger as it swells, which results in pressure building up within the brain tissue, or intracranial pressure (ICP).
If you suspect your patient with altered mental status has increasing ICP, check for Cushing’s triad: increasing blood pressure, decreasing heart rate, and changes in breathing patterns. You may need to manually ventilate the patient with a bag-valve mask and oxygen if the breathing rate becomes too slow or irregular.
If the pupils become unequal in size or if they become dilated and fixed, you have to actually increase the ventilation rate slightly, or hyperventilate.
Recognize that not all wheezes are asthma
Wheezing simply means the bronchioles are constricted. That may be because they are irritated, causing an asthma attack. But the constriction can also be due to fluid buildup around smaller bronchioles, as in congestive heart failure (CHF).
Be sure to look at the whole picture; a patient with breathing difficulty, jugular venous distension, high blood pressure, pedal edema and wheezing is more likely to be in CHF, not having an asthma attack.
List the causes of altered mental status
An easy way to remember a variety of causes for altered mental status is AEIOUTIPS:
A – Alcohol intoxication
E – Epilepsy or seizure
I – Insulin shock or diabetic coma
O – Overdose of medications or drugs
U – Uremia or renal failure
T – Trauma
I – Infection
P – Psychological
S – Stroke or shock
Understand that not all myocardial infarctions have chest pain as a symptom
The classic sign of a myocardial infarction (MI) in Caucasian males is chest pain or pressure that radiates to the arm or jaw. Women or patients from other racial backgrounds may experience more of an achiness or nondescript discomfort centered between the shoulders or in the epigastrium.
Older patients and patients with advanced diabetic disease may not have any complaint of chest discomfort at all and may experience unexplained shortness of breath, nausea, or sudden syncope (fainting). If you see these symptoms, first think of cardiac conditions.
Crying is a good sign in pediatric patients
In emergency care, loud crying is a sign that the pediatric patient recognizes pain or an unknown, frightening situation. Another good sign is the pediatric patient who clings or stays close to the parent. If the child isn’t responding to the environment, is quiet, or otherwise doesn’t respond appropriately, you have cause for concern.