Initial Emergency Department Patient Assessment

A systematic approach for the evaluation of a newly arrived ED patient will allow the emergency department (ED) technician to properly evaluate and help prioritize the patient. The ED technician (EDT) may be the first person to have contact with the patient, and the information gathered and the initial decisions made are critical to providing rapid, effective care. Remember, if an ED Tech ever feels uncomfortable about a patient, they should escalate the evaluation to an ED physician or nurse.

Doorway Examination

There is a significant amount of information that can be ascertained simply by seeing a patient for the first time from the “doorway,” and this “first impression” is valuable in answering the initial question: “Is this patient sick or not sick?”

Among the observations that the tech should consider are:

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What do you see, hear, and smell?
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Was the patient ambulatory?
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How old do they appear relative to their chronologic age?
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Do they appear to be in any respiratory distress?
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Is there any obvious trauma?

The answers to these questions should inform the speed with which a patient should be treated. For example, an older-appearing male with a “gray” appearance who is clutching his chest and breathing hard requires a more rapid response than that of a nondistressed, younger female who walked to her bed, speaks in full sentences, and appears “well.” The EDT will refine their clinical judgment as they gain more experience. This chapter will provide guidelines and suggestions to assist with the process of building the EDT’s assessment judgment.

Primary Survey: ABCDE

The ABCDE framework provides a systematic method of evaluating and assessing patients for life-threatening conditions. This approach is standard in advanced trauma life support (ATLS), but it has been widely adopted to help evaluate any patient.

The ABDCE approach is stepwise algorithm, meaning that the first step must be addressed before going on to the next ( Table 5.1 ). The sequence is as follows:

A:Airway—Is the airway patent? Are there any signs of obstruction?
B:Breathing—Does the patient have symmetric chest rise? Is the patient working hard to breathe, or is their respiratory rate either very slow or very fast?
C:Circulation—Are the patient’s extremities cool to the touch? Are you able to feel peripheral pulses (pulses in each extremity should be palpated)? Is their heart rate unusually rapid or slow?

D:Disability—What is the patient’s level of consciousness? In most patients, the AVPU (alert, voice, pain, unresponsive) scale is sufficient ( Table 5.2 ). In trauma patients, the Glasgow Coma Scale ( Table 5.3 ) is used.

Table 5.2

AVPU Scale

This is a simple bedside tool to describe the patient’s level of alertness.
A = Alert	Patient is fully alert and does not need to be repeatedly stimulated to maintain alertness.
V = Verbal	Patient will not remain alert, but regains alertness in response to verbal stimuli.
P = Pain	Patient will not remain alert, but regains alertness after painful stimuli.
U = Unconscious	Patient will not arouse to either voice or pain.

Table 5.3

Glasgow Coma Scale

The best score is 15, and the worst score is 3, reported either as the total number or by category (e.g., E4, V5, M6).
Revised Scale	Score
Eye opening (E)
Spontaneous	4
To sound	3
To pressure	2
None	1
Nontestable	NT
Verbal response (V)
Oriented	5
Confused	4
Words	3
Sounds	2
None	1
Nontestable	NT
Best motor response (M)
Obeys commands	6
Localizing	5
Normal flexion	4
Abnormal flexion	3
Extension	2
None	1
Nontestable	NT

E: Exposure—What other injuries or deformities might be present on exam? Are there any burns, bullet wounds, signs of bleeding, or other obvious signs of trauma? It is important to completely expose the patient to identify all injuries.

Table 5.1

Primary Survey, Adapted From Advanced Trauma Life Support and Basic Emergency Care From World Health Organization & International Committee of the Red Cross (ICRC). Basic emergency care: approach to the acutely ill and injured: participant workbook. World Health Organization. 2018. https://apps.who.int/iris/handle/10665/275635 .

Primary Survey	Assessment	Intervention/Management
A: Airway	Can the patient talk normally? If yes, then the airway is open.If the patient cannot talk normally, listen for: • Air movement from the mouth or nose • Abnormal sounds, such as stridor, grunting, snoring, raspy voice (stridor and swelling/hives suggest a severe allergic reaction, indicating anaphylaxis) Look for: • Fluid, such as blood, vomit, saliva • Foreign body • Abnormal swelling • Signs of trauma	If the patient is unconscious, not breathing normally, and there are no signs of trauma: • Open the airway using the head-tilt and chin-lift maneuver • Use the jaw thrust maneuver Place an oropharyngeal or nasopharyngeal airwayIf the patient is not breathing normally and there are signs of or concerns for trauma: Maintain cervical spine immobilization Use the jaw thrust maneuver Avoid adjunct airways if there is suspected injury If a foreign body is suspected: • If the patient is conscious and able to make any meaningful sounds, encourage coughing and keep the patient calm • Remove the object if visible, being careful not to push the object deeper • If the patient is unable to cough or move air (i.e., suspected complete occlusion of airway), use age-appropriate chest thrusts/abdominal thrusts/back blows • If patient becomes unconscious while choking, perform CPR If secretions or vomit are present: • Suction, when available • Place patient in lateral decubitus/recovery position (only after patient has been cleared from secondary survey if trauma is suspected) • If the patient has swelling, hives, or stridor, consider anaphylaxis
B: Breathing	Look for: • Chest rise: is rise equal, or is there an absence of movement on one side? • Effort/work of breathing: nasal flaring, tripod position, accessory muscle use Number of respirations per minute Listen for: • Abnormal sounds such as wheezing or crackling • Absence of sounds on one side (absence of sounds on one side, tracheal deviation, and distended neck veins suggest a tension pneumothorax) • Check O ₂saturation	Start bag-valve mask ventilation for the following scenarios: • Unconscious with abnormal breathing • Either tachypnea or bradypnea with reduced level of consciousness • If patient is hypoxic, place patient on nasal cannula, nonrebreather mask, or bag-valve mask • If there is concern for anaphylaxis or tension pneumothorax, notify emergency medicine physician immediately
C: Circulation	Look and feel for signs of poor perfusion: • Cool, moist extremities • Delayed capillary refill >3 seconds • Low blood pressure • Tachypnea and/or tachycardia • Absent pulses Look for and consider areas of blood loss (“Four and the floor”): • Chest • Abdomen • Pelvis • Thigh compartments • External/extremity bleeds • Check blood pressure as well as peripheral pulses for heart rate • Think about placing ECG leads	For cardiopulmonary arrest, begin performing CPR and make sure to place defibrillator pads on patient’s chest Consider removing chest hair or drying chest if moist If there are signs of poor perfusion, obtain IV access in order to give fluids and blood For external bleeding, apply direct pressure to site For distal extremity bleeding, consider applying tourniquets proximal to the bleed If there is suspected internal bleeding due to trauma to the pelvis, consider a pelvic binder
D: Disability	Assess level of consciousness with AVPU scale or, in trauma cases, the GCS See Table 5.2 for determining AVPU and Table 5.3 for GCS Check glucose level for all altered or unconscious patients Check pupils for size, whether they are equal, and whether they react to light Check movement and sensation in all four limbs	If glucose levels are low, then alert the physician and nursing, as glucose should be administered as soon as possible If pupils are constricted and patient’s breathing is slow, consider opioid overdose and administer naloxone nasal spray If pupils are not equal, consider increased intracranial pressure and raise the head of the bed to 30 degrees Immobilize the cervical spine if there is concern for trauma
E: Exposure	Remove all clothing either with patient cooperation or, if the patient is unable to, using shears/scissors Examine the entire body for injuries, rashes, bites, other lesions, taking care to maintain C-spine or log-roll precautions	Remove all jewelry, as rings, necklaces, or bracelets can constrict limbs or fingers due to swelling; take care to place clothing and patient possessions into separate bag Cover the patient as soon as possible to prevent hypothermia Remove wet clothing immediately and work to dry patients off While not always possible, attempt to respect the patient and protect modesty during exposure