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Form Name	Emt Trauma Assessment
Form Length	12 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min
Other names	patient assessment trauma scenarios, emt trauma assessment sheet, trauma assessment emt scenarios, emt trauma assessment cheat sheet

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State of Indiana EMR Psychomotor Skills Examination

			Patient Assessment/Management - Trauma
Candidate:				Examiner Name:
Date:				Scenario #:
Date:				Scenario #:
					Possible		Points
Actual Time Started					Points		Awarded
Takes or verbalizes appropriate body substance isolation precautions					1
SCENE SIZE-UP
Determines the scene/situation is safe					1

Determines the mechanism of injury					1

Determines the number of patients					1

Request additional help, if necessary					1

Considers stabilization of the spine					1

PRIMARY SURVEY/RESUSCITATION (Initial Assessment)
Verbalizes general impression of the patient					1

Determines responsiveness/level of consciousness					1

Determines chief complaint/apparent life threats					1

Airway		Opens and assesses the airway			1

		Inserts an adjunct as indicated			1
		Inserts an adjunct as indicated			1

		Assesses breathing			1

Breathing		Assures adequate ventilation			1

		Initiates adequate oxygen therapy			1
		Initiates adequate oxygen therapy			1

		Manages any injury which may compromise breathing/ventilation			1

		Checks for pulse			1

		Assesses skin (color, temperature, & condition)			1

Circulation		Assess for and controls major bleeding, if present			1
		Evaluates for and initiates shock management, if applicable
		(includes patient positioning, oxygen, and body heat conservation)			1

Identifies patient priority and makes treatment/transport decision					1

History Gathering
Selects appropriate assessment (focused or rapid assessment)					1

Attempts to obtain a SAMPLE history					1

SECONDARY ASSESSMENT (Detailed Exam) *Credit should be given to candidates					that use a	brief
exam for life-threatening injuries in the Primary Survey so long as it does not delay appropriate care.
			Inspects mouth, nose, and assesses facial area		1
	Head
	Head		Inspects and palpates scalp and ears		1
			Assesses eyes		1

			Checks position of trachea		1
	Neck
	Neck		Checks jugular veins		1
			Palpates cervical spine		1

			Inspects chest		1
	Chest
	Chest		Palpates chest		1
			Auscultates chest		1

			Inspects and palpates abdomen		1
Abdomen/pelvis
Abdomen/pelvis			Assesses pelvis		1
			Verbalizes assessment of genitalia/perineum, as needed		1

Lower Extremities			Inspects, palpates, & assesses motor, sensory &		2
Lower Extremities			distal function (1 point per each leg)		2
			distal function (1 point per each leg)

Upper Extremities			Inspects, palpates, & assesses motor, sensory &		2
Upper Extremities			distal function (1 point per each arm)		2
			distal function (1 point per each arm)

Posterior			Inspects & palpates posterior thorax		1

			Inspects & palpates lumbar and buttocks regions		1
			Inspects & palpates lumbar and buttocks regions		1

Vital Signs
Obtains baseline vitals (minimum is heart rate, blood pressure & respiratory)					1
Manages Secondary injuries and wounds appropriately					1
REASSESSMENT

Describes how and when to reassess the patient.

Actual Time Ended:

TOTAL 43

** Examiner must list times above and then sign on reverse after reviewing Critical Criteria**

Critical Criteria:

Failure to take or verbalize body substance isolation precautions

Failure to determine scene safety before approaching patient

Failure to initially consider and/or provide for stabilization of the spine when indicated Failure to assess/provide adequate ventilations

Failure to verbalize/provide adequate supplemental oxygen as scenario indicates

Failure to find or manage problems associated with airway, breathing, hemorrhage or shock. Failure to differentiate between patient's need for immediate transportation versus continued assessment or treatment on the scene

Performs secondary assessment before assessing or treating threats to airway, breathing or circulation

Requests, uses or orders a dangerous or inappropriate intervention

Failure to manage the patient as a competent EMR

Exhibits unacceptable affect with patient or other personnel

You must factually document your rationale for checking any of the above critical items on this form in the space below, being specific as what occurred or did not occur versus repeating the statement above.

Critical Criteria Explanation:

There were NO observed Critical Criteria per my evaluation.

Signature of the Examiner

Notes or Clarifications:

State of Indiana EMR Psychomotor Skills Examination

Candidate:

Date:

Actual Time Started

Oxygen Administration

Examiner Name:

Signature:

Possible Points

Points Awarded

Demonstrates/verbalizes initial or continued consideration of BSI precautions	1
Cracks the oxygen tank valve before attaching the regulator	1

Attaches the regulator to the oxygen tank	1

Opens the oxygen tank valve with the regulator attached	1

Checks oxygen regulator and tank for leaks	1

Checks and verbalizes the oxygen tank pressure	1

Attaches non-breather mask to oxygen	1

Prefills the oxygen reservoir mask with oxygen	1

Adjusts the regulator to assure oxygen flow rate of fifteen (15) liters per minute	1

Attaches mask to patient's face and adjusts to fit snugly	1

NOTE: Examiner must now inform the candidate that the patient is not tolerating the non-rebreather mask and that a nasal cannula should be applied to the patient.

Removes non-rebreather mask and then attaches nasal cannula to oxygen	1

Adjusts liter flow to six (6) liters per minute or less	1

Applies nasal cannula to the patient properly	1

NOTE: Examiner must now instruct the candidate to discontinue oxygen therapy.
Removes the nasal cannula from the patient	1
Shuts off the regulator	1

Relieves the pressure within the regulator	1

Actual Time Ended:

TOTAL 16

** Examiner must list times above and then sign below after reviewing Critical Criteria**

Critical Criteria:

Failure to assemble the oxygen tank and regulator without leaks.

Failure to pre-fill the oxygen reservoir bag of the non-rebreather mask.

Failure to adjust the oxygen flow rate for the non-rebreather of at least 15 liters/minute. Failure to adjust the oxygen flow rate for the nasal cannula to 6 liters/minute or less. Failure to attach either mask in a manner that does not produce proper oxygen delivery. Use or orders a dangerous or inappropriate intervention.

Failure to manage the patient as a competent EMR.

Exhibits unacceptable affect with patient or other personnel.

You must factually document your rationale for checking any of the above critical items on this form in the space below, being specific as what occurred or did not occur.

Critical Criteria Explanation:

There were NO observed Critical Criteria per my evaluation.

Signature of the Examiner

State of Indiana EMR Psychomotor Skills Examination

Mouth to Mask with Supplemental Oxygen

Candidate:		Examiner Name:
Date:		Signature:

				Possible	Points
Actual Time Started				Points	Awarded
Demonstrates/verbalizes initial or continued consideration of BSI precautions				1

Connects the one way valve to the mask				1

Opens the patient's airway or confirms the patient's airway is open				1
	(may be done manually or with an adjunct)			1
	(may be done manually or with an adjunct)

Establishes and maintains a proper mask to face seal				1

Ventilates the patient with visible chest rise and fall				1
	(The observed rates should be between 10-12 breaths per minute)			1


Connects the mask to a high concentration of oxygen				1

Adjusts the oxygen flow rate to at least fifteen (15) liters/minute				1

Continues ventilations of the patient with visible chest rise and fall				1
	(The observed rates should be between 10-12 breaths per minute)			1


NOTE: Examiner must witness ventilations for at least 30 seconds.
			TOTAL	8

Actual Time Ended:

** Examiner must list times above and then sign below after reviewing Critical Criteria**

Critical Criteria:

Failure to correctly connect the one-way valve to the mask.

Failure to adjust the oxygen flow rate to at least 15 liters/minute.

Failure to produce visible chest rise and fall with ventilations .

(more than 2 inadequate ventilations per minute observed) Failure to ventilate the patient at a rate of 10-12 breaths per minute. Failure to manage the patient as a competent EMR

Exhibits unacceptable affect with patient or other personnel

You must factually document your rationale for checking any of the above critical items on this form in the space below, being specific as what occurred or did not occur.

Critical Criteria Explanation:

There were NO observed Critical Criteria per my evaluation.

Signature of the Examiner

State of Indiana EMR Psychomotor Skills Examination

Candidate:

Date:

Actual Time Started

Long Bone Immobilization

Examiner Name:

Signature

Possible Points

Points Awarded

Demonstrates/verbalizes initial or continued consideration of BSI precautions	1

Candidate directs application of manual stabilization of the injury	1

Assesses motor, sensory, & circulatory function in the injured extremity.	1

NOTE: The examiner acknowledges "motor, sensory, & circulatory function are present and normal."

Measures the splint.	1

Applies the splint	1

Immobilizes the joint above the injury site	1

Immobilizes the joint below the injury site	1

Secures the entire injured extremity	1

Immobilizes the affected hand/foot in the position of function	1

Reassesses motor, sensory & circulatory function in the injured extremity	1

NOTE: The examiner acknowledges "motor, sensory, & circulatory function are present and normal."

TOTAL 10

Actual Time Ended:

** Examiner must list times above and then sign below after reviewing Critical Criteria**

Critical Criteria:

Grossly moves the injured extremity.

Did not immobilize the joint above and the joint below the injury site.

Did not immobilize the affected hand or foot in a position of function.

Uses or orders a dangerous or inappropriate intervention.

Did not assess motor, sensory, and circulatory function in the injured extremity.

BOTH BEFORE AND AFTER splinting.

Failure to manage the patient as a competent EMR.

Exhibits unacceptable affect with patient or other personnel.

You must factually document your rationale for checking any of the above critical criteria below.

Critical Criteria Explanation:

There were NO observed Critical Criteria per my evaluation.

Signature of the Examiner

State of Indiana EMR Psychomotor Skills Examination

Bleeding Control/Shock Management

Candidate:	Examiner Name:

Date:	Signature

		Possible	Points
Actual Time Started		Points	Awarded
Demonstrates/verbalizes initial or continued consideration of BSI precautions		1

Candidate applies direct pressure to the wound		1

Candidate elevates the extremity		1

NOTE: The examiner must now inform the candidate that the wound continues to heavily bleed.

Candidate applies tourniquet in an appropriate manner and location

NOTE: The examiner must now inform the candidate that the patient is now showing signs and symptoms indicative of hypoperfusion.

Candidate properly positions the patient

Candidate administers high concentration of oxygen

Candidate initiates steps to prevent heat loss from the patient

Candidate indicates need for immediate transport

TOTAL 8

Actual Time Ended:

** Examiner must list times above and then sign below after reviewing Critical Criteria**

Critical Criteria:

Did not apply high flow oxygen with an appropriate mask.

Applied a tourniquet before attempting other methods of bleeding control.

Did not control hemorrhage using correct procedures in a timely manner.

Did not indicate the need for immediate transport.

Uses or orders a dangerous or inappropriate intervention.

Failure to manage the patient as a competent EMR

Exhibits unacceptable affect with patient or other personnel

You must factually document your rationale for checking any of the above critical criteria below.

Critical Criteria Explanation:

There were NO observed Critical Criteria per my evaluation.

Signature of the Examiner

State of Indiana EMR Psychomotor Skills Examination

	Ventilation & Airway Management for Apneic Patient
Candidate:		Examiner Name:

Date:		Signature:

				Possible	Points
Actual Time Started				Points	Awarded
Demonstrates/verbalizes initial or continued consideration of BSI precautions				1
Checks	NOTE: After checking responsiveness and breathing for			1
Responsiveness	at least 5 but no more than 10 seconds, examiner informs			1
Responsiveness	at least 5 but no more than 10 seconds, examiner informs

Checks Breathing	the candidate: "The patient is unresponsive & apneic"			1
Checks for pulse for at least 5 but no more than 10 seconds				1

NOTE: Examiner must now inform the candidate: "Your palpate a weak carotid pulse of 60."
Candidate opens the airway manually				1

NOTE: Examiner must now inform the candidate: "The mouth is full of secretions and vomitus."
Candidate turns on/prepares the suction device				1

Candidate assures presence of mechanical suction				1

Candidate attaches and inserts rigid suction catheter without applying suction				1

Candidate suctions the mouth and oropharynx				1

NOTE: Examiner must now inform the candidate:
	"The mouth and oropharynx are now clear-but there are no signs of breathing."
Candidate re-opens the airway manually				1

Candidate measures airway and selects an appropriately sized OP airway				1

Candidate inserts OP airway without pushing the tongue to the posterior				1

NOTE: Examiner must now inform the candidate: "No gag reflex is present and the patient accepts the
airway adjunct."
Ventilates the patient immediately (within 30 seconds) with a BVM device.				1

Candidate attaches the BVM assembly to high flow oxygen (15 liters per minute)				1

NOTE: Examiner must now inform the candidate: "ventilation is being performed without difficulty."
Re-checks the pulse for at least 5 but no more than 10 seconds				1

Candidate adequately ventilates and confirms there is chest rise/fall				1

Ventilates patient at a proper rate (10-12 per minute not to exceed 12 per minute)				1

			TOTAL	17
Actual Time Ended:

** Examiner must list times above and then sign on reverse after reviewing Critical Criteria**

Critical Criteria:

Failure to initiate ventilations within 30 seconds after suctioning or interrupts ventilations for greater than 30 seconds.

Failure to suction before ventilating the patient.

Did not demonstrate acceptable suction technique (including suctioning for prolonged time). Failure to check responsiveness, breathing or pulse for a period of between 5-10 seconds. Inserts any adjunct in a manner dangerous to the patient.

Failure to voice and ultimately provide high flow/concentration of oxygen.

Failure to ventilate the patient at a rate of at least 10 per minute and no more than 12 per minute.

Failure to provide adequate volumes per breath (maximum of 2 errors/minute permissible) Uses or orders a dangerous or inappropriate intervention.

Failure to manage the patient as a competent EMR

Exhibits unacceptable affect with patient or other personnel

Critical Criteria Explanation:

There were NO observed Critical Criteria per my evaluation.

Signature of the Examiner

Notes or Clarifications:

State of Indiana EMR Psychomotor Skills Examination

Spinal Immobilization (Supine Patient)

Candidate:

Date:

Actual Time Started

Examiner Name:

Signature

Possible Points

Points Awarded

Demonstrates/verbalizes initial or continued consideration of BSI precautions	1

Directs assistant to place and maintain manual immobilization of the head	1
	1
in the neutral, in-line position

Assesses motor, sensory, and circulatory function in each extremity	1

Appropriately sizes and correctly applies extrication collar	1

Directs/supervises assistants to assist with moving the patient onto the device	1
	1
in a manner that prevents compromising the integrity of the spine

Evaluates and VERBALIZES need for padding of voids, and pads as necessary	1

Immobilizes the patient's torso (chest AND hip straps) to the device	1

Evaluates and VERBALIZES need for padding behind the head, and pads as needed	1

Immobilizes the patient's head to the device	1

Secures the patient's legs to the device	1

Secures the patient's arms to the device	1

Reassesses motor, sensory, and circulatory function in each extremity	1

Actual Time Ended:

TOTAL 12

** Examiner must list times above and then sign below after reviewing Critical Criteria**

Critical Criteria:

Did not immediately direct, take, or maintain manual immobilization of the head. Released or ordered release of manual stabilization before it was maintained mechanically. Did not properly apply appropriately sized cervical collar before ordering the release of manual stabilization.

Manipulated or moved the patient excessively causing potential spinal compromise. Upon completion of immobilization, device allows for excessive patient movement. Head immobilized to the device before device sufficiently secured to the torso.

Head immobilization allows for excessive movement.

Upon completion of immobilization, head is not in a neutral, in-line position.

Did not assess motor, sensory, and circulatory function in each extremity

BOTH BEFORE AND AFTER immobilization to the long board device.

Exhibits unacceptable affect with patient or other personnel.

Failure to manage the patient as a competent EMT.

You must factually document your rationale for checking any of the above critical criteria below.

Critical Criteria Explanation:

There were NO observed Critical Criteria per my evaluation.

Signature of the Examiner

State of Indiana EMR Psychomotor Skills Examination

Cardiac Arrest Management/AED

Candidate:

Date:

Actual Time Started

Examiner Name:

Signature

Possible Points

Points Awarded

Demonstrates/verbalizes initial or continued consideration of BSI precautions	1
Determines the scene/situation is safe	1

Attempts to question bystanders about arrest events	1

Determines patient responsiveness	1

NOTE: The examiner must now inform the candidate: "The patient is unresponsive."

Assesses patient for spontaneous signs of breathing

NOTE: The examiner must now inform the candidate: "The patient is apneic, agonal, or gasping"

Checks carotid pulse (no more than 10 seconds)

NOTE: The examiner must now inform the candidate: "The patient is pulseless."

Immediately begins chest compressions

**Adequate depth and rate must be performed with chest recoil

Candidate performs 2 minutes of high quality, single-rescuer CPR

	Requests additional EMS response		1

	Adequate depth and rate observed		1

	Correct compression to ventilation ratio observed		1

	Candidate allows the chest to recoil completely		1

	Directs or controls adequate volumes delivered for each breath with OPA/NPA		1
	and BVM Device		1
	and BVM Device

	Minimal interruptions of less than 10 seconds throughout		1

	NOTE: After 2 minutes (5 cycles), patient is assessed and remains pulseless & apneic.
	A second rescuer arrives to perform compressions while the candidate operates the AED.
	Candidate turns power on AED		1

	Candidate follows prompts and correctly attaches AED pads to patient		1

	Directs CPR to be halted and ensures all individuals are clear for rhythm analysis		1

	Ensures all individuals are clear of the patient and delivers AED shock.		1

	Immediately directs rescuer to resume chest compressions		1

	Minimal interruptions of less than 10 seconds throughout		1

Actual Time Ended:

TOTAL 19

** Examiner must list times above and then sign on reverse after reviewing Critical Criteria**

Critical Criteria:

Did not confirm patient to PULSELESS and APNEIC.

Failure to initiate or resume CPR at appropriate periods

Interrupts CPR for more than 10 seconds at any point .

Failure to demonstrate CPR rates & depths consistent with current AHA guidelines.

Failure to operate the AED properly (failure to deliver shock or turns off AED during testing). Failure to attach AED pads correctly on the patient.

Failure to provide high flow/concentration of oxygen.

Failure to assure that all individuals are clear of the patient during rhythm analysis and before delivering shock(s). Must verbalize and observe "All Clear."

Requests, uses or orders a dangerous or inappropriate intervention

Failure to manage the patient as a competent EMR.

Exhibits unacceptable affect with patient or other personnel.

You must factually document your rationale for checking any of the above critical items on reverse side.

State of Indiana EMR Psychomotor Skills Examination

		Patient Assessment/Management - Medical
Candidate:			Examiner Name:

Date:			Scenario #:

					Possible	Points
Actual Time Started					Points	Awarded
Takes or verbalizes appropriate body substance isolation precautions					1
SCENE SIZE-UP
Determines the scene/situation is safe					1

Determines the mechanism of injury/nature of illness					1

Determines the number of patients					1

Request additional help, if necessary					1

Considers stabilization of the spine					1

PRIMARY SURVEY/RESUSCITATION
Verbalizes general impression of the patient					1

Determines responsiveness/level of consciousness					1

Determines chief complaint/apparent life threats					1

Airway	Opens and assesses the airway				1

	Inserts an adjunct as indicated				1
	Inserts an adjunct as indicated				1

	Assesses breathing				1

Breathing	Assures adequate ventilation				1
	Initiates adequate oxygen therapy				1

	Checks for pulse				1

Circulation	Assesses skin (color, temperature, & condition)				1
	Assess for and controls major bleeding and/or shock, if present				1

Identifies patient priority and makes treatment/transport decision					1

History Taking
History of present illness
Candidate should ask		No questions about present illness asked			Critical Fail/ 0 points
pertinent signs &		One question about present illness asked			Award 1 point
pertinent signs &		Two questions about present illness asked			Award 2 points
symptoms questions		Two questions about present illness asked			Award 2 points
symptoms questions		Three questions about present illness asked			Award 3 points
related to illness (such as		Three questions about present illness asked			Award 3 points
related to illness (such as		Four or more questions about present illness asked			Award 4 points
OPQRST)		Examiner should award 0-4 points			4
		Examiner should award 0-4 points			4

Past Medical History
Allergy questions asked					1

Medication questions asked					1

Past pertinent medical history questions asked					1

Last oral intake questions asked					1

Events leading to present illness questions asked					1

Secondary Assessment
Assesses appropriate body part/systems related to the present illness					1
**Could include: cardiovascular, pulmonary, neurological, musculoskeletal,

skin, GI/GU, reproductive, and psychological/social

Vital Signs / Application of assessment
Obtains baseline vitals (minimum is heart rate, blood pressure & respiratory)					1
States field impression of patient (including ALS or BLS transport requested)					1
Interventions:	Verbalizes proper interventions/treatment				1
REASSESSMENT
Describes/demonstrates how and when to reassess the patient					1
Gives brief report to arriving transport unit					1
				TOTAL	33
Actual Time Ended:
Actual Time Ended:

** Examiner must list times above and then sign on reverse after reviewing Critical Criteria**

Critical Criteria:

Failure to take or verbalize body substance isolation precautions

Failure to determine scene safety before approaching patient

Failure to initially consider and/or provide for stabilization of the spine when indicated Failure to assess/provide adequate ventilations

Failure to verbalize/provide adequate supplemental oxygen as scenario indicates

Performs secondary assessment before assessing or treating threats to airway, breathing or circulation

Requests, uses or orders a dangerous/inappropriate intervention or outside scope of practice Failure to manage the patient as a competent EMR

Exhibits unacceptable affect with patient or other personnel

Critical Criteria Explanation:

There were NO observed Critical Criteria per my evaluation.

Signature of the Examiner

Notes or Clarifications:

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