Paramedic Essentials: Comprehensive Guide

Pain Assessment (FLACC & SOCRATES)

Pathophysiology: Pain triggers the sympathetic nervous system (tachycardia, hypertension, increased myocardial O2 demand). Interventions: Pharmacological (Paracetamol, Ibuprofen, Methoxyflurane, Fentanyl, Ketamine) & Non-Pharmacological (Splinting, positioning).

SOCRATES (Verbal Adult): Site, Onset, Character, Radiation, Associations, Time course, Exacerbating/Relieving factors, Severity.

FLACC Scale (Paediatric / Non-Verbal): Score 0-10.

Category	Score 0	Score 1	Score 2
Face	No particular expression or smile	Occasional grimace or frown, withdrawn	Frequent to constant quivering chin, clenched jaw
Legs	Normal position or relaxed	Uneasy, restless, tense	Kicking, or legs drawn up
Activity	Lying quietly, normal position	Squirming, shifting back and forth, tense	Arched, rigid or jerking
Cry	No cry (awake or asleep)	Moans or whimpers	Crying steadily, screams or sobs
Consolability	Content, relaxed	Reassured by occasional touching	Difficult to console or comfort

Altered Conscious States (AEIOU-TIPS)

Pathophysiology: Brain metabolism relies on constant glucose and oxygen. Disruption via toxins, poor perfusion (shock), or structural damage leads to rapid neuronal dysfunction.

Letter	Potential Causes	Letter	Potential Causes
A	Alcohol, Acidosis	T	Trauma, Temperature, Tumour
E	Epilepsy, Endocrine, Electrolytes	I	Infection (Sepsis, Meningitis)
I	Insulin (Hypo/Hyperglycaemia)	P	Psychiatric, Poisons (Overdose)
O	Oxygen (Hypoxia), Overdose	S	Stroke, Shock, Space-occupying lesion
U	Uraemia (Renal failure)

Stroke Assessment (BEFAST & Hunter 8)

Pathophysiology: 85% of strokes are ischaemic; 15% are haemorrhagic. Large Vessel Occlusions (LVOs) involve major arteries causing massive deficits.

• B - Balance: Sudden loss of balance or dizziness.
• E - Eyes: Sudden vision loss or change.
• F - Face: Unilateral facial droop.
• A - Arms: Unilateral arm drift or weakness.
• S - Speech: Slurred or strange speech.
• T - Time: Note exact time last seen well. Pre-notify hospital.

Hunter 8 (LVO Detection Tool): A clinical score to predict Large Vessel Occlusion.

Assessment Item	Score
Unilateral Arm Weakness	0, 1, or 2
Unilateral Leg Weakness	0, 1, or 2
Facial Palsy	0 or 1
Gaze Deviation	0 or 1
Speech Disturbance	0 or 1
Ignore / Neglect	0 or 1

Modified Rankin Scale (mRS)

Clinical Application: Used to measure the degree of disability or dependence in the daily activities of people who have suffered a stroke or other neurological event. Helps hospitals determine baseline function prior to stroke onset.

Score	Description	Clinical Translation
0	No symptoms at all	Completely Independent
1	No significant disability despite symptoms	Able to carry out all usual duties and activities
2	Slight disability	Unable to carry out all previous activities, but able to look after own affairs without assistance
3	Moderate disability	Requiring some help, but able to walk without assistance
4	Moderately severe disability	Unable to walk and attend to bodily needs without assistance
5	Severe disability	Bedridden, incontinent, requiring constant nursing care and attention
6	Dead	-

Head-to-Toe Assessment (DCAP-BTLS)

Pathophysiology: Identifies mechanical energy transfer causing tissue, bone, and organ damage. Hidden internal bleeding leads to hypovolaemic shock.

D - Deformities	B - Burns
C - Contusions (Bruises)	T - Tenderness
A - Abrasions	L - Lacerations
P - Punctures / Penetrations	S - Swelling

Abdominal Examination (Nine-Region Assessment)

Pathophysiology: Visceral pain (dull) = hollow organ distension. Somatic pain (sharp) = peritoneal irritation (peritonitis). Interventions: Nil by mouth (NBM), anti-emetics, analgesia, position of comfort.

Region	Common Differential Diagnoses
Right Hypochondriac	Cholecystitis, Hepatitis, Gallstones, Liver abscess, Pneumonia
Epigastric	Peptic ulcer, Gastritis, Pancreatitis, Myocardial Infarction, GERD, AAA
Left Hypochondriac	Splenic injury/rupture, Pancreatitis, Gastritis, Pneumonia
Right Lumbar	Kidney stones (renal colic), Pyelonephritis, Constipation
Umbilical	Early appendicitis, Small bowel obstruction, AAA, Gastroenteritis
Left Lumbar	Kidney stones, Pyelonephritis, Constipation, Diverticulitis
Right Iliac (Fossa)	Appendicitis, Ovarian cyst, Ectopic pregnancy, Inguinal hernia
Hypogastric (Suprapubic)	Urinary tract infection (UTI), Bladder distention, PID, Ectopic pregnancy
Left Iliac (Fossa)	Diverticulitis, Ovarian cyst, Ectopic pregnancy, Inguinal hernia

Respiratory Examination

Assess: Inspect (effort, cyanosis), Palpate (crepitus), Percuss (resonance), Auscultate.

Added Sound	Description	Common Differential Diagnoses / Intervention
Wheeze	High-pitched continuous sound (expiration)	Asthma, COPD, Anaphylaxis. Tx: Salbutamol, Ipratropium, Adrenaline
Crackles (Rales)	Fine/coarse popping sounds (inspiration)	APO, Pneumonia. Tx: GTN, CPAP (for APO)
Stridor	High-pitched, harsh sound (inspiration)	Upper airway obstruction (Croup, Epiglottitis). Medical Emergency.
Pleural Rub	Leathery, grating sound	Pleurisy (inflammation of the pleura).

Cardiovascular Examination

Assess: Inspect (perfusion, JVD, oedema), Palpate (pulses, capillary refill), Auscultate (heart sounds, murmurs). Interventions: Acquire 12-lead ECG. Aspirin, GTN, and analgesia for ACS.

Finding	Common Differential Diagnoses
Central Chest Pain	Acute Coronary Syndrome (ACS), Pulmonary Embolism (PE), Aortic Dissection, Pericarditis.
Raised JVD + Peripheral Edema	Congestive Heart Failure (right-sided backup), Cardiac Tamponade.
Absent/Weak Pulses	Shock, Peripheral Arterial Disease, Aortic Dissection.

Neurological and Cranial Nerve Examination

Pathophysiology: Upper motor neuron lesions cause spasticity/hyperreflexia; lower motor neuron lesions cause flaccidity. Cranial nerve deficits localise brainstem lesions.

Nerve	Function	Pre-hospital Test
II - Optic	Vision	Assess visual fields.
III, IV, VI - Oculomotor, Trochlear, Abducens	Eye Movements	Assess extraocular movements ("H" pattern), check for PERRL.
V - Trigeminal	Facial Sensation, Mastication	Test sensation on face, ask patient to clench jaw.
VII - Facial	Facial Expression	Ask patient to smile, raise eyebrows, puff cheeks.
VIII - Vestibulocochlear	Hearing and Balance	Rub fingers by ear, assess balance/gait.
IX, X - Glossopharyngeal, Vagus	Swallow, Gag, Voice	Assess speech, ask patient to swallow.
XI - Accessory	Shoulder Shrug	Ask patient to shrug shoulders against resistance.
XII - Hypoglossal	Tongue Movement	Ask patient to stick out tongue and move it side to side.

Mental State Examination (MSE - 12 Domains)

Clinical Application: Distinguishes organic causes (delirium) from functional causes (primary psychiatric illness).

Domain	What to Assess	Domain	What to Assess
1. Appearance	Grooming, hygiene, clothing, posture	7. Thought Content	Themes, delusions, preoccupations
2. Behaviour	Eye contact, psychomotor activity	8. Perception	Hallucinations, illusions
3. Speech	Rate, volume, tone, quantity	9. Cognition	Orientation, memory, attention
4. Mood	Subjective emotional state (ask them)	10. Insight	Understanding of their situation
5. Affect	Observable emotional state (range)	11. Judgement	Ability to make sound decisions
6. Thought Form	Logical/linear vs. disorganised	12. Rapport	Quality of interaction with crew

Suicidality Risk Assessment

Clinical Application: Critical for mental health crises. Acute crisis narrows cognitive perspective. Interventions: Remove lethal means, maintain constant observation, transport to mental health services.

• Ideation: Thoughts of harming self or ending life.
• Intent: How strong the thoughts are; desire to act.
• Plan: Specific thoughts on how, where, and when.
• Access: Do they have access to the planned means?
• Past Attempts: Previous history of self-harm.
• Protective Factors: Things stopping them from acting (family, pets, religion).

Behavioural Disturbance (SAT Score)

Pathophysiology: Severe agitation can lead to Excitable Delirium Syndrome (catecholamine surge/cardiac arrest). Interventions: Scores of +2 or +3 often require chemical restraint (Droperidol, Midazolam, Ketamine) for safety.

Score	Responsiveness	Speech
+3	Combative, violent, out of control	Continual loud outbursts
+2	Very anxious and agitated	Loud outbursts
+1	Anxious / Restless	Normal/Talkative
0	Awake and Calm / Cooperative	Speaks normally
-1	Asleep but rouses if name is called	Slurring or prominent pausing
-2	Responds to physical stimulation	Few recognisable words
-3	No response to stimulation	Nil

Lower Back Pain (Red Flag Criteria)

Pathophysiology: Mechanical pain vs. structural/infectious/oncological emergencies. Cauda Equina Syndrome requires urgent surgical decompression to prevent permanent paralysis/incontinence.

• T - Trauma (Significant, or minor in osteoporotic patient)
• U - Unexplained weight loss
• N - Neurological symptoms (Saddle anaesthesia, bowel/bladder incontinence) [Cauda Equina]
• A - Age (>50 or <20)
• F - Fever
• I - IV drug use (Risk of spinal epidural abscess)
• S - Steroid use (Osteoporosis risk)
• H - History of cancer

Skin Tear Assessment (STAR Classification System)

Interventions: Gently realign flap using a moist cotton tip. Secure with adhesive strips (Steri-Strips), apply a non-adherent silicone dressing and bandage.

Category	Description
1a	Edges can be realigned perfectly; flap colour is healthy (not pale/dusky).
1b	Edges can be realigned perfectly; flap colour is pale, dusky or darkened.
2a	Edges cannot be fully realigned; flap colour is healthy.
2b	Edges cannot be fully realigned; flap colour is pale, dusky or darkened.
3	Skin flap is completely absent.

Canadian C-Spine Rule

Clinical Application: A validated rule to determine if cervical spine immobilisation is required in alert, stable trauma patients.

1. High-Risk Factors (Mandates immobilisation): Age >= 65, Dangerous Mechanism (fall > 1m, high-speed MVC, axial load), or Paresthesia in extremities.
2. Low-Risk Factors (Allows safe assessment of ROM): Simple rear-end MVC, sitting position in ED/Ambulance, ambulatory at any time, delayed onset of neck pain, OR absence of midline c-spine tenderness.
3. Range of Motion (ROM): If low risk, can the patient actively rotate their neck 45 degrees left and right? If NO -> Immobilise. If YES -> No collar required.

Neonate Assessment (APGAR)

Interventions: Scored at 1 and 5 mins. Score 7-10: Routine care. Score 4-6: Stimulation, airway positioning, oxygen. Score 0-3 (or HR < 100): Intermittent Positive Pressure Ventilation (IPPV) / CPR if HR < 60.

Criteria	0 Points	1 Point	2 Points
Appearance (Skin colour)	Blue / Pale	Body pink, extremities blue	Completely pink
Pulse (Heart rate)	Absent	< 100 bpm	> 100 bpm
Grimace (Reflex irritability)	No response	Grimace / Feeble cry	Cry or active withdrawal
Activity (Muscle tone)	Flaccid	Some flexion	Active motion
Respiration	Absent	Weak, irregular gasp	Good, strong cry

Elderly Risk Assessments (EAR & FROP-COM)

Pathophysiology: Decreased physiological reserve, osteoporosis, and altered pharmacokinetics.

• EAR (Elder Abuse Risk): Screens for physical, psychological, financial, or neglect abuse. Look for unexplained injuries, fear around caregivers, or poor hygiene. Action: Mandatory reporting/safeguarding referral.
• FROP-COM (Falls Risk): Assesses falls history, medications (polypharmacy/sedatives), mobility, cognitive status, and environmental hazards. Action: Refer to falls prevention clinics.

• I - Identification: Patient's name, age, and gender.
• M - Mechanism / Medical Complaint: The reason for the call.
• I - Injuries / Information: The primary physical findings or relevant history.
• S - Signs: The patient's vital signs and GCS.
• T - Treatment and Trends: Interventions provided and the patient's response.

• A - Allergies: Any known allergies.
• M - Medications: Current medications.
• B - Background: Relevant past medical history.
• O - Other: Any other pertinent information (e.g., social situation, advance care directives).