The primary assessment

1. You findAs you approach, you take in the scene, the chief complaint and how the patient looks: moving or still, breathing or gasping, pale and sweaty, in the tripod position.You doThat is the general impression. A patient who looks lifeless gets a pulse check and compressions first (C-A-B); a patient with signs of life gets airway, breathing and circulation in order (A-B-C).
2. You findYou speak to the patient, then touch, then pinch the trapezius if there is no response.You doThat places him on the AVPU scale: Alert, responds to Verbal stimuli, responds only to Painful stimuli, or Unresponsive. If a spinal injury is possible, a partner holds the head in line while you do this.
3. You findA patient who is talking or crying clearly has an open airway. In a patient who is not alert you cannot assume the airway is open, so you assess it; noisy breathing means a partial obstruction.You doOpen the airway with a head-tilt/chin-lift, or a jaw-thrust if a spinal injury is suspected, and suction what is in it. An oropharyngeal airway goes in only if there is no gag reflex; a nasopharyngeal airway is not used with a suspected basilar skull fracture or severe facial fracture.
4. You findYou look at the rate and depth of breathing and listen for how hard the patient is working.You doBreathing that is absent or inadequate gets ventilations with oxygen; adequate breathing with signs of distress or low oxygen gets oxygen guided by the pulse oximeter and the exam.
5. You findYou check for a pulse (radial, or carotid if there is no radial pulse) and note its rate, strength and regularity; you look at the skin and sweep for bleeding.You doSevere bleeding is controlled the moment you find it, because it can kill within minutes.
6. You findEverything you have found sorts the patient as stable, potentially unstable or unstable.You doThat is the transport priority. High priority: unresponsiveness or a poor general impression, inability to follow commands, difficulty breathing, shock, complicated childbirth, chest pain with a systolic blood pressure under 100, uncontrolled bleeding, and severe pain anywhere.

• The primary assessment has six parts in order: general impression, mental status, airway, breathing, circulation, priority.
• A-B-C is a guide, not a rule. Exsanguinating bleeding comes before everything, material in the airway is suctioned before you ventilate, and a pulseless patient gets C-A-B.
• Mental status uses AVPU. An alert patient is then checked for orientation to person, place and time. A depressed mental status may mean hypoxia, shock or another cause such as low blood sugar: assess oxygenation, give oxygen if indicated (titrated to an SpO₂ of at least 94%), and make the patient a high priority.
• Spinal motion restriction starts on first contact when the mechanism suggests a spinal injury, but it never outranks the airway, ventilation or bleeding control.
• Priority can change during the call, so the primary assessment is repeated whenever the patient changes.

The wrong idea: The ABCs are a strict order: you must finish the airway before you are allowed to touch the bleeding.

What is actually true: Exsanguinating bleeding is the first concern in the primary assessment, ahead of the airway. A-B-C guides the order of interventions; you do what the patient needs most first, and with more than one EMT several priorities are handled at the same time.

The primary assessment finds and treats immediate threats to life in six parts: general impression, mental status (AVPU, with spinal stabilization if indicated), airway, breathing, circulation and priority. A-B-C guides the order, but exsanguinating bleeding comes first, the airway is cleared before ventilating, and a lifeless patient gets C-A-B. It ends with a priority decision, which is repeated whenever the patient changes.

Direct pressure and the bleeding ladder →