Primary Assessment

Primary assessment — 6 parts

The primary assessment, also called the initial assessment, is the first part of patient assessment. Its focus is exclusively on threats to life: the airway, breathing, and circulation. In one sentence, its purpose is to quickly and efficiently identify and treat any threats to the patient's life. The primary assessment has 6 parts, performed in this order:

1. Form a general impression.
2. Assess mental status, with manual stabilization of the spine if it is indicated.
3. Assess the airway.
4. Assess breathing.
5. Assess circulation.
6. Determine the patient's priority.

A-B-C is a guide to interventions, not a mandatory sequence. Do what the patient needs most, in whatever order that requires. C-A-B, with compressions first, is used for a patient who appears lifeless or pulseless; A-B-C is used for a patient who shows signs of life. When several EMTs are present, they can handle several priorities at the same time.

Priority order of concerns

Within the primary assessment, some problems must be dealt with before others. The first concern is exsanguinating (severe) bleeding, which must be controlled immediately. The second is vomit or other material in the airway that the patient could aspirate; suction it before you ventilate. The third is a patient who is not breathing or who has only agonal breathing; check the pulse and begin CPR if it is needed. If there is no immediate threat to life, administer oxygen as appropriate and evaluate the patient for shock.

Spinal motion restriction (SMR)

Spinal motion restriction (SMR) restricts movement of the head, neck, and spine whenever a spinal injury is possible or likely, judged from the mechanism of injury (MOI), the history, and the signs and symptoms. Apply it on first contact with the patient and continue it until the physical examination rules a spinal injury out. Manual stabilization means holding the head still in a neutral, in-line position, facing forward; do not pull or twist it.

SMR is not the highest priority when it interferes with the airway, ventilation, or bleeding control. If you are alone, some spinal movement may be necessary to ventilate the patient effectively. With a responsive patient, an alternative is to instruct the patient not to move and to keep the nose in line with the umbilicus.

Forming a general impression

The general impression is formed from the environment, the chief complaint, and the patient's appearance. The chief complaint is the reason EMS was called, usually in the patient's own words, and it may differ from the actual problem; jaw pain, for example, can be a myocardial infarction (MI). The table below lists the signs that shape the general impression and what each one means.

Table 12.1Forming a general impression

The absence of these red-flag signs does not guarantee that the patient is stable.

Assess mental status — AVPU

Mental status is assessed with the AVPU scale, which the table below sets out.

Table 12.2Assess mental status — AVPU

If the patient is alert, check orientation to person, then place, then time. A depressed mental status may indicate hypoxia or shock, so administer oxygen (O2) and treat the patient as a high transport priority.

Assess airway, breathing & circulation

A patient who is alert and talking or crying clearly has an open airway. A patient who is not alert, or whose breathing is noisy, has a compromised airway. Open it with a jaw-thrust or a head-tilt/chin-lift, suction as needed, and insert an oropharyngeal or nasopharyngeal airway.

Breathing problems range from the most severe to the least. A patient in respiratory arrest who still has a pulse needs rescue breathing. A patient who is not alert and is breathing inadequately needs positive pressure ventilation with O2. A patient with some alertness but inadequate breathing needs assisted ventilations with 100% O2. A patient who is breathing adequately but shows signs of distress or hypoxia receives O2 based on the pulse oximetry reading, the examination, and the complaint.

Circulation is assessed through the pulse, the skin, and any bleeding. In a light-skinned patient, check the pulse and the skin color at the wrist; in a dark-skinned patient, check the lips and nail beds. The pulse check during the primary assessment needs only 3 outcomes: normal, unusually slow, or unusually fast. Control severe bleeding immediately, because it can kill in 1–2 minutes.

Determine priority

The last step of the primary assessment is to determine the patient's priority. Patients fall into one of three categories, described in the table below.

Table 12.3Determine priority

Priority can change during the call. An unresponsive patient is automatically a high priority. The high-priority conditions are a poor general impression, unresponsiveness, failure to follow commands, difficulty breathing, shock, complicated childbirth, cardiac-type chest pain, uncontrolled bleeding, and severe pain anywhere.

Capillary refill is checked by pressing the nail (or the back of the hand or foot in an infant); the color should return to pink in less than 2 seconds. Prolonged or absent refill indicates a circulation problem, although the test is less reliable in the elderly and in cold environments. An infant's airway is kept in a neutral position, not tilted back like an adult's.