Chapter 12: The Primary Assessment

Breathing

1. Assess respiratory rate, quality, and auscultate lung sounds 2. Provide supplemental oxygen or artificial ventilation as needed. 3. Manage life-threatening conditions associated with breathing (eg. initiate artificial ventilations for frail chest and apply an occlusive dressing for sucking chest)

NOTE: for unresponsive patients, the 2010 guidelines for emergency cardiac care and basic life support advocate checking for cardiac arrest and initiating CPR as quickly as possible. To accomplish this, a CAB approach to assessment is recommended for unresponsive patients

1. Circulation: If the patient is unresponsive, with no signs of breathing, or agonal breaths, and no confirmed pulse within 10 seconds, initiate CPR and incorporate AED as soon as it is available. CPR should begin the need for chest compression. 2. Airway: Check the airway and intervene as needed. Opening the airway for an unresponsive patients should be done after determining the need for chest compressions. 3. Breathing: Assess breathing and intervene as needed. Assessing for breathing (look, listen, feel) and artificial ventilations are performed after determining the need for chest compression.

Medical Patient Responsive

1. General impression: Form general impression of patient's condition. 2. Mental status: AVPU (alert) 3. Airway is open. 4. Breathing: Look for rise and fall of chest, listen and feel for rate and depth of breathing. Look for work of breathing (use of accessory muscles, retractions). Assess oxygen saturation. Interventions: Administer oxygen based on the patient's complaint, level of distress, and oxygen saturation reading. If breathing becomes inadequate, provide positive pressure ventilations and high-concentration oxygen. 5. Circulation: Pulse; bleeding; skin color, temperature, condition Interventions: Control bleeding. Treat for shock. If cardiac arrest occurs, perform CPR. 6. Priority: A responsive patient's priority depends on chief complaint, status of ABCs, and other factors.

Medical Patient Unresponsive

1. General impression: Form general impression of patient's condition. 2. Mental status: AVPU (responsive to only verbal or painful stimulus or not responsive) Intervention: Oxygen administration based on patient's complaint, level of distress and oxygen saturation. 3. Airway is compromised. Interventions: Open airway with head-tilt, chin-lift maneuver; consider oro- or nasopharyngeal airway; suction as needed. For foreign body obstruction, use abdominal thrusts or other blockage-clearing technique. 4. Breathing: Look for rise and fall of chest, listen and feel for rate and depth of breathing. Look for work of breathing (use of accessory muscles, retractions). Interventions: If there is hypoxia; respiratory distress; or threat to the airway, ventilation, oxygenation, or circulation, administer high-concentration oxygen by nonrebreather mask. Position patient on side. If breathing is inadequate, provide positive pressure ventilations and high-concentration oxygen. If respiratory arrest develops, perform rescue breathing. 5. Circulation: Pulse; bleeding; skin color, temperature, condition Interventions: Control bleeding. Treat for shock. If cardiac arrest occurs, perform CPR. 6. Priority: An unresponsive patient is automatically a high priority for immediate transport.

Trauma Patient Responsive

1. General impression: Form general impression of patient's condition. Evaluate mechanism of injury. Intervention: Manual stabilization of head and neck if you suspect spinal injury. 2. Mental status: AVPU (alert) 3. Airway is open. 4. Breathing: Look for rise and fall of chest, listen and feel for rate and depth of breathing. Look for work of breathing (use of accessory muscles, retractions). Interventions: Patients with minor or isolated injuries may not require oxygen. If there is hypoxia; respiratory distress; or threat to the airway, ventilation, oxygenation, or circulation, administer high concentration oxygen by nonrebreather mask. If breathing becomes inadequate, provide positive pressure ventilations and high concentration oxygen. 5. Circulation: Pulse; bleeding; skin color, temperature, condition Interventions: Control bleeding. Treat for shock. If cardiac arrest occurs, perform CPR. 6. Priority: A responsive patient's priority depends on chief complaint, status of ABCs, and other factors.

Assessing Mental Status: Level of Consciousness

During the primary assessment, the first assessment of level of consciousness (LOC) is general, not specific. Determine if the patient is: 1. conscious and alert 2. conscious and altered 3. unconscious

Airway

If the patient is alert and talking clearly or crying loudly, you know that the airway is open. If the airway is not open or is endangered (the patient is not alert, is supine, or is breathing noisily), take measures to open the airway, such as the jaw-thrust or head-tilt, chin-lift maneuver; suctioning; or insertion of an oropharyngeal or nasopharyngeal airway.

Assessing Mental Status: Person, Place, Time, and Event

If the patient is awake and alert, a more thorough assessment of LOC should be completed. 1. Person: The patient knows his or her name 2. Place: The patient knows where he or she is 3. Time: The patient knows the year, month, and approximate date and time 4. Event: The patient can describe the MOI or NOI

Circulation on light-skin vs dark-skin

If the patient is light skinned, you can check the pulse and skin at the same time. As you take the radial pulse, note whether the skin at the wrist is warm, pink, and dry—indicating good circulation—or pale and clammy (cool and moist)—suggesting shock, which is a serious condition. If your patient is dark skinned, you can check the color of the lips or nail beds, which should be pink.

SIDE NOTE: ABC vs. CAB

It may seem easiest to assume that you will assess each patient in A-B-C order (airway, breathing, circulation), this is not necessarily the case for all patients. You will likely assess a patient in C-A-B (circulation [compressions], airway, breathing) order for a patient who appears lifeless and has no pulse. Meaning, If the patient shows signs of life, you will begin to work through the ABCs in an order dictated by your patient's priorities. If the patient appears lifeless—that is, not moving and apparently not breathing—you will take a different course of action and shift toward resuscitation beginning with chest compressions and preparation of the defibrillator if the patient is pulseless. In short, you will perform your primary assessment in the way your patient needs it most.

Primary Assessment of Adult

Mental Status: AVPU: Is the patient alert? Responsive to verbal stimulus? Responsive to painful stimulus? Unresponsive? If alert, is patient-oriented to person, place, and time? Airway: Trauma: jaw-thrust maneuver. Medical: head-tilt, chin-lift maneuver. Both: Consider oro- or nasopharyngeal airway, suctioning. Breathing: If respiratory arrest, perform rescue breathing. If depressed mental status and inadequate breathing (slower than 8 per minute), give positive pressure ventilations with 100 percent oxygen. Administer oxygen, when indicated, according to the patient's complaint, level of respiratory distress, and pulse oximetry readings. Circulation: Assess skin, radial pulse, and bleeding. If the patient is in cardiac arrest, perform CPR. See the chapter "Bleeding and Shock" on how to treat bleeding and shock.

Primary Assessment of Infant (up to 1 year)

Mental Status: If not alert, shout as a verbal stimulus, flick feet as a painful stimulus. (Crying would be infant's expected response.) Airway: Same as children, but see the "Airway Management" chapter and BCLS Review for special infant airway techniques. Breathing: Same as children, but normal rates for infants are faster than for children and adults. (See the chapter "Vital Signs and Monitoring Devices" for normal infant respiration rates.) Circulation: Assess skin, brachial pulse, bleeding, and capillary refill. See the "Vital Signs and Monitoring Devices" chapter for normal child pulse rates (faster than for children and adults). If the patient is in cardiac arrest, perform CPR. See BCLS Review for special infant techniques. See the "Bleeding and Shock" chapter on how to treat for bleeding and shock.

Primary Assessment of Children (1-5 Years)

Mental Status: Same as adults Airway: Same as adults. Review for special child airway techniques. If performing head-tilt, chin-lift maneuver, do so without hyperextending (stretching) the neck. Breathing: As for adults, but normal rates for children are faster than for adults. Parents may have to hold oxygen mask to reduce the child's fear of mask. Circulation: Assess skin, radial pulse, bleeding, and capillary refill. See the "Vital Signs and Monitoring Devices" chapter for normal child pulse rates (faster than for adults). If patient is in cardiac arrest, perform CPR. See BCLS Review for child techniques. See the chapter "Bleeding and Shock" on how to treat for bleeding and shock.

When is a patient stable or unstable?

TO BE STABLE, A PATIENT NEEDS TO HAVE VITAL SIGNS THAT ARE IN THE NORMAL RANGE OR JUST SLIGHTLY ABNORMAL. If they are abnormal, they must be small deviations from normal or easily explained by factors other than injury and illness (e.g., sweating on a hot day). Stable vital signs are not the only requirement for a stable classification, but they are necessary. A THREAT TO THE AIRWAY, BREATHING, OR CIRCULATION, EITHER ACTUAL OR IMMINENT, RULES OUT STABLE. This puts a patient in either the unstable or potentially unstable category, depending on the severity of the patient's condition. THERE ARE MANY TIMES WHEN IT IS NOT CRYSTAL CLEAR WHAT A PATIENT'S PROBLEM IS, SO THERE WILL BE MANY POSSIBLE DIAGNOSES, SOME MORE SERIOUS THAN OTHERS. When a patient does not have any immediate threats to life but you believe he may deteriorate because of the nature of the problem, you should consider the potentially unstable category for the patient. This means you will not delay transport, but it does not necessarily mean you will use lights and siren to transport the patient to the hospital. A PATIENT'S PRIORITY CAN CHANGE. For example, an unconscious diabetic patient with low blood sugar would initially be unstable because of the threat to the airway. If the patient became awake enough to swallow oral glucose then became alert and oriented, it would be appropriate to change this patient's priority to stable. NOTE: If any life-threatening problem cannot be controlled or threatens to recur, or if the patient has a depressed level of responsiveness, he has an immediate priority for transport to the hospital, with assessment and care continuing en route.

Assessing Mental Status: AVPU scale

The AVPU scale can be used to rapidly determine the patient's general responsiveness: 1. A = awake and alert (will talk and answer questions sensibly) 2. V = responsive to voice (shouting or moaning) 3. P = responsive to pain (such as pinching a toe or ear or squeezing the trapezius muscle between the neck and the shoulder) 4. U = unresponsive (when the patient does not even respond to painful stimuli)

Chief Complaint (CC)

The chief complaint is the reason EMS was called, usually in the patient's own words. It may be as specific as abdominal pain or as vague as "not feeling good." In any case it is the patient's description of why you were called.

General impression

The impression of the patient's condition that is formed on first approaching the patient, based on the patient's environment, chief complaint, and appearance. The general impression is the information you are able to immediately determine upon arriving at the patient, such as the patient's age, sex, level of distress, and overall appearance. Determine the level of patient exposure needed. At times, it will be necessary to remove some or all of the patient's clothing to assess for life-threatening conditions, If exposure is indicated, protect the patient's privacy as best as you can.

When does primary assessment begin?

The primary assessment begins when you arrive at the patient. The purpose of the primary assessment is to identify and treat immediate life-threatening conditions. Manuel cervical spine stabilization. If cervical spine (c-spine) injury is suspected, manual c-spine precautions should be taken immediately according to local protocol.

Circulation

To evaluate circulation, assess pulse, skin, and bleeding. 1. Assess central versus peripheral pulses - Initiate CPR as needed - Check the brachial pulse on infants 2. Assess for and control life-threatening bleeding - Direct pressure is the first technique to control external bleeding - Note: The posterior should be assessed for life-threatening conditions during the primary assessment. Conditions such as a sucking chest wound or life-threatening bleeding should be found and managed before the primary assessment is completed. 3. Check skin color 4. Check capillary refill for pediatric patients NOTE: You don't have to take the pulse for a full 30 seconds and obtain an exact rate. During the primary assessment, there are only three possible results of the pulse check that you will be looking for: - Within normal limits - Unusually slow - Unusually fast

Mental status

level of responsiveness

Primary assessment

the first element in a patient assessment; steps taken for the purpose of discovering and dealing with any life-threatening problems. The six parts of primary assessment are: (1) forming a general impression, (2) assessing mental status, (3) assessing airway, (4) assessing breathing, (5) assessing circulation, and (6) determining the priority of the patient for treatment and transport to the hospital.

Trauma Patient Unresponsive

1. General impression: Form general impression of patient's condition. Evaluate mechanism of injury. Intervention: Manual stabilization of head and neck if you suspect spinal injury. 2. Mental status: AVPU (responsive to only verbal or painful stimulus or not responsive) Intervention: Oxygen administration. For patients with shock, hypoxia, or severe injuries, you will administer high-concentration oxygen. 3. Airway is compromised. Interventions: Open airway with jaw-thrust maneuver; consider oro- or nasopharyngeal airway; suction as needed. For foreign body obstruction, use abdominal thrusts or other blockage-clearing technique. 4. Breathing: Look for rise and fall of chest, listen and feel for rate and depth of breathing. Look for work of breathing (use of accessory muscles, retractions). Expose and palpate the chest for signs of trauma that will affect breathing. Interventions: If there is hypoxia; respiratory distress; or threat to the airway, ventilation, oxygenation, or circulation, administer high-concentration oxygen by nonrebreather mask. Position patient on side once spinal stability is assured. If breathing is inadequate, provide positive pressure ventilations and high-concentration oxygen. If respiratory arrest develops, perform rescue breathing. 5. Circulation: Pulse; bleeding; skin color, temperature, condition Interventions: Control bleeding. Treat for shock. If cardiac arrest occurs, perform CPR. 6. Priority: An unresponsive patient is automatically a high priority for immediate transport.

There are four general situations that call for assistance with breathing, listed here from more to less severe:

1. IF THE PATIENT IS IN RESPIRATORY ARREST WITH A PULSE, perform rescue breathing. 2. IF THE PATIENT IS NOT ALERT AND HIS BREATHING IS INADEQUATE (WITH AN INSUFFICIENT MINUTE VOLUME BECAUSE OF DECREASED RATE OR DEPTH OR BOTH), provide positive pressure ventilations with 100 percent oxygen. 3. IF THE PATIENT HAS SOME LEVEL OF ALERTNESS AND HIS BREATHING IS INADEQUATE, assist his ventilations with 100 percent oxygen. Synchronize your ventilations with the patient's own respirations so they are working together, not against each other. 4. IF THE PATIENT'S BREATHING IS ADEQUATE BUT THERE ARE SIGNS OR SYMPTOMS SUGGESTING RESPIRATORY DISTRESS OR HYPOXIA, provide oxygen based on the patient's need as determined by your examination, the patient's complaint and level of distress, and the pulse oximetry readings.

Patient Position

1. If the patient is prone, log-roll the patient to the supine position 2. Move the patient with manual c-spine precautions if indicated.

Airway assessments and interventions should be performed in the following order:

1. Manual airway, maneuvers as needed: - Head-tilt, chin-lift if no spinal injury suspected - Jaw thrust maneuver if spinal injury suspected 2. Suction as needed 3. Mechanical airway adjuncts as needed: - Oropharyngeal airway (OPA) for unresponsive patients - Consider nasopharyngeal airway (NPA) for patients with decreased LOC

General Impression: Identify patients who may be critical

1. Patients who appear lifeless - Resuscitate by beginning C P R compressions. - Prepare A E D as soon as possible. 2. Patients who have an obvious altered mental status 3. Patients who appear unusually anxious and those who appear pale and sweaty 4. Obvious trauma to the head, chest, abdomen, or pelvis 5. Specific positions indicate distress. - Tripod position: Difficulty breathing - Levine's sign: Chest pain or discomfort

Rapid Scan (Included only in EMT crash-course book)

1. Perform a rapid scan to identify any remaining life-threatening such as signs of internal bleeding, unstable pelvis, closed femur fracture 2. The rapid scan exists specifically to identify any remaining life threats and should take no longer than 90 seconds. Do not spend time on non-threatening conditions during the rapid scan. 3. The rapid can should include inspection, palpation, and auscultation as needed. - Some conditions can only be seen or felt, not both - Auscultate lung sounds here if not done during breathing or there is a change in the patient's condition or bag compliance

What conditions are considered high priority?

A number of findings indicate a high priority for transport (i.e., the patient is categorized as unstable or potentially unstable). These are conditions for which, usually, there is little or no treatment that can be given in the field that will make a difference in how well the patient does: Poor general impression Unresponsive Responsive, but not following commands Difficulty breathing Shock Complicated childbirth Chest pain consistent with cardiac problems Uncontrolled bleeding Severe pain anywhere

Transport priority

Any life-threatening airway, breathing, or circulation problem must be treated as soon as it is discovered. Once life threats are under control, you will decide on the patient's priority for immediate transport versus further on-scene assessment and care.

SIDE NOTE: To determine exactly what you will do and in what sequence during the primary assessment, there are certain general considerations you will take into account.

Any vomit in the airway that enters the lungs is very serious and often fatal. The stomach contents contain solids that may obstruct the airway as well as strong acids that can cause irritation within the airway. Some patients are saved by defibrillation but later die because of aspiration pneumonia or pneumonitis. - It is a vital component of the primary assessment to suction the airway as soon as needed and before ventilating. Exsanguinating (very severe, life-threatening) bleeding must be stopped immediately. Damage to major vessels, especially arteries, can cause death extremely rapidly from bleeding. - Life-threatening bleeding must be controlled immediately. Breathing and circulation are obviously vital for life. You must make sure your patient is breathing and breathing adequately to support life. - In cases where there appears to be no breathing or only very occasional, ineffective breaths (agonal breathing), you should check for a pulse and begin CPR if necessary. If immediate interventions such as bleeding control or CPR are not required, you will shift into an important but less urgent mode in which you will administer oxygen appropriate for the patient's condition and evaluate for shock.