Primary Assessment

Training in Primary Assessment is included in this California-based EMT program as it is required in each of the higher level scenario-based skills tested in National NREMT registration and skills verification for California Registration.

In every call for a patient you must identify and manage immediate threats to life as part of the Primary Assessment. This happens after you have:

1. Done your scene size up (with your PENMAN mnemonic in which you identified any need for C-spine immobilization and initiated it), and
2. Formed your General Impression (rapidly identified any potential life threats and determined priority). For obvious life threatening hemorrhage, you would address it at this point, before proceeding to airway.

Your next step is:

Primary Assessment, in which you methodically identify and address immediate threat to life. The Advanced Trauma Life Support (ATLS) system uses the mnemonic ABCDE for Airway, Breathing, Circulation, Disability and Exposure to assist the first responder in ensuring threats are addressed in the most effective order, and with only minor modifications, it is equally applicable in both medical and trauma emergencies.

Airway

Airway obstruction is a major, preventable cause of death in medical and trauma emergencies alike, and therefore it is the initial step of the primary survey. Assessing the conscious patient's airway starts with talking to the patient:

1. Ask the patient their name to see if they respond clearly and appropriately. This will help assess the patency of the airway as well as mental status.
2. Look for signs of respiratory distress and listen for stridor
3. Inspect the face, oral cavity and neck as well as palpate the patient's neck and face. When inspecting and palpating the patient, look for swelling, oral secretions, vomit, or in trauma situations oral or dental injury and conditions that would complicate airway management such as unstable mid-face fractures.

Addressing the immediate threat to life:

• If the patient is unconscious or not protecting their airway, an OPA or a NPA should be inserted.
• If there are "snoring" respirations, suction to clear the airway

Breathing

Once the airway is secured or maintained by the patient, breathing and ventilation should be assessed for effectiveness. This involves:

1. Visual inspection of the patient's chest. Look for adequate rise and fall and a rate within normal limits for the patient's age. In a trauma situation, be alert for paradoxical chest movement (which indicates flail chest), or penetrating injury/tracheal deviation which would indicate a pneumothorax.
2. Auscultate the lungs listening for decreased breath sounds.
3. Palpate the chest for signs of crepitus.
4. Evaluate the patient's oxygen saturation if you have a pulse oximeter.

Addressing the immediate threat to life:

• If the patient has clinical signs of hypoxia initiate oxygen therapy
• Assist ventilation with a BVM if bradypneic (slow respirations)

Circulation

The assessment of circulation focuses on whether the patient's tissues are being adequately perfused, and looking for signs of shock. In medical calls, be alert to signs of Myocardial Infarction. In trauma this is looking for and controlling hemorrhage that has not been previously controlled. Hemorrhage has been identified as the most common cause of preventable death in trauma victims.

1. Visually evaluate the patient, looking for external hemorrhage or signs of shock like pallor indicating cardiac dysfunction or internal hemorrhage. Locations to look for signs of major internal hemorrhage include the thorax, abdomen, flank, or around pelvic or long bone fractures.
2. Palpate the patient's carotid and femoral pulses while assessing if the skin is cold and diaphoretic. If the patient does not have palpable central pulses, further investigation and intervention are needed.
3. The patient's mentation can also offer clues to how well they are perfusing their vital organs, but in patients with a possible head injury this may not be a reliable indicator.
4. Look for signs of other potential causes of shock such as tension pneumothorax, cardiac tamponade, or spinal cord injury.

Addressing the immediate threat to life:

• Treat any life threatening hemorrhage
• Provide supportive measures for shock such as keeping the patient warm, and lying them down to improve perfusion to the brain

Disability

Once airway, breathing, and circulation have been evaluated and stabilized, the patient's neurologic function should be assessed:

1. Your first step in Airway assessment also gives you some insight into their mentation. If it is profoundly impaired, assess the patient's consciousness using the Glasgow coma score (GCS). For patients with a GCS of 8 or less consideration should be given to definitive airway control (if not already achieved).
2. In trauma, assess the patient's motor ability and sensation in all four extremities to look for signs of spinal cord injury.
3. Check pupils for size and reactivity - asymmetry indicates increased intracranial pressure.
4. If signs of a stroke perform a FAST exam, looking for:
   • Facial drooping: Look for any asymmetry in facial expressions or reactivity
   • Arm weakness: Hold the patient's arms in front of them, have them close their eyes and maintain
   • Speech difficulties: Inability or difficulty to understand or produce speech including slurred speech or comprehension - it is useful to check with friends and family members if the patient's current condition differs from their baseline.
   • Time: If the patient's condition differs from their baseline, it is important to ask how long the symptoms have been present.

Addressing the immediate threat to life:

• If any of the symptoms above are showing, initiate oxygen therapy and transport immediately to a stroke center as time to definitive care is of the essence (time is brain)

Exposure

The fifth and final step of the primary survey in any situation where the patient has been exposed to extremes of heat or cold, the role of the environment in their disability should be considered. In a trauma, the exposure step includes removing all clothing to assess for signs of injury such as gunshot wounds, stab wounds, abrasions, lacerations, ecchymosis, or any other traumatic findings. During this stage, it is important to remember to keep the patient warm as hypothermia can lead to multi-organ failure.

Transport Decision

At this point the first responder should decide if the patient needs immediate transport and/or transport to a trauma center or other specialized center like a stroke center or cardiac catheterization. Local protocols, medical direction, and time to definitive care will dictate if you call for an ALS backup to provide transport or initiate transport directly. Patients that are not hemodynamically stable should be prioritized for transport. For high priority, unresponsive, and/or unstable patients, the rest of the medical or trauma assessment should be performed inside the ambulance en-route to the hospital.