Primary Assessment

1. 2 Primary Assessment

2. Multimedia Directory Slide 16 Medical Patient Assessment Video

3. Standard • Assessment

4. Competency • Integrate scene and patient assessment findings with knowledge of epidemiology and pathophysiology to form a field impression. • This includes developing a list of differential diagnoses through clinical reasoning to modify the assessment and formulate a treatment plan.

5. Introduction • Primary assessment: • Basis of all prehospital emergency medical care. • Identify and correct immediately life-threatening conditions of patient's airway, breathing, circulation (ABCs). • If you find these conditions during assessment, treat at once.

6. Introduction • Following primary assessment, decide priority regarding transport or on-scene assessment and care. • Not step-by-step process; series of decisions based on what you find. • Proceed systematically through ABCs.

7. Introduction • Steps of Primary Assessment • Form general impression • Stabilize cervical spine as needed • Assess baseline mental status • Assess and manage airway • Assess and manage breathing • Assess and manage circulation • Determine priorities

8. Forming a General Impression • General impression: first, intuitive evaluation of patient. • Determine general clinical status and priority for immediate transport. • Environment • Mechanism of injury; nature of illness • Patient's posture and overall look • Chief complaint • Your instincts

9. Forming a General Impression • Patient looks dead: quick evaluation of responsiveness and breathing. • Feel for pulse; if absent, begin chest compressions immediately. • Patient shows signs of life: conduct standard primary assessment (ABC). • Patient's age, gender, race often influences index of suspicion.

10. Forming a General Impression • Determine whether problem results from trauma or medical problem. • Sometimes not readily apparent. • More serious the condition, quieter patient will be. • Look, listen, smell environment. • Gather clues as you enter scene.

11. Forming a General Impression • Use Standard Precautions with every patient. • If patient alert, identify yourself; establish rapport. • Reassure patient; listen to him; do not trivialize complaints. • Support your patient psychologically and physiologically.

12. Forming a General Impression • If mechanism of injury significant or patient unresponsive, manually stabilize patient's head and neck. • If patient awake, explain what you are doing; ask him not to move his neck. • If patient is small child, place towel or pad beneath shoulders to maintain proper alignment of cervical spine.

13. Manually stabilize the head and neck on first patient contact.

14. Place a folded towel under your young patient's shoulders to keep the airway aligned. Airway aligned after using a towel.

15. Mental Status Assessment • Baseline mental status crucial. • Head-injury patients. • Medical situations that cause altered levels of response; stroke patients. • AVPU • Alert • Verbal stimuli • Painful stimuli • Unresponsive

16. Medical Patient Assessment Video Click here to view a video on the topic of primary assessment steps. Back to Directory

17. Mental Status Assessment • AVPU Levels—Alert • Patient awake; open eyes. • Oriented to person, place, time, situation. • Organized, coherent answers to questions. • Or may be disoriented and confused. • Quiet child usually seriously injured or ill.

18. Mental Status Assessment • AVPU Levels—Verbal • Appears to be sleeping but responds when you talk to him; he is responsive to verbal stimuli. • Responds by speaking, opening eyes, moaning, or just moving. • Note level of verbal response. • Infants: you may have to shout to elicit response.

19. Mental Status Assessment • AVPU Levels—Pain • If patient does not respond to verbal stimuli, try to elicit response with painful stimuli. • May respond by waking up, speaking, moaning, opening eyes, moving. • Decorticate or decerebrate posturing is nonpurposeful; suggests serious brain injury.

20. Mental Status Assessment • AVPU Levels—Unresponsive • Comatose; fails to respond to any noxious stimuli. • Any alteration or deterioration in mental status may indicate emergent or serious problem. • Take immediate steps to protect patient's airway.

21. Airway Assessment • If patient responsive and can speak clearly, assume airway patent. • If patient unconscious, airway may be obstructed. • Assume unconscious patient has no gag reflex; cannot protect his airway. • Oropharyngeal suctioning will clear secretions.

22. Airway Assessment • If cervical spine injury, open airway using jaw thrust without head extension. • For all other patients, use head-tilt/chin-lift maneuver. • Use head-tilt/chin-lift maneuver if jaw thrust does not open airway.

23. Use the jaw-thrust maneuver to open your patient's airway if you suspect a cervical spine injury.

24. The head-tilt/chin-lift maneuver in an adult.

25. Airway Assessment • To open airways of infants and children, apply gentle and conservative extension of head and neck. • To assess airway, look for chest rise while you listen and feel for air movement. • Noisy airway partially obstructed. • Gurgling indicates fluid blocking upper airway.

26. Airway Assessment • Stridor caused by life-threatening upper airway obstruction. • Foreign body obstruction: abdominal thrusts to dislodge object. • Positive pressure ventilation, continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), intubation, cricothyrotomy: only if airway becomes totally obstructed.

27. Airway Assessment • Respiratory burns: rapid massive swelling of upper airway; rapid endotracheal intubation. • Anaphylaxis: vasoconstrictor medications to decrease upper airway swelling. • Wheezing: constricted bronchioles; smaller, lower airways; bronchodilator medication.

28. Airway Assessment • If patient is not moving air, he is in respiratory arrest. • Immediately provide ventilation with bag-valve mask and high-flow oxygen. • If patient unconscious and lacks gag reflex, insert oropharyngeal airway. • If gag reflex or significant orofacial trauma, insert nasopharyngeal airway.

29. Immediately use a bag-valve mask to ventilate patients who are not moving air.

30. Use an oropharyngeal airway for unconscious patients without a gag reflex.

31. The nasopharyngeal airway rests between the tongue and the posterior pharyngeal wall.

32. Airway Assessment • If patient has no gag reflex and cannot protects airway, use advanced techniques to maintain airway patency. • Endotracheal intubation • Multilumen airways • Transtracheal techniques • If patient has airway problem and shows signs of hypoxia, administer oxygen by nonrebreather mask.

33. Breathing Assessment • Altered mental status, confusion, apprehension, or agitation • Shortness of breath while speaking • Retractions (supraclavicular, suprasternal, intercostal) • Asymmetric chest wall movement • Accessory muscle use (neck, abdominal)

34. Breathing Assessment • Cyanosis • Audible sounds • Abnormally rapid, slow, shallow breathing • Nasal flaring

35. Breathing Assessment • Assess respiratory rate and quality.

36. Respiratory Rates

37. Breathing Assessment • Note respiratory pattern. • Rapid (tachypneic), deep (hyperpneic) respirations compensatory mechanism. • Cheyne-Stokes respirations: increasing and decreasing breaths followed by period of apnea.

38. Breathing Assessment • Biot's respirations: short, gasping, irregular breaths. • Some patients with acute pulmonary edema can benefit from CPAP unit. • Assess neck and chest before moving on to circulation. • Identify and correct life-threatening conditions before moving on.

39. CPAP can provide positive airway pressure, which will maintain lower airway patency.

40. Breathing Assessment • Tension pneumothorax: immediately decompress affected side with large IV catheter at second intercostal space, midclavicular line.

41. Circulation Assessment • Evaluate pulse and skin. • Control hemorrhage. • Go to wrist and feel for radial pulse. • If radial pulse absent, check for carotid pulse. • In infant, palpate brachial pulse. • If pulse absent, begin chest compressions immediately.

42. To assess an adult's circulation, feel for a radial pulse.

43. If you cannot feel a radial pulse, palpate for a carotid pulse.

44. Circulation Assessment • Assess pulse for rate and quality.

45. Normal Pulse Rate Ranges

46. Circulation Assessment • Very fast rates (tachycardia). • Very slow rates (bradycardia). • Note quality of pulse; normal pulse should be regular and strong.

47. Circulation Assessment • Stop patient's bleeding. • Major bleeding originates with trauma or medical emergency. • New hemostatic agents now used by civilian EMS responders. • Internal bleeding not easily controlled in prehospital setting; transport.

48. Circulation Assessment • Assess skin: temperature, moisture, color. • Skin: mottled (blotchy), cyanotic (bluish), pale, or ashen; cool and moist (clammy). • Suspect conditions related to or caused by poor perfusion.

49. Assess the skin for color, temperature, and moisture.

50. Priority Determination • Serious illness or injury: rapid head-to-toe assessment; transport immediately.