Primary Assessment
Primary assessment is a critical initial step in patient evaluation, focusing on identifying and managing immediate life threats.
Related topics include pathophysiology, airway management, respiration, and artificial ventilation, which are essential for understanding and performing effective primary assessments.
Secondary assessment, cardiac emergencies, and diabetic emergencies/altered mental status are closely connected, as they provide further evaluation and management strategies following the primary assessment.
Standard
You use scene information and patient assessment findings—including scene size-up, primary and secondary assessments, patient history, and reassessment—to guide emergency management decisions.
Scene size-up helps you identify potential hazards, determine the number of patients, and decide if additional resources are needed.
Primary assessment focuses on identifying and treating immediate life threats by evaluating airway, breathing, circulation, and level of consciousness.
Secondary assessment and patient history provide more detailed information about the patient’s condition, which informs further care.
Reassessment ensures that you monitor changes in the patient’s status and adjust your management plan as needed.
Core Concepts
Establish a general impression to quickly gauge the severity of the patient's condition and the need for immediate intervention.
Stabilize and protect the head and neck in trauma patients to prevent further injury, especially if spinal injury is suspected.
Assess mental status using the AVPU scale (Alert, responds to Verbal stimuli, responds to Painful stimuli, Unresponsive) to determine the patient's level of consciousness.
Identify and treat life-threatening problems with the airway, breathing, and circulation as immediate priorities.
Make a priority decision regarding the urgency of transport and further care based on initial findings.
Learning Objectives
Primary assessment is a systematic, ongoing process used to quickly identify and manage life-threatening conditions in patients.
Key components of the primary assessment include assessing mental status, airway, breathing, circulation, and identifying any immediate threats to life.
The steps of primary assessment are repeated as needed because a patient's condition can change rapidly, requiring continuous reassessment.
The sequence of primary assessment steps may vary depending on the scenario, but always prioritizes life-threatening issues first.
Specific actions are taken when problems are found during the primary assessment, such as opening the airway, providing ventilation, or controlling bleeding.
Approaches differ for stable, potentially unstable, and unstable patients: stable patients may require less urgent intervention, while unstable patients need immediate, aggressive management.
Manual stabilization of the head and neck is performed when trauma is suspected to prevent further spinal injury.
Mental status is categorized using the AVPU scale: Alert, responds to Verbal stimuli, responds to Painful stimuli, or Unresponsive.
Patients are classified as stable, potentially stable, or unstable based on primary assessment findings, which guides the urgency and type of care provided.
Clinical judgment is essential in primary assessment, evolving with experience from novice to expert EMTs, allowing for better interpretation and response to patient needs.
Observations during assessment can change the interpretation of the chief complaint, requiring flexibility and adaptation in care.
Analyzing the primary assessment involves integrating findings and clinical judgment to determine the best course of action for the patient.
Key Terms
The primary assessment is the initial, hands-on evaluation of a patient, focused on identifying and immediately addressing life-threatening conditions.
Key actions during the primary assessment include managing the airway (such as suctioning), performing CPR if necessary, and recognizing early signs of shock.
You must form a general impression of the patient's overall condition to determine if it is serious and to guide further assessment and interventions.
The main goal is to quickly and efficiently find and treat any threats to the patient's life, prioritizing interventions that can prevent death or serious harm.
The Primary Assessment
The primary assessment is focused solely on identifying and managing immediate life threats, particularly those affecting airway, breathing, and circulation (the "ABCs").
This assessment is always performed first when evaluating a patient, before any other part of the assessment process.
The approach to the primary assessment involves quickly determining if any conditions are present that could immediately endanger life, guiding your next actions in patient care.
Approach to the Primary Assessment
The primary assessment sequence (A-B-C: airway, breathing, circulation) is flexible and should be adapted based on the patient's specific condition, the number of EMS personnel present, and situational priorities.
For unresponsive patients with no pulse, use the C-A-B (circulation, airway, breathing) approach, prioritizing chest compressions and defibrillation.
Immediate life threats dictate the order of interventions: for example, clear a blocked airway first in choking, suction vomit before ventilating in cases of aspiration risk, and control severe bleeding immediately if present.
Exsanguinating (life-threatening) bleeding must be stopped without delay, as arterial bleeding can cause death within minutes.
A-B-C is a helpful mnemonic, but not a strict order; the sequence of actions depends on the patient's needs and the urgency of their conditions.
Multiple EMTs can perform critical interventions simultaneously, such as one person controlling bleeding while another manages the airway.
If no immediate life threats are present, focus on providing oxygen as appropriate and assessing for shock.
Aspiration of vomit is a serious and often fatal complication; always suction the airway before ventilating if vomit is present.
Agonal or absent breathing requires you to check for a pulse and begin CPR if necessary.
Teamwork and delegation, including involving bystanders or the patient, can help address multiple priorities efficiently.
Performing the Primary Assessment
Your initial impression of the patient determines the order of primary assessment steps. If the patient shows signs of life, you prioritize Airway, Breathing, and Circulation (A-B-C) based on what is most immediately life-threatening. If the patient appears lifeless (not moving, not breathing), you use the C-A-B approach: start with Chest Compressions, then Airway and Breathing, especially if the patient is pulseless.
The primary assessment consists of six key parts: forming a general impression, assessing mental status (and stabilizing head/neck if needed), assessing airway, assessing breathing, assessing circulation, and determining patient priority.
Immediate interventions are required for any life-threatening conditions found during the primary assessment. The assessment is dynamic—if you find a critical issue, you must act right away to correct it.
Patient priority guides your next steps: Unstable or crashing patients require rapid transport ("Load and Go"), time-sensitive issues like myocardial infarction or stroke need prompt transport, and stable patients can have a more thorough secondary assessment on scene.
The order of A-B-C (or C-A-B) is flexible and based on what will kill the patient first. The American Heart Association (AHA) recommends starting with compressions (C-A-B) for lifeless patients. Some patients may only need minimal assessment and care during the primary assessment.
Chapter 12 Visual Guide
Primary assessment focuses on identifying and treating life threats by evaluating the patient's chief complaint, appearance, and overall condition.
You can assess airway, breathing, and circulation (the ABCs) in any order, depending on the patient's needs, and multiple EMTs can perform parts of the assessment simultaneously.
Mental status is crucial: Unresponsive patients or those with altered mental status (such as from stroke) may not be able to maintain their airway, and altered mental status combined with inadequate breathing can indicate respiratory failure.
Airway assessment: Always check if the patient's airway is open, as a blocked airway is immediately life-threatening.
Breathing assessment: Treat oxygen saturation readings below 94–95% as hypoxic (except in acute coronary syndrome or stroke, where below 90% is the threshold), and provide supplemental oxygen. Significant respiratory distress, hypoxia, absent breathing, or respiratory failure require immediate intervention.
Circulation assessment: Check for a pulse, signs of shock, and life-threatening bleeding, as these are critical indicators of circulatory compromise.
Priority determination: Decide on the urgency of care—stable patients allow for a slower, more detailed assessment; potentially unstable patients require expedited transport and limited on-scene interventions; unstable patients need rapid transport with only lifesaving interventions performed on scene.
Form a General Impression
Forming a general impression is crucial for prioritizing care and transport, relying on your immediate assessment of the environment, the patient’s chief complaint, and appearance. Key initial steps include checking for responsiveness, scanning for breathing, and observing for severe bleeding.
Environmental clues provide important information about the patient’s condition and history, such as evidence of trauma (e.g., overturned ladder) or exposure to harsh conditions, which help distinguish between medical and trauma cases.
Assess for signs of shock or serious conditions by observing changes in mental status, skin color, and condition as you approach the patient.
Spinal motion restriction (SMR) should be applied when spinal injury is suspected, using manual stabilization to keep the head and neck in a neutral, in-line position. Adapt techniques based on the patient’s position and prioritize life-threatening interventions (airway, breathing, bleeding) if necessary.
Manual stabilization involves holding the patient’s head steady without pulling or twisting, with specific hand placements depending on whether the patient is sitting or supine.
If alone or faced with multiple patients, prioritize airway, ventilation, and bleeding control over strict spinal motion restriction, minimizing head and neck movement as much as possible.
Responsive patients can be instructed to self-splint by keeping their nose aligned with their umbilicus until manual stabilization and a cervical collar are applied.
Local EMS protocols dictate when to use manual stabilization and SMR, so always follow system-specific guidelines.
The “look test” helps identify critical patients quickly by combining environmental observations and initial patient appearance. Key indicators include:
Patients who appear lifeless (no movement, breathing, or only gasping) require immediate CPR and defibrillation if pulseless.
Obvious altered mental status signals potential life-threatening problems and requires aggressive assessment and expedited transport.
Unusual anxiety, pallor, and sweatiness are early signs of shock, prompting further assessment for rapid pulse and respiratory rates.
Obvious trauma to the head, chest, abdomen, or pelvis indicates risk for airway compromise, shock, or death.
Specific positions, such as the tripod position (severe breathing difficulty) and Levine’s sign (fist over chest, indicating severe chest pain), signal high-priority complaints.
Clinical clues are not exhaustive; subtle complaints like “I feel weak” may indicate serious problems, and the absence of obvious signs does not guarantee patient stability. Always integrate all available information for assessment.
Pediatric Note
The pediatric assessment triangle helps you quickly evaluate a child’s condition by focusing on three key areas: appearance, work of breathing, and circulation to the skin.
Appearance assesses how the child responds to their environment, including their muscle tone, interactivity, ability to be consoled, gaze, and speech or cry. A child who is limp, indifferent, or has abnormal tone or gaze may be seriously ill.
Work of breathing involves observing for signs of respiratory distress such as abnormal sounds (wheezing, grunting), abnormal positioning, use of accessory muscles (retractions), nasal flaring, apnea, or gasping. Increased work of breathing is a critical sign of potential respiratory failure.
Circulation to the skin is evaluated by checking for pallor, moisture, mottling, or cyanosis. In children with darker skin, check the lips, oral mucosa, and nail beds for color changes. Cyanosis indicates significant hypoxia, and pale, moist skin may suggest shock.
The chief complaint is the patient’s own description of why help was called, which may differ from the actual medical problem. It provides a starting point for your assessment.
Forming a general impression involves observing the patient’s age, sex, position, and any abnormal sounds or odors at the scene. These observations, combined with your intuition or “sixth sense,” contribute to your clinical judgment.
While clinical judgment improves with experience, it should always be supported by a systematic assessment to ensure life-threatening conditions are not overlooked.
Assess Mental Status
Mental status (level of responsiveness) is assessed using the AVPU scale: Alert, Verbal response, Painful response, and Unresponsive.
Alert patients are awake and answer questions sensibly. Some patients may not be fully awake but will respond to verbal stimuli (talking or shouting).
A lower level of responsiveness is indicated when a patient responds only to painful stimuli (e.g., pinching a toe or ear, squeezing the trapezius muscle).
Unresponsiveness is the most serious status, where the patient does not respond even to painful stimuli.
Orientation is further assessed in alert patients by determining if they are oriented to person, place, and time:
Orientation to person: Can state their name.
Orientation to place: Can state where they are.
Orientation to time: Can state the time, day, or date.
A depressed mental status may signal a life-threatening condition such as inadequate oxygen to the brain or shock.
If responsiveness is below alert, provide oxygen as appropriate and consider the patient a high transport priority.
Assess the A-B-Cs
Always assess airway, breathing, and circulation (A-B-Cs) first to identify and correct any life-threatening problems.
The primary assessment serves two main purposes: to address immediate threats to life (A-B-Cs) and to gather information about the severity and nature of the patient’s condition.
The assessment process adapts to the patient’s condition and follows these pathways:
If the patient appears lifeless or pulseless (unresponsive, not breathing, or only gasping), immediately activate EMS, ensure an AED is available, check the carotid pulse for up to 10 seconds, and if no pulse is found, start chest compressions, apply the AED, and follow its prompts (C-A-B: Compressions, Airway, Breathing). If a pulse is present, begin ventilations and continue with the primary assessment (A-B-C).
If the patient shows signs of life or has a pulse (responsive or breathing), proceed to assess airway, breathing, and circulation in order.
If there is severe bleeding, control it immediately using direct pressure, and if necessary, apply a tourniquet or hemostatic agent before continuing with other assessments.
The order of assessment steps may be adjusted based on the patient’s specific needs and the most immediate threats to life.
SCAN 12-2
Assessing airway status is the first priority in a primary assessment for a patient with a pulse.
If the patient is alert and speaking clearly or crying loudly, the airway is considered open.
If the airway is not open or is at risk (such as when the patient is not alert, lying on their back, or breathing noisily), you should intervene to open the airway.
Airway-opening techniques include the jaw-thrust maneuver, head-tilt chin-lift maneuver, suctioning, or inserting an oropharyngeal or nasopharyngeal airway.
If the airway is blocked, perform appropriate clearance procedures to remove the obstruction.
Point of View: Patient
Primary assessment focuses on the A-B-Cs: Airway, Breathing, and Circulation. Ensuring an open airway is the first priority, followed by assessing and supporting breathing, and then evaluating circulation.
Assistance with breathing is required in four general situations, ranked from most to least severe. Chest injuries can compromise breathing by reducing rate and depth, and open chest wounds are particularly dangerous and must be identified through observation and palpation.
Circulation assessment involves checking pulse, skin condition, and bleeding. Begin with the pulse; if the patient is unresponsive, initiate CPR immediately. Cardiac arrest, shock, and severe blood loss are all life-threatening circulation issues.
Pulse assessment during primary evaluation focuses on three outcomes: within normal limits, unusually slow, or unusually fast. Abnormal pulse rates, especially when combined with other symptoms (e.g., rapid pulse with trauma, slow pulse with chest pain), indicate a high-priority, unstable patient.
Skin assessment helps identify shock: In light-skinned patients, check if the skin at the wrist is warm, pink, and dry (good circulation) or pale and clammy (possible shock). In dark-skinned patients, check the color of lips or nail beds for pinkness.
Severe external bleeding must be controlled quickly, as significant blood loss can be fatal within minutes. The order of care is determined by addressing the most life-threatening condition first.
Physical contact is essential in primary assessment, even with alert patients, to check pulse and skin condition, which can help detect shock early and potentially save lives.
Determine Priority
Immediate treatment of life-threatening airway, breathing, or circulation problems is essential; address these issues as soon as they are identified before considering further assessment or transport.
Patient priority is classified as stable, potentially unstable, or unstable: Stable: Vital signs are within or close to normal limits, with only minor, easily explained deviations. Potentially unstable: Any actual or imminent threat to airway, breathing, or circulation excludes stability and may require prompt transport. * Unstable: Unclear diagnosis but risk of deterioration; immediate transport may be necessary, especially if life threats cannot be controlled or recur.
Patient priority can change with treatment; for example, a diabetic patient who regains alertness after glucose administration may shift from unstable to stable.
High-priority conditions for transport include: poor general impression, unresponsiveness, not following commands, difficulty breathing, shock, complicated childbirth, chest pain or cardiac symptoms, uncontrolled bleeding, and severe pain.
Primary assessment steps for both medical and trauma patients include: Forming a general impression and, for trauma, evaluating the mechanism of injury (with spinal stabilization if needed). Assessing mental status using AVPU (Alert, Verbal, Pain, Unresponsive). Ensuring airway is open; if compromised, use appropriate maneuvers (head-tilt, chin-lift, or jaw-thrust) and airway adjuncts, and clear obstructions as needed. Evaluating breathing by observing chest movement, rate, depth, and work of breathing; administer oxygen or provide ventilations as indicated by patient status. Checking circulation: pulse, bleeding, skin color, temperature, and condition; control bleeding, treat for shock, and perform CPR if cardiac arrest occurs. Determining transport priority: unresponsive patients are always high priority for immediate transport; for responsive patients, priority depends on chief complaint and status of airway, breathing, and circulation.
Think Like an EMT
Priority determination at the end of the primary assessment is crucial because it guides the urgency and sequence of further assessment and care.
High-priority patients include those with compromised airway, breathing, or circulation, altered mental status, or severe pain, as these conditions can rapidly worsen and require immediate intervention and transport.
Examples of high-priority cases from the scenarios include: a responsive patient with difficulty breathing who cannot lie flat (indicating severe respiratory distress), an unresponsive man who passed out (suggesting a potentially life-threatening condition), a responsive patient with severe abdominal pain (which could indicate a serious internal issue), and a patient who only moans and may have ingested alcohol (showing significantly altered mental status).
A responsive child with a possible broken foot is generally considered lower priority if there are no signs of life-threatening conditions, as the injury is localized and the patient is alert.
Patient Characteristics and Primary Assessment
Primary assessment steps are adapted based on patient type, mental status, age, and whether the issue is medical or trauma-related.
For a responsive adult medical patient (e.g., Mr. Schmidt), you assess general impression, mental status, airway, breathing, and circulation. If all are stable (alert, normal breathing, normal pulse, no bleeding, normal skin), the patient is considered stable but still requires ongoing monitoring.
For an unresponsive adult medical patient (e.g., Mrs. Bashar), you check responsiveness to verbal and painful stimuli, aggressively manage the airway (head-tilt, chin-lift, or airway adjuncts), assess breathing and provide high-concentration oxygen if needed, and check circulation (pulse, skin color, and temperature). Abnormal findings (e.g., pallor, cool skin, low oxygen saturation) indicate high priority and need for immediate transport.
For a responsive child trauma patient (e.g., Clara Diller), you use the pediatric assessment triangle (appearance, work of breathing, circulation), check mental status, airway, and breathing, and assess circulation (pulse, bleeding, capillary refill). If the child is alert, with a clear airway and controlled bleeding, and capillary refill is less than 2 seconds, the patient is stable and low priority for immediate transport.
For an unresponsive adult trauma patient (e.g., Jesus Moreno), you recognize the mechanism of injury, stabilize the cervical spine, manage airway with jaw thrust (especially if snoring respirations are present), assess breathing and provide high-concentration oxygen, and check circulation (pulse, skin signs). Signs of shock (rapid, weak pulse; pale, cool, clammy skin) indicate high priority and the need for rapid transport and additional help.
Key relationships: Depressed mental status or abnormal airway/breathing/circulation findings always increase patient priority and urgency for intervention and transport. Mechanism of injury and age-specific considerations (e.g., capillary refill in children) guide assessment and management choices.
Pediatric Note
Children require special approaches to build trust during assessment, such as kneeling to their level and spending time to develop rapport, especially if injuries are not severe and the child is stable.
Infants and children have faster breathing and heart rates than adults, so you must adjust your evaluation of their vital signs accordingly; anxiety can further elevate these rates.
Capillary refill is a key circulation check in children, performed by pressing the nail bed or, for infants/small children, the back of the hand or top of the foot. Normal refill is less than 2 seconds; prolonged or absent refill suggests circulatory problems.
Capillary refill is less reliable in adults and can be affected by factors like cold weather, so it should be considered alongside other assessment findings, not as the sole indicator.
Airway management differs for infants and children; their airway should be opened by moving the head to a neutral position, not by tilting it back as with adults.
Mental status in unresponsive infants is checked by verbal stimulation and flicking the feet, rather than adult-oriented methods.
Comparing the Primary Assessments
Primary assessment steps are consistent for all patients: You always form a general impression, assess mental status, check airway, breathing, and circulation (correcting life-threatening problems immediately), and decide on transport priority, regardless of age, responsiveness, or whether the issue is medical or trauma-related.
Patient differences affect assessment details and urgency: Trauma patients (Clara Diller, Jesus Moreno) require consideration of c-spine stabilization, while medical patients (Mr. Schmidt, Mrs. Bashar) do not if there’s no injury mechanism. Patients with altered mental status and airway/circulation issues (Mrs. Bashar, Jesus Moreno) are high priority for immediate transport.
Mental status assessment varies by age: For adults and children, use the AVPU scale (Alert, Verbal, Painful, Unresponsive) and check orientation if alert. For infants, use verbal stimuli (shout) and painful stimuli (flick feet); crying is a normal response.
Airway management adapts to patient type and age: For trauma, use jaw-thrust; for medical, use head-tilt, chin-lift (without hyperextending the neck in children/infants). Consider airway adjuncts and suctioning as needed, with special techniques for children and infants.
Breathing assessment and intervention are age-specific: Rescue breathing is performed in respiratory arrest; positive pressure ventilation with 100% oxygen is given if mental status is depressed and breathing is inadequate. Children and infants have faster normal respiratory rates than adults, and infants/children may need special approaches (e.g., parent holding oxygen mask).
Circulation checks differ by age: For adults, assess skin, radial pulse, and bleeding. For children, also check capillary refill and use normal child pulse rates (faster than adults). For infants, use brachial pulse and normal infant pulse rates (faster than children and adults). CPR techniques and shock management are age-specific.
Consistent application of primary assessment is critical: Skipping or altering steps can result in missing life-threatening problems, so the process must be followed for every patient, regardless of their condition or demographics.