The primary assessment is first in the systematic patient assessment method for a reason: it is the point where we determine our patient's level of consciousness, and address immediate threats to life. Whether our patient has called for a medical problem, or has sustained a traumatic injury, this portion of the patient assessment remains the same for all patients. Affectionately known in the EMS world as the ABC check, the primary assessment focuses on five main areas:
Establishing the patient's level of awareness.
Airway
Breathing
Circulation
Control of life threatening bleeding.
This is the order of priorities in the responsive patient. In an unresponsive patient, the priorities are the same, with one exception: we assess CAB rather than ABC. The reason is simple: we want to rapidly determine if the unresponsive patient has a pulse, and initiate CPR if it is absent.
Many patients do not actually require any immediate interventions during the primary assessment, and, with practice, this quick check can be done in a matter of seconds. Some critical patients may require immediate intervention in one or more area of the primary assessment, and missing any component can have serious consequences for the patient. It is for this reason that the paramedic cannot move beyond any one part of the primary assessment until the identified life threat has been corrected. If, for example, your patient is unresponsive, has a pulse, but is not breathing; you need to address airway and ventilation before any further assessment or patient care can occur.
So, let's look at the primary assessment from start to finish.
Establishing level of awareness:
When assessing here, we want to quickly determine if the patient is ALERT, rouses to VERBAL, responds to PAIN (usually a sternal rub), or remains UNRESPONSIVE. The acronym AVPU is used to assist in remembering this part.
Airway:
We need to determine if the patient has a patent airway, or if there is any form of obstruction that compromises air entry. If your patient is awake and speaking clearly, it is safe to say the airway is patent. A noisy airway, however, is obstructed to some degree. Hoarseness, gurgling, and sonorous respirations all indicate obstruction. This may be the result of foreign bodies, fluid, or most commonly the tongue falling back in the mouth. Obstruction is most common in unconscious patients, but can occur in conscious ones in cases such as choking, or anaphylaxis where angioedema closes off the larynx. A general rule to live by is that a noisy airway requires visual inspection. In the unconscious patient, the head-tilt-chin-lift, or jaw thrust may be utilized to realign the airway. Suction can clear debris, and we can utilize airway adjuncts or advanced airways in cases where the patient is unable to maintain the airway themselves.
Breathing:
Paramedics, and healthcare providers in general, are somewhat notorious for not counting respirations. We have written standards that state normal versus abnormal respiratory rates, and we know that the typical adult patient should be breathing 12-20 breaths every 60 seconds. I would suggest that as a new provider, or student, it is worthwhile to count your patient's respirations until you gain enough experience to rapidly identify rates that are too fast or too slow. In assessing the patient's breathing we want to observe rate, rhythm, and depth of respirations. In a patient who is complaining of respiratory distress, we can also pay attention to how may words they are speaking before having to catch their breath. In general we want to identify if the patient is:
Mildly short of breath: Speaking clearly, in full sentences, with some exertional dyspnea.
Moderately short of breath: Tachypneic, but still speaking full sentences, with dyspnea at rest.
Severely short of breath: Speaking 1-5 word sentences, with accessory muscle use, and tachypnea.
It is during our assessment of the patient's breathing that we want to consider oxygen administration. I would recommend obtaining an early oxygen saturation on all patients complaining of dyspnea, however this should not be the determining factor in delivering oxygen. A patient who is in moderate to severe distress should have oxygen applied at this point in the primary assessment.
Circulation:
Here we want to assess radial pulse and/or carotid pulse for rate, rhythm, and strength. We also want to assess skin colour, condition, and capillary refill. This affords us a clear picture of the patient's circulatory status. A patient who is pulseless needs immediate resuscitation, tachycardia or bradycardia, especially in conjunction with cool, pale, clammy skin, and poor cap refill suggest shock states. In such cases, we can anticipate the need to establish IV cannulation, and potentially administer fluids or pressors.
Life threatening bleeding:
This refers to obvious gross bleeds of significant volume, requiring immediate intervention. I have placed it last in this discussion, however they really can be addressed as soon as they are noted. Use appropriate BLS care to stop these bleeds.
As previously stated, most patients do not require immediate intervention during the primary survey. Often you can introduce yourself while palpating a radial pulse and listen to the patient's chief complaint. If the patient is alert, speaking clearly, exhibiting no dyspnea, is warm, dry, and has a regular radial with good cap refill, you can move on to your secondary assessment. This systematic approach allows us to catch critical risk factors before we move on.
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