Chapter 3: Primary and Secondary Assessments

Overview

When you arrive at the scene of an emergency, after ensuring the safety of yourself and others, you must quickly determine whether the patient has any life-threatening injuries or conditions by conducting a primary assessment. This includes assessing any life-threatening bleeding, mechanism of injury, the chief complaint, level of responsiveness, airway, breathing, breathing quality, circulation, circulatory emergencies, deformity, disability, environmental exposure, and everyone else. Once the primary assessment has been complete on everyone, and everyone has been removed from any hazardous environmental exposures, you can begin your secondary assessment. The secondary assessment includes assessing and documenting vital signs, conducting a thorough physical examination, interviewing the patient for a SAMPLE History, treating any secondary injuries and illnesses, monitoring what happened and when, clearing the spine, and creating a rescue plan. You must also check to ensure that the ABC’s are present at least every 5 minutes for an unstable patient (a patient with a life-threatening condition), or every 10 minutes for a stable patient. This check is just to confirm that the ABCs haven’t changed.

This assessment model may be modified depending on the situation. For example, a responsive patient may complain of an ankle injury. In this case, a full head-to-toe assessment is probably unnecessary, unless you have a reason to suspect that additional injuries or conditions may be present.

First Aid Emergency Care Flow Diagram

Primary Assessment – Part 1: Scene Size-Up, Life Threatening Bleeding, Chief Complaint

These steps should be conducted in this order help to ensure your safety and that of the patients and bystanders. They will also increase the patients’ chance of a positive outcome.

Scene Size-Up. Before you approach the patients:

  • PPE: Gloves, glasses, gas mask
  • HEMP: Hazards, environment, mechanism of injury (MOI), patients.
  • Hazards: Fire, darkness, glass, blast?
  • Environment: Get rid of unessentials (crowd control), ask anyone present how many people may be involved, bring in resources.

As you approach the patients:

  • MOI: What happened? What are the problems?
  • Patients: Number of patients? Triage for the most likely to survive. Look carefully for hidden patients. It is easy in an emergency situation to overlook an infant or a small child.

Life Threatening Bleeding. Once you reach the patient:

  • Quickly assess if there is any life threatening bleeding. If there is, immediately go into Bleeding Control (Chapter 4 – Immediate Life Threats – Bleeding Control).
  • You may also decide that it is necessary to relocate a patient prior to your primary assessment or bleeding control. If spinal injury is suspected (Positive Mechanism of Injury – see below), you should take all possible precautions to minimize movement of the spine while performing these interventions, unless doing so would interfere with care for life-threatening conditions.

Chief Complaint. The chief complaint is the injury or condition that the patient verbally identifies as the most serious. If the patient is unresponsive, the chief complaint is unresponsiveness.

If the patient has a Positive Mechanism of Injury, tell them to remain still as you are concerned about their spine. The checklist for a positive mechanism of injury are as follows:

  • Fall 3 times the patient’s height
  • Direct blow to the head, neck, or spine
  • Sudden stop
  • Tumbling fall
  • Lightning
  • Unresponsiveness
  • Unknown MOI

Workflow:

  1. Positive MOI? If yes, say,

“Please remain still. I am concerned about your spine”

  1. Introduce yourself and gain permission to treat. Ask the PT:

“What happened? How do you feel? My name is _____. I am trained in _____. Can I help you?”

  1. If yes to Positive MOI, say to the PT:

“I am going to hold your head still. I am placing a reminder under your chin and on your head to remind you to remain still.”

­2 – Primary Assessment – Part 2: Awake, Airway

Awake (Level of Responsiveness). A patient’s LOR can be identified using the AVPU scale. The letters A, V, P, and U each refer to a stage of awareness – Alert, Verbal, Painful, and Unresponsive.

  • When determining whether a patient is responsive, do not jostle or move the patient, as this could exacerbate any injuries.
  • A patient who can speak or cry is responsive.
  • Unresponsiveness usually indicates a serious medical emergency, so it is important to establish LOR as soon as possible.
  • Any deterioration in a patient’s LOR can indicate a life-threatening condition.
  • If you must leave a patient who has a decreased LOR for any reason, place them in the recovery position to maintain an open air.

Airway. Open and check for a clear airway.

  • If a patient is speaking, moaning, or crying, the patient has an open airway.
  • If the patient’s position prevents you from checking the airway effectively, roll the patient gently onto their back, keeping the head and spine in as straight a line as possible.
  • If a patient is unresponsive, open the airway by tilting the head back and lifting the chin. This is called the head-tilt/chin-lift, which repositions the tongue and epiglottis so that they do not block the airway.
  • If you suspect a head or spinal injury, attempt to open the airway using the jaw thrust technique (see figure below) – this opens the airway without repositioning the patient’s neck.
  • If there is liquid in the airway, roll them into the recovery position. If there is any material in the airway, clear it with a finger, being careful not to lodge it deeper in the airway.

Primary Assessment – Part 3: Breathing, Breathing Quality

Breathing. Open the airway and check breathing – chin-lift/head-tilt. Look, listen, feel for 5 seconds.

If the patient is not breathing or experiencing agonal respirations (not breathing adequately, associated with cardiac arrest and presented as sporadic, gasping breaths, or snorting, gurgling, moaning, or laboured breathing), begin with two rescue breaths to get oxygen into the lungs.

Breathing Quality. If the patient is choking, wheezing, gasping, or breathing too fast/slow, proceed to Chapter 4 – Immediate Life Threats – Airway Management and Respiratory Emergencies.

Primary Assessment – Part 4: Circulation, Circulatory Emergencies

Circulation

a) Life Threatening Bleeding. Begin with a rapid body survey (RBS) to look for life-threatening bleeding. Stop life-threatening bleeding first (see Chapter 4 – Immediate Life Threats – Bleeding Control).

An RBS should check the patient in the following order: head, neck, chest, abdomen, pelvis, legs/feet, arms/hands, and back. Palpate each of these areas, checking your gloves for blood or other bodily fluids. If you see any bodily fluids on your gloves, expose and examine the area of origin before proceeding. If you discover the need for a critical intervention, pause the RBS and perform the intervention before continuing the survey

b) Pulse. If the patient is unconscious and not breathing, check for pulse. You must determine whether the patient’s heart is beating.

The method of assessing pulse is different for infants than for adults and children. If an adult or child is responsive, check their pulse using the radial artery. If the adult or child is unresponsive, check the pulse at one of the carotid arteries in the neck.

    • To find the carotid pulse, feel for the Adam’s apple and then slide your fingers into the groove at the side of the neck closest to you. Sometimes the pulse may be difficult to find, especially if it is slow or weak. If at first you do not find a pulse, relocate the Adam’s apple and slide your fingers into place.
    • To find an infant’s pulse, place one or two fingers over the brachial artery, located on the underside of the infant’s arm, halfway between the elbow and the shoulder.

Easily Located Pulse Sites

If no pulse is detected after a maximum of 10 seconds, start the CPR/AED protocol (see Chapter 4 – Immediate Life Threats – Circulatory Emergencies).

c) Pulse Oximetry (SpO2). Pulse oximetry is a non-invasive method used to measure the percentage of oxygen saturation in the blood. The reading is taken by a pulse oximeter, which measures the percentage of hemoglobin that is saturated with oxygen. The reading is taken as a percentage of hemoglobin saturated with oxygen. Pulse oximeters also measure the patient’s pulse.

Pulse oximetry should be applied whenever a patient’s oxygenation is a concern, for example:

    • Patients with neurological, respiratory, or cardiovascular complaints.
    • Patients with abnormal vital signs.
    • Patients under the effect of respiratory depressants (morphine, diazepam, midazolam).
    • Multi-system trauma patients.

Note: Smokers who are breathing room air can have oxygen saturation of around 94 to 96%. People with chronic lung disease may have oxygen saturations as low as 90% on room air, even when they are not ill.

Circulatory Emergencies. If the patient is presenting signs and symptoms of an Myocardial Infarction (heart attack), or stroke, start the protocol for Circulatory Emergencies. (Chapter 4 – Immediate Life Threats – Circulatory Emergencies).

Signs and symptoms of an MI include:

  • Chest pain – tightness, pressure possibly radiating into arm and/or neck/jaw
  • Upper abdominal pain
  • Weakness
  • Nausea
  • Denial
  • Shock
  • Sweating
  • Anxious
  • Sense of impending doom
  • Female patient – “bra feels tight”

Signs and symptoms of a stroke include:

  • Sudden weakness and/or numbness of the face, arm, or leg, usually only on one side of the body.
  • Slurred speech, or difficulty speaking or understanding speech
  • Blurred or dimmed vision
  • Pupils of unequal size
  • Sudden, severe headache
  • Dizziness
  • Confusion
  • Changes in mood
  • Ringing in the ears
  • Unresponsiveness or changes in responsiveness
  • Loss of bowel or bladder control

Primary Assessment – Part 5: Deformity Physical Exam

Perform a quick head-to-toe physical exam to note any areas that may need treatment.

  • Head. Using the flat part of your hands, push on the skull to check for soft skull or crunchy, gravily feeling.
  • Shoulders. Push down on the shoulders. Note if the patient complains of pain or the shoulders are not firm.
  • Ribs. Push diagonally and inward on the patient’s ribs. Note if the patient complains of pain or the ribs are not firm.
  • Abs. Push down with the palm of your hand. Is the stomach hard? Expose the stomach. Is the skin discolored? If yes, internal bleeding is possible. Improvise an abdominal binder. Wrap the binder around the patient’s torso and tighten – Continue Exam.
  • Pelvis. Push in and side-to-side inward – does the pelvis move? If yes, improvise a pelvic binder. Wrap binder around the patient’s pelvis and tighten – Continue Exam.
  • Legs/Ankles/Feet. Push down on bones and feel for crunchy, gravily feeling, or if the patient complains of pain.
  • Arms/Wrists/Hands. Push down on bones and feel for crunchy, gravily feeling, or if the patient complains of pain.

Primary Assessment – Part 6: Disability Physical Exam

Perform a quick hands, feet, and spine physical exam to note any loss of circulation.

  • Movement – Hands. Place your fingers in patient’s hands and ask patient to squeeze your fingers. Make note of response.
  • Sensation – Hands. Tap on one finger on each of patient’s hands. Ask “What finger am I tapping?” Make note of response.
  • Movement – Feet. Place your hands against balls of patient’s feet. Ask patient to push against your hands. Make note of response.
  • Sensation – Feet. Tap on one toe on each of patient’s feet. Ask “What toe am I tapping?”. Make note of response.
  • Spine. Log roll patient (see log roll checklist). Palpate spine. Expose and note deformities. Expose pain points. Look for bleeding and apply bleeding control.

Log Roll Checklist:

    1. Get the pad to protect the patient from the ground.
    2. Place the pad opposite to the side of the patient.
    3. Lift patient’s arm closest to the pad so that the arm is resting on the pad.
    4. Completely remove the reminders from the patient’s head.
    5. Check for and remove bulky items in the patient’s head.
    6. Place the patient’s ankle furthest from you on top of the ankle closest to you.
    7. Raise patient’s arms above their head. Place both arms tight up against the patient’s head – no gaps between arm and head. The arm furthest from you should be on top.
    8. With one of your hands, grab on hips – pocket or belt loop.
    9. With your other hand, grab high on shoulders and have your fingers touch the back of the patient’s head for support.
    10. Roll patient toward you.
    11. Look for blood on patient’s back side (head, back, butt, legs)
    12. Palpate entire length of spine using your hand that is holding patient’s hip. Feel for vertebrae out-of-place, exposed bone, or soft, crunchy bone. Do not remove your hand from the patient’s head/shoulder during exam.

Primary Assessment – Part 7: Environment Exposure, Transport Decision, Everyone Else

Environment Exposure. Log roll patient onto pad and protect them from the elements. (See log roll checklist – continued)

  • Conduction – get them off the ground
  • Convection – get them out of the wind, and in insulation
  • Evaporation – get them out of their wet clothes, or vapour barrier them
  • Radiation – reflect heat back to them with a survival blanket

Log Roll Checklist – Continued:

    1. Roll patient past 90 degrees onto your knees. Never let go of the patient’s shoulder or head.
    2. Using the hand that was on the patient’s hip, position the pad tight up against patient.
    3. Grab patient on hip
    4. Roll patient onto the pad.
    5. Move patient’s arms back down to the patient’s sides.
    6. Uncross patient’s ankle and move patient’s leg back to pad.
    7. Replace reminders on patient’s head.

Transport Decision. Now that basic life support has been provided, you must decide whether the patient requires immediate transport. If so, the patient is considered to be in the rapid transport category (RTC). A patient with a life-threatening condition will fall into the RTC. Examples of RTCs include:

  • Severe or multi-system trauma
  • Instability or absence of the ABCs
  • Internal or external hemorrhage
  • Neurological deficits
  • Decreased LOR or unresponsiveness
  • Ongoing seizures
  • Chest pain
  • Burns with signs of inhalation injury
  • Extensive burns
  • Abdominal distension and tenderness
  • Unstable pelvic injury
  • Fractured femur
  • Amputation
  • Childbirth complications
  • Severe hypothermia
  • Electrocution
  • Decompression illness

Everyone Else. Check on others in the group who may require attention. Share your transport decision to others of your patient. Assign tasks to others in the group.

Secondary Assessment

Once you have made a decision about transport, you can begin gathering more information through a secondary assessment.

The secondary assessment begins with the following three steps, and can be performed in any order.

If the patient is experiencing pain of any kind, use OPQRST to ask the patient to accurately describe the pain (See below, in the SAMPLE figure).

1. Interview the patient and bystanders

  • Note: Do not move the patient unless needed.
  • First ask the patient his full name. “We’re going to go through what happened and see if you’re feeling any other pain”.

2. Check vital signs

  • LOR using AVPU, or the Glasgow Coma Scale if neurological injury exists (check pupils to help determine if head injury exists– pupils that are unequal, fully dilated, or unresponsive to light may indicate a serious head injury).

  • Heart Rate. An abnormal pulse may be a sign of a potential problem. These signs include:
    • Irregular pulse
    • Weak and hard-to-find pulse
    • Excessively fast or slow pulse
  • Respiration Rate. You are concerned with the rate, rhythm, and volume of breathing. Look for the rise and fall of the patient’s chest or abdomen. Listen for sounds as the patient inhales and exhales. Count the number of times a patient respirates in 15 seconds and multiply that number by four – this is the number of breaths per minute. Try to assess breathing without the patient’s knowledge.
  • Blood Pressure. Changes in blood pressure can indicate a change in the patient’s condition, and may indicate a need for interventions. Use Palpation or Auscultation to determine the patient’s blood pressure.
    • Palpation. Begin by having the patient sit or lie down. Wrap the blood pressure cuff around the patient’s arm so that the lower edge is about 1 inch above the crease of the elbow. The centre of the cuff should be over the brachial artery. The cuff should be directly against the skin. Next, locate the radial pulse. Close the regulating valve on the blood pressure cuff, and inflate the cuff until you can no longer feel the radial pulse. Note the number displayed on the gauge.

Continue to inflate the cuff for another 20 mmHg beyond this point. Slowly reduce the pressure in the cuff by releasing the valve slowly. Allow the cuff to deflate at a rate of about 2 mmHg per second. Continue to feel for the radial pulse as the cuff deflates. The point at which the pulse returns is the approximate systolic blood pressure by palpation. Using this method, the systolic pressure found is about 10-20 mmHg less than systolic pressure found by auscultation. This blood pressure reading is expressed such as 130/P (P = Palpation. Once you know the approximate systolic pressure, quickly deflate the cuff. Record the systolic pressure and whether the patient was sitting or lying down.

    • Auscultation. Before auscultation, it is best to begin by determining the systolic pressure using the palpation method. This will rapidly provide a baseline against which you can compare the results of auscultation, as well as a starting pressure for the blood pressure cuffs

Next, locate the brachial pulse. Place the earpieces of the stethoscope in your ears and the diaphragm over the brachial pulse. Apply the cuff as for palpation (or leave it in place after performing palpation) and inflate the cuff to 20 mmHg above the approximate systolic blood pressure.

Slowly deflate the cuff at a rate of about 2 mmHg per second. As you deflate the cuff, listen carefully for the pulse. The point at which the pulse is first heard is the systolic pressure.

As the cuff deflates, the sound of the pulse will fade. The point at which the sound disappears s the diastolic pressure. release the remaining air quickly. Record the blood pressure such as 130/80 and whether the patient was sitting or lying down.

Normal Heart Rates, Respiration Rates, and Blood Pressures for People of Different Ages

  • Skin. Colour, temperature, and condition of the skin.
    • A patient with a breathing problem may have a flushed or pale face.
    • The skin looks red when the body is forced to work harder. The heart pumps faster to get more blood to the tissues. In contrast, if the blood flow is directed away from the skin’s surface, the skin becomes pale or bluish, and feels cool and moist. This is referred to as cyanosis. In patients with darker skin, cyanosis may be harder to recognise: skin may appear ashen-grey, yellow-brown, or greyish-blue. Changes may be most easily visible on the inside of the lips, the nail beds, or the skin around the mouth.
  • Blood Glucose Level (BGL). Test BGL with a Glucometer. Normal range before meals is 4 to 6 mmoI/L, and for the 2 hours after meals it is 5 to 8 mmoI/L. Hypoglycemia is defined as a BLG of less than 4 mmoI/L, whereas hyperglycemia is defined as a BLG of greater than 8 mmoI/L.
    • Using a Glucometer. Follow these steps:
      1. Ensure you are wearing proper PPE, you have a sharps container ready.
      2. Prepare the lancet and lanced device.
      3. Insert the test strip into the glucometer. Some are self-calibrating, while others require you to match a code on the screen to the test strip vial for calibration.
      4. Wipe the pad of the patient’s finger with an alcohol swab. Allow for the skin to dry completely.
      5. Force blood into the finger by squeezing.
      6. Using a sterile lancet, prick the side of the fingertip and wait for a drop of blood to appear.
      7. Bring the glucometer to the patient’s finger and touch the tip of the test strip to the drop of blood. Most glucometers will alert you that the sample as been received.
      8. Document the results when they are displayed.
      9. Bandage the patient’s finger.
      10. Remove the test strip. Place the lancet in the sharps container and dispose of the test strip and any other contaminants.
      11. Ensure that your glucometer is ready for its next use.

3. Do a head-to-toe physical examination. This involves inspection, auscultation, and palpation. Do not waste time on this if a life-threatening condition exists. Maintain patient’s dignity. Explain to the patient what you are doing, and direct them to keep still. If you encounter a painful area, have the patient characterise using OPQRST.

  1. Medical Bracelet. Look for medical bracelet or necklace.
  2. Head. Look for signs of a SKULL FRACTURE. Look for bruising, blood, or clear fluid in or around the ears, nose, and mouth. Push on head using flat surfaces of the hand. Check the pupils again and note any changes.
  3. Face. Push on cheekbones and jaw bones.
  4. Neck. Look and feel for abnormalities around the neck. Is the trachea in-line or is it pushing off to one side? Any blood vessels bulging?
  5. Collarbones and shoulders. Push on shoulder bones to check for pain or deformity. Walk fingers along collar bone. Ask patient to shrug.
  6. Chest. Ask patient to take deep breaths. Look, listen, and feel for subtle signs of breathing difficulty. Feel the ribs for deformity or pain. Respiratory issues and chest trauma hurt when they breath, cardiac usually doesn’t. Cardiac feels like a crushing weight and sharp pain. Check their cough. Push on sternum. Ribs – push diagonally and inward.
  7. Abdomen. Must be checked laying down. Expose, look for discolouration, open wounds, or distension. Look for any pulsating. If there’s no pulsating, apply slight pressure to each quadrant. Note if the patient reports pain when you push in or when you release. The abdomen should be soft. Rigidness indicates a problem. Gallbladder pain radiates to shoulder – check by breathing with fingers under the ribs. Appendix pain develops slowly, food poising develops quickly. Don’t take Tylenol (take Advil) if an alcoholic.
  8. Hips. Place your hands on both sides of the pelvis and side-to-side and inward. Does the pelvis move? If yes, wrap a pelvic binder around the patient’s pelvis and tighten.
  9. Legs, Ankles, Feet, Arms, Wrists, Hands. Feel each limb for pain or deformity. Ask patient to move fingers, hands, arms, toes, feet, and legs. Check for distal circulation, sensation, and movement in all extremities.
  10. Spine and Back: Log roll patient onto their side and palpate both sides of the spine from the neck down with fingertips. Look for any bleeding or abnormalities. Roll patient back onto pad.

Wounds and Illness Treatment. Following the above three steps, treat all secondary injuries and illnesses (see links below):

  • Chest, Abdominal, and Pelvic Injuries
  • Fractures and Sprains/Strains
  • Burns
  • Lightning Injuries
  • Frost Bite
  • Friction Blisters
  • Poisoning
  • Acute and Chronic Illnesses
  • Mammal Bites
  • Snake Bites
  • Insect Bites and Stings
  • Aquatic Bites and Stings
  • Pregnancy, Labour, and Delivery

Monitor What and When. Record what injuries and treatments were done and when.

Clear Spine (if applicable) or Immobilize the Patient. Clear spine or immobilize the patient using the workflow diagram below. Techniques for spinal motion restriction are described in Chapter 1: Principles and Practices – Reaching, Positioning, and Extricating Patients.

Create Rescue Plan. See Chapter 1: Principles and Practices – Reaching, Positioning, and Extricating Patients.