1. Introduction to Emergency Medical Care 1
Advance Preparation
Prepare video clips and media graphics.
Invite programmed patients.
Prepare assessment equipment for psychomotor sessions.
Prepare standardized skill sheets for demonstration and psychomotor sessions.
Invite assistant instructors to assist with psychomotor sessions

2. OBJECTIVES
11.1 Define key terms introduced in this chapter. Slides 11–12, 14, 19–21, Explain the purpose of the primary assessment. Slides 11–13
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3. OBJECTIVES
11.3 Discuss the difference in first steps to assessment if the patient is apparently lifeless (C-A-B approach) or if the patient has signs of life, including a pulse (A-B-C approach). Slides 11–13
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4. OBJECTIVES
11.4 Given several scenarios, do the following: form a general impression, determine the chief complaint, determine the patient’s mental status, assess the airway, assess breathing, assess circulation, determine the patient’s priority for transport. Slides 18–29
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5. OBJECTIVES
11.5 Recognize findings in the primary assessment that require immediate intervention. Slides 22, 27
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6. OBJECTIVES
11.6 Differentiate the approach to the primary assessment based on the following: mechanism of injury/nature of the illness and level of responsiveness, patient’s age (adult, child, or infant). Slides 34–35

7. MULTIMEDIA Slide 31 Prehospital Patient Video
Slide 32 Initial Assessment Procedures Video
These videos appear later in the presentation; you may want to preview them prior to class to ensure they load and play properly. Click on the links above in slideshow view to go directly to the slides.

8. Deciding on the approach to the primary assessment
Manual stabilization of the head and neck
The general impression
Assessment of mental status using the AVPU scale
The ABCs as part of the assessment process
How to make a priority decision

9. Topics Primary Assessment
Patient Characteristics and Primary Assessment
Planning Your Time: Plan 50 minutes for this chapter.
Primary Assessment (30 minutes)
Patient Characteristics and Primary Assessment (20 minutes)
Note: The total teaching time recommended is only a guideline.

10. Primary Assessment Teaching Time: 30 minutes
Teaching Tips: This is a very important foundational lesson, but it also requires learning many steps. Break this lesson down into component parts and build one upon the other. Use standardized skill sheets. Allow students the guidance of working from a sheet as they practice. Begin working from skill sheets and add scenarios as students become more proficient. Beware of adding too many variables early on. Allow students to learn the steps in context first, and then add realistic twists later. The primary assessment is about decision making. Require students always to make patient priority decisions after completing their primary assessments.

11. Approach to the Primary Assessment
Focus on life threats
Airway (A), breathing (B), circulation (C)
May vary depending on
Patient’s condition
On the scene resources
Other
Point to Emphasize: Use warning signs in the general impression to help identify critical patients.
Talking Points: The order in which interventions are performed depends on the patient’s specific condition and the number and priority of the urgent conditions that you are presented with. Remember: Multiple EMTs can accomplish multiple priorities simultaneously.
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12. Approach to the Primary Assessment
Order of A-B-C depends on initial impression of patient
Sequence will vary
A-B-C if patient has signs of life
C-A-B if patient appears lifeless, no pulse
Immediate interventions may be needed
Talking Points: Interventions will be performed based upon the initial impression and the immediate needs of the patient. Compressions may come first in a lifeless patient. Airway might come first in a patient with a suspected airway threat. Bleeding control might come first in a patient with an exsanguinating hemorrhage.

13. Primary Assessment Steps
Forming a general impression
Assessing mental status
Assessing airway
Assessing breathing
Assessing circulation
Determining patient priority
Talking Points: Life-threatening conditions discovered during the primary assessment require immediate interventions.

14. General Impression
Assesses environment, patient’s chief complaint, and appearance
Helps determine patient severity
Helps set priorities for care and transport
Point to Emphasize: The chief complaint is the reason that EMS was called, usually in the patient’s own words.
Talking Points: Although the EMT cannot rely completely on the patient’s environment to rule out trauma, when combined with the chief complaint, environmental clues become extremely useful.
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15. General Impression
“Look Test”: feeling from environmental observations as well as first look at patient
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16. General Impression Findings that indicate critical patient
Altered mental status
Anxiety
Pale, sweaty skin
Obvious trauma to head, chest, abdomen, pelvis
Specific positions indicating distress
Talking Points: Specific positions indicating distress include tripod position and Levine’s sign. The presence of any of these signs usually indicates a serious patient, but absence of these signs does not guarantee that the patient is stable.
Discussion Topic: Describe findings in the general impression that might indicate a critical patient.
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17. General Impression Patients appearing lifeless
Resuscitate by beginning CPR compressions
Prepare AED as soon as possible
Talking Points: Appearance of lifelessness includes no movement or apparent evidence of breathing or only gasping breathing.
Knowledge Application: Present pictures and/or video clips of patients to the class. Ask students to describe their general impression.

18. Forming a General Impression
Look
Patient’s age, sex, and position
Listen
Moaning, snoring, or gurgling respirations
Smell
Fumes, urine, feces, vomitus, or decay
Talking Points: After you gain some practice assessing and managing patients, you may develop a “sixth sense” that clues you in to the severity of a patient’s condition. This is part of “clinical judgment,” or judgment based on experience in observing and treating patients.
Discussion Topic: Describe findings in the general impression that might indicate a critical patient.

19. Chief Complaint Patient’s description of why EMS was called
May be specific—“abdominal pain”
May be vague—“not feeling good”

20. Assess Mental Status: AVPU
Alert
Document orientation to person, place, and time
Verbal response
Painful response
Unresponsive
Point to Emphasize: Determining mental status is an important element of the primary assessment.
Talking Points: Patients who can speak clearly can almost always tell you their name (orientation to person). A few patients are oriented to person, but cannot tell you where they are (orientation to place). Some patients are oriented to person and place but cannot tell you the time, day, or date (orientation to time).
Discussion Topic: What criteria are necessary for a patient to be deemed “alert and oriented”?
Knowledge Application: Have students work in small groups. Use a programmed patient to present various mental status levels. Discuss the use of the AVPU scale.
Critical Thinking: How might a patient with Alzheimer’s disease affect your ability to assess mental status?

21. Assess ABCs
Order of primary assessment will vary depending on patient’s condition
Airway
Breathing
Circulation
Point to Emphasize: Assessment of airway, breathing, and circulation will allow for rapid identification of life threats.
Talking Points: If the patient can speak, airway is open. Investigate airway further in unresponsive patients.

22. Airway
If airway is not open or is endangered, take measures to open

23. Breathing Situations calling for breathing assistance
Respiratory arrest
Not alert, inadequate breathing
Some alertness, inadequate breathing
Adequate breathing, but signs suggesting respiratory distress or hypoxia
Talking Points: Inadequate breathing can be caused by insufficient minute volume because of decreased rate or depth or both.
Discussion Topic: In primary assessment of breathing, what four general situations call for immediate respiratory assistance?

24. Circulation Assess pulse Assess skin Assess bleeding
Talking Points: Note that if the patient has appeared lifeless, CPR will have begun.

25. Circulation Three results of assessing pulse Within normal limits
Unusually slow
Unusually fast
Talking Points: During primary assessment, pulse check is performed rapidly. It is not necessary to take the pulse for a full 30 seconds and obtain an exact rate. Any result other than within normal limits is cause for concern.
Discussion Topic: Describe the three possible results of a pulse check performed in the primary assessment.
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26. Circulation Assessing skin Good circulation: warm, pink, dry skin
Shock: pale, clammy (cool and moist) skin
Talking Points: With dark-skinned patient, check color of lips or nail beds, which should be pink if circulation is good.

27. Immediate Intervention
Treat any life-threatening ABC problem as soon as discovered!
Point to Emphasize: Any life threats found while evaluating the ABC’s must be treated immediately.
Knowledge Application: Have students use a standardized skill sheet to write out the steps that they would take and the questions that they would ask to accomplish the listed elements of the primary assessment.

28. Determining Patient Priority
Stable
Vital signs in normal range
Potentially unstable
Potential for deterioration can indicate potentially unstable category
Unstable
Threat to ABC’s rules out stability
Talking Points: A threat to the ABC’s can be either actual or imminent. A patient’s priority can change as the patient’s condition changes.
Discussion Topic: Describe findings in the primary assessment that might lead you to categorize a patient as “unstable.”

29. Need for Priority Transport
Initiate priority transport if a life-threatening problem cannot be controlled or threatens to recur
Continue assessment and care en route
Class Activity: Assign primary assessments as homework. Ask each student to complete five primary assessments, using a standardized skill sheet, for the next session.

30. Think About It
Why must you continue to re-evaluate the primary assessment?
Talking Points: Although the primary assessment occurs immediately, it is a part of your ongoing assessment. Re-evaluation of the primary assessment identifies life threats that may appear after the primary assessment and identifies problems that have deteriorated and now pose a life threat.

31. Prehospital Patient Video
Video Clip
Prehospital Patient
Why is patient assessment so important?
What are the steps of assessment?
List three life-saving management techniques used by an EMT.
How can the dynamics of an emergency scene influence a patient’s assessment?
What role does the mechanism of injury play in the assessment of a trauma patient?
Click here to view a video on the subject of assessment of the prehospital patient.
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32. Initial Assessment Procedures Video
Video Clip
Initial Assessment Procedures
What factors should be incorporated into the general assessment of a patient?
How long should a primary assessment take to perform?
What supplies does an EMT need to perform a primary assessment?
What should an EMT do if he identifies the need for additional resources during the scene size-up?
How should an EMT assess a patient’s circulation?
What types of interventions might need to be performed during a primary assessment?
Click here to view a video on the subject of initial assessment procedures.
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33. Patient Characteristics and Primary Assessment
Teaching Time: 20 minutes
Teaching Tips: This section adds context and realism to the basic steps discussed in the previous section. Make sure that students have achieved basic competency in the previous section before moving on to these topics. This section uses specific examples to illustrate points. Consider following this trend as these themes are presented. The real world requires flexibility. Use scenarios to demonstrate how assessment technique might differ from patient to patient. Highlight how the standardized steps are consistently accomplished despite differences in patient situations. Emphasize consistency.

34. Patient Characteristics
Patient characteristics determine the form of assessment
Medical or traumatic problem?
Altered mental status?
Child or adult?
Points to Emphasize: Patient assessment may need to be adjusted based on the patient’s characteristics. Mental status, nature of illness, and severity of injury all impact the assessment technique. General impression and evaluation of mental status vary greatly between conscious patients and unconscious patients. EMTs must consider spinal immobilization during the primary assessment of a trauma patient.
Discussion Topics: Describe how your assessment might differ between a conscious patient and an unconscious patient. Describe the additional steps necessary when assessing a trauma patient.
Class Activity: In a class discussion, ask students to brainstorm types of patients for whom they might need to adjust the assessment technique.
Knowledge Application: Have students work in small groups. Present each group with a different patient and ask group members to describe the assessment technique that they would use. Have each group present its plan to the class; discuss differences.

35. Pediatric Note
Point to Emphasize: EMTs must adapt the expectations of the primary assessment based upon the age of the patient.
Discussion Topics: Describe how the assessment of a 4-year-old patient might differ from that of an 84-year-old patient.
Knowledge Application: Use programmed patients to present assessment scenarios that require adaptive thinking. Discuss the specific strategies used.
Adjust assessment to social and physiological norms of children

36. Think About It
How might normal findings in a primary assessment differ for a child compared with an adult?
Talking Points: Many physiologic differences alter findings of a pediatric primary assessment. Respiratory and heart rates are faster. Capillary refill is a useful tool and the same quantities of bleeding might be life threatening in a child, but not in an adult.

37. Steps of Primary Assessment
Despite patient characteristics, follow primary assessment steps systematically
General impression
Mental status
ABCs
Priority for transport
Point to Emphasize: Although the application of the primary assessment may vary based on patient type, it is exceptionally important to be systematic and to include all the essential components.
Discussion Topic: Discuss the key elements of a primary assessment that must be accomplished regardless of the patient’s condition.
Knowledge Application: Take a field trip. Visit a day care center or nursing home to experience actual patients and the difficulties that they present to assessment.
Critical Thinking: You are conducting your primary assessment when the scene suddenly becomes unsafe. How might this dynamic scene change affect your primary assessment?

38. Chapter Review

39. Chapter Review
Primary assessment is a systematic approach to quickly find and treat immediate threats to life.
General impression, although subjective, can provide extremely useful information regarding urgency of a patient’s condition.
Determination of mental status follows the AVPU approach.
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40. Chapter Review
Evaluating airway, breathing, and circulation quickly but thoroughly will reveal immediate threats to life that must be treated before further assessment.
Patient’s priority describes how urgent patient’s need to be transported is and how to conduct the rest of the assessment.

41. Remember Determine if a problem is medical or traumatic in nature.
Determine if a patient is responsive or unresponsive; an adult, child, or infant.
Rapidly identify the need for immediate airway intervention.
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42. Remember
Determine if the patient’s condition is stable enough to allow further assessment and treatment at the scene.

43. Questions to Consider
What factors will you take into account in forming a general impression of a patient?
How should you assess a patient’s mental status with regard to the AVPU levels of responsiveness?
Talking Points: The general impression combines environmental findings and initial patient findings. Important elements include chief complaint, environmental clues such as mechanism of injury, and level of distress of the patient.
AVPU is an acronym that stands for 4 categories of mental status—alert, verbal, painful stimuli, and unresponsive.
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44. Questions to Consider
How should you assess airway, breathing, and circulation during the primary assessment?
What is meant by the term priority decision?
Talking Points: Airway and breathing are first assessed by talking to the patient. If patient can speak, then at least at some level the airway and breathing are intact. If no airway is present, steps must be taken to provide one. Breathing is assessed by ensuring adequacy of breathing and recognizing respiratory arrest or respiratory failure. Circulation is assessed by evaluating pulses, skin, and gross bleeding.
Priority decision is the determination of the need for either immediate intervention or transport (or both). This decision is completed after assessing ABC’s and is directly related to recognizing life threats.

45. Critical Thinking
A middle-aged male is lying on the street after being hit by a car. He appears unresponsive as you approach. You notice that he is bleeding from a laceration on his forearm and making gurgling sounds from his airway.
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46. Critical Thinking
If you are alone, what factors do you consider in deciding what to do first? Why?
Talking Points: Gurgling sounds in the airway require immediate suctioning unless the bleeding is life threatening. In general, the airway is the more important concern except in the case of exsanguinating hemorrhage.

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