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Primary Survey


EMT Primary Survey Assessment

Primary Assessment EMT

The primary survey, also called the primary assessment, is done by the Emergency Medical Technician (EMT) after arriving on scene. It is done quickly at first contact with the patient. The primary survey is the beginning portion of a longer patient assessment which also includes the SAMPLE history and the secondary survey. The goal of the primary survey is to rapidly identify any life threatening problems and initiate treatments.

 

The National Registry of Emergency Medical Technicians (NREMT) requires that all EMTs pass two psychomotor exams dealing with patient assessments. Both of these hands on exams contain the primary survey. The NREMT psychomotor skill exams are the NREMT Medical assessment and NREMT Trauma assessment.

 

For this reason, lower in this post the primary survey is separated into the primary survey trauma and the primary survey medical to include more details for passing the NREMT exam.

 

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You can find a full list of the NREMT skills needed to pass the entire psychomotor exam on the NREMT Exam page.

 

Below the primary survey is listed out, beginning at the EMTs arrival at the scene. This means it also includes the scene size up and body substance isolation (BSI).

 

For more explanation about each part of the primary survey, scroll lower in the page for more details about what’s needed to pass the NREMT patient assessment exams.

 

→ If at any point during the primary assessment you determine a life threat, it may indicate a need to “load and go” instead of continuing the exam.

 

Primary Survey

 

Personal Protective Equipment (PPE) for BSI.

 

Scene Size Up

Determine scene safety.

Determine number of patients.

Determine mechanism of injury (MOI) or Nature of Illness (NOI).

 

Quick Tip: MOI indicates trauma and NOI indicates medical illness.

 

Request EMS assistance if needed.

Consider if patient needs spine stabilization.

 

Primary Survey

Form a General Impression of the patient: Age, Sex, Position.

 

Determine LOC using AVPU: Is patient A & O x 4? (See below for explanation.)

 

Determine Chief Complaint & any life threat: Why are you there?

 

Assess Airway: Is it patent? Insert adjunct if needed.

 

Assess Breathing: Rate, Quality and Depth. Apply O2 if needed.

 

Assess Circulation: Pulse – Rate, Rhythm and Quality. Assess and treat major bleeding. Skin – color, temp, condition.

 

Initiate Shock Treatments if needed. (see NREMT Trauma Assessment below for S/Sx of shock.)

 

Determine transport decision based on patient priority.

 

The primary survey should be done rapidly in under 10 – 15 minutes, depending on the patients condition.

 


 

In fact, if you’re testing for the NREMT Medical assessment call for transport must be done within 15 minutes to pass and within 10 minutes to pass the NREMT Trauma assessment.

 

Both these patient assessments are discussed below in more detail. 

 

Primary Assessment for NREMT

The NREMT exam has two patient assessments which require testing on the primary survey. The two patient assessment exams consist of the NREMT medical assessment and the NREMT trauma assessment, both of which are covered below.

 

Both of these patient assessments have slightly different requirements for passing based on the patient’s condition and response to treatment.

 

Patient Assessment Medical

When arriving on scene for the NREMT medical assessment you follow the same Scene Size up steps listed above, including considering spinal precautions.

 

This is true even though there is no trauma because it’s possible the patient fell unconscious and tripped or injured themselves.

 

During the NREMT medical assessment exam you will be talking to both your patient and the proctor throughout the test. 

 

Primary Survey Medical

General Impression of the patient. Age (estimate), Sex, Position. The general impression is done before having any contact with the patient, it is often said it’s done from the doorway. For the NREMT medical assessment you need to verbalize out loud your general impression of the patient.

 



 

Patient is 30 y/o F in tripod position.

72 y/o M supine on floor.

 

Determine level of consciousness (LOC) using AVPU. Is patient responsive or unresponsive? If patient is unresponsive move onto AVPU to determine LOC.

 

Is the patient oriented to person, place, time and event? Ask the patient “what happened?” to determine orientation to event. If they answer everything appropriately on the NREMT medical assessment you can verbalize:

 

Patient is A&Ox4

 

Alert – Is the patient awake, responsive with eyes tracking you during the conversation?

 

Verbal – This is for the patient that appears unresponsive but responds to verbal stimulus from you. This patient isn’t required to talk to you or even speak, a response can be moaning, grunting or just looking at you.

 

Painful – This is for the patient that is unresponsive, doesn’t respond to verbal stimulus but responds when you apply a painful stimulus. An example of painful stimulus is the sternal rub.

 

Unresponsive – This is a patient who does not respond to your verbal and painful stimuli.

 

Determine Chief Complaint (CC) and any life threats. CC can be determined by using what you have observed and by asking the patient a question like:

 

Why did you call an ambulance today?  

 

Also verbalize that you are checking patient for any life threats at this time.

 

Asses Airway and Breathing. The NREMT medical assessment awards 3 points to the EMT here. One for the assessment, 1 for assuring adequate ventilations, and 1 for initiating adequate oxygen therapy. You must do these three items correctly at this time in the primary survey to be awarded points.

 

Airway – Is the patient’s airway patent.  Depending on the CC, you may need to check the mouth. For example,  if the call is allergic reaction you should check the patient’s mouth and throat for swelling.

 

Is the patient ventilating adequately? You can check lung sounds at this point if needed due to CC.

 

Breathing – What is the Rate, Quality and Depth (tidal volume) of respirations? Use this information to decide appropriate oxygen therapy for the patient. Apply oxygen now if it’s appropriate. (Common settings will be O2 @ 15 Lpm via NRB or 6 Lpm via NC.)

 

Assess Circulation. The NREMT medical assessment awards another 3 points to the EMT here. One point for Assessing and controlling major bleeding, 1 for checking pulse, and 1 point for assessing skin color, temperature and condition.

 

Bleeding – You can ask the proctor:

 

Do I see any major bleeding?

 

Often you can cover this when you determine life threats and CC earlier in the primary survey.

 

Pulse – Check for Rate, Rhythm, and Quality of the pulse. For the NREMT medical assessment you will check the radial pulse on a conscious patient and the carotid on an unconscious patient.

 

Skin – Check for Color, Temp, and Condition of skin. During the NREMT medical assessment you can verbalize to the proctor:

 

Patient’s skin is pink, warm and dry. Is this accurate?

 

At this point the EMT testing candidate needs to identify patient priority and make a transport decision about their patient.

 

Transport Decision. You must decide whether to continue treating the patient on scene, call for ALS to transport, or load and go with the patient yourself at the end of the primary survey.

 

For the NREMT medical assessment this decision must be made within 15 minutes or the EMT candidate automatically fails the scenario. You must verbalize your transport decision, the reason why, along with patient priority to the proctor.

 

At this point the primary survey is over and the NREMT medical assessment will likely continue with the SAMPLE history in the back of the ambulance. Look for a post soon about assessing a patient using the SAMPLE history.

 

  NREMT Trauma Assessment

When arriving on scene for the NREMT trauma assessment you follow the same Scene Size up steps listed at the top of this page. This includes considering and implementing spinal precautions, which are very likely in a trauma assessment. 

 

During the NREMT trauma assessment exam you will be talking to both your patient and the proctor throughout the test, even if the patient is unresponsive.

 

Primary Survey Trauma

General Impression of the patient. Age (estimate), Sex, Position. The general impression is done prior to any contact with the patient and should include the seriousness of the injury if you’re able to tell before contact.

 

For the NREMT trauma assessment you need to verbalize out loud your general impression of the patient.

 

Male in his twenties supine on the sidewalk with a severe injury.

 

Determine level of consciousness (LOC) using AVPU. Is patient responsive or unresponsive? If patient is unresponsive move onto AVPU to determine LOC.

 

Is the patient oriented to person, place, time and event? Ask the patient “what happened?” to determine orientation to event. If they answer everything appropriately on the NREMT trauma assessment you can verbalize patient is A&Ox4.

 

For the trauma assessment it’s more likely you will need to report:

 

Patient is unresponsive

 

It’s likely that during the NREMT trauma assessment the patient will not be alert and oriented. 

 

Alert – Is the patient awake, responsive with eyes tracking you during conversation?

 

Verbal – This is for the patient that appears unresponsive but responds to verbal stimulus from you. This patient isn’t required to talk to you or speak at all. A response can be moaning, grunting or just looking at you.

 

Painful – This is for the patient that is unresponsive, doesn’t respond to verbal stimulus but responds when you apply a painful stimulus. An example of painful stimulus is the sternal rub.

 

Unresponsive – This is a patient who does not respond to your verbal and painful stimuli.

 

Determine Chief Complaint (CC) and any life threats. If the patient is unresponsive you will not know the CC because typically the patient reports the CC to you.

 

During the NREMT trauma assessment the EMT candidate may need to verbalize:

 

CC is unknown because patient is unresponsive.

 

To find any life threats on an unresponsive patient you must expose the patient to look for wounds, bleeding, etc. During the NREMT trauma assessment you will need to verbalize exposing the patient and possibly have to remove clothing in real life.

 

While removing the clothing you can ask the proctor if you see any bleeding or life threats. At this point you will be required to treat any threats to life. For example, if you find a gunshot wound (GSW) treat it and then ask the proctors if your treatment is adequate.

 

Assess Airway. There are two points awarded for airway in the NREMT trauma assessment. One point for opening and assessing airway and one point for inserting adjunct as indicated.

 

If your patient is confused or unresponsive during the NREMT trauma assessment you will need to open the patient’s mouth and check for any airway obstructions. A jaw thrust maneuver should be used for any trauma patient with a risk for spinal injury.

 

You are looking for things like blood, mucous, vomit, and even teeth depending on what your MOI was. If obstructions are present you will be required to remove them, usually by suctioning the patient for less than 15 seconds at a time.

 

Once obstructions are removed the EMT candidate will need to insert an airway adjunct for any unconscious patient. Typically an OPA is used and you should ask the proctor if the patient accepts the airway after you place it. 

 

Assess Breathing. There are four points awarded under the Breathing category on the NREMT trauma assessment. One point for assessing breathing, one point for assuring adequate ventilation, one point for initiating appropriate oxygen therapy, and one point for managing any injury which may compromise breathing/ventilation. 

 

While assessing breathing you want to look at the patient’s chest, listen to breath signs and look for equal rise and fall while assessing the rate, rhythm, and quality of breaths.

 

During a trauma assessment of an unresponsive patient it’s important to assess whether breathing is regular, shallow or labored because these will affect your ventilation and oxygen therapy decisions.

 

Follow protocol for your area when deciding how to administer oxygen, but as a general guide, patients with a respiratory rate between 8 and 28 who do not have labored or shallow breathing can be placed on O2 via NRB at 15 Lpm.

 

Trauma patients with shallow or labored breathing or with a rate < 8 or > 28 should be ventilated with a BVM device.

 

During the NREMT trauma assessment candidates will need to verbalize BOTH ventilation and oxygen treatments. For Ex:

 

I’m going to ventilate patient with a BVM connected to 15 LPM 100% O2.

 

During the NREMT trauma assessment there is one point awarded for managing any injury compromising breathing or ventilations. It’s possible that you will achieve this point earlier in the primary survey, prior to the breathing assessment phase.

 

It’s common for treatment to be required when you are checking for life threats earlier in the primary survey because anything compromising ventilations or breathing is likely to be a life threat.

 

One final word on breathing during the NREMT trauma assessment. It’s always important to check if your interventions were effective in helping the patient.

 

Ask the proctor if your O2 therapy is adequate. If it’s not, take a moment to see if you have forgotten anything. Did you place the airway, remove obstructions, etc?

 

Assess Circulation. There are four points awarded in the Circulation category of the NREMT trauma assessment. One point for checking pulse and one point for assessing skin color, temperature and condition. During the trauma primary survey there is also one point for assessing and controlling major bleeding and one point for initiating shock management if needed. (Ex: Positioning patient and conserving body heat.)

 

Check Pulse. Check Rate, Rhythm and Quality of the pulse. Use the carotid pulse if patient is unconscious and radial pulse if patient is conscious.

 

Check Skin. Assess skin Color, Temperature and Condition. During the NREMT trauma assessment keep an eye out for indicators of shock during the skin check.

 

If the proctor tells you the patient’s skin is pale, cool, clammy or diaphoretic this should be a red flag for you to consider whether this patient could be experiencing shock. (Scroll down for the signs and symptoms of shock.)

 

If you haven’t found a reason the patient would be in shock during the primary survey, this is the time to look for any hidden major bleeding that could be causing the patient’s condition.

 

Assess Bleeding. During the NREMT trauma assessment there is one point awarded for assessing and controlling major bleeding. You might find a bleed while assessing the skin, but it’s possible that you will achieve this point earlier in the primary survey prior to the circulation assessment phase.

 

It’s common to treat major bleeding when you are checking for life threats earlier in the primary survey because any major bleeding is likely to be a life threat that requires immediate treatment.

 

However, do not overlook checking the patient for any other injuries while in a rush to transport. It is an automatic fail if you don’t find all problems related to major bleeding.

 

EMT candidates should do a rapid trauma assessment and verbalize checking the head, neck, chest, pelvis and femurs for anything emergent prior to transport.

 

Another important point is to verbalize maintaining c-spine precautions if needed while transporting the patient onto the backboard and into the ambulance.

 

This also gives you the opportunity to verbalize checking the back and buttocks for injury and bleeding while log-rolling the patient

 

Shock Management. If you determine shock is present during the NREMT trauma assessment you will be expected to position the patient properly and conserve the patient’s body heat. These interventions frequently mean elevating the legs and using a blanket. 

 

Transport Decision. You must decide whether to continue treating the patient on scene, call for ALS to transport, or load and go with the patient yourself at the end of the primary survey.

 

For the NREMT trauma assessment this decision must be made within 10 minutes or the EMT candidate automatically fails the scenario. You must verbalize your transport decision and patient priority along with the Glasgow coma scale ranking to the proctor at this time.

 

It is likely the patient will be a high priority transport during the NREMT trauma assessment.

 

Patient is high priority due to GSW and GCS of 3 so I’m transporting this patient emergent to the hospital now.

 

At this point the primary survey is over and the NREMT trauma assessment will likely continue with the SAMPLE history in the back of the ambulance. Look for a post soon about assessing a patient using the SAMPLE history.

 

Signs and Symptoms of Shock

Here are some common signs and symptoms of compensated shock in the trauma patient.

 

 Increase Respiratory Rate
Shallow breathing

Increased Heart Rate
Weak peripheral pulses

Color – pallor, cyanotic, pale
Temperature – cool, cold to touch
Condition – Diaphoretic, clammy

Nausea/ Vomiting, Increased thirst

Altered mental status, Anxiety, Agitation, Restlessness

 

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Want more help with assessment skills? Check out:

Taking a SAMPLE History and OPQRST Pain Assessment

Guide to Auscultating Lung Sounds

Pediatric Assessment Triangle

 

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