EMT Module 4: Primary Assessment

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MODULE 4 Primary Assessment: How to Think Through a Patient Scenario Memorize → Understand → Connect → Apply. Original phone-friendly EMT study material based on topics visible in the supplied Emergency Care, 14th ed., primary assessment chapter-review screenshots (pp. 335–337). Not a substitute for Army AIT checklists or local protocols. 1. The big idea: find what can kill the patient first A primary assessment is a rapid search for immediate threats. It is NOT a full diagnosis. Your first task is to recognize a dangerous pattern and respond appropriately. • Scene size-up: PPE, scene safety, mechanism of injury (MOI) or nature of illness (NOI), number of patients, resources. • General impression: appearance, position, speech, breathing, skin, obvious bleeding. • Responsiveness: AVPU = Alert, responds to Verbal stimulus, responds to Pain, Unresponsive. • Immediate threats: catastrophic bleeding, obstructed airway, inadequate breathing, absent pulse/abnormal breathing, poor perfusion.

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• Transport priority: recognize instability and do not delay transport for nonessential history. WHY? A complete history is valuable later; oxygen delivery and blood flow must be preserved now. 2. Read the question before picking an answer • FIRST: What threat or safety problem needs attention immediately? • NEXT: What has already been done? Do not repeat it. • MOST concerning: Which finding best suggests deterioration? • BEST intervention: Which option addresses the immediate physiological problem at EMT level? • Priority patient: Who is most unstable, not simply who has the strangest number? 3. Scene safety and general impression Traffic, violence, electricity, chemical exposure, and unstable structures can create additional victims. If the scene is unsafe, establish safety and request appropriate resources before entering.

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An upright, tripod-position patient who can only say two words at a time may be struggling to breathe. WHY? Speech requires airflow and coordination with exhalation. Severe breathlessness limits speech, although it does not alone prove respiratory failure. Pale, cool, sweaty skin can indicate sympathetic activation and reduced skin blood flow. WHY? In poor perfusion, vessels in the skin constrict to help preserve blood flow to vital organs. This sign is not specific; combine it with other findings. 4. Mental status is a clue to oxygen delivery AVPU: Alert → Verbal → Pain → Unresponsive is a quick responsiveness scale, not a diagnosis. A decline in responsiveness is concerning. WHY? Brain cells require oxygen, glucose, and adequate blood flow. Hypoxia, high CO2, low glucose, brain injury, intoxication, or shock can all cause confusion or reduced responsiveness. Scenario connection: A patient who was alert and now responds only to voice requires immediate reassessment of airway, breathing, and circulation, not simply a note in the chart.

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5. Airway: can air reach the lungs? Gurgling: blood, vomit, or secretions may block the airway; suction/position appropriately. Snoring in an unresponsive patient: relaxed soft tissue may obstruct airflow; open the airway. Stridor: upper airway narrowing is possible and potentially dangerous. WHY airway first? No amount of supplemental oxygen can reach the alveoli through a fully obstructed airway. Airway opening and clearing obstruction make ventilation possible. Airway makes ventilation possible airway obstruction air cannot reach alveoli opening/clearing allows ventilation When cervical injury is suspected, a jaw-thrust is generally preferred initially; if ineffective, achieving an open airway takes priority. Follow the course protocol for adjuncts and spinal motion restriction.

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6. Breathing: rate is not the same as effectiveness Check respiratory rate, depth, effort, chest rise, air movement, and mental status. SpO2 adds information about oxygen saturation but does not measure CO2 removal. WHY? Shallow breaths can move too little air into alveoli even when RR is high. A tired patient may go from fast breathing to dangerously slow, weak breaths as respiratory muscles fatigue. Watch breathing quality rapid, shallow breaths fatigue may develop slow, weak breaths may follow Clinical priority: An inadequate breathing pattern calls for airway support and assisted ventilation with BVM as indicated; oxygen alone does not move enough air.

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7. Circulation: why a normal BP can mislead Look for severe bleeding, pulse quality, skin signs, mental status, and evidence of poor perfusion. Control life-threatening external hemorrhage promptly. WHY HR rises with blood loss: Less blood returns to the heart → stroke volume may fall → sympathetic activation increases heart rate and constricts peripheral vessels to support cardiac output and BP. WHY BP may remain normal: Compensatory vasoconstriction can maintain pressure for a while. Therefore, HR 130 with cool, clammy skin after trauma can suggest shock even with BP 120/80. A normal BP can mislead blood volume may fall HR rises; vessels constrict BP may remain normal early Memorize: Cardiac output = HR × stroke volume. BP is influenced by cardiac output and vascular resistance. Normal BP does not prove normal tissue perfusion.

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8. The practical decision sequence Safe scene? Protect responders and patient; request resources. Catastrophic bleeding? Control it immediately; blood loss rapidly destroys perfusion. Responsive and breathing normally? If unresponsive with absent/abnormal breathing, check pulse promptly and follow BLS pathway. Open airway? Position, clear obstruction, suction, and use adjuncts as indicated. Adequate breathing? Evaluate rate AND depth; assist ineffective ventilations. Adequate circulation? Assess bleeding and perfusion; recognize shock. Need urgent transport/reassessment? Repeat assessment after interventions and monitor for deterioration. Important: This is a thinking aid, not a rigid order for every emergency. Catastrophic bleeding, cardiac arrest, and other immediate threats change priorities. Follow the latest BLS algorithm and Army AIT protocols.

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9. Guided example: possible compensated shock Scene: 23-year-old fell 15 feet. HR 132, BP 116/74, RR 28, pale cool skin, anxious. What stands out? Fast HR and RR, concerning mechanism, abnormal skin. Possible mechanism? Internal bleeding could reduce circulating volume; pain and fear may also contribute. Why normal BP? HR and vessel constriction can temporarily maintain it. What next? Search for immediate threats, assess for shock, manage within EMT scope, and prioritize appropriate transport. Transfer rule: Do not use a single normal BP to dismiss the rest of a concerning trauma presentation. 10. Guided example: respiratory fatigue Scene: 35-year-old was breathing 34/min and speaking in short phrases. Now drowsy, RR 8, very shallow chest rise.

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Why worse? Breathing has slowed as effort and mental status decline; this can signal exhaustion and

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Practice — Question 1

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Practice — Question 12

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14. How to review your misses For each missed question, write three short lines: (1) The clue I missed; (2) Why that clue matters physiologically; (3) The action that addresses the immediate threat. Retest the missed questions later without reading the explanations first. Study target: Aim for 10/12 or better on fresh scenarios, and explain the WHY in your own words. This is a study target, not the NREMT passing rule. Scope note: These are original EMT-level educational examples. Real care follows instructor, medical direction, and local protocols. Source scope: user-supplied review pages from Emergency Care, 14th ed., especially Chapter 12. Full chapter text was not supplied.