Patient Assessment System — Lesson 2

Overview: Systematic Patient Assessment

You check every patient the same way, in the same order. First comes the XABCDE primary survey, then the head-to-toe secondary survey. That order finds the life threats fast and tells you what to treat first when help is far away.

Treat as you find. You assess and treat at the same time. If you find a life threat halfway through, you fix it right then and finish the assessment after.

Why a fixed order

Going in the same order every time means you don't skip anything, and the problems that kill fastest come up first. What you find then drives the evacuation call and what you tell the next rescuer. It also gives you something to hold onto when your own heart rate is up.

Key points

The assessment doesn't stop. Reassess often, and change your treatment as the patient changes.

Out here, your own exam is the only diagnostic test you've got, so be thorough with it.

Write down what you find so EMS, or whoever takes over, can pick up where you left off.

Primary Survey: XABCDE

The primary survey finds the problems that can kill the patient soonest. Each letter is one of them. Go in order, and treat each problem as you find it.

X Exsanguinating hemorrhage

A Airway

B Breathing

C Circulation

D Disability

E Expose/Environment

X = Exsanguinating hemorrhage

What it is: Massive, life-threatening bleeding. You control it before any other assessment step.

Life-threatening bleeding is the leading cause of preventable death in trauma
Look for arterial bleeding: bright red and pulsing, often from a limb or the groin
Bleeding from an arm or leg that's obviously life-threatening (spurting, pooling fast, soaking through dressings, or an amputation) gets a tourniquet immediately, high and tight. Don't try pressure first. Hold direct pressure only while you get the tourniquet ready, and note the time it goes on.
Other bleeding: firm direct pressure right away, and keep it there
Pack wounds in junctional areas where a tourniquet can't go (groin, armpit/axilla). Never pack a neck wound. Use firm, sustained direct pressure instead.

Bleeding before airway. Check and treat exsanguinating hemorrhage before you look at the airway. If the patient is pouring blood, you stop it first.

A = Airway

Goal: Make sure the airway is open (patent) and not at risk of getting blocked.

Assessment: Look for the chest or belly moving, listen for sounds, feel for air moving
Obstructive sounds: Gurgling (fluid or blood), stridor (partial obstruction), snoring (the tongue has relaxed back)
In an unresponsive patient, snoring or gurgling means the airway is partly blocked. Reposition it now. Open the airway, and roll a breathing patient onto their side.

Opening the airway

Head-tilt chin-lift: Use it when you don't suspect a spinal injury. Gently tilt the head back and lift the chin. That lifts the tongue off the back of the throat (pharynx).
Jaw thrust: Use it when you do suspect a spinal injury. Grip the angles of the jaw and pull it forward without tilting the head. It protects the cervical spine.

Positioning

Unconscious and breathing, no spinal concern: recovery position on their side, to protect the airway if they vomit. Either side is fine, but the left side is better in late pregnancy. Rest the head on their extended arm and bend the top leg so they don't roll.
Suspected spinal injury: keep them on their back and in line (supine alignment). Hold the head and use a jaw thrust if you can stay with them. If they vomit and you can't logroll them, if you have to leave them, or if you can't keep the airway open, roll them onto their side with the head and body in line as best you can. The airway wins.

B = Breathing

Goal: Make sure enough air is moving in and out (ventilation) and enough oxygen is getting in (oxygenation).

Respiratory rate: Normal for an adult is 12-20 breaths a minute. Over 20 is fast and worth watching. Under 10 or over 30 is a red flag.
Depth: Enough air per breath (tidal volume). You can see the chest rise and fall.
Effort: Is it easy, or are they working hard for each breath (labored)?
Look and listen: Watch that both sides of the chest rise and fall equally. Listen near the mouth and chest for abnormal sounds (gurgling, wheezing, stridor).

Signs of respiratory distress

Fast breathing (tachypnea) with retractions, the skin pulling inward
Using accessory muscles (in the neck and between the ribs)
Nasal flaring (the nostrils widen)
Tripod position (sitting forward, braced on the hands)
Seesaw breathing (the belly goes in as the chest goes out, the opposite of normal)

C = Circulation

Goal: Check heart rate, rhythm, and perfusion (how well blood is getting around).

Unresponsive and not breathing, or only gasping? Don't look for a pulse. Start CPR now (Lesson 3).
Pulse: In a breathing patient, check it at the wrist (radial). If you can't find it there, try the neck (carotid).
Rate: Normal is 60-100 bpm at rest. Under 60 (bradycardia) or over 100 (tachycardia) can mean a problem.
Rhythm: Regular or irregular? A regularly irregular pattern can point to specific conditions.
Quality: Strong, or thready (weak)? Bounding (forceful)?

Skin assessment (signs of perfusion)

Color: Pink (normal), pale (poor perfusion or cold), mottled (shock, severe hypoperfusion), cyanotic (blue, from hypoxia)
Temperature: Warm (normal), cool or cold (peripheral vasoconstriction from shock or cold exposure)
Moisture: Dry (normal), moist or diaphoretic (sweating from shock, a cardiac event, fear, or exertion)
Capillary refill: Press a nail bed until it blanches, then let go. Color should return in under 2 seconds. Slower refill suggests poor perfusion, though cold hands and feet can also slow it.

The shock triad. Pale, cool, sweaty (diaphoretic) skin means shock or poor perfusion. Treat it now and start an emergent evacuation.

D = Disability (neurologic status)

Goal: A quick check of how awake they are and how their brain and nerves are working.

AVPU scale

Alert: Awake, oriented, and aware of their surroundings
Verbal: Responds to your voice, but may be confused
Pain: Responds only to a painful stimulus, like a trapezius squeeze (pinch the muscle between the neck and shoulder)
Unresponsive: No response to any stimulus

Pupil assessment (PERRL)

Pupils Equal: Both the same size
Round: Not irregular in shape
Reactive to Light: They shrink (constrict) when you shine a light in and widen (dilate) in the dark

Unequal pupils, fixed pupils, or a slow reaction to light can mean a serious brain injury. You may hear EMS use the Glasgow Coma Scale (GCS). AVPU is the wilderness-level tool, and it's enough.

E = Expose/Environment

Goal: Examine the whole patient for injuries without letting them lose heat.

Move or remove clothing so you can see every place they could be hurt, and protect their privacy as much as you can
Look at and feel the entire body, front and back
Look for wounds, deformities, swelling, and bruising
Prevent hypothermia: Once you've looked, cover them back up with blankets or insulation right away.
Keep watching the weather, the temperature, and anything else on scene that could hurt either of you

Secondary Survey: Full Head-to-Toe Exam

The secondary survey is a careful, detailed exam from head to toe. You do it after you've found and stabilized the life threats. It turns up the rest of the injuries and feeds your evacuation decision.

Head-to-toe exam sequence

Head (DCAP-BTLS)

Deformity: Abnormal shape or asymmetry?
Contusions: Bruising from trauma?
Abrasions: Scrapes or road rash?
Punctures/Penetrations: Wounds breaking the skin?
Burns: Any thermal injuries?
Tenderness: Pain when the area is pressed (palpated)?
Lacerations: Cuts?
Swelling: Edema?

Neck

Feel (palpate) for tenderness, swelling, and any step or deformity along the spine
For reference: EMS may also check the neck for jugular vein distension or tracheal deviation. Both are late, unreliable signs of serious chest problems. Your job is to spot severe trouble breathing and evacuate emergently.

Chest

Look for paradoxical motion: a flail segment, where part of the ribcage moves opposite to the rest of the chest
Watch that both sides rise equally. Listen near the mouth and chest for abnormal breathing sounds.
Feel for crepitus, a crackling from air in the tissues
Check for deformity or swelling

Abdomen

Divide the abdomen into four quadrants (right upper, left upper, right lower, left lower)
Look for swelling (distension), bruising, and penetrating wounds
Gently palpate each quadrant for tenderness
Check for guarding (they tighten the muscles when you touch) and rigidity (a hard, boardlike belly)
Guarding and rigidity suggest internal bleeding or peritonitis. That's an emergent evacuation.

Pelvis

Look, and ask about pain. Don't push on it, squeeze it, or rock it to test for stability.
If the mechanism fits (a high fall, a crush, a high-energy impact), assume it's broken. Treat based on the mechanism and the signs (Lesson 4).
A pelvic fracture can bleed massively on the inside

Extremities

Check each limb for deformity, swelling, wounds, and color
Neurovascular (NV) check: Beyond the injury (distal), check circulation (pulses, skin color and temperature), sensation, and motion (can they move, and squeeze your hands?). That's CSM: Circulation, Sensation, Motion.
CSM check: Circulation, Sensation, Motion beyond (distal to) the injury
Write down the NV status each time you check. It guides your splinting decisions.

Back

Check the back when you roll them anyway, like when you get insulation underneath. With a spine concern, roll them as one unit with the head in line, and keep the rolls to a minimum.
Inspect the back for wounds, bruising, and deformity
Feel down the spine for tenderness, or a step or deformity

SAMPLE history

The history tells you what normal looks like for this patient and what led up to today:

S = Signs & Symptoms: What's the main complaint? What are they feeling?
- OPQRST for pain:
  - Onset: When did it start?
  - Provocation: What makes it worse?
  - Quality: Sharp, dull, burning, pressure, aching?
  - Radiation: Does it spread anywhere else?
  - Severity: Pain scale 0-10
  - Time: How long has it been going on?
A = Allergies: Medications, foods, anything environmental? Ever had anaphylaxis?
M = Medications: What do they take, including over-the-counter drugs and supplements?
P = Past Medical History: Past surgeries, illnesses, chronic conditions? Anything recent?
L = Last Oral Intake: What did they last eat and drink, and when? A full stomach raises the risk of vomiting, and the hospital needs to know before any anesthesia.
E = Events: What led up to this? What was the mechanism of injury?

Vital signs to document

Pulse: Rate and quality (strong, or weak and thready)
Respirations: Rate and depth of breathing
Skin: Color, temperature, moisture
Level of consciousness: AVPU, and any change
Pupils: Equal, round, reactive to light?
Temperature: With a thermometer if you have one, otherwise by touch
Pain scale: The patient's own rating, 0-10

Building a field impression

Once you've assessed, settle on a working diagnosis. That's your field impression, your best guess at what's wrong, based on:

Mechanism of injury (what happened)
The patient's signs and symptoms
Your exam findings
Their history
The environment

Write it plainly: "Patient is a 45-year-old male hiker who fell 10 feet onto his left leg. Complains of severe pain. Left leg is swollen, deformed, neurovascularly intact distally. Field impression: left tibia/fibula fracture."

How often to reassess

Patients change. Reassess and document your findings at regular intervals:

Stable patient: Reassess every 15 minutes
Unstable patient: Reassess every 5 minutes
Document the trend: improving, stable, or getting worse? One set is a snapshot, two are a trend, and the trend is the truth.
When what you find changes, change your treatment

Vital Signs & Patient Documentation

A full set of vitals

Vitals are objective. They don't lie, and they often change before the patient starts complaining.

Pulse (heart rate):
- Normal adult: 60-100 bpm at rest
- For a quick rate, count for 15 seconds and multiply by 4
- Rate, rhythm (regular or irregular), and quality (strong, or weak and thready)
Respirations (breathing rate):
- Normal adult: 12-20 breaths per minute. Over 20 is fast and worth watching; under 10 or over 30 is a red flag.
- Count for a full 60 seconds for accuracy. It'll feel longer than it is.
- Check depth and effort, not just rate
Skin:
- Color: Pink (normal), pale, mottled, cyanotic (blue)
- Temperature: Warm, cool, cold
- Moisture: Dry, moist, diaphoretic (sweating)
- Capillary refill: press a nail bed and release. Color should return in under 2 seconds.
- Together, these tell you a lot about perfusion and whether they're in shock
Level of consciousness:
- AVPU scale (Alert, Verbal, Pain, Unresponsive)
- Any drop is a warning sign. Step up your treatment.
- Altered mental status that your fix doesn't fully and quickly reverse means evacuate (emergent)
Pupils:
- Equal in size? Reacting to light?
- Unequal pupils can mean a serious brain problem
Temperature:
- Core body temperature, if you have a thermometer
- Otherwise, a general read: warm, cool, or cold
Pain scale:
- The patient rates it from 0 (no pain) to 10 (worst pain imaginable)
- Track how it changes after anything you do for the pain

Documentation: SOAP notes

Good notes let the next rescuer pick up exactly where you left off. Use the SOAP format:

S = Subjective: What the patient tells you
- Chief complaint
- History of present illness
- SAMPLE history
- The patient's own words
O = Objective: What you measure and observe
- Vital signs
- Physical examination findings
- Mechanism of injury
- Observable signs and symptoms
A = Assessment: Your working diagnosis
- Your field impression, based on everything you've gathered
- What do you think is wrong?
P = Plan: Your treatment and evacuation decision
- Treatment started, and how they responded
- Evacuation urgency: emergent (a life threat now or likely soon), urgent (a hospital within hours, not minutes), or non-urgent (they can walk out or finish the day with a plan). Lesson 13 covers these in full.
- How they'll get out (walking, litter, helicopter)
- How you'll monitor them during the evacuation

Case Scenarios

Scenario 1: Unresponsive hiker on a remote trail

Setting: Your group finds a 62-year-old male hiker unresponsive on a mountain trail, 6 miles from the trailhead. He has no obvious external injuries and no ID. You have basic first aid training and a satellite communicator.

Primary survey:

X: Check for massive bleeding. None visible.
A: Check the airway. He's unresponsive, with no sounds of airway obstruction.
B: Is he breathing normally? If he isn't, or he's only gasping, start CPR now (Lesson 3). Don't stop to look for a pulse. If he is, what's the rate, and is it adequate?
C: He's breathing, so check his pulse rate and quality. Look at his skin.
D: AVPU puts him at unresponsive. Check the pupils. Any obvious head trauma?
E: Remove clothing to check for injuries. Any signs of trauma? A medical alert bracelet?

Secondary survey:

Full head-to-toe exam, looking for the cause
If he's carrying his own glucometer, check his blood sugar with it. This could be a diabetic emergency.
Look for signs of head trauma, stroke, seizure, or medication effects

Documentation: Unresponsive male, name unknown, no identifiable mechanism of injury. Pupils equal and reactive. Breathing regular at 14/min. Pulse 88 bpm, regular. Skin warm and dry. No obvious signs of trauma. Field impression: altered mental status, cause unknown (possible stroke, cardiac event, medication effect, hypoglycemia). Emergent evacuation by helicopter, because he has altered mental status with no fix you can make. Use the satellite communicator to call for a SAR response. Nobody saw what happened and he may have fallen, so keep his head and neck in line. If he vomits, you can't stay at his head, or you can't keep his airway open, roll him onto his side as one unit to protect his airway. Monitor him closely while you wait.

Scenario 2: Rock climber with multiple complaints

Setting: A 28-year-old rock climber is rappelling down a cliff when a rope catches, and she falls 8 feet onto a ledge with loose rock. She's conscious and in a lot of pain. Her left wrist hurts, her left knee is swelling, and her left shoulder hurts. She's shaken up but insists she's okay. Your group is 3 hours from the trailhead.

Primary survey:

X: No massive bleeding visible
A: She's alert and talking, so the airway is open (patent)
B: She's speaking in full sentences, and her breathing isn't labored
C: Radial pulse present, regular, adequate rate. Skin is pink, with normal temperature and moisture.
D: Alert and oriented × 3 (knows person, place, time). Pupils equal and reactive.
E: An 8-foot fall can cause significant injuries. Expose her to check for hidden ones.

Secondary survey:

Head-to-toe exam, focused on where it hurts
Left wrist: check for a fracture. NV check beyond the injury. Compare with the right wrist.
Left knee: it's swollen. Check NV status. Can she bear weight?
Left shoulder: it hurts to move. Check NV and range of motion. Dislocation, fracture, or strain?
Vital signs: get a baseline for pain management

Spine check: A fall from height is a spine mechanism, so ask the spine questions before anyone moves. Here she has no neck or back pain, no tingling, and normal hands and feet. Her wrist is a distracting injury, though, so stay conservative. "I'm okay" isn't an exam finding.

Documentation: 28-year-old female, fall 8 feet onto ledge. Alert and oriented. Pain in left wrist (deformity present, NV intact), left knee (swelling, no deformity, able to bear weight), left shoulder (pain with movement, no deformity, NV intact). Vital signs stable. No head injury signs. Field impression: multiple musculoskeletal injuries (left wrist possible fracture; left knee contusion or possible ligament injury; left shoulder strain or possible dislocation). Her vitals are stable, but the distracting wrist means you can't trust her spine exam, so she doesn't walk out. Keep her still and plan an urgent litter evacuation, which usually means calling for a rescue team. Splint the wrist and knee. Monitor neurovascular status.

Knowledge Check

10 questions. Pick an answer to get immediate feedback. Answer order is shuffled each attempt, and your best score is saved on this device.

Lesson Summary

The short version

The XABCDE primary survey finds and treats life threats, deadliest first.

Exsanguinating hemorrhage comes before airway. Stop the bleeding first.

The secondary survey is a systematic head-to-toe exam, done after the life threats are stabilized.

SAMPLE for the history and OPQRST for pain guide the rest of the assessment.

Vital signs record where the patient stands. When they change, adjust treatment.

Serial reassessment, every 5-15 minutes depending on stability, shows which way the patient is heading.

A clear SOAP note lets the next rescuer pick up where you left off.

Assessment drives the plan

What you find sets your treatment priorities and your evacuation decision. Take the time to do the assessment properly, but keep moving. Thorough doesn't mean slow.

Glossary

Primary Survey

The rapid XABCDE assessment that finds and treats life-threatening conditions

Secondary Survey

The full head-to-toe exam you do once the primary survey has stabilized the patient

AVPU

Consciousness scale: Alert, Verbal, Pain, Unresponsive

XABCDE

Primary survey mnemonic: Exsanguinating hemorrhage, Airway, Breathing, Circulation, Disability, Expose

OPQRST

Questions that pin down pain: Onset, Provocation, Quality, Radiation, Severity, Time

SAMPLE

History framework: Signs/Symptoms, Allergies, Medications, Past history, Last intake, Events

DCAP-BTLS

What to look and feel for at each part of the body, head to toe: Deformity, Contusions, Abrasions, Punctures, Burns, Tenderness, Lacerations, Swelling

Tachycardia

A fast heart rate, typically over 100 bpm at rest. It can mean shock, fear, pain, or fever.

Diaphoretic

Sweating, often cold and clammy. A sign of shock, a cardiac event, pain, or fear.

Field Impression

Your working diagnosis, built from everything the assessment turned up. Your treatment plan follows from it.

Serial Assessment

Reassessing at set intervals (every 5-15 min) to track how the patient is changing