so when I have a student ask me what exactly is the primary assessment this is what it's broken down to we're going to go in this video right now through all these in great detail you're going to walk away knowing exactly what you need to know for primary assessment for class come on with me now primary assessment to identify and begin treatment of eminent life threats so what is EMS what do we do as EMTs and paramedics Advanced EMTs First Responders what do we do our whole goal goal number one is to assess and find life threats out as early as possible that is why in class we go over so much learning the signs and symptoms and learning what all these emerges are about cuz we can't treat something so we figure out and find what it is so the primary assessment happens we already sized the scene up we see the scene is safe we see we have this patient right here let's just say we don't need any additional resources the patient's a medical patient we're here in front of the patient one patient right it's you and your EMC partner for example and now we start our assessment of then the primary assessment is looking for life threats so the general impression in one word the general impression is we look at the patient we look at the scene what do we see the level of Consciousness how alert and oriented and awake is your patient what do they look like when we approach we're going to assess the airway so Airway breathing circulation okay ABC see now hang on folks when is circulation interrupt Airway and go beforehand you may have heard of cab all this hoopla about is it ABC or C or or cab God whoa this is so simple so easy it's ABC unless you walk up to your patient and see they have a major bleed like a external major bleed like arterial bleed and they're spurting blood then we say well let's do circulation first and stop the bleeding that sounds fair that's all it is simple as that okay now performing the rapid exam we'll go through and then determine the priority for the patient care and transport well all that is is how sick or how injured the patient is are we Wasing Sirens are we not are we going to Community Hospital a Trauma Center a stroke center Heart Center cath lab wherever we going right so this is the start of it this is your primary assessments notice a lot of it is about life threats so we walk up to the patient what are some pearls I can give you about the general impression here they are so we defined it as a visual assessment of the patient focusing on quick identification of threads presence so for example look at this patient's age gender race the stress level appearance patient positioning so picture patient a let's say we have a 74-year-old female sitting upright on the couch who's actively throwing up patient B we have a 22-year-old female who is in the tripod position and is can only speak in one or two words percent two different patients two different General Impressions right and the only way mention those two cases is what's the scene environment look like where are they located are they at home are they not right so that we we look at what at the scene and what is the patient doing as we approach right one's vomiting one can't breathe right for as an example okay we want to avoid this standing over the patient like this this what we do and you may I might go off screen we want to kneel down we want to get to the patient's level okay we don't want to stand over the patient okay the only time when we H we don't want to do go doing all that is in psychiatric patients what I mean is with psychiatric patients or patients who are violent or altered we might not want to get that close and nail down to them but we don't want to say we never want stand over the patient on word authority with anybody want to make him feel comfortable but a psychiatric patient or violent patient just might want to keep a little bit of distance this is a little bit of distance okay so me to think about now refer the patient by their name so we're all humans here nothing special about us we're just here to help we have some skills and some training to help this person and we happen to call us for now one hey my name is Evan I'm a paramedic with the ambulance what's your name and what's going on today simple as that okay introduce yourself and determine as you've complaint there it is okay now the patient's response or a lack of response can give you an Insight onto their level of Consciousness and how their Airway breathing and circulation is doing okay so we're going to determine if the patient is stable potentially unstable or unstable to help guide assessment and treatment if we notice life threats during the general impression treat them immediately for example what do we talk about folks when do we do the circulation step first before Airway only when we see uncontrolled major bleeding right before eyes so it say walk up to a 50-year-old man in the kitchen and he's screaming ah and he's bleeding arterial breed like crazy from both arms arms we don't go sir open your mouth let me see your Airway would that make sense no that make no sense you treat the major bleeding right okay what do we mean by assess a level of Consciousness well here's what we mean it tells us to the extent which information the patient gives you is reliable and can determine if the patient is able to follow your directions there's a lot of medications and there's a lot of procedures inside of EMS the patient has to be alert and oriented or they have to obey commands in order to deliver for example CPAP I can't give somebody CPAP if they're not alert if they're not awake if they can't obey commands they're not it's not going to work right so we we look at this it's an afo scale so it's a v p u so a is their awaken alert okay essentially your patient is alert they're awake they're oriented like me right now like you right now we're we're guess we're kind of normal right okay a little bit we're EMS but that's all right but we're alert and oriented that's fair okay V is verbal okay V is veral what that means is they only respond to when you call their name or their eyes open their eyes open Mary yeah right p is a painful stimulus so what so people talk about pitching the ear a sternal rub right uh touching the bottom of the foot whatever it may be but some sort of painful stimulus it makes them either open their eyes or now they wake up for a minute right if it wasn't for that painful response they weren't responding to you at all by name so basically it's a wakeen alert they respond to their name when we say their name but then they go back to not being really painful stimulus is the only that gets them to even move or withdraw from anything unresponsive is you they don't respond to their name they're definitely not awak and alert and they're not moving or talking to you at all they're unresponsive so obviously someone who is for example let's say they were a patient who is in a opiate overdose and they're not breathing they're going to be unresponsive but if theming Cardiac Arrest they're going to be unresponsive okay make sense if someone has let's say for example um they were involved in a a a motor vehicle accidents and they were strained but they're able to talk to you in full senses and they know they're aware of their surroundings where they are what happened they're awakeing alert right okay usually it's the it's the patients at the further extremes we're going to see and these we do see them but it's it can be more rare right usually if they're in V or P they're trending towards you okay and just know for some patients V could be their Baseline with like severe Dementia or something like that so find their Baseline just want to give you a pro now that was how alert they are what about orientation so orientation is broken down into four things you may have heard of a term called alert and oriented times four folks you can be alert but not oriented okay so for example a patient who has dementia they may be wide awake and alert but they're not oriented right so alert oriented is how B essentially the most simplest way to say it to you how awake are you right what orientation is what is your understanding of yourself and the world around you essentially are you confused or not is basically what it breaks down to okay so person is remembering their name they know who they are place is identifying their current location correctly time is identifying the correct year month or day of the week event is describing what happened to them and their Chief complaint so what this means if they answer all correctly they're alert oriented times four if they answer incorrectly there may be altered mental status that's a key termal buzz word altered mental status okay so someone has to be alarn oriented for example to get CPAP to be able to obey commands right think about it folks the patient with dementia they might know their name but they don't know where they are they don't know what year it is and the events and they're kind of wishy-washy maybe they're a o * 2 is right Mak sense okay hope you're enjoying our lesson today if you don't know in the first link in the description is my Video Vault training What You Get There is access to over 480 videos and over 2,000 National Registry practice test questions and we cover every level EMR EMT Advanced EMT paramedic this is where I send all my students whether you're getting ready for school you're in school right now or you're getting ready for National reg exams you'll see this video right here go watch that video and I will tell you all about it let's go back to the lesson so as a new EMS provider what are some of the clear-cut things we walk on scene before we even get into our real meat and potatoes of the primary assessment what can't we miss well here's some things we can't miss I I wrote down a little chart for you these are conditions that cause sudden death Cardiac Arrest which means the heart completely stops you are you are clinically at this point deceased your heart is not pumping anymore blood and oxygen to all your organs Cardiac Arrest respiratory arrest is you stop your heart will they still work some be pumping blood so you still might have a blood pressure okay but you're not breathing anymore refat so Cardiac Arrest you're going to actively do CPR to that patient respiratory arrest I think about that in which can happen unfortunately in very sick Pediatrics but I also think about respiratory arrest when I think about opiate overdose again we see it so much shock what's that shock is here's a term for you hypo perfusion hypo profusion what this means hypo profusion is if I if I say the word perused my body is being profused that means my all my tissues and my organs are getting plenty of blood and oxygen right if I am a hypo low on my profusion hypo perused or what happens by definition shock is your tissues and organs are not getting enough blood and oxygen and there's many ways that's a whole other video but there's many ways that can occur from your heart from your blood flow from your lungs right from trauma from infection from oric reactions from bleeding out from severe dehydration name a few but either way at the end of the day your blood pressure is so low that you can't maintain your blood and oxy to your organs that's shock severe bleeding exactly how it sounds whether it's external we see it or we at sneaky trauma and there's internal bleeding we can't see so we left to learn about that Airway obstruction is quite simply again you think of a choking victim or a child put you know uh put some in your mouth they shouldn't right stuff like that fully blocked Airway okay Airway obstructions right these are some of the things we talk about with sudden death suddenly right so we want to recognize these early as possible okay and again patient has severe external bleeding again you see over here treat cab also some people in class call it X ABC right patient is in Cardiac Arrest assess all three at the same time to not delay compressions if something's in Cardiac Arrest what's the first thing we do get on that chest CPR and then obviously you're an EMT you have an ad with you get that a going so essentially it's CPR get the a way established get the a going all at the same time you have enough hands right okay so let's go to the next step here so Airway is pretty simple when we break it down the airway is simply this we first look at the airway is it patent let may be a new word for you what that means is is the airway clear is the airway open is it clear of obstructions right can the P can the patient literally breathe in and out right is the air can air move through the inway simply that's what it is so this is where people get confused right so if the patient and folks this is so so simple please hear me on this folks if the patient is talking or a baby is has a strong cry well we know the airway is patent we know it's open and we know it's clear because they're talking right if if someone's talking in full sentences their Airway is open and clear but because if it wasn't and it was fully obstructed you can't talk and you can't cry right now if we're in the middle we'll talk about in a second you might hear some weird noises like Strider which is a partially obstructed Airway Strider you can hear that across the room it's an upper Airway sound and means you're partially obstructed but not fully fully you won't be able to hear anything and again if they're partially obstructed get the patient to cough okay to try and clear it again we talking about here patient is awake but not talking or crying they may have a complete air obstruction or restro distress failure stay tuned for that I'm going to break down distress failure in this video right here because I love you all and we're going to crush it with school and exams and everything now we're talking about managing Airway threats let's go through that real quick so first position the airway head to Chin lift position medical jaw do maneuver trauma to help open it we need suction secretions from the airway way removing any obvious foreign body from the patient's mouth and if we need to abdominal or chest thrust to remove the foreign body in the airway can I give you a pearl that I tell my students let's go to the next slide real quick okay and I I'll let you just look at this as I share this demonic with you okay when we think about Airway if you remember this quick tip for the rest of your career you're going to be gold and the tip is this open clear keep ventilate open clear keep ventilate open means I'm going to open the airway clear means I make sure the airway is clear or I suction if I need to keep is placement of a Airway adjunct to keep the airway open okay an Opa and NPA ventilate is simply well now we got to breathe the patient we got to ventilate that's a BVM a BVM that's going to ventilate the patient okay good so I talking about this earlier what are signs of Airway obstruction well noisy breathing Strider snoring gurgling shallow or absent breathing or any obvious vomiting blood trauma coming from the airway you got to get flexing that out okay more on managing the airway but again remember my my tips open clear keep ventilate you'll be Golder I am so proud to announce that the paramid coach is now capsi your credited and we're now recertifying your National Rue certification so if you're an EMF provider out there and you need c and you need hours you need a recertify we now offer 100% online with me as your paramedic coach you can do it right here on our website recertification hours you're going to see a link down this description it will say recertify your ENT something along those lines and it will take you to a website looks like this watch the video here I explain the whole reification process you're going to love it and I can't wait for you to see it and back to the video so the breathing step of course we're going to look at the patient's chest we're going to listen to a quick listen to lung sounds we're going to look for equal rise and fall right we're going to look for the position of the patient again they tripod they laying down somebody can't breathe just you want to sit them upright so they can breathe better laying someone down they can't breathe isn't good want to set them up now this is what we're talking about life threats we got to watch for I want to explain you the difference between rid distress repid failure and repor rest it's a big difference so restor stress is difficulty breathing causing increased work of breathing it typically has an increased respitory effort rates I'm going to show you an amazing graph here in a moment so hang with me please rest failure blood is inadequately oxygenated or ventilation is poor so it is unable to meet the oxygen demand of the body in restory Failure is we are unable to breathe in enough oxygen to peruse the body in rest it was it is a result of restory failure if left untreated so we go to stress failure or rest before this would be like mild symptoms coming on then dist stress failure or rest that's where we're going under here is cardiac arrest deceased okay now here's my chart so I've made a chart here between distress and breathing so we can see on the distress side what we have agitation restlessness anxiety we have an increased reatory rate wheezing or Strider we have increased heart rate tardia accessory muscle use in they're on the neck of the clavicle retractions pulling between the ribs nasal flaring seesaw breathing head bobbing these last three nasal flaring seesaw breathing head bombing more common in children and infants bad sign them okay we want to keep them out of failure and help them get back back and out of the stress if they end up in Failure here's what happens I want you to think about this a patient is tripoding like this and they having a hard time breathing when they end up like this during respiratory failure now the body has physically gave up mentally they're trying to fight but physically the body is starting to decompensate and it will show in the patient presentation vitals right here they become lethargic and difficult to wake up okay they have a fast respiratory rate and it might even be regular and it might get to the point where It Gos really really slow so notice over here everything starts to go up but over here everything starts to go down okay braic cardia we were fast here with the heart rate now we're slow we were fast here now we're getting more slow and irregular okay chest and chest rise and fall is inadequate we have poor movement of our diaphragm low muscle tone and our respiratory rate and effort has decreased this patient is about to go into respiratory arrest it's hanging in a cardiac arrest this patient is probably going to be not able to obey commands this one we hope still can they should be able to they may not could be on the border but they should be able to this one here is probably going to be on our AF poo heading down towards the U you make make sense okay very good very good now what are some signs here we can look at accessory muscle use cyanosis retractions nasal flaring Strider okay signs Assurance of breath or low spo2 levels an oxygen level under 94% okay chest injuries tracheal deviation and trachea has moved or bulging neck veins jvd okay we see this on exam it may indicate life threats in the breathing area now let's move on now under circulation this video I want to touch on controlling external bleeding and the differences yes under circulation we talk about looking at skin color condition but in this video here specifically I want to focus on the bleeding under circulation we because we have to understand this it's the most important so we're going to assess control external bleeding it's the first priority when scanning did I say that yes the first priority when scanning the patient look for external bleed because if you're in a scenario you're out the field and you miss a major bleed that patient is bleeding out and you're missing it so we got to expose patient and look for it under a general impression phase hey is there any major bleeding if there is external bleeding present start with it immediately control the external bleeding because blood loss can be quick especially if it is arterial so arterial bleeding is the worst kind of bleeding then it's Venus then capillary so arterial is bright red and spurting Venus is dark red it's aady stream capillary is dark red and oozing capillary is like a cut everyone's probably gone I'm doubtful that people have gotten arterial bleeds watching this video maybe somebody has at some point but it's spurting out we don't want that okay so we want to expose our patients especially if they're unresponsive we can have sneaky trauma so expose your patient and look for major bleeding first we got to do that now how do we how do we actually manage an external bleed well here's the deal folks direct pressure of course we have supplies in the ambulance to help banage that wound now remember we can only use a tourit on extremity extremities so we do have some tools in the ambulance like quick clot okay right that can help that that bleed that maybe it's not in the extremity right try to actually solve faster right yes exactly so provide direct pressure with a glove hand then place a sterile bandage over the wound while contining to apply pressure again for example like quick clot you can put that in there as well that will help with the bleeding now this will commonly be enough to the the clotting process think of all the blades you had in your life or Cuts usually that does a trick but if it's uncontrolled bleeding like arterial or maybe even a bad Venus cut okay but more really arterial okay in case of O control bleeding apply a tourniquet apply a tourniquet okay so that is our bleeding step here with circulation now the final two pieces here I want to touch on this video disability exposure and then I want to make a brief statement about the rapid exam when we perform disability essentially what we're looking for here is to assess their level of Consciousness maybe do a stroke exam do a GCS go Gooma scale okay we have videos on that assess pupil size and reactivity assess speech assess motor function and under exposure again I going to say it again expose your patient expose your patient especially if you're being tested on in school you got to expose your patient but even out in the field folks from me to you there have been times in the field where I have uncovered things and I was like wow did not know that was there I exposed the patient especially we're talking about the patient's posterior the patient's back okay we can forget that don't forget to expose the back what if we have a trauma to the spine or bleeding back here because both P sit like this right but don't forget about back here okay again behind the legs behind the back don't forget about this okay now an example it may reveal hidden injuries especially in cases of bullet wounds head injuries stab wounds or large hematomas assault victims that's what I'm talking about sneaky trauma don't miss out on that now our final Pearl here for this video is performing a rapid physical exam the rapid physical exam is a quick head totoe exam or scanning for Decap btls deformities contusions abrasions penetration or punctures btls Burns tenderness lacerations and swelling and we're going to scan the whole patient for that okay that is what we're looking for when we're doing the exam now it's a quick exam we're going to be more detailed in a secondary assessment later on different video in this video we're saying is a rapid physical exam under a primary assessment should be about a minute minute and a half no more so no more 90 seconds to quick scan head toe make sure we didn't miss anything and we're moving on and we're going to move on to making our transport decision are we going light and Sirens are we going no light and Sirens are we going to a community hospital are we going to a Trauma Center are we flying the patient out what what is do we need to intercept with a paramedic so here are some things what you can consider high priority patients unresponsive severe chest pain difficulty breathing uncontrolled bleeding alter mental status shock severe pain anywhere in the body complicated child birth not mentioned here there's a million things for example like Strokes heart attack etc etc but this is a little list you can keep in your mind and go hm maybe I should get a medic on this or H maybe we should upgrade this call okay just some pros I want to give to you and man I hope you enjoyed this video I'll see you you on the next one I'll see you there by clicking in the first link in the description you get lifetime access to my Video Vault program The Video Vault includes over 480 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