02 Patient Assessment
A practical guide to EMT patient assessment, emphasizing rapid recognition of life threats, structured history-taking, prioritization, and reassessment.
Assessment Priorities and Scene Safety
Patient assessment is a structured process for identifying immediate life threats, determining the chief complaint and history, guiding treatment, and detecting changes over time. The correct sequence is flexible when a major threat is found: treat the life threat as soon as it is identified.
A useful progression is:
Ensure scene size-up and safety.
Form a .
Perform the primary assessment.
Obtain vital signs and a focused history.
Perform a focused or secondary examination.
Reassess repeatedly and provide ongoing care.
Always work within training, equipment, local protocols, and medical direction. A detailed history or routine measurement must not delay treatment of an immediate threat.
Primary Assessment
The primary assessment rapidly identifies conditions that can cause death. Begin with the and continue through responsiveness, , breathing, circulation, and .
and mental status
Observe the patient while approaching. Note apparent age, position, activity, skin color and condition, work of breathing, ability to speak, visible bleeding or injury, and overall distress. A patient who is pale, diaphoretic, upright, and able to speak only a few words has a concerning .
Assess responsiveness using and determine whether the patient is oriented. Being awake does not guarantee normal mental status. New confusion or disorientation may reflect hypoxia, hypoglycemia, stroke, intoxication, shock, or another serious problem. When appropriate, ask family or bystanders what is normal for the patient.
and breathing
Determine whether the is open and maintainable. Snoring may indicate partial obstruction by the tongue or soft tissue. Gurgling may indicate fluid, blood, or vomitus. Stridor may indicate upper- narrowing, while hoarseness or a voice change may suggest irritation or swelling. Silence in an unresponsive patient does not prove that the is open.
Open an obstructed , remove visible obstructions when possible, and suction when indicated. Use a head-tilt and chin-lift when spinal injury is not suspected. When spinal injury is suspected, use a jaw-thrust while maintaining manual spinal stabilization, according to training and protocol.
After establishing an open , determine whether breathing is present and adequate. Evaluate rate, rhythm, depth, effort, chest rise, skin condition, ability to speak, and signs of fatigue or altered mental status. Do not judge breathing by rate alone. Shallow respirations with poor chest rise and increasing confusion indicate even if the rate appears normal.
If breathing is inadequate, provide ventilatory support according to training, equipment, and local protocol. Supplemental oxygen may be appropriate for some patients, but it does not replace ventilation when the patient cannot move enough air.
Circulation and bleeding
Assess pulse, skin color, temperature, moisture, perfusion, and severe external bleeding. Pale, cool, diaphoretic skin, weakness, anxiety, confusion, and deteriorating responsiveness may indicate shock. Control life-threatening external bleeding immediately with direct pressure and other measures allowed by protocol. In some emergencies, massive bleeding or cardiac arrest changes the usual sequence of priorities.
Takeaway
Find and treat the most immediate life threat first. and breathing problems, uncontrolled bleeding, and signs of poor perfusion take priority over a detailed history or nonessential measurements.
Vital Signs and Clinical Context
Vital signs provide objective information about severity and change over time, but no single value should be interpreted in isolation.
Respirations: Record rate, rhythm, depth, effort, chest movement, ability to speak, and other signs of adequate or .
Pulse: Assess rate, rhythm, and strength, then compare the finding with the patient’s appearance and other signs.
Blood pressure: Use it as one indicator of perfusion. A single normal reading does not rule out serious illness or injury because a patient may compensate for shock initially.
Skin: Assess color, temperature, and moisture. Pale, cool, and diaphoretic skin may suggest shock or another serious condition, while flushed, hot, or dry skin may occur in heat illness or fever. Skin findings are nonspecific.
Pupils and neurologic findings: When relevant, assess pupil size, equality, and reaction to light. Also note speech, movement, sensation, coordination, and changes from baseline.
Pulse oximetry: Use it as an aid rather than a substitute for evaluating work of breathing, mental status, skin findings, and overall appearance. Readings can be affected by poor circulation, motion, nail products, carbon monoxide exposure, or equipment limitations.
Interpret measurements as a trend and in the context of the complete clinical picture. Repeat them at appropriate intervals and after significant interventions or changes in condition.
Focused History and Secondary Assessment
Once immediate threats have been addressed, direct the history and examination toward the chief complaint or mechanism of injury.
Focused history
Use to identify symptoms, allergies, medications, relevant medical history, recent intake when relevant, and events leading to the illness or injury. For pain or other symptoms, use to clarify onset, triggers, quality, location or radiation, severity, and changes over time.
A structured history should support—not delay—life-saving care. Ask concise questions and adapt them to the patient’s ability to communicate. Consider information from family members or bystanders when the patient cannot provide a reliable history.
Focused examination
For medical complaints, examine the body systems related to the symptoms and look for findings that change urgency or treatment. For trauma, inspect and palpate systematically for deformity, tenderness, instability, crepitus, swelling, burns, wounds, and abnormal movement. Remain alert for hidden injuries and reassess areas that become painful or abnormal.
Use the primary assessment and ongoing findings to decide whether the patient is high priority. High-priority indicators include failure to maintain the , , shock or poor perfusion, altered mental status, severe chest pain or respiratory distress, uncontrolled bleeding, serious mechanism of injury, or rapid worsening.
A high-priority patient generally needs immediate treatment of life threats, rapid notification or additional resources, and consideration of prompt transport. Do not delay transport for nonessential assessment steps.
Takeaway
A focused assessment is purposeful: gather the information that explains the complaint, identifies hidden threats, and changes treatment or transport decisions.
and Clinical Reasoning
determines whether care is working and whether the patient is improving, worsening, or unchanged. It is more than repeating the first examination mechanically.
A practical sequence is:
Recheck the and level of consciousness.
Reassess patency.
Reassess breathing, including adequacy and work of breathing.
Reassess circulation, major bleeding, skin condition, and perfusion.
Repeat vital signs at appropriate intervals.
Evaluate the response to treatment.
Identify new or worsening symptoms.
Communicate important changes and update the destination or transport plan as required.
Reassess unstable patients more frequently than stable patients. Repeat the assessment after an intervention and whenever the patient reports a change or appears different.
Applying the sequence to decisions
For exam-style prioritization, ask:
Is the scene safe?
What is the most immediate life threat?
Is the patent and is breathing adequate?
Is there uncontrolled bleeding or shock?
What intervention must occur before more information is obtained?
Is the patient stable enough for a detailed assessment?
Did the patient improve after treatment?
Choose the action that addresses the immediate life threat and remains within EMT scope. For example, severe respiratory distress calls for and breathing assessment before a detailed history, while rapidly pooling blood from a wound calls for immediate hemorrhage control. A patient who reports less pain but becomes pale and weak still requires a repeat primary assessment and vital signs.
Takeaway
Patient assessment is a continuous cycle: recognize threats, treat them, measure the response, and change the plan when the patient’s condition changes.