Primary Assessment¶

Category: Patient Assessment Sources: raw/supplemental/patient-assessment-sequence.md, raw/nremt/psychomotor-skills.md; UCLA EMT Ultimate Study Guide (2026) Last updated: 2026-05-06

Overview¶

The primary assessment identifies and immediately treats life threats. It is conducted on every patient, every time, directly after scene-size-up. The goal is simple: find and fix anything that will kill the patient in the next few minutes. Airway, breathing, circulation — in that order.

Why This Sequence¶

The order airway → breathing → circulation is not a convention or a memory trick. It is ordered by time to death.

Airway obstruction kills in 4–6 minutes. A complete obstruction — foreign body, angioedema, tongue in an unconscious patient, hematoma from facial trauma — stops oxygen delivery entirely. The patient loses consciousness, stops breathing, and arrests. There is no compensation mechanism. The body cannot maintain any function without a patent airway.

Respiratory failure kills in the same window once airway is confirmed open. No chest rise, agonal respirations, or a rate of 4/min means oxygen is not reaching the alveoli regardless of whether the airway is open. The brain begins dying within minutes.

Circulatory failure from hemorrhage takes longer. A patient losing blood activates compensatory mechanisms — tachycardia increases cardiac output, peripheral vasoconstriction shunts blood to vital organs, increased respiratory rate helps maintain oxygenation. A patient can lose 15–30% of their blood volume and still have a normal blood pressure. The body is buying time. You have more of it — not unlimited, but more.

This is why you do not skip ahead to check the pulse before the airway is confirmed. A talking patient is not a patient with a confirmed airway — they are a patient whose airway is currently open. Angioedema, an expanding neck hematoma, or a foreign body lodged above the cords can close that airway in minutes while the patient is still conscious and answering your questions.

The sequence is the sequence because deviating from it kills patients by spending time on lower-priority assessments while a higher-priority problem goes unaddressed.

See also: load-and-go-vs-stay-and-play — airway compromise that cannot be managed on scene is a mandatory load-and-go condition.

Key Points¶

General impression: Form immediately on approach. Age, sex, apparent distress, is anything obviously life-threatening? This informs your urgency before you even speak to the patient.
AVPU scale for level of consciousness (see avpu for full clinical reference):
A — Alert (oriented to person, place, time, event)
V — Responds to Verbal stimuli
P — Responds to Painful stimuli
U — Unresponsive
Airway: Is it patent (open)? Maintainable? Not maintainable?
Trauma: jaw thrust (no head extension); no-trauma: head-tilt/chin-lift
Suction secretions, blood, or vomit if present
Insert OPA (unresponsive, no gag reflex) or NPA (conscious or intact gag) if needed
Breathing: Present? Rate? Depth? Quality?
Normal adult rate: 12–20 breaths/min; child: 15–30; infant: 25–50
Distressed but breathing: apply oxygen via non-rebreather mask at 10–15 LPM
Inadequate or absent breathing: bvm-ventilation immediately
Circulation: Pulse present? Rate and quality? Skin color/temperature/moisture (CTM)? Major bleeding?
Control major bleeding immediately — direct pressure, tourniquet if needed (see bleeding-control-shock)
Poor perfusion (pale, cool, diaphoretic skin; weak rapid pulse) → treat for shock
Transport decision: Priority (load and go) or non-priority?

Assessment Relevance¶

The primary assessment is the most critical component of patient care. Any life threat found here must be addressed before moving on — do not proceed to history or secondary assessment if the airway is not secured or major bleeding is not controlled. Transport decision made here determines whether the rest of the assessment happens on scene or en route.

Priority indicators (load and go): - Poor general impression - Unresponsive or altered LOC - Difficulty breathing - Signs of shock (poor perfusion) - Uncontrolled bleeding - Complicated childbirth - Chest pain with SBP <100 - Severe pain

Procedures¶

Form general impression on approach.
Assess LOC using AVPU.
Open airway using appropriate technique; insert adjunct if needed.
Assess breathing — rate, depth, quality; intervene if inadequate.
Assess circulation — pulse, skin signs, major bleeding.
Control major bleeding immediately if found.
Make transport decision (priority vs non-priority).

What Missing This Costs¶

Each component of the primary assessment has a specific cost when skipped or rushed.

Missing an obstructed airway: The patient deteriorates while you gather history. By the time you recognize the problem, they have had 4+ minutes of hypoxia. Neurological damage may already be occurring. In a patient with vomit in the airway who was initially responsive, a missed airway means arriving at the ED with a patient in respiratory failure that started in your unit.

Missing inadequate breathing: A respiratory rate of 8 with shallow depth looks like "he's breathing" until you count it. Inadequate ventilation — too slow, too shallow, or both — produces CO2 accumulation and hypoxia simultaneously. Supplemental oxygen alone does not correct hypoventilation. Missing this means the patient's CO2 climbs en route, their mental status deteriorates, and you are now managing a full airway emergency in a moving vehicle instead of on scene where you had space and help.

Missing signs of shock in circulation: Pale, cool, diaphoretic skin with a rapid weak pulse is compensated shock. Blood pressure may be normal. Students who look only at the BP number and see 110/70 may declare a non-priority patient who is already in the compensatory phase of hemorrhagic shock. The BP will drop — you just don't know when. Missing early shock signs means delayed transport and delayed access to hemorrhage control or surgical intervention.

Delaying the transport decision: Every minute spent on scene treating a priority patient is a minute farther from definitive care. For surgical emergencies (internal hemorrhage, tension pneumothorax, aortic injury), the only definitive treatment is in an OR. Spending 15 minutes on scene to "stabilize" a patient who needs surgery doesn't stabilize them — it delays them.

NM Protocol Notes¶

NM protocols authorize EMT-B to apply OPA, NPA, and suction as airway adjuncts.
BVM ventilation is within EMT-B scope; two-rescuer technique is preferred when crew is available.
Oxygen administration is authorized; device selection based on patient condition (NRB for distress, NC for mild hypoxia, BVM for inadequate breathing).
Transport priority in San Juan County may be affected by long transport times to regional trauma centers (Farmington, Albuquerque) — early load-and-go decisions are critical.

NREMT Relevance¶

Primary assessment is tested on both Trauma and Medical patient assessment/management skills sheets. Examiners look for: - Verbalizing general impression - Correctly applying AVPU - Demonstrating appropriate airway management - Assessing breathing rate and depth - Assessing circulation including skin signs and pulse quality - Controlling major bleeding when present - Making and verbalizing a transport decision

Critical failure: not recognizing and treating an inadequate airway or absent breathing.

NREMT Differentiators¶