A Method for primary assessment

by Buck Reed

No matter what a first aider treats in the scope of their clinical career, there is always some degree of assessment involved to determine the correct management procedure. This assessment is divided into two parts, PRIMARY ASSESSMENT, or the assessment which ascertains the overall condition of the casualty, and SECONDARY ASSESSMENT, which determines more detail about the exact physiological conditions and injuries from which the casualty is suffering.

In first aid, the basis of Primary Assessment is DRABC. If the DRABC guidelines are followed, then you will be able to determine with some confidence whether the casualty is reasonably healthy, reasonably unhealth, or somewhere in between. The major questions which are being answered in Primary Assessment are:

  • Does the casualty have a clear airway?
  • Is the casualty breathing? What is the nature of that breathing?
  • Does the casualty have a pulse? What is the nature of that pulse?
To an extent, these questions answer what basic functions you will have to perform for the casualty to allow them to continue living. If they cannot clear their airway, you will have to clear it for them (head tilt, etc.). If they cannot breath, you will have to breath for them (EAR). If their heart isn't pumping, you will have to pump it for them (ECC). If they are unconscious and cannot protect themselves, you will have to protect them (Lateral Position, etc.).

Now let's slowly walk through the steps of Primary Assessment from the time you enter the scene as a first aider. Please not that this article is entitled "A Method for Primary Assessment" not "THE Method for Primary Assessment". This is because there is not an exactly correct way to perform this task. Each first aider will look for slightly different things in a slightly different manner, dependent on their experience and training. The important thing is that the question stated above are answered in the logical progression that the DRABC system provides.

D - Danger

We have all seen scenarios where the first aider walks into a room and is given a situation verbally by an examiner. In real life we take in the same sort of information about a situation, but instead of an examiner giving us the information, we have to ascertain it ourselves. We do this by using our five senses to collect information about the environment we are working in as first aiders. Each first aider has to be acutely aware of their environment, because, like a big jigsaw puzzle, it provides clues towards learning the history of the patient. If the casualty is alone and unconscious, our five senses may be the only things that give us any information about the casualty.

It is very important for the first aider to retain a complete picture of their total surroundings. All too often a first aider will become focused on the casualty and overlook factors in the environment which can either help or hinder the first aid process.

Using Your Senses:

Next time you walk into a room, just stop for a minute and look around. See what information your senses give you about the place you are in. Think about WHY you know where you are and HOW your senses have given you that information. Identify the individual pieces of information that make up the collective picture of your environment.

Sight

What do you see when you walk into a room that hold a casualty? You will obviously see the casualty, and that is where many first aiders make the mistake of stopping. What else could you see that would give you an indication of what has happened? Could it be the open bottle of pills next to the casualty's hand? Could it be the toaster with the frayed chord? Would disarray in the room indicate that a struggle took place? You don't have to stop and look intently at every corner of the room, just make a brief glance around. There is a fine line that is walked between taking too much and too little time to assess a situation.

Hearing

What do you hear that gives you an indication of the casualty's environment? What sounds are inconsistent with the picture that your eyes give you? Is it the hissing of gas? Is it the sparking of electricity? Is the engine of the car still running? Again, what do you hear that can cause a danger?

Smell

Most of your information will be gained from your first two senses, however, don't discount the other three. What smells out of place in the environment? Think about what you have smelled before. Is it gas? Is it chemicals? Is it just a cheap perfume and the casualty has no taste?

Touch

Touch doesn't actually tell you much at the danger stage of DRABC. But again, look for what feels out of place. Is the place unusually hot? Is there a draught coming from somewhere? Is the tea in the cup by the casualty's hand cold? If it is, they may have been there for some time.

Taste

You probably don't have time to run around the room tasting things, but think of what can cause a strange taste in your mouth when you enter a room. This should be an indication that something is amiss.

R - Response

The act of checking for response will give you an indication of the victim's level of consciousness. Consciousness is a variable factor, so a casualty may have a level of consciousness anywhere between fully conscious and fully unconscious. Remember that the Level of Consciousness (LOC) also reflects an impaired consciousness. Are they the same old Bob? Are the casualty's friends giving you quizzical looks when the casualty asks you for half a kilo of Turkey, and the request seems somewhat out of place considering that you are standing on a beach? All these things indicate the level of consciousness. If a casualty is talking or responding at all, ask them a series of simple questions which will indicate whether their consciousness is impaired. Ask them:

  • What is your name?
  • Where are you?
  • What day of the week is it?
There is absolutely no benefit in asking them what the name of their cousin's wife's hairdresser's pet alpaca, because they probably wouldn't remember anyway. Once you have asked the questions, or tried getting any sort of response out of them at all, give them a rough score out of 5 (the NSW Ambulance works on a five level system), using this basic guise:

  • 5 - Fully Conscious - Full Response
  • 4 - Moderately Disoriented - Responding, but abnormally
  • 3 - Very Disoriented/Semi-conscious - Responding only to shouting
  • 2 - Responding only to painful stimulus/No verbal response
  • 1 - Fully Unconscious - No response
Once you have finished assessing response, use a bit of common sense to carry you into your ABC. If the casualty is talking to you, they will have an open airway, breathing and a pulse. There are few people who can talk to you in any other state. If they are unconscious, you will have to assess for yourself their ABC.

If they are unconscious (they have an LOC of 1 or 2) immediately roll them into the lateral position.

A - Airway

If they are unconscious, it will be necessary to check for breathing and circulation. Before breathing can be checked, you have to make sure that the airway is clear, otherwise breathing will not happen correctly anyway, so checking the airway removes the biggest variable in respiratory distress. While the casualty is in the lateral position, open the mouth and check for foreign bodies. If foreign bodies are present, then scoop them out with your fingers. If there is no obstruction present, then gently tilt the head back to allow the lower jaw and tongue to come forward and open the airway.

B - Breathing

With the casualty still in the lateral position, check for breathing by using your senses again. LOOK - for chest expansion. LISTEN - for inspiration and expiration. FEEL - for chest expansion and contraction and breath on the side of your face as you put your cheek about two inchs in front of the casualty's mouth. Using three senses allows a system of checks making the assessment more accurate. Make a note about the type of breathing you see. Is it deep or shallow? Is it easy or laboured? Is it fast or slow?

If breathing is present, retain the casualty in the lateral position. If breathing is absent, commence EAR.

C - Circulation

If a casualty is breathing, then common sense will tell you that there is circulation. If the casualty is not breathing, you will have performed five quick breaths as the initial step of resuscitation. After these breaths check for a pulse. A pulse is exactly that, a pulsation cased by rapid of arterial blood vessels as the heart ejects blood into the circulatory system. The pulse you feel is a sudden increase in pressure moving through the artery. The pulse can only accurately be felt in arteries as the blood pressure in veins as much lower and more consistent.

There are several places in the body to check the pulse. The most commonly used is the pulse of the Carotid Artery. It is located in the neck about one and a half inches on either side of the Adam's Apple. To check this gently press two or three fingers into the notch at the top of the muscle you will feel in the neck (the Sternocleidomastiod if you are curious). You should feel the pulsation of the artery. It is advisable to check the carotid pulse on the same side of the casualty as you are. This will remove the risk of damage to the trachea if any undue or accidental over-pressure is used in looking for the artery.

Another pulse often used for pre resuscitation assessment is the pulse of the Femoral Artery. It is located in the inner thigh immediately next to the groin where the artery passes over the Femur. It is a very accurate pulse to take however, there are some social aspects to this procedure which need to be taken into account when this pulse is used. It is not advisable to take the femoral pulse in a public situation unless it is absolutely necessary. The public can often not understand what you are actually doing. The Femoral Pulse in this primary assessment role should generally be used to double check if you suspect that there is a doubt about the casualty's Carotid Pulse.

Finally, the third most often used pulse is the Radial Pulse. It is found by looking in the notch in the distal (outside) side of the wrist. Again, two or three fingers pressed lightly on the artery should reveal the pulse. Please note, however, that when the body is in shock, as unconscious persons often are, then the body will often shut down the peripheral circulation, including the radial pulse. Therefore, it is not a good artery to determine the need for resuscitation on.

When checking for the presence of the pulse, check for a full 5 seconds before continuing. Make a note about the type of pulse you feel. Is it strong, weak, thready, bounding of otherwise? Is the rhythm consistent? Is it fast or slow? If pulse is absent, commence full CPR.

Conclusion

This has been A method for primary assessment. It was designed to assist first aiders by looking at assessment as a series of logical steps. Once these steps have been carried out a number of times, they will become instinctive. The only way to achieve this is to continually practice these steps so that when you use them, you will be assessing as quickly and efficiently as possible.

Bibliography

The Authorised Manual of the Australian Red Cross
Angus and Robertson, Sydney; 1993

Grant, Harvey and Robert Murray and J. David Bergeron. Emergency Care.
Brady, New Jersy; 1989

Komersaroff, David. Cardio Pulmonary Resuscitation
The Victorian College of General Practice, Melbourne; 1982
Thanks for taking the time to read this. Just another quick note, the Australian Resuscitation Council has instructed that Australian First Aiders use 5 quick breaths as opposed to the American 2 full breaths. Just disreguard this as I don't want to start a flame war over resus techniques.

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