Primary Assessment Study Guide for the EMT Test

Next Steps

Based on your primary assessment, you and your team must decide the next appropriate actions to take. In some instances, your time on the scene should be very brief to allow for rapid transport. In other cases, patient management may need to be a little more extensive on the scene. Management of the patient’s condition may depend on their symptoms and your scope of practice. Medical management may include life-saving interventions, such as airway management and CPR, as well as administration of medications. The exact management varies widely.

Both careful consideration and speed are necessary in making this decision. The following is some information to aid you in planning the next steps in your rescue mission.

Chest Injuries

Complications are possible when there is a breach in the integrity of the chest wall. The heart, lungs, and great vessels are at risk. Common signs and symptoms of complications are absent breath sounds, air and/or blood in the pleural spaces, the pericardial sac fills with fluid, shock, crackling sensation on skin upon palpation, cracked ribs, jugular vein distention, cyanosis, and tracheal deviation. Management of these symptoms and rapid transport is critical to patient survival and outcomes. There is an urgency to transport, especially for surgically indicated management, that may be vital to sustain life.

Here are some concepts and terms to know:

tension, open, simple, spontaneous types of pneumothorax—a pneumothorax is a condition in which air enters the pleural space (area between the lungs and chest wall), causing the lung to partially (simple) or fully collapse (tension). Spontaneous pneumothorax occurs without any underlying lung disease or external cause.
sucking chest wound—open pneumothorax; occurs when a chest-wall wound allows air to move freely in and out of the pleural space
hemothorax—accumulation of blood in the pleural space resulting from trauma or injury
hemopneumothorax—accumulation of blood and air in the pleural space
occlusive dressing—a type of airtight dressing used to seal wounds that communicate with the chest cavity (sucking chest wound); prevents air from entering the pleural space
flutter valve—one-way valve; device used to treat sucking chest wounds by allowing air to escape from the pleural space and preventing it from entering
subcutaneous emphysema—accumulation of air trapped under the skin of the chest, neck, or face that has escaped from the lungs into the surrounding tissue
cardiac tamponade—a life-threatening condition in which fluid, blood, or other substances accumulate in the pericardial sac surrounding the heart, putting pressure on the heart and preventing it from filling properly
pericardium—double-layered protective sac that surrounds the heart
flail chest—serious injury that occurs when two or more adjacent ribs are broken in two or more places
how to identify JVD and tracheal deviation—Jugular vein distension (JVD) and tracheal deviation can be observed during assessment of the patient’s neck, JVD, or will present as large bulging or swollen veins on either side of the patient’s anterior neck and will sometimes be pulsating. Tracheal deviation can be identified when the patient’s trachea appears to be displaced laterally to either side of the midline of the anterior neck.

Emergency Care of Abdominal Injuries

The patient with a closed abdominal injury is often at higher risk due to the inability to identify exact internal tissue and organ impacts. Severe injuries need to be presumed, leading to transport of the patient to the appropriate trauma level hospital with surgical staff. Patients with open, penetrating, or eviscerated injuries also require swift triage and emergency care. There are more visible signs and symptoms of injury, and expertise is needed to triage accordingly, based on acuity. Pay special attention in assessing and treating any exit wounds.

Here are some terms and concepts to know:

mesentery—fold of peritoneum that attaches the intestines to the posterior abdominal wall
prehospital emergency treatment of open and closed abdominal wounds—There is not much treatment for closed abdominal wounds other than assessment, identification, vital signs, and monitoring. Open abdominal wounds can be treated primarily by applying gauze pads.
dos and don’ts of evisceration management—When treating an abdominal evisceration, do not attempt to reinsert the contents back into the abdominal cavity. Cover the abdominal contents with a moist, sterile dressing and wrap them in an airtight cellophane wrapping. Monitor the patient and transport them quickly to definitive care.

Emergency Care for Gastrointestinal Emergencies

Emergency care involves assessing and treating the patient for shock. Vomiting can lead to airway compromise, so patients should be positioned to maintain airway patency. In situations where a patient is vomiting, it’s important to protect yourself from contamination.

Emergency Care of Genitourinary Injuries

The GU system organs are difficult to assess for damage because of their placement in the abdominal cavity, which is behind other organs. There may or may not be obvious signs of bruises or lacerations when a kidney has been impacted. Observe for signs of shock, hematuria, and blood at the opening of the urethra. Examine for blood on underclothes and clothing near the rectum or perineum. Assess and treat for signs of trauma at the lower abdomen, external male genitalia, internal and external female genitalia, pelvic, and perineal areas.

Here is a concept to know:

care of an avulsed penis—put any removed body parts on ice in a plastic container and bring to the hospital, keep the appendage clean and bandage appropriately, monitor the patient’s condition, and transport promptly

Care for Dialysis Emergencies

Patients with end-stage renal disease may need dialysis. Dialysis performs the work of the kidneys when they are not functioning properly. In some cases, a patient may experience side effects from dialysis. EMTs may treat patients who are experiencing side effects and dialysis emergencies. Emergencies may include bleeding at the access site, vomiting, and infection. Emergency care involves assessing and managing the airway, circulation, and breathing.

Gynecological Emergency Care

Be sure to maintain the patient’s privacy as much as possible when you’re treating a patient with a gynecological emergency. If possible, have a female EMT treat the patient. Bleeding may be an issue, so watch for signs of shock and treat accordingly. Injuries to the genitals can be very painful due to the abundance of nerve fibers. Treat lacerations with sterile dressings and do not attempt to remove foreign bodies from the vaginia.

Management of Conditions

Specific gynecological conditions require certain treatment. In some cases, prehospital treatment may be limited. For example, therapy for pelvic inflammatory disease in a prehospital setting involves pain management and monitoring during transport. In a prehospital setting, you may also be called to treat a sexual assault victim. Care involves assessing for injuries, controlling bleeding, and providing supportive care. Careful consideration should be given to the sensitive nature of the incident. Law enforcement should be involved and they should provide information on preserving evidence as it pertains to the victim’s medical care.

Here are some terms to know:

chlamydia—a common sexually transmitted infection caused by bacteria; often affecting the urethra, cervix, rectum, or throat; spread through sexual contact; can either be asymptomatic or cause painful urination, genital discharge, bleeding, and pain
perineum—area of the body located between the anus and genitals
cervix—lower, narrow part of the uterus that connects the uterine cavity to the vagina
ovulation—process in the female reproductive cycle when a mature egg is released from one of the ovaries, making it available for fertilization
pelvic inflammatory disease—infection of a woman’s upper reproductive organs (uterus, fallopian tubes, ovaries) caused by sexually transmitted bacteria

Emergency Delivery

An emergency delivery implies any imminent birth that must occur before reaching a hospital. This event requires immediate action by first responders and EMTs, including quick assessment of the mother’s condition, rapid preparation, and implementation of safe delivery techniques in order to best protect the mother and newborn child. EMTs must focus on maintaining airway, breathing and circulation, controlling major bleeding, and providing supportive care. Not all deliveries go smoothly; EMTs must be ready for immediate intervention and safe, rapid transport in the event of any complications.

Normal Delivery

During a normal delivery, labor is divided into three stages: dilation of the cervix, delivery of the baby, and delivery of the placenta. As an EMT, if you are called during the early stages of labor, your role will be to monitor the patient while transporting them. However, there may be instances where delivery cannot wait until the patient is transported to the hospital. If you have to deliver the baby:

Open your OB kit and position the woman appropriately for delivery and privacy.
Check for crowning, which means the baby’s head is at the vaginal opening.
As the woman pushes the baby out, support the baby’s head as it emerges.
Check to see if the umbilical cord is around the baby’s neck. If so, gently lift it over the baby’s head.
After the head is delivered, the baby will rotate to one side as the shoulders are delivered.
After the shoulders, the rest of the body should emerge.

Normal Post-Delivery

After the baby is born:

Place the infant on the mother’s chest for skin to skin contact.
Dry the baby with a towel and keep the baby warm with a clean, dry blanket.
Clamp the cord after it stops pulsating.
The last stage of labor is delivery of the placenta, which usually occurs on its own with only a little assistance from the EMT. The placenta may be delivered a few minutes after the baby, but if not, do not delay transport to the hospital.

Neonatal Care

The immediate steps of caring for a newborn involve warming and drying the baby. Consider suctioning the baby’s mouth and nose if secretions are present. Assess the baby to determine if resuscitation is needed by checking for breathing, muscle tone, and heart rate. If the baby is not crying, provide stimulation by flicking the soles of the feet. If the baby is still not crying, he needs further intervention. Resuscitation efforts may include manual ventilation and chest compressions.

Delivery Complications

There are various possible delivery complications. One of the most common complications is a breech delivery. Normally, babies are born headfirst. A breech delivery involves a foot or buttocks-first presentation. The baby is at a higher risk of trauma during a breech delivery.

A prolapsed umbilical cord is another possible complication. A prolapsed cord occurs when the umbilical cord protrudes before the baby is born.

Whenever you suspect a delivery complication, it is crucial to call for Advanced Life Support (ALS) backup.

Post-Delivery Complications

The most common post-delivery complication you may deal with is bleeding. Some bleeding is normal during and after delivery. But if the uterus does not start to contract, bleeding can become excessive and lead to life-threatening complications. Use a sterile pad to absorb blood loss, administer oxygen, and transport immediately if a patient experiences post-delivery complications.

Here are some terms to know:

abruptio placenta—placental abruption; a serious obstetric emergency in which the placenta separates prematurely from the uterine wall before delivery; has the potential to compromise oxygen and nutrient delivery to the fetus as well as cause bleeding
birth canal—passage through which the baby travels during delivery; formed by the cervix and vagina
APGAR score—It’s a quick assessment tool used to evaluate a newborn’s overall physical condition immediately after birth. The components include five criteria scored from 0 to 2 for a total score of 0 to 10. Categories include appearance (skin color), pulse, grimace, activity, and respirations. The assessment is performed at 1 minute and 5 minutes following birth.
preeclampsia—pregnancy-related condition characterized by high blood pressure and signs of organ damage; most often occurring after 20 weeks of gestation
lightening—descent of the fetal head into the mother’s pelvis toward the end of pregnancy; baby is in position for birth
meconium—newborns first stool
term gestation—a pregnancy that has reached the stage when the fetus is considered fully developed and capable of surviving outside the womb

Emergency Care for Musculoskeletal Injuries

The general framework for providing emergency care to patients with musculoskeletal injuries includes ensuring the stability of airway, breathing, and circulation (ABC). Use sterile dressings to cover wounds or control bleeding. Assess distal pulses and check motor and sensory function. Splint, treat swelling, and stabilize for transport. Essential guides for use of splinting include: use of an appropriate device for the type of injury and application technique to reduce further injury, such as compression of nerves, blood vessels, or tissue. An example is avoiding the use of traction splints on upper extremities and the evaluation of weather and altitude conditions before using air splints.

Here is a concept to know:

various types of splinting and rationale for their use—Different types of splinting materials and techniques can be used to best immobilize certain types of injuries.
- Rigid splints are hard, non-flexible materials such as board splints, which may be used to stabilize long bones.
- Soft splints, such as SAM or air splints, may be used to conform better to smaller, more isolated injuries.
- Traction splints can be applied to midshaft femur fractures.

Emergency Care for Head Injuries

The patient with head or brain trauma is at risk for a compromised airway. One of the major and initial steps in patient management is to ensure the patient’s airway. Use of the jaw-thrust maneuver is the best technique when a spinal injury is suspected. If the jaw-thrust does not work, a secondary method is to use the head tilt-chin lift maneuver and/or other technologically advanced breathing aids, as they are deemed appropriate and within the EMT scope of practice.

Emergency Care for Spinal Injuries

The patient with spinal trauma is at risk for a compromised airway. A significant initial step with a spinal trauma patient is to ensure the airway. The use of the jaw-thrust maneuver is the preferred technique; however, the head tilt-chin lift may be used as an alternative if the first method is unsuccessful. Other appropriate technologically advanced airway adjuncts that are within the EMT scope of practice may also be employed.

Emergency Care for Face and Neck Injuries

Emergency care of soft tissue injury to the face and neck area requires the use of respiratory and neurological assessment and precautions. Soft tissue in the face/neck area has high risk of bleeding. There are also many bones located in this area. A thorough examination of the entire region, including the removal of clothing, eyeglasses, and hats, is crucial to ensure there are no signs of compound fractures, bleeding, or airway obstruction. Take care to use appropriate first aid techniques to address wounds, impaled objects, and fractures.

Basic eye injury care can include flushing the eye with saline, guarding/covering the eye, and stabilizing any impaled object until medical/surgical care can be provided.
Ear injuries can be stabilized in an emergency, but almost always require a physician to examine and/or treat.
Emergency care should include preparation to handle any fractures of the delicate facial bones.
For dental injuries, use first aid techniques as appropriate and be sure to recover chipped or broken teeth, if possible. Handle these teeth or parts on the crown side only.
In the case of cheek injuries, prehospital care would include stabilizing the injury and addressing bleeding, impalement, or fracture.
For laryngeal injuries, emergency care includes managing wounds and bleeding, while watching for any signs of a compromised airway.

Compartment Syndrome

Compartment syndrome can be categorized as an acute or chronic condition. It is described as pressure in the muscle that has built up abnormally. This abnormal pressure prevents blood flow and oxygenation to nerves and muscle cells. Compartment syndrome caused by a severe injury is considered a medical emergency.

Emergency Care for Drowning/Near Drowning

To assess patients in drowning, near-drowning, and diving emergencies, perform the following steps: scene size-up/MOI, primary assessment, patient history, secondary assessment, and reassessment. In addition to paying attention to the characteristics, it is important to understand the possibilities for other related injuries or underlying causes.

When appropriate, use spinal immobilization during ABC before removing the victim from the water. Provide oxygen and monitor for pneumothorax, decompression illness, and other signs and symptoms relevant to prehospital care. For infants and children, even in a near-drowning episode where there appears to be no harm and the patient is stable, medical examination should be sought.

Emergency Care for Neurological Emergencies

Many neurological conditions, such as a stroke, require treatment in a hospital. Prehospital treatment may be limited to airway management and quick transport to the appropriate facility. In some cases, such as a seizure, medication may be administered to decrease seizure activity.

Here are some terms to know:

seizure—sudden uncontrolled electrical disturbance in the brain that can cause changes in behavior, movement, sensations, or consciousness
CVA—cerebral vascular accident, also known as a stroke; occurs when blood flow to a part of the brain is interrupted or reduced, depriving the brain of oxygen, which results in physical deficits
ALOC—altered level of consciousness; any change in a person’s awareness, alertness, or responsiveness compared to their normal baseline
delirium—sudden change in mental status; characterized by confusion, disorientation, and fluctuating levels of consciousness
ischemia—restriction or reduction in oxygen-rich blood flow to a part of the body, resulting in tissue injury
TIA—transient ischemic attack; occurs when blood flow to part of the brain is temporarily blocked, usually by a small clot; typically a self-correcting occlusion and symptoms resolve within 24 hours
status epilepticus—medical emergency categorized by a seizure that lasts longer than 5 minutes or by repeated seizures without full recovery of consciousness in between

Emergency Care for Psychiatric Emergencies

If no physical concerns are found during your assessment, your best treatment tool (until a mental health professional can see the patient) is the ability to listen. You don’t have to offer advice, but these patients need to be heard. Do not attempt to minimize the patient’s concerns, but provide supportive responses, such as, “I understand that would be upsetting.”

Use of Restraints

There may be some situations in which a patient is a danger to themselves or others that necessitate the use of restraints. Restraints should only be used if there is a potential for injury to EMS, the patient, or bystanders. The restraint protocol varies among EMS agencies. Be sure to keep your safety in mind when using restraints and always follow your agency’s protocols.

Emergency Care for Shock

Caring for a patient with shock symptoms requires a focused assessment to determine the most emergent and life-threatening symptoms to address. Patients who are experiencing shock symptoms may have underlying causes that are related to chronic medical conditions or internal/external bleeding. These may require more urgent care than the shock symptoms.

Here is a concept to know:

common causes of shock—severe bleeding, dehydration, burns, vomiting (hypovolemic), myocardial infarction, heart failure, arrhythmias (cardiogenic), sepsis, anaphylaxis, spinal cord injury (distributive), pulmonary embolism, tension pneumothorax, cardiac tamponade (obstructive)

Diabetic Emergency Care

Diabetic emergency care often involves administering oral glucose. Oral glucose is available in various forms, including liquid, chewable tablets, and gels. The gel is most commonly used because it dissolves most quickly. The only contraindication for administering oral glucose is if the patient is unable to swallow. For a patient with an ALOC, place the gel on a tongue depressor and insert it into the patient’s mouth, positioning it between the gums and cheek. Care may also include treating shock and airway management in patients who are experiencing a diabetic emergency.

Immunologic Emergency Care

Emergency care for immunological emergencies typically focuses on airway support and quick transport. In a severe allergic reaction, when anaphylaxis is present, administration of epinephrine is usually indicated. Epinephrine can decrease airway swelling, reduce lung bronchospasm, improve blood flow, and quickly treat anaphylaxis. Epinephrine for an allergic reaction is usually administered via an auto-injector with a pre-measured dose.

Here are some terms to know:

histamine—chemical messenger produced by certain cells in the body in response to injury, allergens, or immune triggers
allergen—any substance that triggers an immune system response in a person sensitized to it
anaphylaxis—severe, life-threatening allergic reaction that occurs rapidly after exposure to an allergen
urticaria—hives or raised itchy, red welts that occur when histamines are released
leukotrienes—chemical messengers produced by the immune system that play a key role in inflammation and allergic reactions
angioedema—rapid swelling of the deeper layers of skin and tissue in the face, lips, tongue, throat; can cause airway compromise

Emergency Care for Poisoning

Emergency care for poisoning should focus on providing support until the patient gets to the hospital. Antidotes and additional treatment will probably need to be administered in a hospital setting. Emergency care should include airway support and close monitoring.

Marine Animal Injury Care

The best way to treat this injury is to remove the patient from the water and use a stiff object, like a credit card, to scrape the skin where the sting occurred. Stings from urchins and sting rays produce toxins that can be treated with hot water or vinegar soaks. Some patients may experience allergic reactions, and the EMT must be prepared to handle cases where anaphylaxis or shock occurs.

Emergency Care for Open and Closed Injuries

Medical care of open and closed injuries during an emergency requires immediate assessment and triage. Deciding what injuries require immediate attention is key and should be the priority of emergency care. Critical open wounds include abdominal, impaled objects, neck injuries, compound fractures, and bites. Examples of closed wounds include complete or closed fractures.

Here are some terms to know:

RICE—treatment method used to manage musculoskeletal injuries (sprains, strains, minor fractures); stands for rest (limit use of injured area), ice (apply ice to reduce pain and swelling), compression (use elastic bandage or wrap for support and reduced swelling), and elevation (raise injury above level of the heart)
evisceration—internal organs, typically abdominal contents, protrude outside the body through a wound or opening
rabid—an animal infected with the rabies virus
key treatment skills for:
- abdominal injuries—control bleeding, apply bandages/dressings
- impaled objects—immobilize/stabilize in place, do not remove, limit movement
- neck injuries—immobilize/stabilize, apply cervical collar, limit movement
- bites—clean/disinfect, bandage as necessary, control bleeding

Emergency Care for Burns

Nine key steps must be followed when treating an emergency burn patient. You should memorize and use them because they are important for decreasing the risk of further injury. This is only a summarized list, and you should investigate and learn all the relevant details about each step, always following local EMS regulations for treatment, as well.

Use standard precautions to prevent infection.
Remove the source of the burn by moving the patient away from it and/or using a blanket to smother flames on their clothing.
If local protocol allows, cool the burned area by immersing it in cool and sterile water or saline, irrigating it, or applying a cool dressing. Apply a sterile, non-stick dressing.
Monitor oxygen levels throughout treatment and provide high-flow oxygen when needed.
Quickly evaluate the severity of the burn; determine the best covering for it; never use any cream, lotion, or antiseptic; and be careful not to break blisters.
Assess the patient for any other serious injuries, making good use of verbal communication.
Assess for and treat for shock, if warranted.
For large burns, prevent further heat loss and hypothermia by covering the patient with warm blankets.
Transport as soon as possible. Do not delay transport pending the completion of assessments or burn covering if the patient is critical.

Managing the care of burns depends on the classification and degree of the burn. The use of high-flow oxygen, cool water, and dry, sterile bandages or clean sheets is a standard treatment regimen. Dressings and bandages are used to prevent these things: further trauma to the open area, bleeding, and contamination.

Here are some concepts and terms to know:

types of burns:
- **thermal (contact, scald, steam, flame, flash)—injuries to the skin and underlying tissues caused by heat sources
- **chemical—injuries to the skin, eyes, or internal tissues caused by acidic, alkaline, or reactive chemicals
- **inhalation—injuries to the airways and lungs caused by inhaling hot gases, smoke, or toxic chemicals
- electrical—injuries caused by the passage or electric current through the body
- taser—type or electrical burn caused by the discharge of a conducted electrical weapon
- radiation—injuries to the skin and underlying tissue caused by exposure to ionizing radiation
excited delirium—extreme agitation, aggression, hyperactivity, and altered mental status
occlusive dressing—wound dressing that forms tight, airtight seal over a wound to prevent air/fluid from entering or escaping
the first two factors of importance in determining burn severity—the depth of the burn and the total body surface area affected
three questions that are important for burn severity rating—What caused the burn? Where is the burn located on the body? How deep does the burn go?
skin layer involvement with first, second, and third-degree burns—first degree: superficial (epidermis only); second degree: partial (epidermis and part of the dermis); third degree: full thickness (all layers of the skin)
classification of burns for adults, children, and infants—classification of burns for all age groups is done by assessing the rule of nines
rule of nines—method used by EMTs to estimate the total body surface area affected by burns; helps to guide fluid resuscitation and triage and transport decisions; estimates the severity of burns based on body percentages: head and neck are 9% together, each arm is 9% (4.5% front and 4.5% back), each leg is 18% (9% front and 9% back), front of torso is 18%, back of torso is 18%, and perineum is 1%
key factors to identify during respiratory assessment of a burn patient—early signs of airway compromise; burns to the face, mouth, or neck; singed nose/facial hairs; soot around mouth and nose; hoarseness; wheezing; airway swelling

Emergency Care for External Bleeding

External bleeding can be as basic as an abrasion or as complicated as profuse bleeding. You need to know the standard precautions and the steps for care and control of general external bleeding, including bleeding from the ear, nose, and mouth.

Here are some terms and concepts to know:

use of standard precautions—Make sure to always wear gloves, use eye and face protection (goggles, masks) when indicated, change out any contaminated protective items, dispose of contaminated materials properly, wash hands, and decontaminate equipment.
common methods to control external bleeding—Bleeding control starts with direct pressure over a wound with gauze pads. Use of hemostatic agents can be considered. If direct pressure does not stop the bleeding and or the bleeding is arterial, a tourniquet should be applied.
basic techniques to control bleeding—Place a gauze pad directly over the wound and apply pressure. Place a tourniquet above the injury, high and tight on the affected extremity, and rotate the windlass until bleeding stops and distal pulses are absent.

hemostatic agents—These are substances or dressings designed to help stop severe bleeding when direct pressure alone is not adequate. They promote rapid clot formation at the site of injury.

tourniquet—This device is used to control severe, life-threatening bleeding from an extremity when direct pressure is ineffective. It works by compressing blood vessels to stop blood flow.
epistaxis—This is the term for a nosebleed.

Emergency Care for Internal Bleeding

In most cases, internal bleeding requires hospital-based care and surgery. You need to be aware of the symptoms and the appropriate steps in prehospital care, including procedures to prevent further damage from internal bleeding.

Here are some terms and concepts to know:

steps to identify and care for internal bleeding—Assess for physical signs (bruising, pain, guarding, distension); pale, cool, and clammy skin; a rapid heart rate; low blood pressure; and vomiting or defecating blood. Care includes support, monitoring, and prompt transport.
pelvic binder—medical device used to stabilize pelvic fractures and control internal bleeding in trauma patients
open book pelvic fracture—severe pelvic injury where the pelvic ring is disrupted and opens outward

Emergency Care for Trauma

Trauma can be physical, emotional, or, commonly, both. In either case, it is a serious issue and may involve multiple components in an emergency. The type of trauma termed multisystem trauma indicates injuries where more than one body system is impacted. When multiple systems are impacted/injured, the patient may be in a life-threatening situation. These impacts create a high acuity level and may require extensive care from an interdisciplinary medical team.

Here are some terms to know:

golden principles—ensure scene safety, determine mechanism of injury, conduct a rapid assessment (ABC), control any life-threatening bleeding, maintain spinal precautions, provide oxygen support, prevent and treat for shock, do a rapid trauma assessment, and give rapid transport
golden hour/period—critical concept in trauma care that refers to the first 60 minutes after a traumatic injury, during which prompt medical treatment and transport increase chances of survival