Secondary Assessment Study Guide for the EMT Test

General Information

Although only between 5% and 9% of the questions on the EMT exam concern the secondary assessment, you should still pay close attention to what is covered here. The concepts are some of the most basic and may overlap with other parts of the call.

The secondary assessment is a much more thorough and systematic physical examination of the patient. You may focus on the primary complaint first if it seems serious or move from head to toe on the patient’s body. It is often focused on certain body systems as determined by the chief complaint or injury. The specific circumstances of the emergency will guide your decision. You may have time to do the secondary assessment at the scene, but it will likely take place en route in the ambulance. If the emergency is life threatening, you may not have a chance to complete a secondary assessment at all.

A secondary assessment is a little more involved than a primary assessment. The goal is to identify hidden injuries or causes that may not have been found during the primary assessment. The secondary assessment should involve checking vital signs, oxygen level, and, possibly, breath sounds. A secondary assessment may vary based on the patient’s symptoms and condition. For example, in some cases, you may examine the abdomen for tenderness or swelling. In other cases, you might check the pupils.

Here are some concepts to know:

auscultate—listening to the internal sounds of the body using a stethoscope (breath sounds, heart sounds, bowel sounds)
focused assessment—detailed, targeted examination performed when a patient has a specific complaint or a problem has been identified. This assessment concentrates on the affected body system or area involved
stridor, breath sounds—high-pitched, harsh, crowing sound heard during inhalation indicating significant upper airway obstruction
tidal volume—the amount of air a person inhales or exhales during one normal breath
wheezing—high-pitched, musical sound heard mainly during exhalation, indicating a narrowing or obstruction of the lower airways
crackles—another term for rales
rales—short, popping, crackling sounds heard mainly during inhalation, caused by fluid in the small airways or alveoli
rhonchi—low-pitched, coarse, rumbling breaths sounds caused by mucus or secretions in the larger airways
tachycardia—faster than normal heart rate (>100BPM in adults)
bradycardia—slower than normal heart rate (<60BPM in adults)
blood pressure—the force of blood pushing against the walls of the arteries as the heart pumps (e.g., 120/80)
systolic pressure—pressure when the heart contracts and pushes blood out
diastolic pressure—pressure when the heart relaxes between beats
hypotension—abnormally low blood pressure; systolic <90 mmHg
hypertension—abnormally high blood pressure; systolic >140 mmHg or diastolic >90 mmHg
PERRLA— acronym for pupillary assessment findings; stands for Pupils Equal, Round, and Reactive to Light and Accommodation
subcutaneous emphysema—presence of air or gas trapped under the skin; most commonly in the chest, neck, or face; typically indicating underlying trauma or pneumothorax
paradoxical motion—occurs when part of the chest or abdominal wall moves opposite to normal breathing
guarding—protective tensing of the abdominal muscles in response to pain or injury
pulse oximetry—noninvasive method to measure the oxygen saturation of a patient’s blood (SpO2)
metabolism—process by which the body converts food and nutrients into energy to fuel all bodily functions
carbon dioxide—waste gas produced by the body’s cells during metabolism; transported in the blood to the lungs for exhalation (CO2)
capnography—monitoring of the concentration or partial pressure of carbon dioxide (CO2) in exhaled air over time

Gathering More Information

Gathering additional information during a patient assessment is critical because it allows the EMT to fully understand the patient’s condition, underlying medical history, and the factors contributing to the current problem. By collecting these details from the patient, bystanders, and the scene, along with all assessment findings, the provider can identify patterns, rule out potential complications, and increase their index of suspicion, which is an awareness of all facets of a patient’s condition. All of these factors combined will also help the EMT develop an appropriate treatment plan, which may be adjusted throughout patient contact based on new information.

Physical Assessment

The physical assessment is the systematic examination of a patient’s body to identify signs of injury, illness, or abnormality. It is performed after the primary assessment to gather more detailed information that helps guide patient care.

Respiratory and Cardiac Patients

The primary assessment information is part of the foundation for the more specific, hands-on secondary assessment. Focus on the key and currently active symptoms to guide further evaluation of the respiratory, circulatory, and cardiovascular systems. Observe and assess skin condition, color, temperature, turgor, capillary refill, etc. Monitor vital signs, including blood pressure, respirations, oxygen saturation, pulse, blood sugar, and pain level. Auscultate lungs and heart, paying attention to key signs and symptoms of cardiovascular and respiratory complications.

Here is a concept to know:

procedure for observing and assessing the heart and lungs—When assessing a patient’s heart and lungs, EMTs rely on observation, palpation, and auscultation to quickly identify signs of respiratory or circulatory compromise. Beginning with general observation, the patient’s work of breathing, level of distress, skin color, position (tripod), presence of cyanosis, and any obvious chest wall deformity/trauma should all be taken into account. Next, assess respiratory rate, rhythm, and quality by watching chest rise and fall. Listen for abnormal lung sounds such as wheezing, stridor, or gurgling during breathing. Assess circulation by checking pulse rate, quality, and regularity, and note skin temperature and perfusion.

Chest Injuries

Chest injuries are high-risk emergencies because they can quickly impair a patient’s ability to breathe and circulate blood. Recognizing the signs of trauma to the chest, such as difficulty breathing, abnormal chest movement, or open wounds, is critical for an EMT in order to prevent rapid deterioration. Understanding chest anatomy, common chest injuries, underlying mechanisms, and necessary interventions allows the EMT to provide stabilization and improve patient outcomes.

Anatomy and Physiology of the Chest

Understanding the organs, veins, and arteries encapsulated within the chest wall and rib cage is very important. Knowing where the anatomy is located is key to the identification and treatment of emergency injuries and symptoms. The anterior cavity of the chest wall houses the critical respiratory system and heart, including major organs, vessels, and arteries. The anterior rib cage is connected to the posterior cage, which is connected to the vertebral column.

Here are some concepts to know:

major organs beneath the anterior chest wall—mainly the heart and lungs
impact on underlying organs when there is injury to the chest wall—Impact on the lungs may result in pneumothorax, hemothorax, or pulmonary contusion. Impact on the heart may cause cardiac contusion or cardiac tamponade.
hemithorax—one side of the chest cavity; either the left or right half of the thorax

Open and Closed Chest Injuries

The EMT may encounter closed or open chest injuries.

An open injury involves the chest wall being pierced or penetrated by a bone or other foreign object. Symptoms associated with an open injury can be pain, bleeding, difficulty breathing, and a compromised airway.
The closed chest injury involves contact with blunt force without puncture. Symptoms are pain, compromised airway, difficulty breathing, bruising, detached organs, ruptured aorta, chest wall damage, and/or internal bleeding.

Here are some terms to know:

types of open and closed chest injury—Closed chest injuries may include contusions, rib fractures/flail chest, pulmonary injuries, cardiac contusions, and blast/crush injuries. Open chest injuries may consist of sucking chest wounds, penetrating trauma, or open rib fractures.
hypoxia—insufficient oxygen reaching the body’s tissues
crepitus—bone rubbing against bone
cyanosis—bluish or purplish discoloration of the skin, lips, or nail beds caused by low oxygen levels in the blood
tachypnea—abnormally rapid breathing (>20 breaths per minute in adults)
pleurisy—inflammation of the pleura (thin membranes that line the lungs and chest cavity)

Other Chest Injuries

There are quite a few injury types concerning the chest wall, depending upon the type of trauma involved. The EMT should be prepared to identify and manage all of these, within the scope of practice: fractures, contusions, acute severe chest compression, heart muscle bruising, blunt chest impact, and laceration of great vessels.

Here are some terms to know:

pulmonary contusion—bruise of the lung tissue caused by blunt chest trauma
common types of chest fractures—rib fractures, sternal fractures, collarbone fractures, and flail chest
traumatic asphyxia—sudden, severe compression of the chest, forcing blood from the chest into the veins of the head, neck, and upper chest
myocardial contusion—bruise of the heart’s tissue caused by blunt chest trauma
commotio cordis—sudden cardiac arrest caused by blunt, non-penetrating impact to the chest, usually directly over the heart and occurring at a precise moment in the heart’s electrical cycle

Abdominal Injury Patient Assessment

The patient assessment of abdominal injuries can be multifaceted. Many potential injuries are related to both open and closed trauma, and a thorough and timely assessment is essential.
It is easy for the patient and EMT to get distracted from apparent and sometimes less threatening injuries and fail to assess or report symptoms that may indicate a more severe problem. Therefore, special attention should be given to reassessment in these cases.

Here are some terms and concepts to know:

melena—passage of black, tarry, foul-smelling stools, indicating digested blood in the gastrointestinal (GI) tract
pediatric special population nuances—airway and breathing (smaller airways, larger tongue, diaphragmatic breathing), circulation and cardiovascular (heart rate is faster, BP is lower, less blood volume), metabolism and oxygen demand (higher metabolic rate, fewer glycogen stores), neurological (brain is more sensitive to hypoxia), medication and dosages (weight-based)

Trauma

Trauma is defined as serious physical and/or emotional injury or damage. It can be a physical wound or injury to the body, as from an accident or act of violence. It can also be an emotional response to a terrible event like rape or a natural disaster. Immediately after the event, shock and denial are typical.

Energy and Trauma

Three concepts of energy relate to patient injuries, with special consideration given to the discipline of physics. The content of Newton’s Laws of Motion is fundamental knowledge that plays a key role in the EMT’s proficiency and competency with injured patients during the physical assessment.

Here are some terms to know:

kinetic energy—energy an object has due to its motion
work energy—transfer of energy that occurs when a force is applied to an object
potential energy—stored energy an object has due to its position or condition
Newton’s Laws of Motion—describe how objects move
- The first law is the law of inertia: “An object at rest stays at rest, and an object in motion stays in motion unless acted on by an external force.”
- The second law is “Force equals mass times acceleration.”
- The third law is “For every action, there is an equal and opposite reaction.”
energy impacts on injury—how the type, amount, and transfer of energy during trauma determines the severity and type of injury

Mechanism of Injury Profiles

An injury can occur in many ways. This can be thought of as the how, what, and where of an injury. You need to know all three of these as they pertain to every injury you treat.

Here are some terms to know:

significant and non-significant injury—A significant injury can be described as any trauma that has a high potential to threaten life, causes major disability, or causes rapid deterioration without immediate care (high-energy mechanism of injury; penetrating head, neck, or chest trauma; amputations; or spinal injury). Conversely, a non-significant injury is typically isolated, low energy, and unlikely to threaten life or cause rapid deterioration.
multisystem injury—trauma that involves two or more major body systems (respiratory, cardiovascular, musculoskeletal, nervous)

Blunt Trauma

Blunt trauma is one of the two categories of trauma. This type of trauma is noninvasive and does not break the skin barrier. However, it can often be more serious than it appears on the outside due to the potential for internal bleeding and/or organ involvement.

Here are some terms to know:

coup and contrecoup brain injury—Coup refers to injury at the site of impact, whereas contrecoup refers to injury that occurs on the opposite side of the impact. When a patient strikes their head, the brain hits the inside of the skull at the point where external force is applied; this is coup. After the initial blow, the brain rebounds and strikes the opposite inner surface of the skull; this is contrecoup.
deceleration—sudden decrease in speed or stopping of a moving body
signs—objective findings that can be observed, measured, or detected by the EMT during assessment (vital signs, bleeding)
symptoms—subjective findings that are reported by the patient and cannot be directly measured (nausea, shortness of breath, dizziness)
index of suspicion—awareness and anticipation of possible injuries based on the mechanism of injury, patient presentation, and scene findings

Penetrating Trauma

Penetrating trauma is the second of the two categories of trauma. This type of trauma penetrates at the skin level as well as at various levels below the skin. Both external and internal wounds are evident in penetrating trauma.

Here are some terms to know:

cavitation—temporary or permanent cavity created in tissues when a projectile or force passes through the body
drag—resistance encountered by an object moving through a medium, such as air or tissue
projectiles— objects that are propelled through space by an external force (bullets, shrapnel, debris) and can cause injury by transferring kinetic energy to the body upon impact
trajectory—path a projectile takes from its source to it’s target; can help predict internal path of injury and which organs may be affected
mechanism of injury—method by which trauma occurs (fall, motor vehicle collision, gunshot)

Blast Injuries

Blast injury may occur in four ways: primary, secondary, tertiary, and quaternary. The type of injury differs based on the mechanism of occurrence. It is not uncommon for a patient to have more than one type of blast injury.

Here are some terms to know:

tiers of blast trauma—
- primary—injuries caused directly by the blast overpressure (shock waves) from an explosion
- secondary—injuries caused by flying debris and fragments propelled by the blast
- tertiary—injuries resulting from the victim being thrown by the blast wave or collapsing structures
- quaternary—all other injuries related to the blast that don’t fit into the first three categories
arterial air embolism—life-threatening condition where air bubbles enter the arterial bloodstream, blocking flow to vital organs
pulmonary blast injuries—injury to the lungs caused by the direct overpressure of an explosion (primary blast injury)
tympanic membrane—the eardrum; a thin membrane that separates the outer ear from the middle ear; transmits sound, protects the middle ear from bacteria, debris, and water

Neurological Assessment

A secondary assessment in a neurological emergency should include measuring vital signs and a possible stroke assessment. This assessment is necessary to detect any changes in brain or spinal cord function that may not have been immediately obvious. Components of this assessment include:

level of consciousness determined by AVPU
orientation (person, place, time, and event)
pupil assessment (size, equality, and reactivity to light)
motor function (movement and strength)
sensory function (touch/pain)
speech clarity
facial symmetry

Psychiatric Assessment

The secondary assessment of a psychiatric patient primarily involves close observation, noting any changes in symptoms and behavior. This assessment can help to identify any emotional, behavioral, or cognitive issues that may affect patient care or safety. It also determines any risk to the patient or others, evaluates their mental status, and can guide transport decisions. Components of this assessment may include observation of the patient’s appearance or behavior, mood or affect, thought process, speech, cognition, and orientation, as well as performance of a risk assessment.

Gastrointestinal Assessment

A secondary assessment should include palpation of the abdomen to determine if tenderness is present. This assessment aims to identify internal injuries, bleeding, or other GI problems. EMTs should not only palpate but also inspect the abdomen, looking for any distention, bruising, scars, protrusions, or visible bleeding. Palpation should be performed in an effort to identify if there is any tenderness, rigidity, guarding, or masses. The EMT may also auscultate for bowel sounds.

Diabetes Assessment

A secondary assessment should include a quick check of vital signs and other symptoms. This evaluation can help to identify blood glucose problems, complications, or related medical issues in diabetic patients. EMTs should ensure that a thorough medical history is obtained from the patient. Assess for signs of hypoglycemia (low blood sugar), including confusion, shaking, diaphoresis, and irritability; also assess for signs of hyperglycemia (high blood sugar), such as polyuria, polydipsia, nausea, vomiting, and fruity breath. In addition to vital signs, if possible, blood glucose should be measured with a finger glucose test (normal range is 80–110 mg/dL).

Urological Assessment

This is a focused secondary evaluation of the urinary system, performed after the primary assessment, to identify kidney-, bladder-, urethra-, or genital-related issues. The EMT should gather specific information about urination patterns and blood in the urine and ask about any recent catheter use or surgeries. Assess for associated signs and symptoms, including pain (flank, abdomen, pelvis), urine changes (color, volume, smell), fever, nausea, and vomiting.

Dialysis Assessment

A focused secondary assessment of a dialysis patient revolves around the hemodialysis or peritoneal dialysis they receive. The purpose of this assessment is to identify complications related to dialysis and determine the patient’s baseline versus current status. The EMT should inspect the AV fistula or graft for redness, swelling, bleeding, or signs of infection, taking care to **never measure blood pressure or place an IV on that arm to avoid damaging the shunt or causing clotting. Additionally, the EMT should identify when the patient’s last dialysis treatment was, if they completed their session, and any recent related issues they may be having. Dialysis complications may include fluid overload, electrolyte imbalance, infection, and bleeding. These issues should be identified and managed by the EMT.

Hematological Assessment

Patients with a sickle cell crisis may have a rapid and weak pulse, so measuring vital signs during a secondary assessment is critical. Other hematological conditions may include hemophilia, anemia, clotting disorders, or issues related to blood thinner use. It is essential for the EMT to identify complications related to these issues and treat them appropriately. The EMT must ensure they gather all detailed information, including what hematological condition the patient suffers from (if known), if the patient has had any recent crises or bleeding episodes, what medications they are currently taking and if they have taken them, any recent illnesses, and if have they experienced any blood loss (GI bleeding, nosebleeds, etc.). Perform a physical exam assessing for any signs of poor perfusion (pale, cool, clammy skin, bruising, pain, etc.).

Gynecological Assessment

During the secondary assessment, check for additional injuries if the woman is a victim of sexual assault. Check vital signs, mental status, and abdominal tenderness. The goal of this assessment is to identify the cause of the symptoms, such as abdominal/pelvic pain, abnormal bleeding, pregnancy-related concerns, infection, or trauma. Any complaint of pelvic pain, vaginal bleeding, vaginal discharge, missed or abnormal menstrual period, or pregnancy concerns should be of concern to the EMT. The EMT should gather all information pertaining to these issues and perform a physical assessment of the affected area in order to properly treat the patient.

Pregnancy Assessment

During a secondary assessment, check for fetal movement and maternal vital signs. Be alert for a drop in blood pressure, which could indicate bleeding. This assessment is aimed at identifying complications specific to pregnancy at any stage. Important factors for the EMT to identify include the number of pregnancies the patient has had (gravida), the number of births past 20–24 weeks the patient has had (para), the baby’s estimated due date, if the patient is receiving prenatal care, any known pregnancy complications, if there has been any bleeding, and any information pertaining to contractions. A physical assessment of the abdomen should be performed to include its size, any tenderness, noted contractions (time and frequency), signs of trauma or bleeding, skin condition, and pedal edema.