ask a doctor
  1. General impression
  2. Mental status
  3. ABCs
  4. Establish priorities

General impression

  • Manage immediate life threats:
    • Check for airway compromises such as airway obstruction. Open their airway.
    • Look for breathing abnormalities such as paradoxical movement a segment of the chest. Provide PPV and O2.
    • Control circulation problems such as major bleeding and open wounds. Direct pressure on open wounds.
  • Chief complaint: "why did you call EMS today?"
  • Trauma or medical.
  • C-spine for trauma patients with a high index of suspicion.

Mental status

  • AVPU
  • A = alert. Can talk to you normally.
  • V = responds to verbal stimulus. Attempts to respond when you talk to him or her.
  • P = responds to painful stimulus.
    • Central stimuli
      • Trapezius pinch: pinch between the neck and shoulder.
      • Supraorbital pressure: press up on the upper ridge of the eye socket.
      • Sternal rub: rub the center of the sternum with knuckles.
      • Armpit pinch: pinch the margin of the armpit.
    • Peripheral stimuli
      • Nail bed pressure.
      • Pinch the thumb-index finger web.
      • Pinch the finger, toe, hand, or foot.
  • U: unresponsive.
  • Nonpurposeful movements
    • Flexion posturing: aka decorticate posturing. Patient arches back and flexes arms inwards. Upper brain stem compression.
    • Extension posturing: aka decerebrate posturing. Patient arches back and extends arms extends arms straight and parallel to the body. Lower brain stem compression.
  • Altered mental status: Not alert, but not completely unresponsive either. Responds to either verbal or painful stimuli.
  • Open and protect the airway and administer oxygen to unresponsive or altered mental status patients.


  • Airway
    • Alert and talking or crying patients have patent airway.
    • Altered mental status or unresponsive patients cannot protect their airway. You need to open their airway.
    • Snoring patients: perform head-tilt chin-lift or jaw thrust, insert airway adjuncts.
    • Gurgling patients: suction.
    • Crowing and stridor: administer oxygen and artificial ventilation.
    • ... read more on airway techniques
  • Breathing
    • Is the patient breathing at all? If not, give two artificial ventilations then check for pulse.
    • If breathing, is the breathing adequate (rate and volume)?
    • Are there breath sounds and chest rise and fall?
    • Look for signs of breathing difficulties such as retractions, use of accessory muscles, nasal flaring, hypoxia and shock signs.
    • Does the pulsox vital sign read above 95%?
    • Treat inadequate breathing / hypoxia with oxygen administration and artificial ventilation.
    • ... read more on breathing
  • Circulation
    • Pulse: Is there a pulse at all? Check the carotid pulse if no radial pulse is felt.
    • No breathing, no pulse = begin CPR: 5 cycles of 30/2 compressions/ventilations followed by AED.
    • If you just witnessed the cardiac arrest, apply AED immediately.
    • Is the pulse rate normal? Is the quality strong and regular?
    • Check for possible major bleeding: are there open wounds? Control any major bleeding (spurting arterial or fast flowing venous blood).
    • Assess perfusion: is the patient in shock? Shock = cool and clammy skin that appears pale, mottled or cyanotic.
    • Check skin:
      • Pale or mottled: onset of shock.
      • Cyanotic: late sign of shock.
      • Red: anaphylactic or vasogenic shock, poisoning, overdose or other medical condition.
      • Yellow: jaundice, liver problems.
      • Cool and clammy: shock.
      • ... read more on skin vital signs

Establish priorities

  • Is the patient in an unstable or stable condition?
    • Unstable: significant MOI, altered mental status, high index of suspicion.
      • Vehicle crash involving death of a passenger, ejection from vehicle, rollover or high speed collision.
      • Vehicle striking pedestrian.
      • Fall of 15 feet or 3 times patient height (For a child it's 10 feed and 2 times height).
      • Trauma resulting in altered mental status.
      • Penetrating injuries to the head, neck, chest or abdomen.
      • Explosions and collisions.
      • Seat-belt injuries.
    • Stable: no significant MOI, alert and orientated, low index of suspicion.
  • For unstable patients, go for the rapid trauma/medical assessment. It's a "load and go" situation. During ongoing assessment, you need to reassess unstable patients every 5 minutes.
  • For stable patients, "sit and play" with a focused trauma/medical assessment. During ongoing assessment, you need to reassess stable patients every 15 minutes.