NREMT Patient Assessment & Decision-Making 2 — Questions and Answers

Question 1: During the primary assessment, an EMT identifies a patient's life threats in which order?

Circulation, Airway, Breathing
Airway, Breathing, Circulation (ABC) (Correct answer)
Disability, Airway, Circulation
Exposure, Airway, Breathing

Correct answer: Airway, Breathing, Circulation (ABC)

The primary assessment follows the ABC sequence: Airway first (open and patent?), then Breathing (adequate?), then Circulation (adequate perfusion, hemorrhage control). This order reflects physiological priorities.

The primary assessment is the EMT's most critical early intervention — a rapid, systematic evaluation designed to identify and immediately correct life-threatening problems. The ABC framework (Airway, Breathing, Circulation) provides a physiologically logical sequence based on the time it takes for each problem to cause death. Airway obstruction is addressed first because a blocked airway causes death in minutes. An inadequate airway must be opened immediately using head-tilt chin-lift, jaw thrust, or airway adjuncts. Breathing is assessed next — the airway may be open but breathing inadequate. Look for chest rise, listen for air movement, and assess respiratory rate and quality. Assist ventilations if breathing is absent or insufficient. Circulation is evaluated third — check pulse, assess skin color and temperature, and identify major hemorrhage that requires immediate control. In trauma, some systems modify this to 'CABC' (Circulation/hemorrhage control first) for massive external bleeding, as exsanguination can occur before respiratory failure in penetrating trauma. However, for standard NREMT purposes, the ABC sequence is the established framework. After completing the primary assessment, form a general impression, determine priority, and decide on transport urgency before moving to the secondary assessment.

Question 2: The Glasgow Coma Scale (GCS) is used to assess which three components?

Pulse, respirations, blood pressure
Eye opening, verbal response, motor response (Correct answer)
Orientation, memory, cognition
Pupil response, limb strength, reflexes

Correct answer: Eye opening, verbal response, motor response

The GCS measures eye opening (1-4 points), verbal response (1-5 points), and motor response (1-6 points). Total scores range from 3 (no response) to 15 (fully alert).

The Glasgow Coma Scale is an objective, reproducible neurological assessment tool that quantifies a patient's level of consciousness across three dimensions. Eye opening is scored 1-4: 1 = no eye opening, 2 = opens to painful stimulation, 3 = opens to voice, 4 = spontaneous eye opening. Verbal response is scored 1-5: 1 = no sound, 2 = incomprehensible sounds, 3 = inappropriate words, 4 = confused conversation, 5 = oriented and appropriate. Motor response is scored 1-6: 1 = no movement, 2 = extension to pain (decerebrate posturing), 3 = flexion to pain (decorticate posturing), 4 = withdrawal from pain, 5 = localizes pain, 6 = obeys commands. The maximum GCS score is 15 (4+5+6), indicating a fully alert, oriented patient. The minimum is 3 (1+1+1), indicating no response in any category. A GCS of 13-15 suggests mild brain injury, 9-12 moderate, and 8 or below severe. A score of 8 or below is traditionally associated with inability to protect the airway, though this threshold should guide but not replace clinical judgment. The GCS is most valuable as a serial measurement — tracking changes over time. A declining GCS suggests neurological deterioration and requires urgent intervention. Always document each component separately (e.g., E3V4M5) in addition to the total score, as this provides more clinical information than the total alone.

Question 3: An EMT arrives to find an unresponsive patient. After ensuring scene safety, what is the FIRST action?

Establish IV access
Assess airway and breathing (Correct answer)
Check blood glucose
Obtain a detailed patient history from bystanders

Correct answer: Assess airway and breathing

For an unresponsive patient, the primary assessment begins immediately with airway and breathing assessment. These must be addressed before any other intervention.

The approach to an unresponsive patient begins with ensuring scene safety, then forming a general impression as you approach. Upon reaching the patient, the primary assessment takes priority over all other actions. The first step is to assess responsiveness — use a verbal stimulus ('Are you okay?') followed by a painful stimulus if needed. If the patient is unresponsive, immediately assess the airway. For an unresponsive patient, open the airway using head-tilt chin-lift (or jaw thrust if trauma is suspected) and look, listen, and feel for breathing. If breathing is absent, deliver two rescue breaths and then check for a pulse. If no pulse is present, begin CPR immediately. If breathing is present but inadequate, provide positive pressure ventilation at the appropriate rate. Gathering history, checking blood glucose, and establishing IV access are all important interventions but come after the airway and breathing have been assessed and secured. Time spent on secondary activities while the airway is compromised will result in rapid deterioration. The principle of 'treat as you find' means addressing each life threat as it is discovered in the primary assessment, not waiting until the entire assessment is complete.

Question 4: When performing a rapid trauma assessment on a patient with a significant mechanism of injury, the EMT should assess the patient's body in which order?

Extremities, then head, then trunk
Head to toe in a systematic manner (Correct answer)
Only areas where the patient reports pain
Vital signs before any physical examination

Correct answer: Head to toe in a systematic manner

A rapid trauma assessment proceeds head-to-toe to ensure a systematic evaluation and prevent missed injuries. Beginning at the head and working toward the feet reduces the risk of overlooking less obvious injuries.

The rapid trauma assessment (RTA) is performed on patients with a significant mechanism of injury (MOI) — falls from height, high-speed MVCs, penetrating trauma, etc. — to identify life-threatening injuries that may not be immediately obvious. The head-to-toe approach ensures systematic coverage and reduces the likelihood of missed injuries. The assessment sequence is: head (DCAP-BTLS: Deformities, Contusions, Abrasions, Punctures, Burns, Tenderness, Lacerations, Swelling), neck (jugular vein distention, tracheal deviation, tenderness), chest (DCAP-BTLS, breath sounds, paradoxical motion), abdomen (DCAP-BTLS, tenderness, rigidity, guarding), pelvis (stability, tenderness), extremities (DCAP-BTLS, pulses, motor, sensory), and posterior (roll the patient while maintaining spinal alignment). The RTA should take 60-90 seconds in a skilled provider. Findings guide management decisions — a tension pneumothorax identified during chest assessment must be addressed immediately, even if the head has not yet been assessed. The RTA is not a complete physical examination; it is a rapid screen for life threats. Document findings using standardized terminology to communicate accurately with the receiving facility.

Question 5: A patient has a pulse oximetry reading of 89% on room air. The EMT should:

Document the reading and continue assessment
Apply a non-rebreather mask at 15 L/min and reassess (Correct answer)
Place the patient on 2 L/min nasal cannula only
Immediately intubate the patient

Correct answer: Apply a non-rebreather mask at 15 L/min and reassess

An SpO2 of 89% on room air indicates significant hypoxemia. High-flow oxygen via non-rebreather mask should be applied immediately and reassessed after a few minutes.

Pulse oximetry (SpO2) measures the percentage of hemoglobin saturated with oxygen. Normal values are generally 94-99% on room air. An SpO2 below 94% indicates hypoxemia, and below 90% is considered severe hypoxemia requiring immediate intervention. At 89%, the patient is on the steep part of the oxyhemoglobin dissociation curve, meaning small further decreases in SpO2 correspond to large decreases in oxygen content. For a patient with an SpO2 of 89% and no contraindications, high-flow supplemental oxygen via non-rebreather mask at 15 L/min is the appropriate initial intervention. Reassess SpO2 after 2-3 minutes of oxygen administration; if no improvement, consider other causes (mucus plugging, bronchospasm, pneumothorax) and escalate interventions accordingly. If SpO2 does not improve despite high-flow oxygen and airway maneuvers, positive pressure ventilation may be required. Important caveats: pulse oximetry is less reliable in patients with poor perfusion (cold extremities, shock), carbon monoxide poisoning (CO-oximetry cannot distinguish), methemoglobinemia, and severe anemia. Dark nail polish and thick skin can also affect readings. Always correlate SpO2 with the clinical picture — a patient who is breathing comfortably and looks well may tolerate a slightly lower SpO2 better than a patient in respiratory distress.

Question 6: When should the EMT perform a focused history and physical examination rather than a rapid full-body assessment?

For any patient over age 65
For a medical patient with a specific complaint and no significant mechanism of injury (Correct answer)
Whenever scene time is limited
For all patients regardless of presentation

Correct answer: For a medical patient with a specific complaint and no significant mechanism of injury

A focused assessment is appropriate for medical patients with an isolated complaint (e.g., chest pain, abdominal pain) where a full-body trauma assessment is not indicated by the mechanism of injury.

The scope of the physical examination in the prehospital setting is determined by the patient's chief complaint and mechanism of injury. For trauma patients with a significant mechanism of injury, a rapid head-to-toe assessment is performed to identify all potential injuries. For medical patients or patients with minor, isolated complaints (a twisted ankle, for example), a focused assessment concentrating on the area of complaint is more appropriate and efficient. A focused history and physical examination for a medical patient might include: a SAMPLE history (Signs/Symptoms, Allergies, Medications, Pertinent past medical history, Last oral intake, Events leading to the complaint), OPQRST for the chief complaint (Onset, Provocation/Palliation, Quality, Radiation, Severity, Time), and a focused physical examination of the relevant body system. The key principle is that the assessment should be appropriately thorough for the patient's condition — neither cursory nor unnecessarily exhaustive. An elderly patient who 'just has ankle pain' may also be assessed for contributing cardiovascular or neurological conditions. Clinical judgment guides the extent of assessment. After completing the history and physical, reassess vital signs, determine priority, and make transport decisions.

NREMT Patient Assessment & Decision-Making 2

During the primary assessment, an EMT identifies a patient's life threats in which order?