Primary Survey (DRCABCDE)
The primary survey is a rapid, systematic approach to identify and manage immediate life-threatening conditions. The sequence must be followed in order, treating life threats as they are found.
D - Danger: Assess the scene for any dangers to yourself, your partner, the patient, and bystanders. Ensure the scene is safe before proceeding.
R - Response: Assess the patient's level of consciousness using the AVPU scale (Alert, Voice, Pain, Unresponsive). For a more detailed assessment, use the Glasgow Coma Scale (GCS).
Glasgow Coma Scale (GCS)
| Response | Score | Paediatric Modification (Pre-verbal) |
|---|
| Eye Opening |
| Spontaneous | 4 | Spontaneous |
| To Voice | 3 | To Shout |
| To Pain | 2 | To Pain |
| None | 1 | None |
| Verbal Response |
| Oriented | 5 | Coos, babbles |
| Confused | 4 | Irritable cry |
| Inappropriate Words | 3 | Cries to pain |
| Incomprehensible Sounds | 2 | Moans to pain |
| None | 1 | None |
| Motor Response |
| Obeys Commands | 6 | Normal spontaneous movements |
| Localises to Pain | 5 | Withdraws to touch |
| Withdraws from Pain | 4 | Withdraws to pain |
| Abnormal Flexion (Decorticate) | 3 | Abnormal Flexion |
| Abnormal Extension (Decerebrate) | 2 | Abnormal Extension |
| None | 1 | None |
Total Score: 15 (Best) to 3 (Worst). A score of ≤ 8 indicates severe brain injury and inability to protect the airway.
Paediatric Assessment Triangle (PAT)
A rapid "from the doorway" assessment tool for paediatrics that provides a general impression of the child's condition before hands-on assessment. It evaluates three components:
- Appearance: Tone, Interactiveness, Consolability, Look/Gaze, Speech/Cry (TICLS). This reflects adequacy of brain perfusion and oxygenation.
- Work of Breathing: Assesses respiratory effort. Look for abnormal sounds (stridor, grunting), abnormal positioning (tripod), retractions, and nasal flaring.
- Circulation to the Skin: Reflects adequacy of cardiac output and core perfusion. Look for pallor, mottling, or cyanosis.
C - Catastrophic Haemorrhage: Check for and control any immediately life-threatening bleeding.
A - Airway: Is the airway patent? Look for obstructions. Use airway opening manoeuvres (head-tilt-chin-lift or jaw thrust if C-spine injury is suspected) and consider basic adjuncts (OPA/NPA) if necessary.
B - Breathing: Look, listen, and feel for breathing. Assess rate, rhythm, and quality. Check for equal chest rise and fall and auscultate for breath sounds. Provide oxygen or assisted ventilations as required.
C - Circulation: Check for a central pulse (carotid in adults/children, brachial in infants) for no more than 10 seconds. Assess skin colour, temperature, and capillary refill. Identify and control any catastrophic external haemorrhage immediately.
D - Disability: A more detailed neurological assessment. Check pupillary response (size, equality, reactivity to light) and BGL. Re-evaluate GCS.
E - Exposure/Environment: Expose the patient to perform a thorough examination, looking for injuries, rashes, etc., while preventing hypothermia by keeping them covered and warm.
Secondary Survey (AMPLE)
Performed after the primary survey is complete and immediate life threats have been managed. This is a systematic approach to gathering a detailed patient history.
A - Allergies: Are you allergic to any medications, foods, or environmental substances? What is the reaction?
M - Medications: What medications do you take, including prescribed, over-the-counter, and recreational drugs? What is the dose and when was the last time you took them?
P - Past Medical History: Do you have any medical conditions? Have you had any surgeries? Are you pregnant?
L - Last Meal (and Last Ins/Outs): When was the last time you ate or drank anything? What was your last bowel motion and urination like?
E - Events Leading Up To Incident: What were you doing when the symptoms started? Describe the sequence of events.
Tertiary Surveys: Focused Assessments
These are detailed, systematic examinations or assessments focused on a specific body system or complaint, performed after the primary and secondary surveys are complete.
Pain Assessment
Quantifying pain is essential for guiding treatment and evaluating its effectiveness. In addition to a numeric score, use a mnemonic like SOCRATES or PQRST to characterize the pain.
Adult: Use a numeric rating scale (0-10) where 0 is no pain and 10 is the worst pain imaginable.
Paediatric (FLACC Scale): A behavioral scale used for pre-verbal or non-verbal children (typically 2 months to 7 years). Score 0, 1, or 2 for each of the five categories, for a total score of 0-10.
| Category | Score 0 | Score 1 | Score 2 |
|---|
| Face | No particular expression or smile | Occasional grimace or frown, withdrawn | Frequent to constant quivering chin, clenched jaw |
| Legs | Normal position or relaxed | Uneasy, restless, tense | Kicking, or legs drawn up |
| Activity | Lying quietly, normal position, moves easily | Squirming, shifting back and forth, tense | Arched, rigid or jerking |
| Cry | No cry (awake or asleep) | Moans or whimpers; occasional complaint | Crying steadily, screams or sobs, frequent complaints |
| Consolability | Content, relaxed | Reassured by occasional touching, hugging or being talked to | Difficult to console or comfort |
Stroke Assessment (BEFAST)
A tool for rapid identification of stroke symptoms to facilitate early recognition and hospital pre-notification.
- B - Balance: Sudden loss of balance, headache, or dizziness.
- E - Eyes: Sudden vision loss or change in one or both eyes.
- F - Face: Ask the patient to smile. Does one side of the face droop?
- A - Arms: Ask the patient to raise both arms. Does one arm drift downward?
- S - Speech: Is speech slurred or strange? Ask the patient to repeat a simple sentence (e.g., "The sky is blue").
- T - Time: If any of these signs are present, it's time to call emergency services. Critically, note the time the patient was last seen well.
Respiratory Examination
A systematic assessment to identify the cause of respiratory distress.
- Inspect: Respiratory rate, rhythm, effort (use of accessory muscles, tripod position), skin color (cyanosis), chest symmetry, and audible sounds (wheeze, stridor).
- Palpate: Chest wall for tenderness, crepitus (subcutaneous emphysema), and symmetrical expansion.
- Percuss: Tapping on the chest wall. Hyper-resonance suggests pneumothorax; dullness suggests fluid or consolidation (effusion, pneumonia).
- Auscultate: Listen for normal (vesicular) breath sounds and identify any added sounds.
| Added Sound | Description | Common Differential Diagnoses |
|---|
| Wheeze | High-pitched continuous sound, usually on expiration. | Asthma, COPD, Anaphylaxis, lower airway obstruction. |
| Crackles (Rales) | Fine or coarse popping/crackling sounds, usually on inspiration. | Pulmonary edema, Pneumonia, Atelectasis, Pulmonary fibrosis. |
| Stridor | High-pitched, harsh sound on inspiration. | Upper airway obstruction (e.g., foreign body, epiglottitis, croup). A medical emergency. |
| Pleural Rub | Leathery, grating sound on inspiration and expiration. | Pleurisy (inflammation of the pleura). |
Cardiovascular Examination
- Inspect: Look for signs of poor perfusion (pallor, cyanosis), peripheral edema, and jugular venous distension (JVD).
- Palpate: Central and peripheral pulses (rate, rhythm, character), capillary refill time, skin temperature, and for heaves or thrills on the chest wall.
- Auscultate: Listen to heart sounds (S1, S2) for rate and rhythm. Identify any murmurs (indicating valvular disease) or extra heart sounds (S3/S4, indicating heart failure).
| Finding | Common Differential Diagnoses |
|---|
| Central Chest Pain | Acute Coronary Syndrome (ACS), Pulmonary Embolism (PE), Aortic Dissection, Pericarditis, Esophageal spasm. |
| Raised JVD + Peripheral Edema | Congestive Heart Failure (right-sided), Cardiac Tamponade. |
| Absent/Weak Pulses | Shock, Peripheral Arterial Disease, Aortic Dissection. |
Abdominal Examination (Nine-Region Assessment)
- Inspect: Look for distension, scars, bruising (e.g., Cullen's or Grey Turner's sign in pancreatitis), or visible pulsations.
- Auscultate: Listen for bowel sounds in all nine regions before palpating.
- Percuss: Assess for tympany (gas) or dullness (fluid/organs).
- Palpate: Start with light palpation away from the area of pain, then proceed to deep palpation. Assess for tenderness, rigidity (involuntary guarding), and masses. A pulsatile mass may indicate an Abdominal Aortic Aneurysm (AAA).
| Region | Common Differential Diagnoses |
|---|
| Right Hypochondriac | Cholecystitis, Hepatitis, Gallstones, Liver abscess, Pneumonia |
| Epigastric | Peptic ulcer, Gastritis, Pancreatitis, Myocardial Infarction, GERD, AAA |
| Left Hypochondriac | Splenic injury/rupture, Pancreatitis, Gastritis, Pneumonia |
| Right Lumbar | Kidney stones (renal colic), Pyelonephritis, Constipation |
| Umbilical | Early appendicitis, Small bowel obstruction, AAA, Gastroenteritis |
| Left Lumbar | Kidney stones (renal colic), Pyelonephritis, Constipation, Diverticulitis |
| Right Iliac (Fossa) | Appendicitis, Ovarian cyst, Ectopic pregnancy, Inguinal hernia, Inflammatory bowel disease |
| Hypogastric (Suprapubic) | Urinary tract infection (UTI), Bladder distention, Pelvic inflammatory disease (PID), Ectopic pregnancy |
| Left Iliac (Fossa) | Diverticulitis, Ovarian cyst, Ectopic pregnancy, Inguinal hernia, Inflammatory bowel disease |
Neurological and Cranial Nerve Examination
A focused neuro exam evaluates the central and peripheral nervous systems.
Components: GCS, pupil assessment, motor function (strength, tone, coordination), and sensory function (response to touch/pain).
Cranial Nerve Assessment: A quick assessment can help localize a lesion.
| Nerve | Function | Pre-hospital Test |
|---|
| II - Optic | Vision | Assess visual fields. |
| III, IV, VI - Oculomotor, Trochlear, Abducens | Eye Movements | Assess extraocular movements ("H" pattern), check for PERRL. |
| V - Trigeminal | Facial Sensation, Mastication | Test sensation on face, ask patient to clench jaw. |
| VII - Facial | Facial Expression | Ask patient to smile, raise eyebrows, puff cheeks. |
| VIII - Vestibulocochlear | Hearing and Balance | Rub fingers by ear, assess balance/gait if safe. |
| IX, X - Glossopharyngeal, Vagus | Swallow, Gag, Voice | Assess speech, ask patient to swallow. |
| XI - Accessory | Shoulder Shrug | Ask patient to shrug shoulders against resistance. |
| XII - Hypoglossal | Tongue Movement | Ask patient to stick out tongue and move it side to side. |
Mental State Examination (MSE)
The MSE is a systematic observation of a patient's psychological functioning at a single point in time. It is a critical tool in assessing mental health presentations.
| Domain | Description | What to Assess |
|---|
| Appearance | Physical appearance | Grooming, hygiene, clothing, posture. |
| Behaviour | Observable actions | Eye contact, psychomotor activity (agitation/retardation), rapport, abnormal movements. |
| Speech | The mechanical production of speech | Rate (pressured/slow), volume, tone, quantity (poverty of speech). |
| Mood | The patient's subjective emotional state | Ask the patient directly: "How has your mood been?". Document in their own words. |
| Affect | The objective, observable emotional state | Range (full, restricted), congruency (with mood), appropriateness, stability. |
| Thought Form | How thoughts are connected | Logical and linear, or disorganised (e.g., flight of ideas, tangential, word salad). |
| Thought Content | What the patient is thinking about | Themes, preoccupations, delusions, suicidal or homicidal ideation. |
| Perception | Sensory experience | Hallucinations (auditory, visual, olfactory, tactile, gustatory), illusions. |
| Cognition | Intellectual functioning | Orientation (time, place, person), attention, concentration, memory (short/long term). |
| Insight | Patient's understanding of their situation | Do they recognize they have a problem? Do they understand its impact? |
| Judgment | Ability to make sound decisions | Assess through their decisions and actions regarding their current situation. |
| Risk | Risk of harm to self or others | Assess suicidal/homicidal ideation, intent, plan, access to means. |
Suicidality Risk Assessment
A critical assessment for any patient in a mental health crisis, or any patient who expresses hopelessness. It must be conducted directly and compassionately.
- Ideation: "Have you been having any thoughts of harming yourself or ending your life?"
- Intent: "How strong are these thoughts?" "Do you want to act on them?"
- Plan: "Have you thought about how you might do this?" (Ask for specifics: what, where, when).
- Access: "Do you have access to [the means mentioned in the plan]?"
- Past Attempts: "Have you ever tried to harm yourself before?"
- Protective Factors: "What are some of the things that have stopped you from acting on these thoughts?" (e.g., family, future plans).
Head-to-Toe Assessment (DCAP-BTLS)
A systematic physical examination used primarily in trauma patients to identify all injuries.
- D - Deformities
- C - Contusions (bruises)
- A - Abrasions
- P - Punctures/Penetrations
- B - Burns
- T - Tenderness
- L - Lacerations
- S - Swelling
Altered Conscious State (AEIOU-TIPS)
A mnemonic used to systematically consider the potential causes of a patient's altered level of consciousness.
- A - Alcohol, Abuse (drugs/substances)
- E - Epilepsy (post-ictal), Electrolytes, Environment (hypo/hyperthermia)
- I - Insulin (hypoglycemia/DKA/HHS)
- O - Overdose, Oxygen (hypoxia)
- U - Uremia (renal failure)
- T - Trauma, Tumor
- I - Infection (sepsis)
- P - Psychiatric, Poisoning
- S - Stroke, Shock
Lower Back Pain Red Flags
While most back pain is musculoskeletal, paramedics must screen for "red flags" that indicate a potentially serious underlying spinal pathology requiring urgent investigation.
- Cauda Equina Syndrome: Saddle anesthesia (numbness in the groin/buttocks), bladder or bowel incontinence/retention.
- Spinal Cord Compression: Severe or progressive bilateral neurological deficit (weakness/sensory loss in legs).
- Spinal Fracture: History of significant trauma, or minor trauma in an osteoporotic patient.
- Cancer/Infection: Unexplained weight loss, fever, history of cancer, IV drug use.
Skin Tear Assessment (STAR Classification System)
The STAR (Skin Tear Audit Research) system provides a simple way to classify skin tears to guide management and documentation.
| Category |
Description |
Management Goal |
| Category 1a |
A skin tear where the
edges can be realigned
to the normal anatomical
position (without undue
stretching) and the skin
or flap colour is not pale,
dusky or darkened. |
Realign flap, secure with steri-strips, apply non-adherent dressing. |
| Category 1b |
A skin tear where the
edges can be realigned
to the normal
anatomical position
(without undue
stretching) and the skin
or flap colour is pale,
dusky or darkened. |
Gently realign flap over as much of the wound as possible, dress as above. |
| Category 2a |
A skin tear where the
edges cannot be
realigned to the normal
anatomical position
and the skin or flap
colour is not pale,
dusky or darkened. |
Protect remaining flap, apply appropriate dressing to promote moist wound healing. |
| Category 2b |
A skin tear where the
edges cannot be
realigned to the normal
anatomical position and
the skin or flap colour is
pale, dusky or
darkened. |
Focus on protecting the exposed wound bed and managing exudate with an appropriate dressing. |
| Category 3 |
A skin tear where the
skin flap is completely
absent. |
Protect the wound bed, manage exudate, and prevent infection. |