A GUIDE TO INITIAL ASSESSMENT

Primary Assessment

A. Airway with simultaneous cervical spine stabilization  and/or immobilization.

B. Breathing.

C. Circulation.

D. Disability (neurologic status),

Secondary Assessment

E.Expose/environmental control (remove clothing and keep patient warm)

F.Full set of vital signs/five interventions (electrocardiographic monitor? pulse oximeter, urinary catheter, gastric tube, and laboratory studies)/facilitate family presence

G.Give comfort measures (verbal reassurance, touch)

H.History and Head-to-toe assessment

I.Inspect posterior surfaces

AIRWAY

ASSESSMENT

Inspect the patient’s airway while maintaining cervical spine stabilization and/or immobilization. Since partial or total airway obstruction may threaten the potency of the upper airway, observe for the following:

•Vocalization

•Tongue obstructing airway in an unresponsive patient

•Loose teeth or foreign objects. 

•Bleeding

•Vomitus or other secretions

•Edema

INTERVENTIONS

Airway Patent

• Maintain cervical spine stabilization and/or immobilization.

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• Any patient whose mechanism of injury, symptoms, or physical findings suggest a spinal injury should be stabilized or remain immobilized.

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• If the patient is awake and breathing, he or she may have assumed a position that maximizes the ability to breathe. Before proceeding with cervical spine stabilization, he sure interventions do NOT compromise the patients breathing status.