1. Primary and Secondary Assessment

2. Information collected during the primary assessment includes which of the following?
Evaluation of the cranial nerve
Documenting pt medications
Presence and quality of central pulses
Arterial blood gas results
C. The primary assessment looks for life-threatening conditions related to airway maintenance, oxygen supply to the body, and hemodynamic response to the event. Presence or absence of pulse and quality of central nervous peripheral pulses are assessments made to assess circulation during the primary survey. In depth neurological assessment (including cranial nerve assessment), obtaining and documenting information about pt history , and blood gas results are part of the secondary assessment.

3. Which of the following statements regarding secondary assessments is false?
Distal extremity wounds are rarely life-threatening and can be assessed on the 2ndary survey unless hemorrhage is present.
Assessment of sensory versus motor function in suspected spinal cord injury is a 2ndary assessment.
Assessment of the mouth and throat for obstruction and patency can wait until the secondary assessment.
The pt is turned and posterior surfaces assessed as part of the 2ndary survey
C. The mouth and throat are airway structures. Assessment of the mouth and throat for obstruction and patency are primary survey assessments. Distal extremity injuries, unless hemorrhage is present, are assessed on the 2ndary assessment. Extensive neurologic evaluation beyond level of consciousness, pupillary response, and GCS and turning the pt to inspect the posterior surface are all part of the 2ndary survey evaluations.

4. The components of an AMPLE history are:
Airway, Mucosa, Pain, LOC, Emotional response
Anaphylaxis, Medications, Pain, Lethal wounds, Environment
Alcohol, Malocclusion, Pain, LOC, Environment
Allergies/Alcohol, Medications, Past Medical Hx, Last Meal, Event causing emergency/Everything done
AMPLE is a common memory aid for the components a useful, general pt.
A=Allergies/Alcohol and abuse substances
M=Medications (current)
P=Past medical hx
L=Last meal/Ingestion of food or fluids
E=Events experienced by the pt or witnessed by others and all interventions performed before the arrival of the transport team.

5. Preplanning any transport, what is your first concern when performing the primary survey?
Is the pt’s airway patent and maintainable?
Where is the pt’s intravenous access?
Did the pt have a brain CT performed?
Is there any visible uncontrolled bleeding?
A. Airway is always the 1st physiologic concern on the primary assessment. While an IV is part of the primary survey as an intervention for Circulation, it is not performed before the airway assessment. All diagnostic studies, while important objective data collection tools, are part of the 2ndary survey. Uncontrolled bleeding is a life-threatening emergency requiring interventions as part of the Circulation assessment.

6. As you prepare any pt for transport, the focus of the primary assessment is to evaluate:
Airway patency, cervical spine immobilization, effectiveness of breathing, and effectiveness of circulation
Effectiveness of pain control, PMS of immobilized extremities, LOC
Application of transport monitors, appropriate preparation of blood products for transport, completeness of medical record and copies of all imaging studies
Psychological status regarding event, ability to cooperate with transport staff, level of sedation
A. The primary survey always starts with evaluation of the airway with simultaneous immobilization of the cervical spine if indicated, evaluation of effectiveness of breathing and circulation. While evaluation of LOC is done in the primary survey, evaluating effectiveness of pain control, the status of immobilized extremities, and comfort measures are part of the 2ndary assessment. Application of transport monitors, medical records, and blood administration is not part of the pt assessment.

7. The PQRST memonic for pain assessment stands for which of the following?
Position, Quantity, Restrictions, Sequelae, Treatment
Provoking Factors, Quality, Region/Radiation, Severity, Time
Position, Quadrant, Radiation, Sequelae, Tympani
Paresthesias, Quivering, Radiation, Sharpness, and Throbbing
The PQRST is a memory aid to assist in the thorough assessment of pain.

8. Which of the following statements are true regarding interventions made during a primary survey?
Cervical spine precautions are initiated on every suspected trauma victim.
ET tube placement requires immediate confirmation by x-ray
Bleeding from an extremity controlled with a pressure dressing does not require reevaluation.
Peripheral IV access can be withheld in pts with no obvious bleeding.
A. Cervical spine precautions are initiated simultaneously with airway assessment for every suspected trauma victim, especially if that pt has an altered mental status or is unresponsive. Physical assessment and 2ndary confirmation devices can confirm tube placement in field responses. X-ray is a diagnostic study and done as part of the 2ndary survey. Extremity CSM needs to be reassessed at regular intervals to prevent neurovascular compromise due to the pressure dressing. These are 2ndary assessments. Bleeding can be present and unseen, such as with long bone fractures or splenic injury. Decision to start an IV is made on more factors than the presence of obvious bleeding.

9. Which of the following statements is true regarding the primary survey?
The purpose of the primary survey is to assess for life-threatening conditions and implement immediate interventions.
Once a primary assessment has been made, it does not have to be repeated.
A primary assessment looks at the pt’s future ability to function independently, providing interventions to preserve vision and hearing.
A primary assessment is a tool used by 1st responders in the pre-hospital setting and has no role in the ER.
A. The purpose of the primary assessment is to find and correct life-threatening conditions (scene response), or to reassess the effectiveness of life-threatening interventions already made.

10. Which of the following is the highest priority in the assessment of the multi-trauma pt?
Examination of the chest x-ray for pneumothoraces
Auscultation of breath sounds
Auscultation of heart tones
Examination of the pt’s mental status
B. The highest priority in the initial assessment of any pt is assurance of a patent airway and adequate breathing.

11. Which of the following is not an integral part of the primary assessment?
Assessment of SpO2 values
Auscultation of breath sounds
Palpation of pulses
Inspection for serious external bleeding
A. While SpO2 is a valuable monitoring tool once correlated with clinical findings, the SpO2 value by itself actually tells you very little. The rate and rhythm of breathing, quality of air movement in the lungs, and rate and quality of pulses all tell you far more about the pt’s cardio respiratory status and immediate threats to life than the SpO2.

12. The main purpose of the 2ndary assessment is:
To gather pt data that can be used to confirm or formulate a diagnosis and plan of care
To assess and secure the most vital physiological functions
To provide pain management to make the pt comfortable
To ensure that you are able to answer the medical control physicians’ questions when you are asked about the pt
A. The purpose of the 2ndary assessment is to gather data that will be pertinent to the care of your pt. Assessment of and securing of the vital functions occurs during the primary assessment, before the 2ndary assessment is performed. While assurance of comfort and analgesia may be an important part of the 2ndary assessment, it is not the primary purpose. While it may be valuable to anticipate and be able to answer the medical control physicians’ questions, again this is not the main purpose of the primary assessment.

13. The following is an important element of any 2ndary assessment:
Arterial or venous blood gas analysis
Cranial nerve examination
Blood glucose analysis
Assessment of pain status, to include a quantified level, quality, location, and duration
D. Early assessment of pain is important not only because the characteristics of the pain is important objective clinical data, but also because it allows the flight nurse/medic to choose the most appropriate pain management strategy and provides a baseline for evaluation of the effectiveness of that intervention. Blood gas analysis, cranial nerve examination, and blood glucose analysis may all be appropriate elements of the assessment of specific pts, but none of these are absolutely critical parts of the assessment of every pt.

14. When is it most appropriate to perform the primary assessment?
Only after receiving report from the transferring RN/CEP
Immediately upon making contact with the pts
After changing the medication infusions and ventilator over to the transport team’s equipment
Immediately before making contact with medical control
B. The primary assessment is immediately performed upon contact with the pt, and elements of it are then repeated frequently throughout the transport and in response to any clinical deterioration.

15. Which action in not an appropriate part of the primary survey?
Evaluation of arterial blood gas (ABG) results
Assessment for the presence of breath sounds
Inspection of the back of the trauma pt for hidden bleeding
Assessing gross sensory and motor ability in the lower extremities by asking the pt to wiggle the toes on the foot you are touching
A. Assessment of any diagnostic test data occurs only after the pt’s vital functions (airway, breathing, and circulation) have been clinically assessed and secured.

16. Choose the actions that are most appropriately performed as part of a typical 2ndary assessment.
A gross neurological exam, a cranial nerve exam, and assessment of two-point discrimination
A thorough medical hx and head-to-toe examination, including visual acuity
A brief, pertinent medical hx, a brief head-to-toe exam, a brief focused exam based on chief complaint or suspected diagnosis, and review of pertinent diagnostic test data
Initial assessment of airway, breathing, and circulation
C. After performing the primary assessment – which ensures vital functions and uncovers immediate threats – the focus turns to gathering data that will allow for investigation of the chief complaint and/or confirmation of the most probable diagnosis and likely differentials. While a rapid head-to-toe exam is acceptable – especially in a trauma pt or when you have very little pt information (i.e. an unresponsive pt) to guide your assessment – gathering of pt data is usually best done by a focused assessment that looks thoroughly at the body system that is most likely causing the presenting problem.

17. Which of the following conditions would be managed during the 2ndary survey?
Sucking chest wound
Obstructed airway
Fractured femur
Hemothorax
C. A femur fracture will be stabilized in a traction splint on the 2ndary survey. Sucking chest wounds, an obstructed airway and a hemothorax are identified and treated as part of the primary survey.

18. Which of the following assessment findings may indicate a hemothorax versus a pneumothorax during the primary or 2ndary survey?
Tracheal deviation
Absent or diminished breath sounds
Flat neck veins
Distended neck veins
C. In a hemothorax as blood is lost into the pleural space, the central venous pressure drops and the neck veins cannot distend. Tracheal deviation and absent or diminished breath sounds can be found in a hemothorax and pneumothorax. Distended neck veins are seen with a tension pneumothorax.

19. Which of the following assessment findings would indicate a left sided pneumothorax?
Low oxygen saturations, tympanic abdomen on palpation, subcutaneous air around the pt’s neck and shoulders
Decreased breath sounds over the left chest, right tracheal deviation, jugular vein distention, increased compliance on manual ventilation with a BVM
Distended neck veins, crackles in both bases, shallow and rapid respirations
Bilateral expiratory wheezes, diminished breath sounds in both bases, prolonged expiratory phase, pursed lip breathing
B. As air is trapped in the left pleural space, the mediastinum is pushed to the right side, accounting for the decreased left-sided breath sounds and tracheal deviation to the right. Jugular veins distend as intrathorasic pressure increases and venous return decreases. Bagging the pt becomes harder as the chest fills with trapped air; compliance does not improve with suctioning or sedation. Low SpO2 and subcutaneous air may indicate indirectly the presence of pneumothorax; they are not the classic symptoms of a tension pneumothorax. Distended neck veins with bilateral crackles and shallow , rapid respirations are the assessment commonly found with fluid in the lungs. Bilateral wheezes with diminished breath sounds and prolonged expiratory phase is the assessment seen in pts with restricted airways. The pursed lip breathing is due to the need to exhale more slowly against resistance to more fully empty their lungs.

20. All of the following statements are true regarding the 2ndary assessment except:
The purpose of the 2ndary survey is to identify all injuries once interventions have been made for life-threatening problems
On-scene 2ndary assessment may be limited due to lighting, nature of critical injuries, and limited available space to perform the assessment.
Detailed 2ndary assessment must be completed on scene before the pt can be safely transported
The 2ndary assessment included visual inspection and palpation of the entire body once it has been exposed
C. A detailed 2ndary inspection may not be completed at night in the dark, or aboard the aircraft with limited space, or when the pt has significant life-threatening injury, such as hemorrhage that requires surgical attention. The other options regarding the 2ndary assessment are true.