Initial assessment in

ER
Dr. Suresh MD
1st year CCT-EM resident
 Definition
• A systemic, rapid evaluation of patient’s presenting condition
conducted upon arrival to determine the severity of illness or injuries,
prioritising care and initial appropriate interventions.
 Objectives
• Establish a baseline information about patient’s health state
• To identify immediate medical/safety concerns and risks that require
prompt intervention
• Formulation of diagnosis
• To provide plan of care/ treatment
• To Ensure continuity of care
• To ensure accurate recording for legal, clinical and communication
purposes
Concepts of initial assessment
• Preparation
• Triage
• Primary survey (ABCDE)
• Resuscitation
• Adjuncts to primary survey and resuscitation
• Secondary survey (history, head-to-toe, systemic examination)
• Adjuncts to secondary survey
• Continued post-resuscitation monitoring and re-evaluation
• Definitive care
Note:
• Repeat primary and secondary survey when finding any deterioration
in the patient’s status
• Primary survey and resuscitation are done simultaneously
 Preparation
• Prehospital:
1. Airway maintenance
2. Vitals monitoring
3. Control of external bleeding and shock (in trauma)
4. Medical interventions
5. Immobilisation of the patient
6. Communication with hospital
7. History taking

• Inhospital
1. Advanced planning
2. Equipment and personnel
3. Communicable disease protection
4. Clinical forms.
 Triage
• Process of rapid assessment and prioritising patients based on the
severity of their condition
• To ensure that most critically ill receive immediate care
• Red
1. Serious but salvageable life threatening illness/injury
2. Requires high priority, immediate action/ immediate resuscitation

• Yellow
1. Moderate to serious injury/ illness not immediately life threatening
2. Medium priority
3. Requires observation and re- triage
4. Requires care within 10 to 30 mins
• Green
1. Ambulatory patients, not seriously injured
2. Can be termed “walking wounded”
3. Can await a delayed evaluation
4. Requires care in 1 to 2 hours

• Black
1. Dead or moribund
2. No treatment
Primary survey
• Adult/ paediatric patients - same priority
• Identify the life threatening conditions and simultaneously managed
• A: Airway maintenance
• B: Breathing and ventilation
• C: Circulation
• D: Disability
• E: Exposure/ Environmental control
Airway
• 1st priority in assessing and managing a critically ill or injured patient

• Goals
1. Ensure the airway is patent
2. Identify and manage acute or potential obstructions
3. Protect the airway in patient with decreased consciousness or in
unconsciousness
• Airway assessment:
1. Look - for signs of obstruction (eg., foreign body, swelling, trauma)
2. Listen- for abnormal sounds ( Stridor, gurgling, snoring)
3. Feel- for air movement at the mouth/ nose

• Signs of airway compromise:

1. Noisy breathing ( Stridor, gurgling)
2. Use of accessory muscles
3. Inability to speak
4. Cyanosis
5. Altered consciousness
Airway management
1. Basic manoeuvres : head tilt- chin lift or jaw thrust( if trauma
suspected )
2. Suction : to clear secretions or blood
3. Airway adjuncts : Oropharyngeal or Nasopharyngeal airway
4. Definitive airway : Endotracheal intubation or Surgical airway
( cricothyrotomy)
Breathing
• Once the airway is confirmed to be open, next step is to assess and
support patient’s ventilation and oxygenation.

• Goals:
1. Ensure adequate exchange of gases
2. Identify and treat life threatening respiratory problems
• Breathing Assessment

1. Look:
• chest rise and fall ( rate, symmetry, effort)
• Signs of respiratory distress ( use of accessory muscles, nasal flaring,
retractions)
• Cyanosis

2. Listen:
• Breath sounds (wheezing, crackles, silence)
• Rate and rhythm of breathing
3. Feel:
• Chest wall movement
• Tracheal position
• Subcutaneous emphysema

4. Monitor:
• RR (normal : 12-20/min)
• SpO2 ( normal : > or = to 94)
Interventions:
• Oxygen therapy: Nasal prongs -> O2 mask -> NRBM
• Ventilation support: bag- valve mask, NIV, Intubation

Treat the underlying cause:

• Pneumothorax = needle decompression
• Asthma/ COPD = bronchodilators, steroids
• Pulmonary edema = diuretics, nitrates
• Hemothorax = intercostal drain
Circulation
• After ensuring airway and breathing are adequate, next step is to
assess and support circulation.

• Goals:
1. Ensure adequate tissue perfusion
2. Detect and treat shock/ hemorrhage
3. Maintain organ perfusion.
Circulation assessment
[Link]:
• Rate (normal= 70 – 110bpm), rhythm, volume of both central and
peripheral pulse.
2. Blood pressure (normal = 90-120/ 60-80 mmHg)
3. Capillary refilling time ( normal = <2sec)
4. Skin (pallor, cyanosis, hypothermia)
5. Neck veins
6. Look for Internal/ External Bleeding
Investigations
• ECG
• Blood test ( CBC, ABG)
• e-FAST
• Chest/ pelvic X- ray

Immediate interventions
• Control of bleeding = direct pressure, tourniquet
• IV access = 2 large bore IV cannulas
• Fluid resuscitation = isotonic crystalloids ( NS, RL)
• Blood transfusion = if ongoing or major blood loss
Disability
• It is a quick neurological assessment to identify any impairment in
brain function

• Goals:
1. Assess level of consciousness
2. Detect signs of neurological deterioration
3. Identify causes
Disability assessment
• AVPU Scale
A= Alert
V= Responds to voice
P= Responds to pain
U= Unresponsive

• GCS =
• Pupils = size, equality, reactivity to light ( unequal suggest of brain
injury)
• Blood glucose (GRBS) = Normal = 70 to 140 mg/dL
• Assess limb movements for motor weakness
Exposure
• This step involves full examination of patients.

• Goals:
1. Perform head to toe examination
2. Look for hidden signs of trauma, infection, illness
3. Prevent hypothermia in critically ill patients.
Exposure assessment
• Undress the patient completely ( cut off the clothes if needed)
• Inspect the entire body
- look for wounds, bruises, bleeding, rashes, deformities, signs of
infection, surgical scars
• Palpate areas of tenderness or abnormal swelling
• Temperature assessment
• Use blankets / warming devices to prevent hypothermia
• Ensure privacy and dignity during examination.
ABCDE Adjuncts
• Airway (A): Pulse oximetry
• Capnography (EtCO₂)
• Airway adjuncts – OPA, NPA, LMA, or ETT

• Breathing (B) : Chest X-ray – detects pneumothorax, hemothorax, rib fractures

• Ultrasound (eFAST) – evaluates pleural spaces and diaphragm
• Arterial blood gases (ABG) – assess oxygenation, ventilation, acid-base status
• SpO₂ – monitors oxygen saturation trends
• Circulation (C):ECG
• Blood pressure monitoring
• Blood tests – CBC, lactate, crossmatch, coagulation profile
• eFAST ultrasound – checks for internal bleeding (abdomen, pelvis,
pericardium)
• Disability (D): Capillary blood glucose – rules out hypoglycemia
• CT brain – if head injury or altered mental status

• Exposure (E):Temperature monitoring – rectal or tympanic thermometers

Secondary survey
• It is a head to toe detailed assessment and systemic assessment done
after primary survey.

• Goals
1. To detect missed injuries or signs
2. To Collect a focused history
3. Guide further investigation and management
Steps in secondary survey
[Link] history
• A = H/o allergies
• M= Regular medications
• P = Past medical history
• L = Last meal
• E = Events related to illness
Head to toe examination
• Head and face = scalp wounds, facial fractures, pupils, vision, ENT bleed
• Neck = cervical spine tenderness, tracheal deviation, jugular vein
distension
• Chest = contusion, rib fractures, breath sounds
• Abdomen = Distension, tenderness, guarding, rigidity, organomagaly,
bruising
• Pelvis = stability, tenderness, bleeding genitals
• Limbs = deformities, fractures, pulses, capillary refill, sensory/ motor
function
• Back = Log-roll to inspect for wound, bruising, spinal tenderness
• Skin = Rashes, needle marks, signs of infection or systemic disease
• Systemic Examination
CVS
• Inspection = Chest shape, pulsations
• Palpation = Apex beat, thrills, heaves
• Percussion = heart boarders
• Auscultation = heart sounds, murmurs, rubs
• Peripheral pulse = rate, rhythm, volume, symmetry
• JVP assessment
• Capillary refill, cyanosis, clubbing, edema
RS
• Inspection = chest movement, symmetry, scars, respiratory
efforts
• Palpation = Tracheal position, chest expansion, tactile Freitas
• Percussion = Resonance or dullness
• Auscultation = Breath sounds, added sounds ( crackles,
wheeze), vocal resonance
GI
• Inspection = Distension, scars, visible peristalsis, hernias
• Palpation = tenderness, organomagaly, masses, rebound,
guarding
• Percussion = Liver span, shifting dullness
• Auscultation = bowel sounds
CNS
• Consciousness level = AVPU/ GCS
• Cranial nerves examination
• Motor = Tone, power, reflexes, co-ordination
• Sensory = Light touch, pain, vibration, proprioception
• Cerebellar signs = finger-nose test, heel-shin test
• Gait and posture
Musculoskeletal
• Joint inspection = swelling, deformities, redness
• Range of motion = active and passive
• Muscle wasting, tenderness, crepitus
• Spine inspection
Secondary adjuncts

Purpose :
• To confirm suspected injuries
• Guide surgical/ medical intervention
• Provide baseline data for on going care
Re- assessment
• It is a continuous process of monitoring patient after initial
stabilisation and treatement
• It is done to ensure that patient is responding to
intervention or undergoing deterioration.
• ABCDE re- evaluation
• Goals:
• To monitor patient’s progress
• To detect new/ missed problems
• To update clinical decisions
• To document the progress
• Airway = patent / not
• Breathing = improved/ worsened ; RR & SpO2 monitoring
• Circulation = improved / worsened ; PR, BP Capillary refilling
monitoring
• Disability = Improved/ worsened ; GCS / AVPU score, pupils re
assessment
• Exposure = temperature variation, new findings
• Vital signs monitoring = HR, RR, PR, BP, SpO2, Urine o/p
• Response to intervention = look for allergic reactions, vital
variations
• Pain Re- assessment = for analgesia
• Documentation
Re Assessment is done in
• Critically ill / unstable patients : Trauma, sepsis, cardiac conditions,
stroke respiratory distress etc.
• Patients undergoing active treatment: IV fluids, medications
• Patients with changing/unclear diagnosis
Re assessment interval
• Red / l = Continous monitoring for every 5 to 15 mins once

• Yellow/ ll = Every 30 to 60 mins once

• Green/ lll = Every 1 to 2 hours once

Clinical handover
• It is a structured transfer of clinical information, responsibility and
accountability from one caregiver to another

• Goals:
1. Provide clear, concise and accurate patient information
2. Ensure continuity of care
3. Minimise risk of missed information/ miscommunication
SBAR format
• S= situation
1. Identify yourself and your role
2. Identity of patient
3. Description of current issue, reason for handover

• B = Background
1. Brief medical history
2. Relevant past medical/ surgical history
3. Investigations or treatments done
• A = Assessment
1. Current clinical findings ( ABCDE summary)
2. Vitals, Labs, image results
3. Response to treatment in ER

• R = Recommendation
1. What needs to be done next
2. Ongoing concerns or risks
3. Specific instructions/ review timelines.
Initial assessment in Trauma
• ATLS protocol, emphasising a structured and systematic approach to
trauma management.
• Primary Survey (ABCDE)
• Airway with Cervical Spine Protection: Ensure airway patency and protect
the cervical spine.
• Breathing: Assess and manage breathing; interventions like intubation or
chest decompression may be necessary.
• Circulation with Haemorrhage Control: Control external bleeding and
assess circulatory status; initiate IV access for fluid resuscitation.
• Disability (Neurological Status): Evaluate GCS and check for pupil
reactions.
• Exposure and Environmental Control: Fully expose the patient to assess
for injuries while maintaining body temperature.
• Focused Assessment with Sonography for Trauma (FAST) is commonly
employed to detect free fluid in the abdomen and pericardium.
Secondary Survey
• Once life-threatening conditions are addressed, a
thorough head-to-toe examination is conducted,
including:
• Head: Inspect for scalp injuries, facial fractures, and
neurological deficits.
• Neck: Assess for signs of cervical spine injury and other
neck trauma.
• Chest and Abdomen: Palpate and auscultate for signs of
internal injuries.
• Extremities: Check for fractures, dislocations, and
neurovascular status.
• Thank you