# Emergency medical responder (EMR)/Primary survey
## C-spine control

In the event of an alleged fall / trauma an EMR should always treat for the worst and hope for the best and deligate C Spine control to your partner or someone of equal or higher training, by placing both hands on either side of Pt.head and esuring that there is no movement during the primary assessment. Later when the neck is being examined a Cervical collar must be applied. Remember to size correctly. Treat for the worst and hope for the best.

## Level of consciousness

Level of Consciousness is important because it can help eliminate other medical conditions. If a patient is conscious and talking to you, than they have a patent airway and are breathing. It is also safe to say that they have a pulse and know about their injuries. This doesn't mean you don't do a patient assessment. However, your Airway, Breathing, Circulation, mechanism of injury portions of the exam are progressed. On the other hand, if a patient is completely unresponsive the medic knows that the patient could be in severe trouble.
The patient's level of consciousness must be analysed using the Glasgow coma scale. To asses the patient using the Glasgow coma scale, the EMR must assess three elements of the patients response to stimuli (how the patient responds with his/her eyes, how the patient responds verbally, and how the patient responds physically with his/her motor functions). The total of the points scored on each will give the patients score. A score of 15 is the highest possible score, while a 3 is the lowest possible score.

##### Eye response

* 4 points: Eyes open spontaneously.
* 3 points: Eyes open to the sound of speech.
* 2 points: Eyes only open as a response to pain.
* 1 point: Patient does not open eyes at all.

##### Verbal response

* 5 points: Alert and oriented. The patient is aware of Person (who he/she is, name, age), Place (where he/she is and why), Time (what day or month it is), and Event (what happened which required the EMR to attend).
* 4 points: Confused. The patient is coherent but not entirely aware of person, place, time, and event.
* 3 points: Inappropriate speech. The patient uses random or exclamatory articulated speech, but no conversational exchange.
* 2 points: Inappropriate sounds. The patient grunts, groans, moans, or makes other sounds without using any actual words.
* 1 point: None. The patient does not make any noises with the exception of noises made by a partial airway obstruction (i.e. snoring, wheezing, and gurgling).

##### Motor response

* 6 points: Obeys commands. The patient obeys commands for movement (i.e. squeezes fingers on command, moves feet on command).
* 5 points: Localizes to pain. The patient makes purposeful movement to reduce pain.
* 4 points: Withdrawal from pain. Patient pulls away from painful stimuli.
* 3 points: Abnormal flexing. Decorticate response
* 2 points: Abnormal extension. Decerebrate response
* 1 point: No motor response.

## Airway

Check to make sure the airway is clear. If the casualty is conscious, you can see if their airway is clear simply by asking them a question and see if they're able to speak.
If the casualty is unconscious, attempt to give a rescue breath.
* If the breath goes in (the chest rises with the breath), then the airway is cleared. Check for a gag reflex by rubbing the tip of the patient’s eye lashes, if the patient’s eyelid does not twitch than no gag reflex should present. Insert an oropharyngeal airway to ensure the tongue does no slide back, blocking off the airway.
* If the breath does not go in, there is an obstruction. First try to clear the airway by using the jaw thrust maneuver if C-spine control has been taken or by the head tilt chin lift maneuver if C-spine control was not required. Try to give ventilation again.
* If a second attempt at ventilation is unsuccessful, begin chest compressions to attempt to dislodge the obstruction. Give thirty chest compressions and then try again to give a breath. Repeat until you are able to get the chest to rise.

## Breathing

Check to make sure the casualty is breathing. If the casualty is conscious, you can check their breathing simply by asking them a question and see if they're able to speak and asking if they're having difficulty breathing.
If the casualty is unconscious, hover your ear a few inches above the casualty's mouth and feel/listen for air. At the same time, watch their chest to see if it rises. If the casualty is not breathing, use a pocket mask or bag-valve mask to breath for them.
A normal rate of breathing should be as follows:
* Adult – 12-20 Breaths per minute
* Child – 15-30 Breaths per minute
* Infant – 25-50 Breaths per minute

## Circulation

Check the patients rate, rhythm and quality of circulation by palpating both the distal and carotidian pulse at the same time.
Palpate for fifteen seconds and then multiply the number of beats by four to determine rate (beats per minute).
Note the rhythm of the pulse, is it normal or "offbeat"?
Note the quality of the pulse, is it strong and bounding, is it weak and thready, or is it some other variation?

## Head

* Ask the patient if they have any pain in their head.
* Look for:
** Deformities
** Contusions
** Abrasions
** Punctures
** Penetrations
** Burns
** Lacerations
** Swelling
** Cerebrospinal fluid coming from the eyes, ears, or nose.
* Feel for:
** Tenderness
** Instability
** Crepitation

## Neck

* Ask the patient if they have any pain in their neck.
* Look for:
** Deformities
** Contusions
** Abrasions
** Penetrations
** Burns
** Lacerations
** Swelling
** Jugular vein distention
* Feel for:
** Trachea deviation
** Tenderness
** Instability
** Crepitation

## Chest

* Ask the patient if they have any pain in their chest.
* Look for:
** Deformities
** Contusions
** Abrasions
** Penetrations
** Burns
** Lacerations
** Swelling
** Equal and bilateral chest rise and fall
** Paradoxical motion
** Subcutaneous emphysema
* Listen with a stethoscope for:
** equal chest sounds
** clear chest sounds
* Feel for:
** Tenderness
** Instability
** Crepitation

## Abdomen

* Ask the patient if they have any pain in their abdomen.
* Look for:
** Deformities
** Contusions
** Abrasions
** Penetrations
** Burns
** Lacerations
** Swelling
** Eviscerated Organs
* Feel for:
** Distension
** Tenderness
** Rigidity
** Pulsating masses

## Pelvis

* Ask the patient if they have any pain in their pelvis.
* Look for:
** Deformities
** Contusions
** Abrasions
** Penetrations
** Burns
** Lacerations
** Swelling
** Incontinence
** Defecation
** Priapism
* Feel for:
** Tenderness
** Instability
** Crepitation

## Lower extremities

* Ask the patient if they have any pain in their legs or feet.
* Look for:
** Deformities
** Contusions
** Abrasions
** Penetrations
** Burns
** Lacerations
** Swelling
* Feel for:
** Tenderness
** Instability
** Crepitation
** Equal pedal pulses
** Equal motor function (conscious patient only)

## Deadly bleed check

At this point it is imperative to check under the patient for deadly bleeding by placing a clean gloved hand under the patient at every elevated space and then checking the glove for blood.

## Upper extremities

* Ask the patient if they have any pain in their arms or hands.
* Look for:
** Deformities
** Contusions
** Abrasions
** Penetrations
** Burns
** Lacerations
** Swelling
* Feel for:
** Tenderness
** Instability
** Crepitation
** Equal distal pulses
** Equal motor function (conscious patient only)