- 🦺Take appropriate PPE precautions — gloves, mask, eye protection as indicated by the situation.
- 👁️Determine scene / situation safety — scan for hazards before approaching the patient.
- 💥Determine severity of MOI / NOI — mechanism of injury or nature of illness.
- 👥Determine number of patients — are there additional casualties?
- 📞Consider additional help — call for backup early if the situation demands it.
- 🦴Consider spinal stabilisation — based on MOI findings.
Teaching Point: Scene safety is the only step that can halt the entire protocol. A provider who is injured cannot help anyone. Always look before you approach.
⚡ Decision 2 — Level of Consciousness (AVPU Scale)
NO → Skip orientation. Proceed directly to chief complaint.
Place — Do they know where they are?
Time — Do they know the date/day?
Event — Do they know what happened?
Primary Survey — XABCDE
- 🩸X — Exsanguinating haemorrhage: Check pulse · Identify and control major bleeding immediately.
- 💨A — Airway: Is it maintained? Is it patent?
- 🫁B — Breathing: Rate · Quality · Effort · Chest expansion · Lung sounds.
- ❤️C — Circulation: Pulse (rate, strength, regularity) · Bleeding · Skin (colour, temp, condition).
- 🧠D — Disability: GCS · Pupils (ERRL) · PMS (Pulse, Motor, Sensation) · Blood glucose.
- 👕E — Exposure: Rapid head-to-toe assessment.
Teaching Point: Work through XABCDE in order every time. A problem found at any step must be managed before moving to the next — never skip ahead.
Manage on scene · Conduct full history & vitals · Complete secondary assessment before transport.
Immediate transport · Continue assessment en route · Notify receiving facility early.
Teaching Point: When in doubt, Load & Go. It is always safer to transport early and continue care en route than to delay transport for a deteriorating patient.
A — Allergies
M — Medications
P — Past medical history
L — Last oral intake
E — Events leading up
R — Risk factors
P — Provocation / Palliation
Q — Quality
R — Region / Radiation
S — Severity (0–10 scale)
T — Time
Normal Vital Sign Ranges
| Vital Sign | Abbr. | Normal Range |
|---|---|---|
| Heart Rate | HR | 60 – 100 bpm |
| Blood Pressure (Systolic) | BP | 90 – 140 mmHg |
| Respiratory Rate | RR | 12 – 20 breaths/min |
| Temperature | Temp | 37 °C |
| Oxygen Saturation | SpO₂ | 94 – 99 % |
| Blood Glucose Level | BGL | 80 – 120 mg/dL |
Teaching Point: A single abnormal vital sign is a finding. A trend of worsening vital signs is an emergency. Always compare values over time, not just in isolation.
Systematic head-to-toe examination — assess each region in order:
- 📟Monitoring devices: Apply ECG monitor and interpret rhythm.
Teaching Point: The secondary assessment is only performed after life threats are addressed. Never let a thorough secondary exam delay treatment of a critical primary finding.
- 🔁Reassess: Primary Survey · Vital Signs · Interventions
Teaching Point: Reassessment is not optional — it is a core clinical skill. A patient who was stable can deteriorate rapidly. The 5/15 minute rule ensures no patient is left unmonitored.
Endorse to Receiving Health Care Provider
Provide full verbal handover: patient condition, findings, interventions, and trends.
Educational use only. This tool is a study reference for the Adult Patient Assessment systematic protocol. Always follow your institution's current clinical guidelines in practice.