Patient Assessment System — Lesson 2

Overview: Systematic Patient Assessment

The foundation of wilderness first aid is a systematic approach to patient assessment. This lesson introduces the XABCDE primary survey and the comprehensive secondary survey that follows. These tools help you quickly identify life threats and prioritize treatment in remote environments.

Key Principle: In wilderness medicine, assessment and treatment happen concurrently. You don't wait for a complete assessment before treating life threats.

Why Systematic Assessment?

A fixed order means nothing gets missed and the deadly problems surface first — and your findings drive the evacuation call and the handoff to the next provider. It also gives you something to hold onto when your own heart rate is up.

Key Points

Assessment is dynamic — reassess frequently and adjust treatment as patient condition changes

In wilderness, your assessment skills ARE your diagnostic tools — use them thoroughly

Document findings clearly for handoff to higher-level providers

Primary Survey: XABCDE

The primary survey identifies and treats life-threatening conditions. Each step addresses immediate threats to life. Treatment happens as you identify each problem.

X Exsanguinating hemorrhage

A Airway

B Breathing

C Circulation

D Disability

E Expose/Environment

X = Exsanguinating Hemorrhage

Definition: Massive life-threatening bleeding that must be controlled BEFORE any other assessment step.

Life-threatening bleeding is the most preventable cause of death in trauma
Look for arterial bleeding: bright red, pulsatile, often from extremities or groin
Apply direct pressure immediately and continuously
For obviously life-threatening extremity bleeding, apply a tourniquet immediately — use direct pressure while the tourniquet is being readied
Pack wounds in junctional areas where tourniquets cannot be applied (groin, axilla). Never pack a neck wound — use firm, sustained direct pressure instead

Critical: Exsanguinating hemorrhage is assessed and treated before checking airway. If a patient is actively losing massive amounts of blood, hemorrhage control is the priority.

A = Airway

Goal: Ensure the airway is patent (open) and not at risk of obstruction.

Assessment: Look for movement of chest/abdomen, listen for sounds, feel for air movement
Obstructive sounds: Gurgling (fluid/blood), stridor (partial obstruction), snoring (tongue relaxation)

Opening Techniques

Head-tilt chin-lift: Use when NO spinal injury is suspected. Tilt head back gently, lift chin upward. Opens airway by lifting tongue off pharynx.
Jaw thrust: Use when spinal injury IS suspected. Grip the angles of the mandible (jaw), pull forward without tilting head. Protects cervical spine.

Positioning

Unconscious patient with no spinal concern: recovery position (on their side — either side is fine, left preferred in late pregnancy; head on extended arm, top leg bent for stability) to protect airway if vomiting occurs
Suspected spinal injury: maintain supine alignment with stabilization

B = Breathing

Goal: Ensure adequate ventilation (air moving in and out) and oxygenation.

Respiratory rate: Normal adult is 12-20 breaths per minute. Rates <10 or >30 are concerning.
Depth: Adequate tidal volume — chest rises and falls visibly
Effort: Is breathing effortless or labored?
Look and listen: Watch for equal rise and fall on both sides of the chest; listen near the mouth and chest for abnormal sounds (gurgling, wheezing, stridor)

Signs of Respiratory Distress

Tachypnea (fast breathing) with retractions (skin pulling inward)
Use of accessory muscles (neck muscles, between ribs)
Nasal flaring (nostril expansion)
Tripod position (patient sitting forward on hands)
Paradoxical motion (abdomen goes in when chest goes out — opposite of normal)

C = Circulation

Goal: Assess heart rate, rhythm, and perfusion status (how well blood is circulating).

Pulse check: Check carotid pulse if unconscious (feel on neck), radial pulse if conscious (wrist)
Rate: Normal is 60-100 bpm at rest. <60 (bradycardia) or >100 (tachycardia) can indicate problems.
Rhythm: Regular or irregular? Regularly irregular patterns may suggest specific conditions.
Quality: Strong/thready (weak)? Bounding (forceful)?

Skin Assessment (Signs of Perfusion)

Color: Pink (normal), pale (poor perfusion/cold), mottled (shock/severe hypoperfusion), cyanotic (blue — hypoxia)
Temperature: Warm (normal), cool/cold (peripheral vasoconstriction from shock or cold exposure)
Moisture: Dry (normal), moist/diaphoretic (sweating — shock, cardiac event, fear, exertion)
Capillary refill: Press a nail bed until it blanches, then release — color should return in under 2 seconds. Slower refill suggests poor perfusion (cold extremities can also delay it)

Shock triad: Pale, cool, diaphoretic skin indicates shock or poor perfusion. Immediate treatment and urgent evacuation required.

D = Disability (Neurologic Status)

Goal: Quickly assess level of consciousness and neurologic function.

AVPU Scale

Alert: Patient is awake and oriented, aware of surroundings
Verbal: Patient responds to verbal stimulus (voice), but may be confused
Pain: Patient only responds to painful stimulus (trapezius squeeze — pinch the muscle between the neck and shoulder)
Unresponsive: No response to any stimulus

Pupil Assessment (PERRL)

Pupils Equal: Both pupils same size
Round: Not irregular or fixed in shape
Reactive to Light: Constrict when light is shined in, dilate in darkness

Note: Unequal pupils, fixed pupils, or slow light reaction can indicate serious brain injury. You may hear EMS use the Glasgow Coma Scale (GCS); AVPU is the wilderness-level tool, and it's enough.

E = Expose/Environment

Goal: Fully examine the patient to identify all injuries while preventing heat loss.

Respectfully undress the patient to expose all potential injury sites (maintain privacy as much as possible)
Perform a visual and tactile inspection of the entire body, front and back
Look for wounds, deformities, swelling, bruising
Prevent hypothermia: Once exposed, re-cover patient with blankets or insulation immediately
Consider environmental hazards: weather, temperature, additional dangers at scene

Secondary Survey: Comprehensive Head-to-Toe Exam

The secondary survey is a systematic, detailed physical examination performed AFTER life threats are identified and stabilized. It identifies injuries requiring treatment and guides evacuation decisions.

Head-to-Toe Physical Exam Sequence

Head Assessment (DCAP-BTLS)

Deformity: Abnormal shape or asymmetry?
Contusions: Bruising indicating trauma?
Abrasions: Scrapes or road rash?
Punctures/Penetrations: Wounds breaking the skin?
Burns: Any thermal injuries?
Tenderness: Pain when the area is pressed (palpated)?
Lacerations: Cuts?
Swelling: Edema?

Neck Assessment

Palpate for tenderness, swelling, steps/deformity in spine
For reference: EMS providers may also assess the neck for jugular vein distension or tracheal deviation — late, unreliable signs of serious chest conditions. Your job is to recognize severe breathing difficulty and evacuate urgently.

Chest Assessment

Look for paradoxical motion (flail segment where ribs move opposite to rest of chest)
Watch for equal chest rise on both sides; listen near the mouth and chest for abnormal breathing sounds
Feel for crepitus (air in tissues making crackling sound)
Check for deformity or swelling

Abdomen Assessment

Divide abdomen into four quadrants (right upper, left upper, right lower, left lower)
Look for distension (swelling), bruising, penetrating wounds
Gently palpate each quadrant for tenderness
Check for guarding (patient tightens muscles when you touch) and rigidity (hard, boardlike abdomen)
Guarding and rigidity suggest internal bleeding or peritonitis — urgent evacuation

Pelvis Assessment

Gently press on the pelvis ONCE to assess stability
DO NOT press repeatedly if unstable (can worsen bleeding)
If the mechanism of injury suggests a pelvic fracture, do not stress the pelvis at all — treat based on mechanism and signs
Instability suggests pelvic fracture with potential for massive internal bleeding

Extremities Assessment

Check each limb for deformity, swelling, wounds, color
Neurovascular (NV) check: Distal to injury, assess circulation (pulses, skin color/temp), sensation, motor function (can they move/squeeze your hands?)
CSM Check: Color, Sensation, Motor function distal to injury
Document NV status carefully — guides splinting decisions

Back Assessment

Log-roll patient carefully (maintain spinal alignment if concerned about spine injury)
Inspect posterior for wounds, bruising, deformity
Palpate spine for tenderness or steps/deformity

SAMPLE History

Complete history to understand the patient's baseline health and incident context:

S = Signs & Symptoms: What is the patient's main complaint? What are they experiencing?
- OPQRST for pain:
  - Onset: When did it start?
  - Provocation: What makes it worse?
  - Quality: Sharp, dull, burning, pressure, aching?
  - Radiation: Does it spread to other areas?
  - Severity: Pain scale 0-10
  - Time: How long has it been happening?
A = Allergies: Medications, foods, environmental? Any anaphylaxis history?
M = Medications: Current medications including over-the-counter supplements?
P = Past Medical History: Previous surgeries, illnesses, chronic conditions, recent illness?
L = Last Oral Intake: Food and water consumed, timing? Important for vomiting/anesthesia concerns.
E = Events: What happened leading up to this incident? Mechanism of injury?

Vital Signs Documentation

Pulse: Rate and quality (strong vs. weak/thready)
Respirations: Rate and depth of breathing
Skin: Color, temperature, moisture
Level of Consciousness: AVPU scale and any changes
Pupils: Equal, round, reactive to light?
Temperature: If thermometer available; otherwise assess by touch
Pain Scale: Patient-reported pain level 0-10

Field Impression Formulation

After assessment, develop your working diagnosis (field impression). This is your best guess of what's wrong based on:

Mechanism of injury (what happened)
Signs and symptoms patient is experiencing
Physical examination findings
Patient history
Environmental context

Document clearly: "Patient is a 45-year-old male hiker who fell 10 feet onto his left leg. Complains of severe pain. Left leg is swollen, deformed, neurovascularly intact distally. Field impression: left tibia/fibula fracture."

Serial Reassessment Intervals

Patient condition can change. Reassess and document findings at regular intervals:

Stable patient: Reassess every 15 minutes
Unstable patient: Reassess every 5 minutes
Document trends: Is the patient improving, stable, or deteriorating?
Adjustments to treatment should be guided by reassessment findings

Vital Signs & Patient Documentation

Complete Vital Signs

Vital signs are objective measurements: They don't lie. Changes in vitals often precede patient complaints.

Pulse (Heart Rate):
- Normal adult: 60-100 bpm at rest
- Count for 15 seconds, multiply by 4 for quick assessment
- Rate, rhythm (regular vs. irregular), quality (strong vs. weak/thready)
Respirations (Breathing Rate):
- Normal adult: 12-20 breaths per minute
- Count for 60 seconds for accuracy
- Assess depth and effort in addition to rate
Skin Assessment:
- Color: Pink (normal), pale, mottled, cyanotic (blue)
- Temperature: Warm, cool, cold
- Moisture: Dry, moist, diaphoretic (sweating)
- Capillary refill: press a nail bed and release — color should return in under 2 seconds
- Together these tell you a lot about perfusion and shock status
Level of Consciousness:
- AVPU scale (Alert, Verbal, Pain, Unresponsive)
- Any deterioration is concerning and requires escalation of treatment
Pupils:
- Equal size and reactivity to light?
- Unequal pupils may indicate serious brain pathology
Temperature:
- Core body temperature if thermometer available
- Otherwise, general assessment (warm, cool, cold)
Pain Scale:
- Patient-reported pain: 0 (no pain) to 10 (worst pain imaginable)
- Track changes after pain management interventions

Documentation: SOAP Notes

Clear documentation ensures continuity of care when handing off to higher-level providers. Use SOAP format:

S = Subjective: What the patient tells you
- Chief complaint
- History of present illness
- SAMPLE history
- Patient's own words
O = Objective: What you measure and observe
- Vital signs
- Physical examination findings
- Mechanism of injury
- Observable signs and symptoms
A = Assessment: Your working diagnosis
- Field impression based on all information gathered
- What do you think is wrong with this patient?
P = Plan: Your treatment and evacuation decision
- Treatments initiated and response
- Evacuation urgency (urgent vs. non-urgent)
- Mode of evacuation (walking, litter, helicopter)
- Monitoring plan during evacuation

Case Scenarios

Scenario 1: Unresponsive Hiker on Remote Trail

Setting: Your group finds a 62-year-old male hiker unresponsive on a mountain trail, 6 miles from the trailhead. He has no obvious external injuries, no ID on him, and you have basic first aid training and a satellite communicator.

Primary Survey:

X: Check for massive bleeding — none visible
A: Check airway — unresponsive patient, no sounds of airway obstruction
B: Check breathing — is he breathing? Rate? If breathing, is it adequate?
C: Check pulse — carotid pulse present? Rate and quality?
D: AVPU — he's unresponsive. Check pupils. Any obvious head trauma?
E: Undress to check for injuries. Any signs of trauma, medical alert bracelet?

Secondary Survey:

Full head-to-toe exam looking for cause of unconsciousness
Check blood glucose using the patient's own glucometer if they have one (could be diabetic emergency)
Assess for head trauma, stroke, seizure, medication effects

Documentation: Unresponsive male, unknown name, no mechanism of injury identifiable. Pupils: equal and reactive. Breathing regular at 14/min. Pulse 88 bpm regular. Skin warm and dry. No obvious signs of trauma. Field impression: Altered mental status — etiology unknown (possible stroke, cardiac event, medication effect, hypoglycemia). Urgent evacuation via helicopter. Activate satellite communicator for SAR response. Place the patient in the recovery position to protect the airway and monitor closely while awaiting evacuation.

Scenario 2: Rock Climber with Multiple Complaints

Setting: A 28-year-old rock climber is rappelling down a cliff when a rope catches. She falls 8 feet onto a ledge with loose rock. She's conscious but in significant pain, complaining of wrist pain, left knee swelling, and left shoulder pain. She's shaken up but insists she's okay. Your group is 3 hours from the trailhead.

Primary Survey:

X: No massive bleeding visible
A: Patient is alert and speaking — airway is patent
B: She's speaking in full sentences, not labored breathing
C: Radial pulse present, regular, adequate rate. Skin is pink, normal temp and moisture
D: Alert and oriented × 3 (knows person, place, time). Pupils equal and reactive.
E: Mechanism of fall — 8 feet. Potential for significant injuries. Expose to check for hidden injuries.

Secondary Survey:

Head to toe exam — focus on areas of complaint
Left wrist: assess for fracture. NV check distal to injury. Compare to right wrist.
Left knee: swelling present. Assess NV status. Can she bear weight?
Left shoulder: pain with movement. Assess NV. Range of motion. Suspected dislocation vs. fracture vs. strain?
Vital signs: Establish baseline for pain management

Spine check: A fall from height is a spine mechanism: ask the spine questions before anyone moves — no neck or back pain, no tingling, normal hands and feet here — and remember her wrist is a distracting injury, so stay conservative.

Documentation: 28-year-old female, fall 8 feet onto ledge. Alert and oriented. Pain in left wrist (deformity present, NV intact), left knee (swelling, no deformity, able to bear weight), left shoulder (pain with movement, no deformity, NV intact). Vital signs stable. No head injury signs. Field impression: Multiple musculoskeletal injuries — left wrist possible fracture, left knee contusion/possible ligament injury, left shoulder strain/possible dislocation. Non-urgent evacuation — can walk with assistance or litter depending on patient tolerance and terrain difficulty. Splint wrist and knee. Monitor neurovascular status.

Knowledge Check

10 questions. Pick an answer to get immediate feedback. Answer order is shuffled each attempt, and your best score is saved on this device.

Lesson Summary

Key Concepts

The XABCDE primary survey identifies and treats life threats in order of lethality

Exsanguinating hemorrhage is addressed before airway — prevent death from bleeding first

The secondary survey is a systematic head-to-toe exam performed after life threats are stabilized

SAMPLE history and OPQRST for pain characterization guide assessment

Vital signs document patient status; changes indicate need for treatment adjustment

Serial reassessment (every 5-15 min depending on stability) tracks patient trajectory

Clear SOAP documentation ensures continuity when handing off to higher-level providers

Assessment Creates the Treatment Plan

Your assessment findings directly guide treatment priorities and evacuation decisions. A thorough, systematic assessment is the foundation of good wilderness medicine. Take time to do it well, but work efficiently — you don't need to be slow, you need to be thorough.

Glossary

Primary Survey

Rapid assessment (XABCDE) identifying and treating life-threatening conditions

Secondary Survey

Comprehensive head-to-toe physical exam performed after primary survey stabilization

AVPU

Scale for consciousness: Alert, Verbal, Pain, Unresponsive

XABCDE

Primary survey mnemonic: Exsanguinating hemorrhage, Airway, Breathing, Circulation, Disability, Expose

OPQRST

Pain characterization: Onset, Provocation, Quality, Radiation, Severity, Time

SAMPLE

History framework: Signs/Symptoms, Allergies, Medications, Past history, Last intake, Events

DCAP-BTLS

Head assessment: Deformity, Contusions, Abrasions, Punctures, Burns, Tenderness, Lacerations, Swelling

Tachycardia

Elevated heart rate, typically >100 bpm at rest; can indicate shock, fear, pain, fever

Diaphoretic

Sweating, often cold and clammy; sign of shock, cardiac event, pain, or fear

Field Impression

Working diagnosis based on all assessment findings; guides treatment plan

Serial Assessment

Repeated reassessment at intervals (every 5-15 min) to track patient status changes