The initial assessment is a quick "once over" designed to identify any immediate life threats. By evaluating the mechanism of injury, you may be able to determine if the problem is primarily medical (illness) or trauma (injury) in nature. If you cannot accurately rule out trauma, assume some type of neck injury is involved. By identifying yourself, your level of training and asking permission to treat, you will have gained insight into your patient's level of consciousness. Continue your assessment by asking the patient their name, where they are and today's date or recent events. These simple questions evaluate if the patient is alert and oriented to `person, place and time.' We call this alert and oriented times 3 (A8.Ox3). If your patient is unresponsive to these questions, using verbal and physical stimuli in combination may rouse them. Use either the "touch and talk" or the "squeeze and shout" method to see if you can get a response.

The four most important skills you can perform for your patient are collectively called the initial assessment. This survey is composed of A, B, C & D. During this skill, you are evaluating and, if necessary, treating the four most critical elements of a full recovery. Here are the ABCD elements of the initial assessment.

A - (Airway) The first step is always to establish an open airway. Without an open airway, your patient will eventually die due to lack of oxygen. To open the airway, use the head tilt-chin lift method. Kneel near the patient's left shoulder. Place the heel of your right on the patient's forehead and the fingertips of your left hand just under the patient's chin. Then place upward pressure on their chin while pressing gently down on the patient's forehead. This rotates the head backward, thereby lifting the tongue off the back of the throat and clearing the airway. When trauma or injury is suspected, you should use the jaw thrust method. This method protects the spine from further damage. To accomplish this, position yourself behind the patient's head, place one hand on either side of their chin with your fingers under their lower jaw. Rotate the lower jaw (mandible) forward. The jaw thrust method is more difficult to use. Once the airway has been opened, you will need to continually monitor and possibly, reposition it.

B - (Breathing) Once an airway has been established, the next step is to evaluate your patient's ability to breathe. Use the look, listen and feel technique. Kneel down next to the patient and place your ear next to their mouth while looking down their chest. You are looking for the chest to rise and fall, listening for the sound of air rushing out of their mouth and nose and attempting to feel the patient exhaling on your cheek. This check should be performed for 5-10 seconds. If you do not hear the patient breathing normally, see the chest rising and falling or feel them exhaling on your cheek, you will need to breathe for them using rescue breaths and a mouth-to-barrier device.

C - (Circulation) When evaluating circulation, we are assessing the body's ability to pump blood. This is accomplished by looking for SIGNS OF CIRCULATION. These include normal respiratory effort or coughing, spontaneous movement, skin color and a pulse check. There are two types of pulses in the human body. Peripheral pulses (located on the thumb side of the wrist, in the upper arm under the biceps muscle, on top of the feet and behind the knees) are the first pulses in the body to become undetectable during illness or injury. Central pulses (on the sides of the neck and where the legs join the body) are the last pulses that remain. Always evaluate an ill or injured person by checking their carotid pulse. To do this, place the pads of two fingers gently on your patient's Adam's apple (thyroid). Slowly drag your fingers back toward you until they drop into a groove on the side of the patient's neck. By applying light pressure, you should be able to feel the patient's pulse. Again, this check needs to be performed for a minimum of 5 and a maximum of 10 seconds. If your patient is exhibiting no signs of circulation or you are unsure if they have a pulse, err on the side of treatment. At this point you will need to begin chest compressions and, if available, initiate the use of an Automatic External Defibrillator.

Another way to help evaluate signs of circulation is to check capillary refill. To determine how well the patient's circulation is working, squeeze and release the bed of their fingernail. You will initially see the nail bed blanch. Once pressure is released, the pink or pigment color will return to the nail bed. Color returning in less than 3 seconds indicates good circulation. Again, if you are unsure if you feel a pulse or see signs of circulation, err on the side of treatment.

The final aspect of circulation is to check for major bleeding. Bleeding can be life-threatening, especially when it comes from a large vein or artery. After you check for a pulse, quickly run your gloved hands down the sides of the patient's body. Evaluate your gloves for blood. Serious bleeding must be treated immediately using direct pressure dressings.

D - (Disability/Defibrillation) This final aspect of the primary survey has two separate components. Disability is used when the patient has their ABC's intact. Defibrillation is the component used when the patient is lacking a heartbeat.

Conduct a quick check of the patient's responsiveness. You nay have already accomplished this when seeking permission to treat. Many times, the patient's ability to recall the rescuer's name indicates they are alert and oriented. This is also the time to evaluate the patient's spinal cord function. Ask your patient to wiggle their fingers and toes. If they comply, at least for the time being, their spinal cord is intact. Signs and symptoms of spinal cord injury may include pain in the neck or back, numbness or tingling in an extremity or the inability to move parts of their body.