When assessing a victim for injuries, you work through a structured sequence: first confirm the scene is safe, then check for life-threatening problems with airway, breathing, and circulation, and only after those are stable do you move to a full head-to-toe examination. This order exists because the most dangerous injuries are often the least obvious, and checking systematically prevents you from being distracted by a dramatic wound while missing something fatal.
Make Sure the Scene Is Safe First
Before you touch the victim, scan the environment. Look for traffic, fire, downed electrical lines, chemical spills, unstable structures, or an active threat like an attacker still present. If the scene is dangerous to you, you cannot help anyone, and you risk becoming a second victim. Only approach once you’ve determined you can do so without putting yourself in immediate danger.
While approaching, start gathering information. How many people are injured? What likely caused the injury: a fall, a vehicle collision, a machinery accident? This context shapes what you look for once you reach the victim.
The ABCDE Primary Assessment
The primary assessment follows the ABCDE sequence. Each letter represents a category of life threat, checked in order. If you find a problem at any step, you address it before moving on.
- A: Airway. Is the victim’s airway open and clear? Look in the mouth for blood, vomit, broken teeth, or any object that could block airflow. If you suspect a neck or spine injury (from a fall, collision, or any mechanism involving force to the head), keep the head and neck as still as possible while opening the airway.
- B: Breathing. Once the airway is clear, check whether the person is actually breathing. Watch the chest rise and fall, listen for breath sounds, and feel for air against your cheek. A normal adult at rest breathes 12 to 18 times per minute. Breathing faster than 25 times per minute or slower than 12 suggests a serious problem. Listen for abnormal sounds like wheezing, gurgling, or gasping.
- C: Circulation. Check for a pulse and look for major bleeding. A normal resting heart rate is 60 to 100 beats per minute. Rapid, weak pulses can indicate shock. You can also press a fingernail bed firmly for a moment and release: the color should return in under 3 seconds. If it takes longer, blood isn’t circulating well, which is an early warning sign of shock. Control any severe bleeding with direct pressure.
- D: Disability. This means a quick check of neurological function. The simplest tool is the AVPU scale. Is the person Alert (aware, tracking objects, following commands)? Do they respond only to your Voice (eyes open when you speak to them, but not spontaneously)? Do they respond only to Pain (moaning or pulling away when pinched)? Or are they completely Unresponsive? Each step down this scale indicates a more serious level of impairment.
- E: Exposure. Remove or cut away clothing to look for injuries you might otherwise miss. Wounds on the back, under heavy clothing, or in skin folds are easy to overlook. Once you’ve checked, cover the person to prevent heat loss, since injured people lose body temperature quickly.
Checking Consciousness and Neurological Signs
The AVPU scale gives you a fast read on how the brain is functioning. An alert person who can tell you their name and what happened is a very different situation from someone who only groans when you squeeze their hand. Any decline from alert to verbally responsive, or from verbally responsive to pain-responsive, signals worsening neurological status and urgency.
Beyond AVPU, check whether both pupils are the same size and whether they shrink when exposed to light. Unequal pupils can indicate pressure building inside the skull. Ask the person to squeeze both your hands and push against your hands with both feet. Weakness on one side suggests a brain or spinal cord injury. If the person is conscious, ask if they can feel you touching their fingers and toes, since loss of sensation points to nerve or spinal damage.
The Head-to-Toe Secondary Assessment
Once you’ve confirmed no immediate life threats, the secondary assessment is a systematic physical check of the entire body. You work from head to toe, using your eyes and hands to find injuries the primary survey didn’t catch. All clothing should be removed or opened enough to see and feel each area. This is where you catch fractures, dislocations, puncture wounds, and signs of internal injury.
Start at the head. Run your fingers gently over the scalp feeling for bumps, depressions, or wet spots that could be bleeding hidden by hair. Check the ears and nose for clear fluid, which can indicate a skull fracture. Look at the face for asymmetry, swelling, or deformity.
Move to the neck. Feel along the spine at the back of the neck for tenderness or a step-off (one vertebra sitting higher or lower than the next). Check the front of the neck for swelling or deviation of the windpipe, which could mean air is trapped in the chest cavity. If there’s any midline neck tenderness, altered mental status, neurological problems, or a distracting injury elsewhere, treat the spine as potentially injured and keep the neck immobilized.
For the chest, press gently on each side of the ribcage. Pain or a crackling sensation under the skin suggests broken ribs or air leaking from a lung. Watch whether both sides of the chest rise equally. Unequal movement can mean a collapsed lung on the side that isn’t moving.
At the abdomen, feel gently across all four quadrants. A rigid, board-like belly or extreme tenderness when you press lightly can indicate internal bleeding or organ damage. Swelling or bruising around the navel or along the flanks is another red flag for bleeding inside the abdomen.
Check the pelvis by pressing gently inward on both hip bones. Do this only once, since repeated pressure on an unstable pelvic fracture can worsen bleeding. Pain or instability means you should avoid moving the victim’s lower body.
Examine each limb by running your hands along the bones, feeling for deformity, swelling, or grinding. Check circulation at the far end of each limb: can the person feel your touch, wiggle fingers and toes, and does the skin look a normal color? Compare one side to the other.
Gathering a Quick Medical History
If the victim is conscious, a brief history can reveal critical information that changes how you respond. The SAMPLE framework covers the essentials:
- Signs and symptoms: What are you feeling right now? Where is the pain? When did it start? Rate it on a scale of 1 to 10.
- Allergies: Any allergies to medications, foods, or environmental triggers?
- Medications: What medications do you take? Blood thinners, for instance, make even minor injuries bleed far more than expected.
- Past medical history: Any major conditions like diabetes, seizures, or heart problems?
- Last meal or drink: When did you last eat or drink? This matters if surgery becomes necessary.
- Events: What happened right before the injury? What were you doing? Did you feel dizzy or lose consciousness before the fall or crash?
Write this information down or relay it to arriving emergency responders. Details that seem minor to you, like a medication name or the fact that the person briefly blacked out before a car accident, can significantly change treatment decisions at the hospital.
Recognizing Internal Injuries
Internal bleeding doesn’t always announce itself with visible blood. The signs are subtler: increasing confusion or anxiety, skin that becomes pale, cool, and clammy, a rapid weak pulse, and a capillary refill time longer than 3 seconds. Abdominal pain and swelling that develop after a blow to the torso, or chest pain after an impact, both suggest bleeding inside a body cavity.
Bruising patterns can also tell a story. Bruising around the navel (sometimes called Cullen’s sign) or along the sides of the abdomen suggests blood pooling internally. Bruising behind the ears can indicate a skull base fracture, even when the scalp looks fine. These signs may not appear immediately, so if you’re with a victim for an extended period, reassess regularly.
Assessing Children Differently
Children are not small adults. Their bodies compensate for blood loss and injury differently, and they can look deceptively stable right up until they crash. The Pediatric Assessment Triangle offers a rapid way to gauge a child’s condition using only what you can see and hear, with no equipment needed.
It has three components. First, appearance: Is the child’s muscle tone normal? Are they interacting with you or their caregiver? Can they be consoled if crying? Is their gaze focused or vacant? Is their cry strong or weak? An infant who is limp, uninterested in surroundings, or inconsolable is showing signs of serious illness or injury. Second, work of breathing: listen for abnormal sounds like grunting, stridor (a high-pitched noise on inhaling), or wheezing, and watch for nostril flaring or visible rib outlines with each breath. Third, circulation to the skin: pale, bluish, or mottled skin indicates that blood is being redirected away from the skin surface to protect vital organs, an early sign of shock.
Any abnormality in even one of these three areas means the child needs immediate intervention. The pattern of which areas are abnormal helps categorize whether the child is in respiratory distress, shock, or a combination of both.
Reassessing Continuously
An injury assessment is not a one-time event. A victim who seemed stable five minutes ago can deteriorate quickly, especially with internal bleeding or a head injury. Repeat your ABCDE checks every few minutes while waiting for emergency services. Pay particular attention to changes in consciousness level, breathing rate, pulse quality, and skin color. If someone who was alert and talking becomes confused or drowsy, that’s a significant change that needs to be communicated immediately to responding paramedics.
Keep a mental or written log of what you find and when. Noting that a person’s pulse went from 80 to 120 over ten minutes, or that they stopped being able to move their left hand, gives emergency responders a timeline that helps them identify what’s happening inside the body.