As you prepare for the NREMT exam, understanding the nuances of patient assessment and treatment prioritization is crucial. One common point of confusion is the prioritization during the primary survey of a patient. The assessment and intervention priority order may vary between medical and trauma patients. Recent evidence-based changes in the recommended sequence of care for trauma patients prioritize the recognition and stabilization of life-threatening external hemorrhage before addressing airway and breathing. This can be represented as “XABC.”

Let’s explore how to navigate these priorities effectively and ensure you are ready for exam day.

Understanding the Basics

The foundational principle in emergency medical services (EMS) is the assessment and stabilization of life-threatening conditions. The primary survey helps EMS providers recognize life-threatening conditions.

XABC

The standard primary approach, XABC, emphasizes:

  • X (Exsanguinating Hemorrhage): Ensuring the life-threatening external hemorrhage is immediately identified and managed.
  • Airway: Ensuring the patient’s airway is open and clear.
  • Breathing: Confirming that the patient is breathing adequately.
  • Circulation: Checking for signs of circulation issues, including severe bleeding.

CAB

In some scenarios where immediate chest compressions and defibrillation are crucial (sudden cardiac arrest), the CAB approach is used.

  • Circulation: Perform chest compressions to ensure circulation of blood and defibrillation.
  • Airway: Ensuring the patient’s airway is open.
  • Breathing: Supporting the patient’s breathing with ventilation and oxygenation.

When to Use XABC vs. CAB

XABC Approach

For trauma patients, your priorities during the primary survey include recognition and control of life-threatening bleeding before assessing airway and breathing.

For medical patients, your priorities during the primary survey are to ensure an open airway and then assess breathing and circulation.

CAB Approach

If there is a cardiac arrest situation. Immediate chest compressions take precedence, followed by airway and breathing management. The NREMT exam will use statements like “patient is unresponsive, not breathing, and has no pulse.”

NREMT Exam Tips and Strategies

  1. Read Questions Carefully: The NREMT exam evaluates your ability to apply knowledge to perform the tasks required of entry-level EMS professionals. Pay close attention to the details provided in the questions.
    • For trauma patients, recognizing and controlling life-threatening external hemorrhage is the first priority (direct pressure, tourniquet).
    • For medical patients, ensuring an open and clear airway is the first priority, followed by breathing and circulation.
    • For cardiac arrest patients, beginning chest compressions and defibrillation are priorities.
    • In many cases, EMS providers evaluate all components of the primary survey simultaneously. The exam questions will require you to identify the priority actions to take during the primary survey if life-threatening conditions are discovered.
  2. Stick to National EMS Standards: Remember that the NREMT exam is based on national EMS education standards. While real-world experience is invaluable, the National Registry exams emphasize practical skills and knowledge that providers use in the field. Exam questions are not based on any one textbook or resource but instead reflect widely accepted and current EMS practices. While most textbooks are current and written to high standards, no single source can fully prepare a candidate for the exam. Therefore, candidates should use multiple references, particularly in areas needing additional support.
  3. Practice, Practice, Practice: Use practice exams and study apps to familiarize yourself with the style of questions you will encounter. Aim to consistently score high to build confidence.

Knowledge Application – NREMT Paramedic Scenarios

Let’s review five scenario questions to help illustrate the principles of XABC and CAB prioritization. Scroll down for answers and expanations.

Question 1

You arrive at the scene of a multi-vehicle collision on a busy highway during rush hour. A patient, a middle-aged male, is found unconscious and unresponsive in the driver’s seat with no visible seatbelt on. His head is resting against the steering wheel, and there is a significant amount of blood on the ground near his head. Bystanders report that he was initially moving but has since become unresponsive. The vehicle’s airbags have deployed, and there is a noticeable deformity in the steering column. What is your first priority?

A) Apply a cervical collar to stabilize the spine
B) Perform a jaw thrust to open the airway
C) Apply direct pressure to the bleeding wound
D) Check for a pulse

Question 2

You are dispatched to a remote construction site where a worker has sustained a gunshot wound to the thigh from a nail gun. Upon arrival, you find the patient conscious but in severe distress, with bright red blood spurting from the wound, indicating arterial bleeding. The patient is pale, diaphoretic, and showing signs of shock. There are limited medical supplies available on-site. What is your first action?

A) Apply a tourniquet above the wound
B) Ensure the patient’s airway is clear
C) Administer high-flow oxygen
D) Check for distal pulses

Question 3

You are treating a construction worker who fell from a height of 20 feet onto a concrete surface. The patient is conscious and alert but reports severe neck pain and difficulty breathing. He is lying in a supine position and has multiple abrasions on his arms and legs. Co-workers inform you that he landed on his back. What should you do first?

A) Perform a head-tilt, chin-lift maneuver
B) Assist their breathing with a bag-valve-mask
C) Administer high-flow oxygen
D) Provide spinal motion restriction

Question 4

A player suddenly collapses on the field during a high school soccer game. Upon arrival, you find the player unresponsive, not breathing, and with no palpable pulse. Spectators inform you that the player had been complaining of chest pain before collapsing. An AED is available on-site. What should you do first?

A) Perform a head-tilt, chin-lift technique to open the airway
B) Administer high-flow oxygen
C) Begin chest compressions
D) Apply an AED

Question 5

You are called to a rural farm where a young adult male has been found unresponsive after being struck by a falling tree branch. On arrival, you find the patient lying supine on the ground with no visible signs of external trauma. His breathing is labored, and his skin is pale and cool. Bystanders report that he was initially responsive but lost consciousness shortly after the incident. What should be your first action?

A) Check for a pulse
B) Ensure the patient’s airway is clear and maintain cervical spine precautions
C) Apply high-flow oxygen
D) Perform a rapid trauma assessment

Answers & Explanations

Question 1

B) Perform a jaw thrust to open the airway

Although the patient has significant bleeding, his unconscious and unresponsive state suggests a compromised airway. According to the XABC guideline, managing the airway takes precedence unless the bleeding is life-threatening, which is not specified in the question. Life-threatening bleeding occurs from arterial bleeding, where the signs are spurting, bright red blood. In questions that indicate arterial bleeding, or state “severe bleeding” during the primary survey, the controlling of bleeding should take priority. XABC is the order of priority for trauma patients. Given the mechanism of injury and current patient status, opening the airway is critical.

Question 2

A) Apply a tourniquet above the wound

The description of blood spurting indicates a potentially life-threatening arterial hemorrhage. In this scenario, the EMS provider should prioritize life-threatening bleeding before the airway or breathing. Applying a tourniquet is the most effective immediate action to control severe arterial bleeding and prevent further blood loss.

Question 3

D) Provide spinal motion restriction

For a patient with a suspected spinal injury, spinal motion restriction is crucial to prevent further harm. In many EMS systems, this would include the application of a cervical collar. The difficulty breathing may be secondary to the spinal injury, and ensuring spinal motion restriction is the priority before addressing other issues. Airway management should be performed with caution to avoid exacerbating the injury.

Question 4

C) Begin chest compressions

In a cardiac arrest situation, the CAB (Circulation, Airway, Breathing) applies. Immediate initiation of chest compressions is crucial to maintaining circulation and increasing the chances of a successful resuscitation. After beginning compressions, the AED should be applied as soon as possible to analyze the heart rhythm and provide defibrillation if indicated.

Question 5

B) Ensure the patient’s airway is clear and maintain cervical spine precautions

In this scenario, the patient’s unresponsive state and labored breathing indicate that airway management should be prioritized while maintaining cervical spine precautions due to the mechanism of injury (falling tree branch). Following the XABC guideline, ensuring the airway is clear, and the cervical spine is stabilized before addressing breathing and circulation.

Mastering the NREMT exam requires a solid understanding of patient assessment priorities and critical thinking. By focusing on the details in the questions, practicing extensively, and staying calm under pressure, you can confidently navigate the complexities of patient assessment and prioritization of life-saving interventions. Remember, the goal is to demonstrate your ability to perform the tasks required of entry-level EMS professionals based on National EMS Education Standards.