The primary survey is the assessment process used to assist in recognition of acute life-threatening injuries and should proceed concurrently with resuscitation. An effective primary survey requires awareness of a limited number of life-threatening entities, rapid and simple systems of physiological assessment and awareness of a plethora of interventions that can be applied to correct the identified problem.
Some aspects of care during the primary survey need special emphasis. As the primary survey assessment is followed, interventions should be taken immediately to correct the problems that are identified with each step.
The primary survey aims to identify and immediately treat life-threatening injuries relying on the ABCDE mnemonic. Injuries not imminently fatal must wait. The ABCDE mnemonic prioritizes the importance of specific injuries and assists clinical performance. In medical facilities with a major trauma service and an effective trauma team response, there will be enough team members to concurrently perform some parts of the primary survey together with the necessary resuscitative interventions.
The ABCDE mnemonic comprises:
- Airway control with stabilization of the cervical spine
- Breathing (work and efficacy)
- Circulation/Hemorrhage including the control of external hemorrhage
- Disability or neurologic status
- Exposure/Environment (undressing of the trauma patient while also protecting the patient from hypothermia)
A - Airway Control with Stabilization of the Cervical Spine
The airway is the first priority. Airway assessment should proceed while maintaining the cervical spine in a neutral position. The cervical spine is best maintained in a neutral position by using a rigid cervical immobilization collar. Emphasis is given to using simple measures to protect the cervical spine when attending to the adequacy of the airway.
The airway should be assessed by determining the ability of air to pass unobstructed into the lungs. Critical findings include:
- Obstruction of the airway due to direct injury, edema or foreign bodies
- Inability to protect the airway because of a depressed level of consciousness
When the airway is jeopardized or when the GCS score is less than 8, an artificial airway is essential. Airway control is commonly achieved by means of rapid-sequence endotracheal intubation performed with in-line stabilization of the cervical spine. Correct placement of the endotracheal tube is confirmed by:
- The aid of an end-tidal carbon dioxide monitoring device
- Observation of the tube passing through the vocal cords
- Auscultation of breath sounds
Several well-defined options for achieving airway control must be established if endotracheal intubation cannot be achieved. These options include:
- Laryngeal mask airway (LMA)
- Intubating LMA
- Fiberoptic intubation
- Percutaneous cricothyroidotomy
- Surgical cricothyroidotomy (tracheostomy in children)
Tracheal inspection is essential to determine if there is peritracheal crepitus or deviation from the midline indicating potential direct airway injury or intrathoracic pulmonary or major vascular injury.
Table 1: Airway
| Disruption/Edema||Cyanosis||Gloved finger, light, suction|
| Foreign bodies||Voice||Oxygen, suctioning|
| Blood and Vomitus||Stridor||Chin lift/jaw thrust, suctioning|
| Soft tissue edema||Confusion||Oropharyngeal airway|
|Deteriorating Consciousness:||Respiratory Distress||Nasopharyngeal airway, Laryngeal mask airway (LMA), Intubating LMA, Fiberoptic intubation|
| ||Air movement||Endotracheal intubation|
| || |
Table 2: C-Spine
|Unstable Fracture ||Assume if:|| |
| || Unconscious||Semi-rigid cervical collar|
| || Head injury||Sandbags/tape|
| || Face injury||Maual in-line immobilization|
B - Breathing
The adequacy of breathing should next be assessed to determine the trauma patient’s ability to ventilate and oxygenate. This assessment is most readily accomplished by:
- Visual inspection of thoracic cage movement
- Palpation of thoracic cage movement
- Auscultation of gas entry (over trachea and lungs)
Critical findings to assess for include:
- Absence of spontaneous ventilation
- Absent or asymmetric breath sounds (consistent with either pneumothorax or endotracheal tube malposition)
- Hyperresonance or dullness to chest percussion (e.g., tension pneumothorax or hemothorax)
- Gross chest wall instability or defects that compromise ventilation (e.g., flail chest, sucking chest wound)
- Local asymmetric chest wall movement (e.g., flail chest)
- Signs of impending respiratory failure such as uncoordinated thoracic cage and abdominal wall movement, accessory muscle use and stridor
Inadequate ventilation may result in hypoxemia, hypercarbia, cyanosis, depressed level of consciousness, bradycardia, tachycardia, hypertension or hypotension. Generally, until adequate ventilation has been achieved, high-flow oxygen should be administered by mask to all trauma patients to help prevent hypoxemia.
Classic signs of a pneumothorax, tension pneumothorax, hemothorax, combined hemopneumothorax and sucking chest wounds include:
- Tracheal deviation
- Jugular vein distension
Intrathoracic tension physiology is a clinical diagnosis and requires immediate decompression. This is initially commonly accomplished by inserting a large-bore catheter (e.g., 14 gauge or larger) into the pleural space at the second intercostal space at the mid-clavicular line (i.e., needle thoracentesis). Trauma patients treated in this way should have a tube thoracostomy (i.e., chest tubes) placed to manage simple pneumothorax and to evacuate thoracic cavity blood if present. Life-threatening hemorrhage identified when placing a tube thoracostomy may be managed with a resuscitative thoracotomy.
Initial treatment for a flail chest is mechanical ventilation which frequently is required for other injuries associated with ventilation and oxygenation deficits.
Table 3: Breathing
|Open pneumothorax||Confusion||Needle thoracentesis|
|Massive flail||Respiratory distress||Tube thoracentesis|
|Reduction in level of consciousness/poor respiratory effort||Shallow respiration||Tracheal intubation|
|Poor chest expansion||Cover open wound|
|High spinal cord injury|
C – Circulation/Hemorrhage Control
Emergent treatment of trauma patients with exsanguinating hemorrhage or shock can be life-saving. This assessment includes identifying and managing rapid external hemorrhage; this can often be achieved with a simple pressure dressing, but surgical intervention may be required. As more experience is gained with procoagulant dressings (used principally by the military), external hemorrhage control may gain pharmacologic support embedded in dressings.
Shock in trauma patients is defined as inadequate organ perfusion and tissue oxygenation. Causes of shock include:
- Cardiac tamponade
- Hemorrhage leading to hypovolemia (most common cause)
- Spinal cord injury
- Tension pneumothorax or hemothorax
Signs of shock include:
- Decreased pulse pressure
- Delayed capillary refill
- Depressed level of consciousness
In trauma patients with hypovolemia, the neck veins may be flat. A normal mental status generally implies adequate cerebral perfusion pressure while diminished mentation may be associated with shock with or without intracranial trauma.
Treatment of hypovolemia should be initiated by rapidly infusing a lactated Ringer solution via two large-bore, peripheral IV catheters. They should be placed preferentially in the upper extremities.
The Committee on Trauma of the American College of Surgeons (ACS-COT) has long published categories of shock that allow the healthcare provider to predict the likelihood of significant blood loss and to anticipate the type and amount of fluid requirements.12
The shock classification (Table 4) allows the healthcare provider to characterize the trauma patient’s response to injury. As blood loss associated with injury progresses, mental status deteriorates, heart rate increases, blood pressure falls and oliguria becomes apparent.12 The trauma patient with persistent vital sign evaluation suggesting hypotension is at significant risk for loss of 30 - 40% of blood volume on presentation.
Table 4: Estimated Fluid and Blood Losses Based on Patient's Initial Presentation12
| ||Class I||Class II||Class III||Class IV|
|Blood Loss (% blood volume)||Up to 15%||15-30%||30-40%||>40%|
|Blood Pressure (mmHg)||Normal or increased||Decreased||Decreased||Decreased|
|Urine Output (mL/h)||>30||20-30||5-15||Negligible|
|CNS/Mental status||Slightly Anxious||Mildly Anxious||Anxious, Confused||Confused, Lethargic|
|Fluid Replacement (3:1 rule)||Crystalloid||Crystalloid||Crystalloid and Blood||Crystalloid and Blood|
Advanced Trauma Life Support (ATLS) also recognizes the four different classes of shock. In summary, Class I and II shock generally do not need red cell mass restoration and are well managed with asanguineous fluids for plasma volume expansion. Hypotension and disordered mentation generally indicate at least Class III shock and should prompt plasma volume expansion and red cell mass repletion if the hypotension fails to resolve after an initial 2000cc crystalloid bolus, according to ATLS.12
A systematic approach for detecting the source of hypovolemic shock should consider five sources of ongoing hemorrhage:
- External (e.g., from the scalp, skin or nose)
- Long-bone fracture
- Peritoneal cavity
- Pleural cavities
Fracture alignment and stabilization is essential in limiting blood loss. Pelvic fractures may be initially stabilized with a pelvic binder or a wrapped sheet secured with a towel clip as a means of reducing pelvic volume to limit hemorrhage.
Table 5: Circulation
|Bleeding:|| || |
| External (Scene, bed, floor)||Pale, clammy, cool||Oxygen, Direct pressure|
| Chest (chest X-ray)||Peripheral cyanosis||Intravenous access (large bore x 2)|
| Abdomen (FAST or DPL)||Confusion||Warmed crystalloid/colloid/blood|
| Pelvis (x-ray)||Tachycardia||Hemorrhage control (direct pressure or surgery)|
| Femurs (clinical exam||Low pulse volume|| |
| Combination||Slow capillary refill||Pressure infusion|
|Neck veins||Blood warming|
|Heart sounds (muffled)||Gastric tube|
| ||Surgery (urinary catheter)|
|Heart:|| || |
| Tension Pneumothorax|| ||Needle/tube thoracentesis|
| Cardiac tamponade|| ||Paricardiocentesis, Subxiphoid pericardial windo|
| Contusion|| || |
| Infarction|| || |
D - Disability
During the acute resuscitation period, a brief assessment of neurologic status should be performed. This assessment should include a global assessment of the trauma patient's level of responsiveness, as well as, the patient's posture (i.e., any asymmetry, decerebrate or decorticate posturing), pupil asymmetry and pupillary response to light.
A recommended system is the AVPU mnemonic:
- A = Patient is awake, alert and appropriate
- V = Patient responds to voice
- P = Patient responds to pain
- U = Patient is unresponsive
The disability of the trauma patient should be assessed by determining:
- Gross mental status and motor examinations using the Glasgow Coma Scale (GCS) (Table 6)
- Existence of a serious head or spinal cord injury
- Observe spontaneous movement of the extremities and spontaneous respiratory effort
- Pupillary size, symmetry and reactiveness to light
Table 6: GCS
|To Verbal Stimuli||3|
|BEST VERBAL||No Response||1|
|Disoriented and Converses||4|
|Oriented and Converses||5|
|BEST MOTOR||No Response||1|
|Extension Abnormal (Decerebrate Rigidity)||2|
|Flexion Abnormal (Decorticate Rigidity)||3|
|TOTAL SCORE|| ||3-15|
Pupillary asymmetry or dilation, impaired or absent light reflexes and hemiplegia or weakness suggest impending herniation of the cerebrum through the tentorial incisura due to an expanding intracranial mass or diffuse cerebral edema.22 These findings indicate the need for emergency treatment of intracranial hypertension, including administration of IV mannitol, hypertonic saline, sedatives and muscle relaxants, after obtaining a definitive airway. Urgent neurosurgical consultation is mandatory.
The absence of a depressed level of consciousness but the presence of paraplegia or quadriplegia indicates spinal cord injury. The possibility of a spinal cord injury requires full spinal immobilization. If inspiratory efforts are weak or when a high cervical cord lesion is suspected, an endotracheal intubation should be performed.23,24
Continuous assessment using the GCS should be made at this time, during the secondary survey and at any time that the trauma patient’s mental status appears to change. A more detailed assessment of the trauma patient’s neurologic status is made during the secondary survey.
Table 7: Disability (CNS)
|Secondary brain injury||Alert||A, B, C|
|Intracranial hematoma||Voice Response||C-spine protection|
|Contusion||Lateralizing signs|| |
|Swelling|| || |
E – Exposure/Environment
The final step in the primary survey includes patient exposure and control of the immediate environment. Trauma patients should be completely disrobed during the primary survey for a thorough physical examination. This exam helps ensure a rapid search for hidden injuries in order to assess for emergently life-threatening damage hidden beneath garments. Practiced trauma teams often pre-designate one or more staff to the essential task of exposure. The clothes are cut off to prevent extraneous movements of the body parts.
Simultaneously, efforts should be made to prevent significant hypothermia by providing a warm ambient room (28 - 30°C). The trauma patient should be treated prophylactically with the administration of warmed IV fluids, blankets, heat lamps, overhead heating and warmed air-circulating blankets as needed. The trauma patient's temperature should be measured on arrival at the emergency department and at intervals thereafter. Strenuous efforts should be made to avoid significant hypothermia during resuscitation and therapeutic intervention.
Table 8: Exposure/Environment Control
|Concealed injuries||Prepare for secondary survey||Cut all clothes off|
|Hypothermia||Patient temperature||Warm ambient room|
Warmed IV fluids
Warmed air-circulating blankets