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primary survey

Article · January 2010

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Muhammad Abid Bashir

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Muhammad Abid Bashir
Faisalabad, Pakistan
Emergency & Trauma
ABC OF PRIMARY SURVEY
A airway
B breathing
C circulation
D disability
E exposure & environment
AIRWAY COMPROMISE
UNCONSCIOUS PATIENT
GCS < 8
Non purposeful movements
FOREIGN BODY
Dentures and teeth
Secretions
Blood
FACIAL TRAUMA
Posteriorly displaced bones
Hemorrhage
NECK TRAUMA
Laryngeal injury
Edema
78
PRIMARY SURVEY
P rimary survey is the quick systemic
examination of an injured person
for early recognition and proper
management of life threatening
conditions that can significantly reduce
mortality and morbidity.
Plan of trauma management includes:
! Primary survey
! Resuscitation and management of
life threatening conditions.
! Detailed head to toe examination
(secondary survey)
! Definitive management.
There is trimodal death pattern in injury
and trauma i.e., death occurs in one of
the three time periods.
The first peak occurs within seconds to
minutes. These patients have sustained
very severe injuries and are rarely
salvageable.
Second peak occurs within minutes to
several hours. Death usually occurs
due to subdural and extradural
hematomas, hemo-pneumothorax
and hemorrhage from multiple
injuries. These patients can be saved
with proper management in the
“golden hour” which does not mean
exactly an hour but it symbolizes the
immediate time period after trauma in
which proper management can have
significant impact on the outcome.
The third peak occurs several days to
months after initial trauma and is due
to sepsis and multiple organ failure.
Golden hour care influences the
patient outcome even during this
period.
Jan to March, 2010
IR-014
Objectives
The objectives of primary survey are:
! Adequate assessment of the
multiple trauma patient quickly
and effectively
! To establish treatment priorities on
the basis of their injuries and vital
signs
! To recognize the life threatening
conditions
! To act immediately to treat life
threatening condition
Quick and effective assessment means
that the examination is performed in an
orderly manner so that no significant
injury is missed. It is important that
immediate life threatening conditions
are dealt first. It is a structured team
approach. Assessment as well as
management of the life threatening
conditions are done simultaneously.
Quick and effective assessment is done
in ABCDE manner where A stands for
airway, B for breathing and ventilation,
C for circulation, D for disability and E
for exposure and environment
Airway
While assessing airway, it is important
to urgently identify airway compromise
and secure a definitive airway. The
quickest way to assess an airway is by
talking to the patient. If the patient can
talk, the airway is clear.
Airway compromise may be sudden or
insidious, partial or complete or
progressive. Airway compromise is
always suspected in patients with
injuries above the clavicle. It includes
head injury, faciomaxillary fractures
and trauma neck. (Box-2)
INDEPENDENT REVIEWS
An unconscious patient is a candidate
for a definitive airway control. Head
injury patient who is conscious, should
be considered a candidate for airway
loss. Reassessment and re-evaluation
of such a patient is of prime impor-
tance.
The patients with facio-maxillary
trauma are at risk of airway
obstruction. It may be due to
oropharyngeal or nasopharyngeal
compromise because of displacement
of fractured bones, hemorrhage or
even broken teeth. Neck injuries can
obstruct airway due to neck hematoma
or laryngeal injury. Foreign bodies and
secretions including blood and
vomitus are most important causes of
acute airway obstruction. Tongue may
fall back, obstructing the airway in
comatosed patient.
A finger should be swiped in the
patient's oropharynx to clear any
foreign body or secretions. Simple
maneuvers like jaw thrust and chin lift
can pull the tongue away, clearing the
airway. Oropharyngeal airway of the
appropriate size is passed to prevent
the tongue falling back again. Cervical
spines should be protected during all
these maneuvers.
Patients of head injury with GCS below
9 and presence of neck trauma require
definitive airway control.
A definitive airway means a tube in the
trachea with the cuff inflated, tube
connected to oxygen enriched assisted
ventilation and secured in place with
tape. Three types of airway can be
classified as definitive airway, i.e.,
orotracheal tube, nasotracheal tube
and surgical airway (tracheostomy).
Choice of orotracheal or nasotracheal
tube depends upon the expertise of the
surgeon and type of injuries.
Needle cricothyroidotomy can be
Jan to March, 2010 INDEPENDENT
performed in emergency in case of
failure in maintaining definitive airway.
It is only a temporizing measure to gain
time for the maintenance of definitive
airway. A wide bore cannula (14 or 16
gauge) is passed through the crico-
thyroid membrane into the trachea.
Oxygen is supplemented at 15 L/min
through a Y connector. The Y
connector facilitates intermittent
insufflations i.e., one second on and
three seconds off to allow some
exhalation. If Y connector is not
available, a hole can be cut in the tube Fig. 1: Insertion of oropharyngeal
for the same purpose. Due to airways
incomplete exhalation, there is
progressive accumulation of CO2
limiting the prolonged use of
cricothyroidotomy.
Breathing and ventilation BREATHING AND VENTILATION
Adequate airway does not mean IDENTIFY
Tension pneumothorax
adequate ventilation. Adequate Cardiac tamponade
ventilation requires coordinated Massive hemothorax
Flail chest
movements of chest wall and
PERFORM
diaphragm as well as normally inflated Needle decompression
lung parenchyma for optimal Pericardiocentesis
Chest intubation
exchange of oxygen and carbon
PROVIDE
dioxide. Oxygen supplementation
Analgesia
Standard examination of chest is
performed. Chest wall is inspected for
symmetry, breathing movements,
wounds and injuries as well as for
presence of any paradoxical
movements. Neck is examined for
engorged veins and position of
trachea. Percussion is helpful in
demonstrating pneumo / hemothorax.
Auscultation is done to assess air entry
and abnormal sounds.
Assessment for the immediate life
threatening conditions is done. These
include;
! Tension pneumothorax
! Open pneumothorax
! Flail chest
! Massive hemothorax
Life threatening conditions are treated Fig. 2: Pericardiocentesis
with ECG monitoring
REVIEWS 79
 as soon as these are recognized.
Mortality can be significantly reduced
by simple measures such as needle
decompression, oxygen supple-
mentation, analgesia and proper
placement of chest tube with
underwater seal.
Patient with tension pneumo-thorax is
usually in shock with distended neck
veins. Breath sounds are absent. There
is hyper-resonant percussion note. The
trachea may be shifted to the opposite
Fig. 3: Tension pneumothorax
side. Aggressive ventilation in a patient
with tracheo-broncheal injury may
aggravate or produce tension
pneumo-thorax if underwater chest
drainage is not present.
Immediate needle decompression is
done in the second intercostal space in
midclavicular line. Tension pneumo-
thorax is a clinical rather than
radiological diagnosis. It is criminal to
send a patient with suspected tension
pneumo-thorax for X-ray. Needle
decompression is followed by proper
chest intubation with underwater seal.
A check X-ray is taken once the patient
is hemodynamically stable.
Properly sized soaked dressing gauze is
put on the sucking wound to cover it
securely in open pneumo-thorax, and
should be taped on three sides. The
fourth side is left as such to create a
CIRCULATION valve to allow expulsion of some air
ASSESS with each expiration. Underwater seal
Level of conscious
Pulse chest tube is passed at another place
Blood pressure and not through the same wound.
Skin
LOCATE Analgesia and supplemental oxygen
External hemorrhage
Internal hemorrhage
are given for flail chest. Positive
FAST pressure ventilation is considered with
X-ray pelvis large flail segment with paradoxical
X-ray chest
movements. Prophylactic chest
CONTROL HEMORRHAGE intubation is considered in selected
Direct Pressure
Pelvic binders patients with suspected tracheo-
PSAG broncheal injuries or significant lung
Fracture alignment parenchymal trauma to avoid
iatrogenic tension pneumothorax.
80 Jan to March, 2010
Circulation
Hemorrhage is the most important
preventable cause of death in trauma
patient. Hypovolemia is the cause of
hypotension in trauma patients until
and unless proved otherwise. (Fig-3)
Hemorrhage may be revealed or
concealed. The revealed hemorrhage
is controlled by direct pressure on the
bleeding point. Tourniquets are not
used except in traumatic amputations
where direct pressure cannot be
adequately applied. it is used for
limited period.
Patient’s hemodynamic status is assess
by assessment of;
! Level of consciousness
! Color of the skin
! Pulse
! Blood pressure
Easily accessible pulses (radial,
brachial, femoral and carotid) are
assessed bilaterally for quality, rate
and regularity. Full, slow and regular
peripheral pulses are usually sign of
normovolemia.
Two large bore (18 or 16 gauge)
intravenous cannula are passed and
warm (body temperature) crystalloid
fluids (ringer lactate or normal saline)
are infused. Central venous line or cut
down is considered if peripheral
venous access is difficult. Blood
transfusion and / or colloids infusion
depends upon the amount of blood
loss and continuous bleeding.
The major cause of shock due to
concealed hemorrhage is bleeding
inside the cavities (thorax, abdomen
and pelvis). Focused Assessment
sonography for Trauma (FAST) helps
source of hemorrhage. A chest X-ray
reveals hemothorax. Properly placed
under water seal chest tube not only
drains air and blood from the pleural
cavity, but also helps in monitoring of
INDEPENDENT REVIEWS
continuous blood loss from chest
injuries.
Non-hemorrhagic causes of shock in
trauma patients include tension pne-
umothorax and cardiac tamponade.
Neck veins are distended and blood
pressure is low with both the cases
increased heart rate.
Cardiac tamponade can be differen-
tiated from tension pneumothorax by
muffled heart sounds and presence of
bilateral breath sounds. FAST can
confirm presence of fluid in the
pericardial sac. Percardiocentesis with
ECG monitoring dramatically im-
proves patient’s condition and has
therapeutic as well as diagnostic value.
Disability
(Neurological Examination)
Quick assessment of the neurological
status can be made by assessing the
level of consciousness (Glasgow
Coma Scale) and pupillary size and
reaction. GCS, is properly recorded for
the future reference. While assessing
GCS, best motor response is
considered. The other causes of
decreased level of conciousness
should also be kept in mind. These
include inadequate cerebral perfusion
(Airway, Breathing and circulation),
hypoglycemia and effect of drugs.
Therefore, an altered level of
consciouness at any stage indicates
immediate review of patient’s airway,
ventilation and perfusion status. In
small children, AVPU status (Alert,
responsive to voice, responsive to
pain, unresponsive) is recorded.
Both the pupils should be examined
and compared for size and reaction
and observations should be properly
recorded for comparison and
subsequent ressessment. Other
lateralizing signs and level of spinal
injury may also be assessed during the
primary survey if the condition of the
Jan to March, 2010 INDEPENDENT
patient permits. Otherwise it may be
deferred till a more detailed clinical
examination (secondary survey) is
performed.
Exposure/Environment
The patient is completely undressed
and a quick examination is performed.
Fractured limbs are splinted. Hypo-
thermia is avoided while exposing the
patient specially in cold climate. The
examination is done from head to toe
and front and back. The patient is log
rolled for examination of the back to
protect the spines. Do not forget to
cover the patient after the examination.
Monitoring
The efficiency of resuscitation is judged
by improvement in the physiological
parameters like pulse, blood pressure,
respiratory rate, temprature, urinary
output and oxygen saturation.
Therefore, continuous monitoring of
these parameters is very important to
evaluate whether the patient is
deteriorating or improving.
Pulse is simple and one of the most
important parameter of patient’s
volume status. But it may be deceiving Fig. 4: Log roll for examination
in elderly, athletes and patients on of back
drugs like beta blockers as the heart
rate may not rise proportionately to the
hypovolemia.
As normal response to hypovolemia,
vasoconstriction leads to increase in
peripheral resistance, increasing the
diastolic pressure. Therefore, pulse
pressure is more important rather than
absolute values in assessing and
monitoring patient’s volume status.
Oxygen saturation is an important
measure of adequacy of airway and
ventilation. It can be easily monitored
with the help of pulse oxymeter and
periodic arterial blood gases.
Urine output is also important indicator
REVIEWS 81
 of volume status. A urinary catheter is
passed for hourly monitoring of the
urinary output provided urethral injury
has been ruled out.
Apart from parameters that show
adequacy of resuscitation, ECG
monitoring of all poly trauma patients
must be done. Dysrythmias not only
indicative of certain injuries, may
themselves be fatal.
Diagnostic aids
Certain diagnostic tests may be
performed during primary survey but it
should be remembered that it should
not delay resuscitation.
Blood samples are drawn at the time of
passage of I/V lines for baseline
investigations. X-ray chest and pelvis
are recommended in all patients of
poly-trauma. Lateral X-ray cervical
spines may be advised if cervical injury
is suspected. An adequate X-ray of the
cervical spine should include all the
cervical vertebrae as well as first
thoracic vertebra.
Focused Assessment Sonography in
Trauma (FAST), is economical, quick
and effective method for the evaluation
of abdominal injuries. It may also be
helpful in the diagnosis of cardiac
tamponade.
References
1. Advance trauma life support for doctors
students manual. 7th addition 2004, ACS
Chicago.
The author :
Muhammad Abid Bashir,
FCPS
is associate professor in
department of Surgery at
Independent Medical
College Faisalabad and
instructor of ATLS®.
abidbashir@hotmail.com
82 Jan to March, 2010
View publication stats
Where FAST is not available,
diagnostic peritoneal lavage (DPL)
may be helpful in detecting intra
peritoneal injuries.
Secondary survey
Once the patient is hemodynamically
stable, a detailed head to toe
examination of the patient (secondary
survey) is performed. Meanwhile
arrangements are made for the
operative management or transfer of
the patient depending upon the
availability of facilities and expertise.
Summary
Primary survey is quick but orderly
assessment of a trauma patient. The
patient is examined with the ABCDE
protocol. Immediate life threatening
conditions are recognized and treated
as the assessment and resuscitation
are done simultaneously. Effective
monitoring of vital signs, oxygen
sa t ur a t i o n , ur i n e o ut p ut a n d
electrocardiography is very important
to recognize any deterioration in
patients condition and if it happens,
reassessment and reevaluation should
be done starting from the airway.
2. Driscoll P., Skinner D., Initial assessment
and management - 1: primary survey (In)
Driscoll P., Skinner D., Earlam R. (Eds) ABC
of Major Trauma, 3rd Edition 2000, BMJ
Books, London. pp1-6.
INDEPENDENT REVIEWS