The primary survey is the initial assessment and management of a trauma patient.
Use a systematic approach based on <C> ABCDE(9, 10) to assess and treat an acutely injured patient. The goal is to manage any life-threatening conditions and identify any emergent concerns, especially in an obstetric trauma patient who may present with other multisystem injuries.
Wherever possible, immediately from the time of commencing a primary survey, pregnant patients beyond 20 weeks gestation should be nursed in a manner which reduces compression of the great vessels by the pregnant uterus (aortocaval compression or supine hypotension syndrome). Supine positioning may result in significant compromise in both circulation and respiratory status.
Avoidance of aortocaval compression can be achieved either by manual left uterine displacement, or by positioning with a left lateral tilt of 15u201330 degrees, using a wedge. Where a wedge is not available, similar effect can be achieved by placing a rolled up towel or bags of saline under the mother’s right hip. Where the patient is immobilised on a spine board, this may mean positioning a wedge beneath the board if manual uterine displacement is not possible.
Increasingly, consensus opinion suggests that manual displacement of the uterus with either a one or two handed technique should be the method of choice, particularly in the haemodynamically unstable or critically injured pregnant patient. Manual left uterine displacement appears to result in less hypotension and less haemodynamic instability than tilting the patient, but does require an additional team member to execute. Manual left uterine displacement also facilitates more effective chest compressions in the event of cardiac arrest, and will facilitate easier access to the patient for the rest of the resuscitation team(11).
Trauma Victoria, 2017
Manual left uterine displacement 2 handed techniqueTrauma Victoria, 2017
Catastrophic haemorrhage
Assess for catastrophic haemorrhage
- Identify any large volume external blood loss.
- Provide immediate management as required, consider; direct pressure, haemostatic dressings and tourniquets.
Airway with cervical spine protection
Assess for airway stability
Attempt to elicit a response from the patient.
Look for signs of airway obstruction (use of accessory muscles, paradoxical chest movements, see-saw respirations).
Listen for any upper-airway noises, breath sounds. Are they absent, diminished, or noisy?
Assess for displaced dentures, especially in the older persons cohort.
Assess for soiled airway
Haemorrhage, vomiting and swelling from facial trauma are common causes of airway obstruction in patients with TBI.
Attempt simple airway manoeuvres if required
Open the airway using a chin lift and jaw thrust whilst avoiding neck extension in order to protect the C-spine.
Suction the airway if excessive secretions are noted or if the patient is unable to clear their airway independently.
Secure the airway if necessary (treat airway obstruction as a medical emergency)
Consider intubation early if there are any signs of a decreased level of consciousness, unprotected airway, uncooperative/combative patient leading to distress or further risk of injury.
Hypoventilation, hypoxia, or a pending airway obstruction such as stridor or hoarse voice.
Intubation should be considered earlier in pregnant patients compared with non-pregnant patients because pregnant women desaturate more rapidly and are more susceptible to irreversible hypoxic injury. Crucially, maternal hypoxia is associated with poor fetal outcomes.
Assist ventilation with a bag and mask while the airway clinician is setting up for intubation.
It is vital that intubation is conducted by a person skilled in airway management. Intubation may cause a transient increase in ICP, which may contribute to secondary brain injury. Attempts at intubation can also result in hypoxia, so preference is for a rapid sequence induction with sedation and paralysis by the most skilled operator available.
Maintain full spinal precautions if indicated
Suspect spinal injuries in polytrauma patients, especially where TBI is involved. Ensure cervical collar, head blocks or in-line immobilisation is maintained throughout patient care.
Breathing and ventilation
Oxygen administration
Administer O2 and maintain SpO2 94-98%. Saturations below this range are associated with poorer outcomes.(4)
Maternal hypoxia is associated with poor outcomes.
Assess the chest
- Be mindful that thoracic injuries may have also occurred.
- Count the patient’s respiration rate and note the depth and adequacy of their breathing.
- Auscultate the chest for breath sounds and assess for any wheeze, stridor, or decreased air entry.
If required, intercostal catheter(s) should be inserted one or two rib spaces higher (in the third or fourth intercostal space) due to the elevation of the diaphragm in pregnancy and potential for inadvertent abdominal insertion.
Circulation with haemorrhage control
Assess circulation and perfusion
- Check heart rate and blood pressure.
- A pregnant patient may not display signs of haemorrhage until as much as 30% of her blood volume is lost. Tachycardia with normotension may be considered an early sign of potentially significant blood loss. If fetal monitoring is immediately available, it may be used as part of the assessment of maternal volume status.
- Inspect for any signs of external haemorrhage and apply direct pressure to any wounds.
- Consider the potential for significant internal haemorrhage, which may lead to signs and symptoms of shock.
Insert two large-bore peripheral intravenous (IV) cannulas. If access is difficult, consider intraosseous insertion (IO) if the equipment/skills are available.
If a pelvic fracture is suspected, apply a pelvic binder if there are no contraindications.
Fluid resuscitation should be initiated if hypovolemia is suspected, to maintain both maternal and fetoplacental perfusion; however, haemorrhage control may be impossible without emergent surgical intervention.
Recheck the patient’s position and ensure that manual uterine displacement or a 15u201330-degree tilt remains in situ. This position is known to significantly improve blood pressure and is an important intervention in pregnant patients.
If possible, perform eFAST scan. It may be difficult in pregnancy where the enlarged uterus displaces other organs or obscures views of the retroperitoneum, but a positive eFAST scan remains a significant finding in pregnant trauma patients.
Disability: neurological status
Assess level of consciousness
Complete an AVPU assessment (Alert, responds to Voice, responds to Pain, Unresponsive). A more detailed neurological assessment using the GCS will be performed in the secondary survey.
Check pupillary size and responses
Unequal or unresponsive pupils may be an indication of severe TBI and raised intracranial pressure. It will be important to note if the pupils change during the patient’s re-assessments.
Test blood sugar levels
Ensure that any alterations in the patient’s level of consciousness are not related to a metabolic cause. Identify and correct hypoglycaemia.
Exposure/environmental control
Remove all clothing from the patient and assess to ensure there are no other obvious, life-threatening injuries present.
Keep the patient normothermic through passive re-warming with blankets and a warm environment.