Primary Survey

The primary survey is the initial assessment and management of a trauma patient. It is conducted to detect and treat actual or imminent life threats and prevent complications from these injuries. A systematic approach using ABCDE is used. If a group of clinicians is assembled to perform the initial assessment, there will be multiple simultaneous activities occurring and resuscitation does not always proceed in a purely linear, sequential fashion.
On arrival to the emergency department, the patient should have full non-invasive monitoring applied, and initial management including:

  • ECG monitoring.
  • Non-invasive blood pressure cuff.
  • Oxygen saturation probe.
  • The patient’s temperature should be recorded.
  • Removal of the patient’ clothes is encouraged so that they can be fully assessed.
  • Oxygen should be applied to achieve saturation of 94-98%
 
The primary survey of a trauma patient involves:
Airway – with cervical spine control
Breathing
Circulation including control of exsanguinating external haemorrhage
Disability
Exposure 6
In single responder settings these may need to be addressed in a linear or sequential fashion; however, when a team is assembled, these elements may be addressed simultaneously. The term ‘survey’ is somewhat misleading in that it implies that only assessment is occurring; however, each phase requires simultaneous assessment for, and management of, any life threats detected.

Control of exsanguinating external haemorrhage

Failure to recognise and control large-volume external haemorrhage has been found to be a frequent occurrence in trauma resuscitation.7 Obvious large volume external blood loss must be managed as an immediate priority in the field and on arrival of the patient into the emergency department, with the aim being to control life-threatening external haemorrhage.
 
ECG Monitoring
Image used with permission from Department of Health, Victoria

Airway with cervical spine protection

An assessment of airway patency and stability should be performed during the primary survey and a plan for airway management instituted if required. Unless the patient is in cardiac arrest, immediate securing of the airway with endotracheal intubation is rarely required upon arrival of a major trauma patient.

Life threats

The following airway life threats must be assessed and managed:
  • Airway obstruction;
    • Vomit, blood, dislodged teeth. Remove with suction.
  • Blunt or penetrating neck injury;
    • Consider early endotracheal intubation if neck wounds or haematomas are causing the airway obstruction or if there is an airway disruption. (See below).
Caution: Rapid-sequence intubation in patients with blunt or penetrating neck injuries carries the risk of total loss of airway patency upon administration of sedative and/or muscle relaxant medication.
  • Reduced conscious state;
    • This can lead to hypoventilation and/or airway obstruction and hypoxia

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 and see-saw respirations).
  • Listen for signs of upper-airway noises and breath sounds. Are they absent, diminished or noisy?

Assess for soiled airway

If the patient has vomit, blood or excessive secretions on their airway, these should be removed with suction. If there is excessive bleeding into the airway that cannot be removed with suction, it may be necessary to manage the patient on their side to allow drainage of blood from the mouth or nose, while maintaining C spine immobilisation. Patients can be placed on their side by performing a log-roll manoeuvre.
If this is insufficient consideration should be given to sitting the patient upright. The risk of potential spinal injury must be weighed against the potential for complete airway obstruction or choking from aspirated blood. If there is uncertainty about the safety of this, a senior doctor with airway experience should be involved or the ARV clinician can be contacted for advice or for telehealth review of the situation.

Attempt simple airway manoeuvres if required

  • Open the airway using a chin lift and jaw thrust.
  • Suction the airway if excessive secretions are noted or if the patient is unable to clear their airway independently.
  • Insert an oropharyngeal airway (OPA)/nasopharyngeal airway (NPA) if required.
Care should be taken to not extend the cervical spine.
Caution: NPA should not be inserted in patients with a head injury in whom a base of skull fracture has not been excluded.8
If the patient is already intubated, document the size and position of the endotracheal tube, including lip level, end-tidal carbon dioxide trace, cuff pressure and any intubation difficulty (or Mallampati score).
Where possible, delegate ongoing airway management to an airway doctor/nurse and continue the initial assessment.

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.
  • A pending airway obstruction, indicated by signs such as a stridor or hoarse voice.

Maintain full spinal precautions if indicated

Suspect spinal injuries in all poly-trauma patients. Ensure a cervical collar, head blocks or in-line immobilisation is maintained throughout patient care.
 

 Breathing and ventilation

Life threats

  • Tension pneumothorax.
  • Massive haemothorax.
  • Open pneumothorax.
  • Flail chest.
  • Ruptured diaphragm.

Oxygen administration

Administer oxygen to achieve oxygen saturations between 94-98%.  

Assess the chest

The chest should be fully exposed and inspected for any open wounds, bruising or deformity. The patient’s respiratory effort, respiratory rate and oxygen saturation should be noted.
A mobile chest x-ray should be performed in the resuscitation bay at the earliest opportunity (and performed with a pelvic and lateral neck x-ray during the primary and secondary survey).
The chest should be auscultated for breath sounds, the most reliable location being in the axillae.
If a tension pneumothorax is detected, management should include:
  1. Emergent decompression using a 14G needle in the second intercostal space in the mid-clavicular line.
  2. Finger thoracostomy with blunt dissection and digital decompression through the pleura.This is an essential step for pleural decompression. Decompression of the pleural space is a primary goal during the reception and resuscitation of the haemodynamically unstable patient with a haemothorax and/or pneumothorax.
  3. Intercostal catheter insertion.Finger thoracostomy should be followed by the insertion of an intercostal catheter connected to an underwater seal drain as a secondary priority that can be completed at a later stage.9
Note: Finger thoracostomies require definitive ongoing management with an ICC unless the patient is positive pressure ventilated.
Record the oxygen saturation (SpO2) and ETCO2 if available.
 

 Circulation with haemorrhage control

Assess circulation and perfusion

Circulation assessment in major trauma focuses on detecting and managing shock, or reduced tissue perfusion. The most common cause of shock in a major trauma patient is hypovolaemic shock from blood loss.10 Blood loss may be external/visible, and therefore compressible, or internal/concealed and non-compressible.

Assess:
  • Heart rate.
  • Blood pressure.
  • Peripheral circulation and skin (pale, cool, clammy).
 

Intravenous access

Insert two large-bore peripheral intravenous (IV) cannulas. If access is difficult consider a central or intraosseous insertion if the equipment/skills are available.

If necessary, perform a FAST scan

Consider the need for FAST (Focused Assessment with Sonography in Trauma) if it is available and staff are trained in its use. FAST is used primarily to detect pericardial and intraperitoneal blood in patients who are haemodynamically unstable. The FAST exam supplements physical examination for detecting intra-abdominal injury.11 If the patient is haemodynamically stable and shows no signs of significant internal bleeding then it may be delayed until the secondary survey. The FAST exam is reliable and repeatable.

Control of exsanguinating external haemorrhage

Control of external haemorrhage usually requires firm compression bandaging with combine pads applied over the wounds, and firm crepe bandages applied circumferentially over the affected areas. Several layers may be required. Haemostatic dressings may be of use if available. Uncontrolled limb haemorrhage requires placement of an arterial tourniquet. This should not be removed until surgical haemorrhage control is achieved.
Causes include major amputations, severe crush injuries, open fractures, massive de-gloving injuries or multiple deep lacerations, especially of the scalp. Where external haemorrhage is identified an attempt must be made to control it using direct pressure, elevation and/or tourniquets (if available).
Smaller injuries (for example, puncture wounds) that are bleeding excessively should be managed by direct, local pressure over the wound with 10 cm × 10 cm gauze squares folded in half, and folded again to make a 5 cm × 5 cm gauze pad, and placed over the wound with firm, single digit pressure. This will control haemorrhaging better than loosely applied, large absorbent pads. It is helpful to take photos of the wounds and injuries to assist with ongoing management plans at the receiving facility.
It is best to avoid suturing or stapling wounds closed prior to transfer, unless the haemorrhaging cannot be controlled with direct pressure. If wounds are closed purely for haemostasis, this must be documented in the clinical record and communicated to the receiving team as they may need to be re-opened and/or explored on arrival at a receiving hospital. 
Continuous monitoring of vital signs is essential in major trauma
Image used with permission from Department of Health, Victoria
 
 

 Disability

Assess level of consciousness

  • Perform an initial Glasgow Coma Scale (best eye opening, motor response and verbalisation).
  • Check pupil size and reactivity if conscious state is altered.

Test blood sugar levels

Ensure that any alterations in level of consciousness are not related to a metabolic cause.

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 Exposure and environment

It is important to keep the patient normothermic
 
By the end of the primary survey the patient should be fully exposed to ensure no injuries posing an immediate life threat are missed.
Consideration must be given to the patient’s age, gender and culture when exposing them for a trauma examination. Exposure may need to be done sequentially, uncovering one body region at a time to maintain patient dignity and temperature control.
Trauma patients are prone to hypothermia, so upon completion of the primary survey, they should be covered with dry, warm blankets. External warming devices may be required if the patient is even mildly hypothermic. All intravenous fluid or blood should be warmed prior to administration if a fluid warmer is available.