Primary Survey

Use a systematic approach based on ABCDE6 to assess and treat an acutely injured patient. The goal is to manage any life-threatening conditions and identify any emergent concerns, especially in a neurotrauma patient who may present with other multisystem injuries.

 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? Noisy ventilations indicate a partial airway obstruction by either the tongue or foreign material.

Assess for soiled airway

Haemorrhage, vomiting and swelling from facial trauma are common causes of airway obstruction in patients with TBI. These should be removed with suction.

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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. Prolonged suctioning can lead to an increase in intracranial pressure (ICP) so be mindful to limit duration.
  • Insert an oropharyngeal airway (OPA) if required.

If the airway is obstructed, simple airway-opening manoeuvres should be performed as described above. Care should be taken to not extend the cervical spine.
Caution: Nasopharyngeal airways (NPA) should not be inserted in patients with a head injury in whom a base of skull fracture has not been excluded.7

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 GCS <9 (severe TBI), unprotected airway, uncooperative/combative patient leading to distress and further risk of injury
  • Hypoventilation, hypoxia or a pending airway obstruction: stridor, hoarse voice.
Assist ventilation with a bag and mask while the provider is setting up for intubation.

It is vital that intubation is carried out by a person skilled in airway management. Intubation may cause a transient increase in ICP, which may lead to secondary brain injury. Attempts at intubation can also invoke hypoxia. Preference is given to performing a rapid sequence induction with sedation and paralysis.

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

Assessing for adequate ventilatory effort is essential in the early stages of TBI.

Oxygen administration

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

Record the oxygen saturation (SpO2)

Adequate oxygenation to the brain is an essential element in avoiding secondary brain injury. Monitor the SpO2 and maintain it between 94-98%.8 9 Saturations below this range is associated with poorer outcomes.

Assess the chest

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. Be mindful that thoracic injuries may have also occurred.

 Circulation with haemorrhage control

Assess circulation and perfusion

Check heart rate and blood pressure.

Maintain an SBP greater than 110 mmHg in order to sustain cerebral perfusion and prevent further brain injury10.

A slow, forceful pulse may indicate intracranial hypertension and impending uncal herniation.
Inspect for any signs of external haemorrhage and apply direct pressure to any wounds. Consider the potential for significant internal bleeding related to the mechanism of injury, which may lead to signs and symptoms of shock.
Insert two large-bore peripheral intravenous (IV) cannulas. If access is difficult consider intraosseous insertion if the equipment/skills are available.
Commence fluid resuscitation as indicated.
If signs of shock are present, establish a cause and treat aggressively with IV fluid to raise the blood pressure and improve cerebral perfusion. Hypotension is not generally associated with isolated head Injury. If hypotension is present, identify the cause.

 Disability: neurological status

Assess level of consciousness

An AVPU assessment (Alert, responds to Voice, responds to Pain, Unresponsive) should be completed along with a check of pupillary response and size. A more detailed neurological assessment using the GCS will be performed in the secondary survey.

Test blood sugar levels

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

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 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.