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. Show
The primary survey of a trauma patient involves: Airway – with cervical spine control Control of exsanguinating external haemorrhageFailure 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 protectionAn 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 threatsThe following airway life threats must be assessed and managed:
Assess for airway stability
Assess for soiled airwayIf 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
Caution: NPA should not be inserted in patients with a head injury in whom a base of skull fracture has not been excluded.8If 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:
Maintain full spinal precautions if indicatedSuspect 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
If a tension pneumothorax is detected, management should include:
Record the oxygen saturation (SpO2) and ETCO2 if available. Circulation with haemorrhage controlAssess circulation and perfusionCirculation 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:
Intravenous accessInsert 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 scanConsider 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 haemorrhageControl 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 traumaImage used with permission from Department of Health, Victoria DisabilityAssess level of consciousness
Test blood sugar levelsEnsure that any alterations in level of consciousness are not related to a metabolic cause. Top of page Exposure and environmentIt is important to keep the patient normothermicBy 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. |