Chapter 21. The primary and secondary survey
The initial assessment of the trauma patient requires a methodology which can be applied consistently and in priority order.
Primary survey
Primary Survey = Assessment + Management of life-threatening injuries.
A primary survey may be completed rapidly if there are no life-threatening injuries. The ability to converse normally with a patient demonstrates a normal airway, adequate breathing and circulation to the brain and an alert conscious level.
The primary survey follows the sequence:
• Catastrophic haemorrhage control (<C>)
• Airway with cervical spine control (A)
• Breathing with ventilation (B)
• Circulation (C)
• Disability and neurological assessment (D)
• Exposure and environment (E).
Patients with significant trauma require immediate evacuation to hospital. Highly organised on-site care is essential. The aim is to prepare the patient for departure from the scene in no more than 10minutes from the ambulance’s arrival.
‘Scoop and run’
Survival rate is increased if the time taken to reach definitive care in hospital is short. This is reflected in the modern ‘scoop and run’ method which incorporates:
• Control of exsanguinating external haemorrhage
• Airway and cervical spine protection
• Breathing assessment and support
• Arrest of major external haemorrhage
• Immobilisation on a long spinal board (where appropriate)
• Rapid evacuation to an appropriate hospital
• Cannulation en route.
Performing the primary survey
The primary survey and resuscitation permit identification of life-threatening conditions and their simultaneous treatment.
Catastrophic haemorrhage
The management of severe, life-threatening, external haemorrhage can take precedence over the rest of the primary survey. This situation is likely to be rare, e.g. a traumatic amputation, and is likely to be obvious when encountered.
Management
Direct pressure on a bleeding wound followed by pressure dressings and elevation should deal with most bleeding peripheries.
Rarely, pressure will need to be applied to pressure points (where an artery can be compressed) such as the brachial or femoral arteries. Improvised tourniquets should not be employed, as they cause venous distension without stopping arterial flow.
Specifically designed tourniquets such as the Combat Application Tourniquet (CAT) can be used to temporarily get control of bleeding from a limb but in the civilian environment should be loosened after 15 minutes to see if control can then be gained by conventional means.
Bleeding from large wounds to the torso will be more difficult to manage and will require packing and constant, direct pressure. If available, novel haemostatic agents may be used. These include Hemcon®, Quikclot® and Celox®.
Airway and cervical spine
Assessment
Any injury severe enough to compromise the airway may also damage the cervical spine. Always assume that the cervical spine is injured and thus it must be protected from movement during airway interventions and transport.
Causes of airway obstruction include:
• Tongue prolapse
• Foreign bodies
• Vomit
• Major facial injury.
Obstruction may occur at any level from the mouth and nose to the trachea.
Complete obstruction of the airway will manifest as an absence of breathing.
Management
If complete or partial airway obstruction is identified it must be rectified as rapidly as possible without endangering the cervical spine. This involves a series of stepped airway interventions of increasing complexity until obstruction is relieved.
1. Airway clearance – manual and aspiration
2. Manual airway opening manoeuvres
3. Jaw thrust
4. Oropharyngeal airway
5. Nasopharyngeal airway
6. Orotracheal intubation
7. Cricothyroid transtracheal jet insufflation
8. Definitive surgical airway.
Cervical spine immobilisation
Once the airway is secure, neck immobilisation must continue with the application of a correctly sized semi-rigid cervical collar and head immobilisation device.
The patient must subsequently be fully immobilised on a long spinal board with at least four body straps.
Restless patients should only be fitted with a semi-rigid collar, since full immobilisation may only exacerbate movement in the cervical spine if the rest of the body is flailing.
If the history conclusively excludes the possibility of a spinal injury, immobilisation is not necessary.
DO NOT immobilise the neck if the patient is restless and thrashing about.
Breathing
Assessment
The following signs should be sought in the neck:
• Swelling
• Surgical emphysema
• Tracheal deviation
• Neck vein distension
• Bruising
• Lacerations.
Breathing must be assessed for:
• Rate
• Adequacy
• Equal bilateral ventilation.
The chest must be inspected to assess:
• Movement
• Instability
• Flail segment
• Wounds.
The chest wall must be felt to detect:
• Surgical emphysema
• Tenderness
• Paradoxical movement.
Percussion bilaterally may reveal one-sided hyper-resonance over a large pneumothorax. Finally, auscultation for the presence of breath sounds bilaterally must be performed.
Distress, confusion and abnormally rapid or slow respiratory rate are alarming signs and the patient may require assisted ventilation.
Clearing the airway does not assure adequate ventilation
Management
The spontaneously breathing patient with significant trauma requires the provision of supplemental oxygen, with a non-rebreathing reservoir mask and an oxygen flow rate of 10–15 L/min.
In adults, a respiratory rate of <10/min or >30/min suggests significant ventilatory inadequacy. Inadequate ventilation demands assisted ventilation. This is most easily performed using a bag-valve-mask and reservoir device.
Formal intermittent positive pressure ventilation with bag and mask or endotracheal tube may be necessary in the event of respiratory arrest. A mechanical ventilator may also be useful, especially for longer transfers.
Displacement of an endotracheal tube in transit, or development of tension pneumothorax secondary to positive pressure ventilation, may occur at any time.
The use of pulse oximetry and end-tidal CO 2 monitors can assist greatly in transit but repeated auscultation is essential.
Immediately life-threatening conditions
A – Airway obstruction (intrathoracic)
T – Tension pneumothorax
O – Open chest injury
M – Massive haemothorax
i – Fla il chest
C – Cardiac tamponade
Airway obstruction
Intrathoracic airway obstruction is fortunately rare. It is usually untreatable in the prehospital environment. If there is a history of foreign body aspiration, a chest thrust or Heimlich manoeuvre may be beneficial. Otherwise apply high flow oxygen and evacuate immediately.
Tension pneumothorax
Tension pneumothorax may be present during initial assessment or appear secondary to positive pressure ventilation, where a simple, undetected pneumothorax is expanded by the pressure of the ventilating gases. The features of tension pneumothorax are given in the table.
Immediate decompression using needle thoracocentesis is required (see p. 133).
Open chest injury
Open chest wounds must be covered with an Asherman® or Bolin® seal or occlusive dressing sealed on three sides.
Massive haemothorax
Massive haemothorax requires a chest drain, best inserted in hospital. Intravenous access can be achieved en route. Needle thoracocentesis is not indicated in haemothorax.
Flail chest
Patients with significant flail chest may require ventilatory support; apart from this, simple support to the flail segment is the only treatment necessary pending arrival in hospital.
Cardiac tamponade
Unless there is a penetrating wound in the appropriate area, cardiac tamponade is extremely difficult to diagnose prehospital. Unless a doctor is present (who may perform an emergency thoracotomy), the patient’s only hope is rapid evacuation to hospital.
Circulation
Pale, cool skin, tachycardia, delayed capillary return and altered mental state indicate significant shock. Hypotension frequently is not apparent until at least 30% of the blood volume has been lost.
Shock is a disorder of the circulation characterised by reduced organ perfusion and tissue oxygenation
Management
Any external blood loss should be arrested by the application of direct pressure. Pelvic and long-bone fractures should be rapidly immobilised. Unless the patient is trapped or the transfer time is likely to be very long, intravenous access should be obtained in transit.
In general, a policy of hypotensive resuscitation should be followed:
• If the patient has a palpable radial pulse, fluid should not be given
• Access should be obtained during transit (unless the transit time is very short)
• Rapidly increasing breathlessness
• Unilaterally absent breath sounds
• Hyper-resonance on percussion of the affected hemithorax
• Raised and congested neck veins
• Hypotension
• Cyanosis
• Tracheal shift away from the affected side (late)
• Resistance to ventilation in the ventilated patient.
• If the radial pulse is not palpable, small aliquots of 250 mL of warm normal saline (or a similar crystalloid) should be given until a palpable pulse returns and repeated to maintain it
• Under no circumstances, however, should any of these actions delay transfer to hospital since patients who are actively bleeding require urgent life-saving surgical intervention
• Elevation of the blood pressure above the level of 90 mmHg may precipitate rebleeding as well as diluting clotting factors and result in a worse prognosis.
Assessment of the circulation
• Skin colour
• Skin temperature
• Pulse rate and volume
• Capillary refill time (normal less than 2 seconds)
• Mental state
• Assess the thorax, abdomen, pelvis and femurs for evidence of injury and consequent concealed haemorrhage (think ‘blood on the floor and four more’).
Disability
Quickly assess responsive pupil size and reactions. The AVPU mnemonic should be used or GCS recorded to establish a baseline level of consciousness.
An AVPU response of P or U is an indication for serious concern due to the likelihood of significant intracranial injury. The blood sugar should be estimated.
Expose and environment
Complete exposure of the patient is impractical in the prehospital environment and will potentially render the patient hypothermic. The chest and neck area are exposed as part of the primary survey.
The patient’s temperature and blood sugar should be checked at this stage.
If during the primary survey the patient deteriorates restart the primary survey from the beginning.
The secondary survey
The secondary survey is the more detailed head-to-toe examination to identify every injury the patient has sustained and is generally performed in hospital.
In prolonged transfers a secondary survey may occasionally be appropriate.
Performing the secondary survey
There will rarely be time to complete a secondary survey in the prehospital environment. It may occasionally be possible, for example, in an entrapment. In the majority of cases, evacuation to the hospital for the management of life threatening (1° survey) injuries is paramount.
Assessment of the head
Look for:
• Lacerations
• Bruising
• Blood and/or cerebrospinal fluid from ears or nose (suggesting basal skull fracture)
• Check pupil size and response
• Battle’s sign and ‘raccoon’ or panda eyes
• Pallor and sweating
• Cyanosis.
Feel for:
• Scalp haematomas
• Depressed skull fractures
• Facial tenderness and fractures.
Listen for:
• Airway ‘noise’ suggesting obstruction
• Breathing adequacy and rate.
Assessment of the neck
To assess the neck, the collar may need to be removed while a colleague maintains in-line immobilisation of the neck.
Look and feel for:
• Lacerations
• Swelling
• Surgical emphysema – skin ‘crackling’
• Distension of neck veins
• Spinal deformity, tenderness or haematoma
• Tracheal deviation
• Laryngeal crepitus.
Assessment of the chest
Look for:
• Wounds and evidence of penetrating injury
• Deformity and abnormal movements
• Breathing distress and pain on inspiration
• Patterning from clothing or seatbelts.
Feel for:
• Tenderness
• Instability and ‘clunking’ of flail segment
• Surgical emphysema.
Listen for:
• Percussion revealing increased resonance over a pneumothorax or stony dullness over a haemothorax
• Presence of equal breath sounds
• Unilateral absence or reduction of breath sounds suggestive of pneumothorax
• Unilateral, usually basal reduction of breath sounds associated with haemothorax (only if the patient is sitting up).
Assessment of the abdomen
Look for:
• Penetrating wounds and contusions
• Seatbelt contusions and clothing imprints
• Distension.
Feel for:
• Tenderness – either localised or generalised
• Guarding – involuntary muscle spasm on gentle palpation
• Rigidity.
Assessment of the pelvis
The need for pelvic splintage should be determined based on the mechanisms of injury and symptomatology.
Assessment of lower and upper extremities
Look for:
• Obvious wounds and contusions
• Deformity and swelling associated with fractures
• Voluntary movement.
Feel for:
• Tenderness and deformity
• Distal pulses
• Intact nerve supply – sensation to touch and pain, motor function
• Normal movement in joints.
On completion of the secondary survey, any injuries which are found should be stabilised and any wounds covered.
Assessment of the totality of the patient’s injuries comprises the secondary survey.
For further information, see Ch. 21 in Emergency Care: A Textbook for Paramedics.
