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
Buy Membership for Emergency Medicine Category to continue reading. Learn more here
