Primary Survey

Medical decision making for a trauma patient involves use of the ABCDEF trauma resuscitation algorithm, with consideration for the patient’s age, physiologic reserve, and underlying chronic conditions. (See the Red Flags box.)

Although performance of the primary survey should be fluid and may involve multiple individuals performing multiple actions simultaneously, the components of the primary survey can be broken down into six sequential steps: airway, breathing, circulation, disability, exposure, and fingers or Foley (ABCDEF) (see Fig. 8-1 and Priority Actions box).

Fig. 8.1 Approach to resuscitation after trauma.

If an indication for intervention is discovered during the primary survey, treatment should be initiated and the primary survey restarted from the beginning (Fig. 8.2).

Fig. 8.2 The patient whose radiograph is shown here initially improved with placement of a chest tube but later experienced decompensation. This case represents a good reason for the need to restart the ABCs (airway, breathing, circulation) of trauma resuscitation after any change in patient condition or after any intervention.

The primary survey starts as the patient enters the room by questioning the patient, evaluating for airway patency, and then directly visualizing the facial structures, neck, and oropharynx (A).

Breathing or ventilatory status can then be evaluated through visual examination of the neck and thorax, auscultation of all lung fields, and palpation of the chest. Palpation can provide clues to rib injury, open or sucking chest wounds, and subcutaneous air in the neck and chest. The respiratory rate, patient report of chest pain or shortness of breath, and pulse oximetry also contribute to this phase of the resuscitation (B).

Evaluation of circulatory status (C) involves a judgment of the patient’s general appearance, heart rate and blood pressure, extremity pulses, and nail bed capillary refill. If the patient has not been connected to a continuous heart rate and blood pressure monitor, this step should be taken at this time.

The next step is a brief neurologic examination (for disability—D). At this point, assessment for disability does not include a detailed neurologic examination but instead a look at the gross motor movement of all extremities and the patient’s level of alertness. The most common tool for evaluating global neurologic function is the Glasgow Coma Scale (GCS) (Table 8.2).³ Three systems are evaluated: eye opening, verbal response, and motor response. The closer that each function is to baseline, the higher the score for each system. A GCS score of 13 or higher correlates with mild brain injury, 9 to 12 with moderate injury, and 8 or less with severe brain injury. A GCS score lower than 8 is an indication for immediate airway control. Thus, the GCS can help in evaluating the need for intubation, provide a marker for serial neurologic examinations, and promote clear communication with consultants regarding patient status.

Table 8.2 Glasgow Coma Scale Scoring*

^* The best of each response is used for the individual score; scores are added for the total Glasgow Coma Scale score.

Completion of the primary survey involves exposure of the entire patient (E) in a way that prevents hypothermia; coordinated in-line cervical spine immobilization should be maintained during this procedure.

The F (fingers and Foley) step of the primary survey involves consideration of placement of a Foley bladder catheter and orogastric tube, a rectal examination, and a bimanual vaginal examination. Even though there has been a trend away from the dogmatic approach to use of a rectal and Foley catheter for everyone who enters the trauma algorithms, these measures are still indicated in certain patients, especially those who are obtunded, have a high likelihood of bowel injury, or are hemodynamically unstable.

Secondary Survey

The secondary survey consists of an expanded history, a head-to-toe examination, focused sonography, and initiation of the standard trauma radiology and laboratory tests. If possible, the history should be taken from the patient or the prehospital personnel (e.g., emergency medical technicians) who delivered the patient to the hospital. The key points of the history can be remembered with use of the mnemonic AMPLE, which stands for allergies, medications, past medical history, last meal, and events of the injury.

The head-to-toe examination involves a second review of the airway and pulmonary examination, including an expanded physical examination to identify further injury.

In a hypotensive patient, because the abdominal cavity can conceal enough blood to be an immediate threat to life, part of the secondary survey is the focused abdominal sonography examination for trauma (FAST). FAST can be done in the resuscitation area. Because it is faster and less invasive to obtain, FAST has replaced diagnostic peritoneal lavage (Table 8.3).^4,5 Likewise, the more sensitive and specific computed tomography (CT) of the abdomen should wait until the end of the secondary survey because CT scanning may be time-consuming and takes the patient out of the resuscitation area.⁶

Table 8.3 Diagnostic Modalities Used for Abdominal Trauma

The advantage of a standardized approach to trauma radiology is that it can identify life-threatening injuries that may necessitate immediate attention. Significant cervical spine fractures may lead to airway compromise, loss of ventilatory drive, or spinal shock. The chest radiograph may identify a treatable condition, such as a large pneumothorax, hemo-thorax, or pulmonary contusion. Pelvic radiology can identify an open-book pelvic fracture, which may lead to hemorr-hagic shock.

For many years, standard trauma series radiographs included plain films of the cervical spine, the chest, and the pelvis. Currently, the only standard plain film is the chest radiograph. The cervical spine radiograph has been replaced by CT of the cervical spine, but a rare exception is the use of screening films for penetrating trauma (Fig. 8.3). In the majority of trauma patients, the pelvic radiograph has been replaced by CT of the abdomen and pelvis with reconstructed images of the bony pelvis. In some patients, such as those who may need immediate pelvic binding to temporize hemorrhage or penetrating injury to the pelvis, a one-view pelvic radiograph in the trauma suite is still useful. Thus, the new standard trauma radiology series involves a chest radiograph and CT scans of the head, cervical spine, and abdomen and pelvis.⁷ Chest CT is indicated for a widened mediastinum or if vascular injury is suspected. Early consideration of the need for CT angiography of the neck or extremities should be undertaken to minimize the load of contrast media.

Fig. 8.3 This case demonstrates the need for trauma series radiographs, even in patients with penetrating trauma. The radiograph shows that this patient sustained a gunshot wound to the shoulder without obvious injury to the neck.

Blood specimens for laboratory studies may be drawn during the initiation of intravenous (IV) access in the primary survey or can be obtained during the secondary survey. Laboratory tests should include a complete blood count, serum chemical analysis, coagulation studies (prothrombin time, partial thromboplastin time), and urinalysis. Two immediately available studies are the urine pregnancy test and fingerstick serum glucose measurement, and the results of either test can significantly change the course of the resuscitation. In the setting of altered mental status, a blood alcohol measurement and toxicology screen may also be useful. The serum lactate level can be monitored as a marker of tissue perfusion.^8,9

After the primary and secondary surveys are completed and the patient is sufficiently resuscitated, the evaluation and treatment plan takes on a much more individualized course.¹⁰