The primary survey is designed to assess and treat any life-threatening injuries quickly. It should be completed very rapidly. The main causes of death in a trauma patient are airway obstruction, respiratory failure, shock from hemorrhage, and brain injuries. Therefore, these are the areas targeted during the primary survey. Following are specific injuries identified during a primary survey, which may be potentially life-threatening:
Typical trauma equipment includes:
In trauma centers, a trauma team is developed to provide a safe and efficient evaluation of the trauma patient. These members are available immediately or within five minutes of a trauma team activation. This an interprofessional team has the following members who have pre-assigned roles.
Other staff may not necessarily be involved in every trauma call but should be available immediately (if needed):
Before patient arrival, roles should be allocated, and universal precautions, including wearing protective clothing, should be enforced. All equipment required should be checked.
The common acronym is ABCDE, each named for an area of focus. If any abnormality is identified, it is resolved before a practitioner progresses through the algorithm. These steps are followed in the same order in every trauma resuscitation procedure to ensure that no critical or life-threatening injuries are overlooked.
Below is each sequential area of focus for evaluation and intervention.
A: Airway with cervical spine precautions /or protection.
This assessment is of the patency of the patient’s airway. It is assessed by asking a question. If the patient can speak, the patient is responsive, and the airway is open.
Perform either a chin lift or jaw thrust if airway obstruction is identified; although, jaw thrust is preferred if cervical spine injury is suspected.
Chin lift by placing the thumb underneath the chin and lifting forward.
Jaw thrust by placing the long fingers behind the angle of the mandible and pushing anteriorly and superiorly.
Foreign bodies, secretions, facial fractures, or airway lacerations are also sought. If there is a foreign body, it should be removed. If there are other causes of obstruction, a definitive airway should be established. During these evaluations and possible interventions, caution should be used to ensure that the cervical spine is immobilized and maintained in-line. The cervical spine should be stabilized by manually maintaining the neck in a neutral position, in alignment with the body. In this procedure, a two-person spinal stabilization technique is recommended. This means one provider maintains the in-line immobilization, and the other manages the airway.
Airway protection is required in many trauma patients. Patients with airway obstruction demand immediate intervention.
B: Breathing and Ventilation
This assessment is performed first by inspection. The practitioner should look for tracheal deviation, an open pneumothorax or chest wounds, flail chest, or paradoxical chest movement, or asymmetric chest wall excursion. Then, auscultation of both lungs should be conducted, to identify decreased or asymmetric lung sounds. Decreased lung sounds and/or decreased chest wall excursion can be a sign of a pneumothorax or hemothorax. These, combined with either tracheal deviation or hemodynamic compromise, can be a sign of a tension pneumothorax that should be treated with needle decompression followed by a thoracotomy tube placement. Open chest wounds should be covered immediately to prevent the entry of atmospheric air into the chest. If a flail chest is present and results in respiratory compromise, positive pressure ventilation should be provided. A flail chest may indicate an underlying pulmonary contusion.
Note that in general, all trauma patients should receive supplemental oxygen.
C: Circulation with hemorrhage control
Adequate circulation is required for oxygenation to the brain and other vital organs. Blood loss is the most common cause of shock in trauma patients.
This is evaluated by assessing the level of responsiveness, obvious hemorrhage, skin color, and pulse (presence, quality, and rate). The level of responsiveness can be quickly assessed by the mnemonic AVPU, as follows:
Any obvious hemorrhaging should be controlled by direct pressure if possible, and if needed, by applying tourniquets to the extremities. Pale or ashen extremities or facial skin is a warning sign of hypovolemia. Rapid, thready pulses in the carotids or femoral arteries are also of concern for hypovolemia.
It is important to remember that up to 30% loss of volume produces and reduces the pressure. But, the pressure may remain within normal limits especially in children. However, there is a consistent drop in pressure if more than 30% of the volume has been lost.
In trauma, hypovolemia is addressed first with 1 L to 2 L isotonic solutions, such as isotonic normal saline or lactated Ringer, but it should then be treated with blood products. Capillary refill time can be used to assess the adequacy of tissue perfusion. A capillary refill time of more than 2 seconds may indicate poor perfusion unless an extremity is cold. Remember, any patient presenting with pale, cold extremities, is in shock until proven otherwise.
With no obvious signs of hemorrhage, and when there is a hemodynamic compromise, a pericardial tamponade must be considered, and if suspected, corrected with pericardiocentesis.
D: Disability (assessing neurologic status)
A rapid assessment of the patient's neurologic status is necessary on arrival in the emergency department. This should include the patient's conscious state and neurological signs. This is assessed by the patient’s Glasgow coma scale (GCS), pupil size and reaction, and lateralizing signs. If the GCS is diminished, this can be a sign that patients will have reduced airway reflexes making them unable to protect their airways; under these circumstances, a definitive airway is required. A maximum score of 15 is reassuring and indicates the optimal level of consciousness; whereas, a minimal score of 3 signifies a deep coma.
E: Exposure and Environmental Control
The patient should be completely undressed and exposed, to ensure that no injuries are missed. They should then be re-covered with warm blankets to limit the risk of hypothermia.
Adjuncts to the Primary Survey:
After the ABCDEs of the primary survey, several adjuncts assist in the evaluation of other life-threatening processes:
After the primary survey, the secondary survey is completed to ensure a comprehensive evaluation and management of the patient’s injuries.
By the end of the primary survey, the trauma patient should have received a well-organized resuscitation, and any immediately life-threatening condition should have been identified and addressed.
Advanced trauma life-support care has been developed to standardize the evaluation and management of trauma patients since time is critical in trauma evaluation. The golden hour starts at the time of injury. A practitioner uses a primary survey to quickly assess, identify, and treat any life-threatening injuries if they exist.
The management of a trauma patient is done with an interprofessional team that includes a surgeon, emergency department physician, nurse, anesthesiologist and an intensivist. The team must know how to resuscitate patients and the priorities of a primary survey. The key is to first identify all life threatening injuries and consult with the appropriate specialist.
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