Continuing Education Activity
The primary survey is designed to assess and treat life-threatening injuries rapidly. The leading causes of death in trauma patients are airway obstruction, respiratory failure, hemorrhagic shock, and brain injury. Therefore, these are the areas targeted by the primary survey. Some injuries identified during a primary study include tension pneumothorax, open pneumothorax, airway obstruction, flail chest, massive internal or external hemorrhage, and cardiac tamponade. This activity reviews the steps, equipment, personnel, and techniques involved in performing the primary survey on trauma patients and also highlights the role of the interprofessional team in caring for trauma patients.
Objectives:
- Describe the key systems evaluated in the primary survey of trauma patients.
- Explain how to perform the primary survey on trauma patients.
- Outline the steps involved in assessing airway patency, effective breathing, appropriate circulation, neurological dysfunction, and any other possible wounds.
- Summarize the importance of collaboration and communication amongst interprofessional team members to improve outcomes for trauma patients undergoing the primary survey.
Introduction
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, massive hemorrhage, and brain injuries. Therefore, these are the areas targeted during the primary survey. The following are some of, but not all, the specific injuries that may be identified during a primary survey, which may be potentially life-threatening:
- Airway obstruction
- Tension pneumothorax
- Massive internal or external hemorrhage
- Open pneumothorax
- Flail chest
- Cardiac tamponade
- Intracranial bleed
- Increased intracranial pressure[1][2][3][4]
Anatomy and Physiology
Hypovolemic shock in the trauma setting occurs mainly due to the massive hemorrhage. The following hemodynamic responses are predicted. Cardiac index, venous capacitance, central vein pressure, and pulmonary capillary wedge pressure would decrease, and the systemic vascular resistance increases. The following characteristics are predictable in the distributive shock; 1. flash capillary refill in less than one second, 2. presence of bounding pulses, 3. warm and dry extremities on the physical examination, 4. widening of the pulse pressure, which would be greater than 40 mmHg.[5]
Equipment
All members of the trauma team should ensure they have sufficient personal protective equipment such as gloves, masks, and gowns to protect themselves. A stethoscope is the next critical piece of equipment as it is necessary in order to listen to breath sounds bilateral; a pulse oximeter should also be applied at this time. Supplies for resuscitation such as large-bore IVs warmed saline, and appropriate tubing should be readily available in the trauma bay. Supplies to maintain the airway should be readily available, including a bag-mask device, end-tidal CO2 monitoring device, intubation tray, and surgical airway kit. In case the patient has a pneumothorax, large-bore angiocatheters for potential needle thoracostomy and a chest tube kit should be easily accessible. The trauma bay should also be equipped with an EKG and a portable x-ray machine to be used once the primary survey is complete as an adjunct to the primary survey.[10][11][12]
Preparation
Before patient arrival, roles should be allocated, and universal precautions, including wearing protective clothing, should be enforced. All equipment required should be checked. The following areas of the hospital should be notified with as much information as possible about the patient:
- Radiology department for portable x-rays and CT scan
- Intensive care unit
- Operating room[19]
Technique or Treatment
The common acronym for performing the primary trauma survey is ABCDE, each letter representing an area of focus. If any abnormality is identified in one of the areas of focus, it should be resolved before a practitioner progresses further 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. If a patient is noncooperative or combative and it interferes with conducting a proper primary trauma survey, then the patient should be sedated and intubated so that the exam may proceed. One caveat is that if a patient appears to be exsanguinating from a massive wound that can be addressed before starting the ABCDE algorithm, fortunately, the widespread adoption of the use of tourniquets in the field has limited the need to staunch massive bleeding in the trauma bay.[20]
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 coherently, the patient is responsive, and the airway is open.
Perform either a chin lift or jaw thrust if airway obstruction is identified, although a 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 out. If there is a foreign body, it should be removed. If there are other causes of obstruction, a definitive airway should be established, whether through intubation or the creation of a surgical airway such as cricothyroidotomy. During these evaluations and possible interventions, caution is necessary 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. Once the patient is stabilized in this scenario, their neck should be secured with a cervical collar.
Airway protection is necessary for many trauma patients. Patients with airway obstruction demand immediate intervention.[21]
B: Breathing and Ventilation
This assessment is performed first by inspection. The practitioner should look for tracheal deviation, an open pneumothorax or significant chest wounds, flail chest, 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 can be a sign of pneumothorax or hemothorax. This, combined with either tracheal deviation or hemodynamic compromise, can signify a tension pneumothorax that should be treated with needle decompression followed by a thoracotomy tube placement. Open chest wounds should be covered immediately with a bandage taped on three sides to prevent the entry of atmospheric air into the chest. If the bandage is taped on all four sides, it may create a tension pneumothorax. If a flail chest is present and 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.[22]
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:
- (A) Alert
- (V) Respond to Verbal stimuli
- (P) Respond to Painful stimuli
- (U) Unresponsive to any stimuli.[23]
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 blood volume can occur before reducing blood pressure. But, the pressure may remain within normal limits after significant blood loss, especially in children.
In trauma, hypovolemia is addressed first with 1 L to 2 L isotonic solutions, such as normal saline or lactated Ringer, but it should then be followed by 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 through the creation of a pericardial window.[24]
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 below 8, this is a sign that the patient may 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 minimum score of 3 signifies a deep coma. If the patient is intubated, their verbal score becomes a 1, and their total score should be followed by a T.The components of the GCS are:MOTOR6 Follows commands5 Localizes to pain4 Withdraws from pain3 Flexes in response to stimuli (decorticate posturing)2 Extends in response to stimuli (decerebrate posturing)1 Does not move in response to stimuliVERBAL5 Coherent speech4 Confused speech3 Incoherent words2 Incomprehensible sounds1 No speech1T IntubatedEYES4 Opens spontaneously3 Opens to noise2 Opens to pain1 Does not open[25]
E: Exposure and Environmental Control
The patient should be completely undressed and exposed to ensure no injuries are missed. They should then be re-covered with warm blankets to limit the risk of hypothermia.[25]
Adjuncts to the Primary Survey:
After the ABCDEs of the primary survey, several adjuncts assist in the evaluation of other life-threatening processes:
- ECG is used to evaluate for dysrhythmias, ST-elevation myocardial infarction (STEMI) STEMIs, pulseless electrical activity (PEA), and cardiac tamponade.
- Urinary Catheters can help in the evaluation of fluid status. However, care must be taken if a contraindication exists, such as blood at the meatus, perineal ecchymosis, or high-riding prostate.
- Gastric catheters can decompress the stomach, reducing the risk of aspiration and limiting pressure on the thorax that a distended stomach can create. Care must be taken to avoid nasal insertion in the presence of facial trauma or concern for a basilar skull fracture.
- A chest X-ray is obtained to evaluate for pneumothorax, hemothorax, or suspicion of an aortic injury.
- A pelvic X-ray is obtained to evaluate for pelvic fractures. If an open book fracture is found, a pelvic binder is indicated to limit pelvic bleeding.
- FAST Examination is the "Focused Assessment with Sonography in Trauma" and is performed to identify free fluid in the abdomen suggestive of intra-abdominal bleeding or pericardial tamponade.
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. After completing the primary and secondary survey, there should be a decision on the patient's disposition: to obtain additional studies, proceed to the OR, take the patient to the ICU, or even progress to discharge if appropriate.[26]
Enhancing Healthcare Team Outcomes
The management of a trauma patient is done with an interprofessional team that includes a surgeon, emergency department physician, nurse, anesthesiologist, and intensivist. The team must know how to resuscitate patients and the priorities of a primary survey. The key is first to identify all life-threatening injuries and consult with the appropriate specialist.[27][28]
Trauma Primary Survey