Trauma Primary Survey


Article Author:
Jason Planas


Article Editor:
Muhammad Waseem


Editors In Chief:
Bette Bogdan
Lori Kerley
Robin Geiger


Managing Editors:
Frank Smeeks
Scott Dulebohn
Erin Hughes
Pritesh Sheth
Mark Pellegrini
James Hughes
Richard Ciresi
Phillip Hynes


Updated:
10/27/2018 12:31:57 PM

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, 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:

  • Airway obstruction
  • Tension pneumothorax
  • Massive internal or external hemorrhage
  • Open pneumothorax
  • Flail chest 
  • Cardiac tamponade.

Indications

A primary survey is indicated in the evaluation of all trauma patients.

Equipment

Typical trauma equipment includes:

  • Cardiac monitor
  • Pulse oximeter
  • End-tidal CO2 monitoring device
  • Intravenous (IV) access supplies including isotonic IV fluids such as normal saline or lactated Ringer solution
  • Airway supplies including, bag-mask device, intubation tray, and surgical airway
  • Needle thoracostomy and chest tube

Personnel

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 multidisciplinary team has the following members who have pre-assigned roles.

  • Team Leader (Physician)
  • Anesthesiologist
  • Trauma Surgeon
  • Emergency Department Physician
  • Two Nurses (at least)
  • Radiographer
  • Scribe

Other staff may not necessarily be involved in every trauma call but should be available immediately (if needed):

  • Neurosurgeon
  • Thoracic Surgeon
  • Plastic Surgeon
  • Radiologist.

Preparation

Before patient arrival, roles should be allocated, and universal precautions, including wearing protective clothing, should be enforced. All equipment required should be checked.

  • Certain areas should be notified
  • Radiology department for portable x-rays and CT scan
  • Intensive care unit
  • Operation room

Technique

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:

  • (A) Alert
  • (V) Respond to Verbal stimuli
  • (P) Respond to Painful stimuli
  • (U)  Unresponsive to any stimuli.

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:

  • 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
  • Chest x-ray is obtained to evaluate for pneumothorax, hemothorax or suspicion of an aortic injury
  • 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 performed, to identify free fluid in the abdomen which may be 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.

Clinical Significance

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.


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Trauma Primary Survey - Questions

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What is not involved during the primary survey of trauma?



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Which mnemonic pertains to the primary survey prehospital report for a trauma patient?



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Which is best facilitated by utilizing across-the-room observation during the primary assessment?



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A 24-year-old male is brought to the emergency department after a motor vehicle collision. Emergency medical services report that he was restrained, required extrication, and was combative at the scene. His vitals en route were BP 124/86, HR 108, RR 22, and SpO2 98% on room air. After arrival at the small emergency department staffed with a single nurse and single physician, the patient is quiet and looking around. You notice a large, gaping wound on his left forearm, oozing blood with muscle and tendon exposed. What should be done first?



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A trauma patient arrives in the emergency department. You are running through the ATLS primary survey and get to D. Performing D includes all the following except which one?



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Trauma Primary Survey - References

References

Advanced Trauma Life Support Time Standards., Hall AB,Boecker FS,Shipp JM,Hanseman D,, Military medicine, 2017 Mar     [PubMed]
Public priorities for osteoporosis and fracture research: results from a general population survey., Paskins Z,Jinks C,Mahmood W,Jayakumar P,Sangan CB,Belcher J,Gwilym S,, Archives of osteoporosis, 2017 Dec     [PubMed]
Addressing Traumatic Stress in the Acute Traumatically Injured Patient., Frank CA,Schroeter K,Shaw C,, Journal of trauma nursing : the official journal of the Society of Trauma Nurses, 2017 Mar/Apr     [PubMed]
Standardizing the initial resuscitation of the trauma patient with the Primary Assessment Completion Tool (PACT) using video review., Wurster LA,Thakkar RK,Haley KJ,Wheeler KK,Larson J,Stoner M,Gewirtz Y,Holman T,Buckingham D,Groner JI,, The journal of trauma and acute care surgery, 2017 Feb 28     [PubMed]

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