The Primary Survey

Information excerpts courtesy of Advanced Trauma Life Support - Program for Physicians, 1993 Instructors Manual
[Return to Case 1 Start Page.]


The Primary survey is a crucial element in the ďInitial AssessmentĒ of a seriously injured patient.

Patients are assessed and treatment priorities are established based on their injuries, the stability of their vitals, and the injury mechanism.

The patientís vital functions must be assessed quickly and efficiently. Patient management must consist of a rapid primary evaluation, resuscitation of vital functions, a more detailed secondary assessment, and finally, the initiation of definitive care. This process constitutes the ABCs of trauma care and identifies lief-threatening conditions.

  1. Airway maintenance with cervical spine control
  2. Breathing and ventilation
  3. Circulation with hemorrhage control
  4. Disability: Neurologic status
  5. Exposure/Environmental Control: Completely undress patient, but prevent hypothermia

During the primary survey, life-threatening conditions are identified and management is begun simultaneously.


A. Airway with Cervical Spine Control

Upon initial evaluation of the trauma patient, the airway should be assessed first to ascertain patency. This rapid assessment for signs of airway obstruction should include inspection for foreign bodies and facial, mandibular, or tracheal/laryngeal fractures that may result in airway obstruction. Measures to establish a patent airway should protect the cervical spine. The chin lift or jaw thrust maneuvers are recommended to achieve this task.

While assessing and managing the patientís airway, great care should be taken to prevent excessive movement of the cervical spine. The patientís head and neck should not be hyperextended, hyperflexed, or rotated to establish and maintain the airway. Based on the history of the trauma incident, the loss of integrity of the cervical spine should be suspected. Nerurologic examination alone does not rule out a cervical spine injury. The integrity of the bony components of the cervical spine can be assessed initially by visualizing all seven cervical vertebrae, including the C-7 to T-1 interspace on a crosstable lateral cervical spine roentgenogram. The lateral cervical spine film does not exclude all cervical spine injuries. Immobilization of the patientís head and neck with appropriate cervical immobilization devices should be accomplished and maintained. If immobilizing devices must be removed temporarily, the head and neck should be stabilized with manual, in-line immobilization by one member of the trauma team. These devices should be left in place until cervical spinal injury is excluded. Remember: Assume a cervical spine injury in any patient with multisystem trauma, especially with an altered level of consciousness or a blunt injury above the clavicle.

Pitfalls:

  1. Foreign body in the airway
  2. Mandibular or maxillofacial fracture
  3. Tracheal or laryngeal disruption
  4. Cervical spine injury

B. Breathing

Airway patency alone does not assure adequate ventilation. Adequate exchange of gases is mandatory to maximize oxygen transfer and carbon dioxide elimination. Ventilation involves adequate function of the lungs, chest wall, and diaphragm. Each component must be examined and evaluated rapidly.

The patientís chest should be exposed to assess ventilatory exchange adequately. Auscultation should be performed to assure air exchange in the lungs. Percussion may reveal the presence of air or blood in the chest. Visual inspection and palpation may reveal injuries to the chest wall that may compromise ventilation.

Injuries that may acutely impair ventilation are tension pneumothorax, flail chest with pulmonary contusion, and open pneumothorax. Hemothorax, simple pneumothorax, fractured ribs, and pulmonary contusion may compromise ventilation to a lesser degree.

Pitfalls:

  1. Tension pneumothorax
  2. Flail Chest with pulmonary contusion
  3. Open pneumothorax
  4. Massive Hemothorax

C. Circulation with hemorrhage Control

1. Blood volume and cardiac output

Hemorrhage is the predominant cause of postinjury deaths that are amenable to effective and rapid treatment in the hospital setting. Hypotension following injury must be considered to be hypovolemic in origin until proved otherwise. Rapid and accurate assessment of the injured patientís hemodynamic status is therefore essential. Two elements of observation yield key information within seconds --- level of consciousness and pulse.

2. Bleeding

External, severe hemorrhage is identified and controlled in the primary survey.

Rapid, external blood loss is managed by direct manual pressure on the wound. Pneumatic splinting devices also may help control bleeding. These devices should be transparent to allow monitoring of underlying bleeding. Tourniquets should not used because they crush tissues and cause distal ischemia. The use of hemostats is time-consuming, and surrounding structures, such as nerves and veins, can be injured. Hemorrhage into the thoracic or abdominal cavities, into muscles surrounding a fracture, or as a result of a penetrating injury can account for major, occult blood loss.

Pitfalls: Hypovolemia resulting from

  1. Intra-abdominal or intrathoracic injury
  2. Fractures of the femur and/or pelvis
  3. Penetrating injuries with arterial or venous involvement
  4. External hemorrhage from any source.