General - Primary Survey

Written by: Wesam Tamimi, M.D.

Keywords: Trauma care, primary survey, ABCDE framework, hemorrhage control, neurological assessment, evidence-based trauma care

Overview

Principles of trauma management based on the ATLS guidelines and the ABCDE approach. The initial assessment prioritizes life-threatening conditions, starting with Airway management and Cervical Spine Protection, followed by Breathing assessment (e.g., identifying pneumothorax or hemothorax), Circulation to detect shock and hemorrhage, Disability evaluation using the Glasgow Coma Scale for neurologic function, and Exposure for a thorough examination and temperature control. The focus is on rapid interventions, including airway clearance, IV access, and resuscitation, while managing potential complications like neurogenic shock, hypothermia, and hemorrhage. The goal is to stabilize the patient and identify critical injuries for timely treatment.

Definition

The mainstay approach for injured patients is based on advanced trauma life support ATLS guidelines and the ABCDE approach

ATLS fundamentals

·        Prioritize addressing the most immediate threat to life.

·        Do not let the absence of a definitive diagnosis delay the initiation of urgently needed treatment.

·        A comprehensive history is not required before starting the evaluation of a patient with acute injuries.

ABCDE Approach

·        Airway and cervical spine protection

·        Breathing

·        Circulation

·        Disability or neurologic condition

·        Exposure and environmental control

NOTE: Primary survey can be repeated any time there is a change in condition.

Airway

Initial airway assessment:

Initial actions:

·        Examine: Check for any visible blockages (e.g., blood, vomit, foreign objects).

·        Clear the airway: Perform the head tilt-chin lift or jaw-thrust maneuver, especially if a cervical spine injury is suspected.

NOTE: Inability to speak suggests mental status depression or airway obstruction, necessitating airway management.

Advanced interventions:

• Suction: Remove fluids from the airway to ensure patency.

• Oropharyngeal or nasopharyngeal airways: Use for unconscious patients without a gag reflex.

• Endotracheal intubation: Indicated for patients with compromised airways (expanding hematoma in the neck) or who are unable to maintain their own airway (Glasgow coma scale 8 or lower).

• Cricothyrotomy or tracheostomy: Considered for patients with severe upper airway obstruction.

Cervical spine precautions:

• Assume all trauma patients have potential cervical spine injury.

• Use a hard cervical collar and maintain log-roll technique during movement.

• During airway management, remove the cervical collar’s anterior portion if needed but ensure manual stabilization.

NOTE: A clinical examination to assess for midline tenderness and range of motion is the most appropriate approach for evaluating the cervical spine in an alert, sober, neurologically intact patient without distracting injuries following a motor vehicle crash.

Breathing

Assess breathing by:

• Visualizing chest movement

• Auscultating breath sounds

• Measuring oxygen saturation

Potential causes of ventilatory problems:

• Tension pneumothorax

  • Can cause respiratory deterioration, unstable hemodynamics, or cardiovascular collapse

  • Diagnosed clinically without the need for radiographic confirmation

  • Symptoms: Tracheal deviation, absent/diminished breath sounds, cardiopulmonary compromise

  • Treatment: Rapid thoracic decompression using a large-bore needle or tube thoracostomy

• Massive hemothorax

  • Requires tube thoracostomy for blood evacuation and lung re-expansion

• Pulmonary contusion

  • Often requires aggressive mechanical ventilation

  • Use elevated levels of positive end-expiratory pressure (PEEP)

Circulation

Primary goal: Determine the presence or absence of shock, defined as end-organ hypoperfusion on physical exam.

Hypotension: While a clear indicator of cardiovascular decompensation, shock can occur before hypotension due to compensatory mechanisms.

Most common cause of shock: Hemorrhage, especially in trauma. Acute blood loss must be ruled out first.

Clinical signs of shock include: 

·        Hypotension

·        Tachycardia (first sign in hypovolemia)

·        Altered mental status

·        Weak pulses

·        Cold extremities.

Initial management:

• Obtain IV access with two large-bore peripheral IV catheters, intraosseous needle, or central venous catheter.

• Start with 1 L of warmed crystalloid solution for resuscitation.

• If the patient doesn't respond, consider product-based resuscitation (blood products).

• Avoid crystalloid infusion >1.5 L as it increases the risk of death.

Rapid assessment for blood loss:

• Identify sources of exsanguination in five major areas: chest, abdomen, retroperitoneum, pelvis, and long bone fractures.

• Initial physical exam: Assess for external blood loss and long bone fractures.

• Management: Apply direct pressure for external bleeding; splint long bone fractures.

Imaging:

• Chest X-ray: Quickly evaluate for hemothorax.

• Pelvic X-ray: Identify pelvic fractures.

• FAST (Focused Abdominal Sonography in Trauma): A rapid ultrasound to assess fluid (likely blood) in the hepatorenal, splenorenal, and pelvic spaces.

• FAST scan advantage: Quick to perform and repeat in the trauma bay.

Disability and Exposure

Rapid neurologic evaluation: Assess global neurologic function to evaluate for traumatic brain injuries (TBI) and spinal cord injuries (SCI).

Glasgow coma scale

Table 1: Glasgow coma scale point measurements

Score interpretation:

·        15: Full consciousness

·        9–14: Varying degrees of impairment

·        8 or less: Severe impairment, coma

·        3: Deep coma or brain death

Spinal cord assessment: Evaluate movement of the extremities to assess spinal cord function.

Neurogenic shock:

• Consider neurogenic shock in hypotension with absent extremity movement, but be cautious in attributing shock solely to SCI.

• Hemorrhage is a more common cause of shock in trauma patients.

• Classic teaching suggests that cervical or high thoracic spine injuries typically cause neurogenic shock.

• If the patient can move their upper extremities, the likelihood of neurogenic shock is significantly reduced.

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Clothing removal: Remove all clothing to allow for a thorough examination, accurate core body temperature measurement, and necessary interventions.

Hypothermia management:

• Hypothermia is part of the "terrible triad of death" in trauma (coagulopathy, acidosis, hypothermia).

• Efforts to restore normal body temperature are crucial: Use blankets, heating devices (e.g., Bair Hugger), warm room/OR temperatures, and warmed resuscitative fluids.

Reference

Carmichael II, S. P., Mowery, N. T., Martin, R. S., & Meredith, J. W. (2024). Management of acute trauma. In C. M. Townsend, R. D. Beauchamp, B. M. Evers, K. L. Mattox, & D. C. Sabiston (Eds.), Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice (21st ed., pp. 386–395). Elsevier.