The primary survey is used to determine firstly whether the patient is time-critical and needs immediate transfer. A simple mnemonic, (C)ABCDE, is used as a memory aid for the order in which problems should be addressed. The stages in the primary survey should be learnt separately and performed fluently.
If the primary survey is performed as it should be, there is no need to miss any abnormalities in a patients condition.
Sometimes it is not possible to complete a primary survey fully as we do not move on from one section until the complication has been resolved, example: If there is a problem maintaining the airway ('A'), breathing ('B') is not assessed until the 'A' is being adequately maintained. If there is a problem in circulation ('C'), disability ('D') will not be assessed until the complications in 'C' have been resolved.
Before commencing the patient examination, some simple steps must be followed to gain the best picture of what has occured and to make sure everyone is safe, this is split into the 3 S's and Mechanism Of Injury (MOI)
Safety: Always ensure you remain safe on scene, use other agencies such as the police where needed and always wear the appropraite Personal Protective Equipment (PPE)
Scene: Take in the scene, make a note of your access and egress, will anything need to be cleared prior to extrication of your patient.
Situation: Information should be provided before arrival on scene, assess the situation as you find it and continue to reassess for the duration.
Is there a sufficient MOI?
Use common sense to look at predicted injury patterns from events leading upto injuries, if sufficient MOI then hold a high index of suspicion for potential injuries. Consider C- spine immobilisation.
Patient Assessment Triangle (PAT)
Appearance (Alert? Verbal, Painful Stimulation or Unresponsive - AVPU)
Breathing (Effort of breathing) Does the patient have an elevated respiration rate?
Are they in a position to enable them to breathe easier (tri-podding/sniffing the morning air etc).
Colour – What is the colour of your patient? Are they flushed? Are they cyanosed? Are they pale/clammy?
*If there is a deficit in any part of the patient assessment triangle the patient should be considered time-critical and time on scene should be minimal, this is the time to REQUEST BACK UP, should you need it.
Is there a catastrophic haemorrhage? How will you manage it?
Torso: Pressure, Compression, Packing. (Paramedic Trauma Kit)
Limbs: Torniquet. (Combat Application Tourniquet - CAT)
Direct pressure on the limbs is useful while applying the torniquet. Arterial torniquets should be applied to areas where there is a single bone – as proximal as necessary/distal as possible.
Consider C-spine – Jaw thrust?
If there is a potential C-spine injury it is important to try and ensure it remains immobilised , jaw thrust is useful here
Is the airway clear? Visually inspect the airway.
Suction can be used to clear the airway of an unresponsive patient.
Stepwise approach: Positional, use of adjuncts Oropharyngeal airway, Nasopharyngeal airway, Igel/LMA, ET tube.
Trauma – O2 therapy should be administered immediately due to the high risk of hypoxia in trauma.
Medical – Obtain an SPO2 reading, if there is a deficit in this O2 should be administered (consider COPD etc which could cause patients to be CO2 retainers).
Rate – Normal? Is it fast or slow - why?
Depth – Normal? How deep or shallow is your patient breathing - why?
Efficacy – Is the patient breathing with adequate efficacy? If not – why not? Have they injured themselves? Is it a medical problem?
If there are deficits in FLAPS, a TWELVE examination should be carried out.
A TWELVE assessment can give indication of a tension (or a developing tension) pneumothorax.
Pulse (radial/carotid) Rate, rhythm and depth should be noted here. NB. Absence of a radial pulse can indicate hypotension but can also be a result of other factors. If there is an injury to a limb, checking a pulse distally is important to ensure the peripherals are adequately perfused.
Capillary refill time (central) Pressing a thumb to the patients forehead/sternum for 5 seconds – an average cap refill time should be 2 seconds or less. Cap refill can be assessed peripherally (ie, if there is injury to the arm, chacking cap refill on the affected limbs hand can indicate whether perfusion is adequate)
Temperture – Quick check of skin temperature (warm/cold)/texture (wet/dry/clammy etc)
Blood on the floor + 4 more (considering concealed haemorrhage)
- Chest (already covered in flaps/twelve).
- Abdo, Pelvis, Long bones (pelvic splint/ traction splint).
- Blood loss in these areas can be significant and life threatening.
- Palpating the abdomen (examining for distention,boarding, guarding, tenderness etc).
- Looking at the areas for signs such as swelling/distention, contusion, fracture etc.
- Looking at surrounding area for any external blood loss is also important.
Tourniquet – If one has been applied – re-check, if bleeding is still an issue, a second tourniquet can be applied. Once a patient relaxes further bleeding can occur. Consider the time span a tourniquet can be kept on for before nerve/muscle/vascular damage occurs.
Compression – Re-check any dressings (any blood lost from the body is ‘lost forever’) Actively control the bleeding rather than collect it within dressings.
Pelvis – apply pelvic splint – consider MOI, abdo and/or lower limb injuries.
AVPU – How responsive is the patient/use of the Glasgow Coma Scale.
PERRL – Are the Pupils, Equal, Round and Reactive to Light? What size are they? Different sized pupils could indicate narcotic involvement, unequeal pupils may indicate a head injury or neurological issue – If pupils are unequal or unreactive to light, ensure you ask the conscious patient if this is normal for them – be mindful of glass eyes.
Haemoglucose test – This can immediately indicate whether hypo/hyperglycaemia is the potential cause for an altered mental state.
Head injury? Check for base of skull/cranial/scalp deficits and/or facial injury.
Look for concealed injuries checking for ‘boggy masses, battle signs, CSF/blood in ears/nose
NB – if a patient is suspected to have a base of skull fracture, use NP airways with caution.
Expose and Examine. Exposing the patient is imperative to ensure we do not miss any injuries that may be concealed by clothing etc. This section is where the secondary survey is performed.
Environment: Be aware of the environment you find the patient in – blanketing in cold temperatures etc – if in public, maintaining dignity. Are environmental factors the reason for the patients condition.
(E*) Evaluate/Re-evaluate: Evaluating our findings and re-evaluating them as the situation changes is very important in our treatment plan for the patient – are they time critical?
Evacuate: Does the patient need conveying to hospital? If so – where is the nearest appropriate treatment centre (ED/MIU/trauma unit/major trauma centre/burns/plastics/PCI)? Does the patient require emergency conveyance (ATMIST) etc.