Primary Survey


What is a Primary Survey?

  • Definition: A primary survey is a methodical tool used to identify life-threatening, time-critical features needing immediate intervention.

  • Characteristics:

    • Swift patient assessment and management process.

    • Duration of 60-90 seconds.

    • General impression of a patient's presentation.

    • Determines the pace of treatment and decision-making.

Components of the Adult Medical Primary Survey

  • Total Duration: 60-90 seconds

  • Steps: DRcABCDE

    • Danger

    • Response

    • Catastrophic haemorrhage

    • Airway (consider c-spine)

    • Breathing

    • Circulation

    • Disability/Dysfunction

    • Expose/Extricate/Examine

    • Reassess

Step 1: Danger Assessment

  • Importance: A scene assessment to ascertain actual and potential dangers is paramount to prevent harm to crew and others on scene.

  • Examples of Possible Dangers:

    • Various hazards may be present, requiring attention immediately.

Step 2: Response Assessment

  • Protocol for Response Assessment:

  • Eliciting Response: AVPU

    • Alert

    • Verbal

    • Pain

    • Unresponsive

Combined Steps Approach

  • Step 1: One person incapacitated with no obvious reason - Approach using standard protocols.

  • Step 2: Two people incapacitated with no obvious reason - Approach with caution using standard protocols.

  • Step 3: Three or more people in close proximity, incapacitated with no obvious reason - Use caution and follow protocols.

Step 3: Catastrophic Haemorrhage

  • Process:

    • Some primary surveys will take the DR c ABCDE format.

    • Although often associated with trauma, they do occur in medical presentations.

    • Common Medical Causes of Major Haemorrhage:

    • Causative factors include conditions that can lead to significant blood loss.

    • Areas commonly involved include:

      • Abdominal cavity

      • Pelvic cavity

Actions for Catastrophic Haemorrhage

  • Controlling Bleeding: Essential to prevent rapid deterioration and death.

  • Possible Actions Include:

    • Direct pressure

    • Tourniquet

    • Haemostatic dressings

    • Intravenous tranexamic acid

    • Binders and splints


Step 5: Airway Management

  • Assessment:

    • Determine if the airway is patent, partially obstructed, or obstructed.

    • If the patient is speaking clearly, the airway is patent.

    • Determine the respiratory rate. Normal range for an adult at rest is 12-20 breaths per minute. Respiratory rate <10 or >29 indicates inadequate ventilation and may require intervention i.e., ventilatory support.

    • In case of unresponsiveness, use the appropriate manoeuvers to assess airway i.e., head-tilt-chin-lift, jaw thrust.

  • No C-Spine Concerns: Use head tilt-chin lift technique.

  • C-Spine Concerns: Use jaw thrust manoeuver.


Common Causes of Airway Obstruction:

  • Vomit

  • Soft tissue

  • Food

  • Foreign objects

  • Swelling

  • Surgical Airways Consideration!


Airway Obstruction/ choking

Symptoms depend on the severity of the obstruction.

Mild episode

Indications:

  • Patient is conscious

  • speak

  • Breathing

  • Coughing


Severe episode

Indications:

  • Patient may still be conscious

  • Unable to speak

  • Unable to breathe

  • Cyanosis- a bluish discolouration of the skin and mucous membranes due to insufficient oxygen in the blood

  • Laboured breathing- Involves the use of accessory muscles, stridor-high-pitched sound indicating airway narrowing.

  • Weak pulse

Interventions:

  • Back blows

  • Abdominal thrusts

Life threatening

Indications:

Patient is unconscious.

Interventions:

  • CPR

  • If choking on a foreign object suspected, perform a laryngoscopy. If unsuccessful or the patient doesn’t recover after the removal of the foreign body and begin spontaneously breathing, begin CPR.

  • Oxygenate the patient after removal of foreign object.

  • Reassess the patient's airway for obstruction and ensure proper positioning to facilitate effective ventilation.


Airway Intervention Steps

  • Techniques for managing the airway include:

    • Positioning

    • Suctioning

    • Oropharyngeal insertion

    • Nasopharyngeal insertion

    • Supraglottic airway insertion

    • Endotracheal intubation

    • Emergency cricothyroidotomy


Step 4: Breathing Assessment

  • Key Questions to Address:

    • Is the patient breathing?

    • What is the respiratory rate? (<10 or >29 indicates inadequate ventilation that may require ventilatory support.)

    • What position is the patient in? Are they tripoding? Are they able to speak? Are they speaking in partial or complete sentences?


Inspect

  • Is the patient using accessory muscles?

  • flail segments? Deformities? Bruising? Paradoxical breathing? (Patient’s chest moves in on inspiration and out on expiration, the opposite to normal, spontaneous breathing.)

  • Sucking chest wounds?

Palpate

  • Feel the chest to determine whether there is equal expansion.

  • Any crepitus? (short popping/ crackling sounds- indicate the sudden opening of collapsed alveoli indicating pneumonia, COPD, pulmonary edema (fluid build up etc))

  • Is the trachea central?

Percuss (chest tapping)

  • Hyper-resonance- abnormally loud, hollow, booming, low-pitched sound when percussing the chest due to their being too much air in the thoracic cavity- Indicates pneumothorax (collapsed lung), emphysema (alveoli in are damaged and enlarged (lack of elasticity so lack of recoil)), severe asthma etc.

  • Hypo-resonance- Dull, dense, low-pitched sound when percussing the chest due to there being less air in the lungs than usual or a build up of fluid, indicating conditions such as pleural effusion (build up of fluid between the lungs and the chest wall), pneumonia, or lung consolidation (filling of the alveoli with fluid, pus, blood etc rather than air).

  • Normal resonance: A clear, low-pitched sound that is produced when the thoracic cavity has normal air content, indicating healthy lung function.

Auscultate

  • Breath sounds at different auscultation sites gives different indications.

  • Bronchial breathing could indicate areas of consolidation in the lungs, which could indicate pneumonia or other respiratory diseases.

  • Absent or diminished breath sounds could indicate pneumothorax/ collapsed lung (air leaks from the lungs into the thoracic cavity), consolidation or pleural effusion.

Breathing Interventions

  • Interventions include:

    • Commence Basic Life Support (BLS) if the patient is not breathing.

    • Oxygen administration

    • Medications

    • Ventilation

    • Seal sucking chest wounds

    • Stabilize flail segments

    • Decompress tension pneumothorax

Step 6: Circulation Assessment

  • Pulse Examination:

    • Check temporal, carotid, brachial, apical, radial, femoral, popliteal, pedal, and posterior tibial pulses.

    • Indicators of Concern:

    • Signs of hemorrhage

    • Radial pulse palpation; if absent, palpate femoral or carotid. Assess the following:

      • Is it fast (tachycardic) or slow (bradycardic)?

      • Is the pulse regular? Is it bounding or weak?

    • Assess patient's pallor: Are they warm, cold, clammy?

    • Check capillary refill time (CRT), both peripheral and central.

Step 7: Disability/Dysfunction Assessment

  • Neurological Evaluation:

    • Assess pupil properties: Equal, Round, Responsive, Light reflex, Accommodation.

    • Balance, eyes, face droop, arm drift/numb/weak, slurred speech.

    • Document time of onset for symptoms.

    • Participate in practice sessions for pupillary assessment.

Step 8: Expose/Examine/Extricate

  • While protecting dignity and considering the environment, expose the patient to examine for injuries or concerns.

  • Things to Check For:

    • Medical alert tags such as opioid patches.

    • Ensure to obtain consent before examination.

    • Evaluate results:

    • Positive Primary Survey: Patient requires aggressive management and rapid transport to hospital with pre-alert.

    • Negative Primary Survey: No major interventions needed, proceed to secondary survey.

Pediatric Assessment Triangle

  • Key Elements of Assessment:

    • Appearance

    • Circulation to skin

    • Work of breathing