11.2 Primary Survey (ABCDE) & Rapid Trauma Assessment

11.2 Primary Survey (ABCDE) & Rapid Trauma Assessment

Clinical Core: The Primary Survey is a rapid, systematic assessment designed to identify and immediately manage life-threatening conditions within minutes of patient arrival. Grounded in the Advanced Trauma Life Support (ATLS) framework, the sequence follows Airway, Breathing, Circulation, Disability, and Exposure (ABCDE). Resuscitation efforts occur simultaneously with assessment; clinical life-threats must be corrected immediately upon discovery before proceeding to the next step.

Airway Maintenance with Cervical Spine Stabilization (A)

Airway compromise is the fastest killer in trauma. Airway assessment and protection must occur concurrently with strict cervical spine (C-spine) immobilization.

Cervical Spine Stabilization

Assume cervical spine injury in all blunt trauma patients, those with altered mental status, or those involved in high-energy mechanisms.

• Manual In-Line Stabilization: A designated team member holds the patient's head and neck in a neutral inline position with hands on both sides of the head.
• Immobilization Devices: Apply a rigid cervical collar, supportive head blocks, and straps on a long spine board (minimized for transport) until C-spine injury is radiographically or clinically cleared.
• Contraindications to Movement: Stop inline stabilization if the patient experiences severe pain, neurological deficits, muscle spasm, or mechanical resistance during alignment; immobilize in the position found.

Airway Patency & Interventions

• Assessment: Ask the patient to speak. A clear verbal response confirms airway patency, adequate phonation, and gross brain perfusion. Signs of compromise include stridor, gurgling, hoarseness, snoring, facial trauma, or foreign body accumulation.
• Airway Maneuvers: Use the Jaw-Thrust maneuver (lifting the angles of the mandible forward) rather than the head-tilt/chin-lift to open the airway without extending the cervical spine.
• Airway Adjuncts & Definitive Airway: Insert an Oropharyngeal Airway (OPA) in unconscious patients without a gag reflex, or a Nasopharyngeal Airway (NPA) in conscious/semiconscious patients (avoid NPA if basilar skull fracture is suspected). Obtain a definitive airway (endotracheal intubation or surgical cricothyroidotomy) for GCS ≤ 8, severe facial burns, expanding neck hematomas, or inability to maintain oxygenation.

---

Breathing and Ventilation (B)

Patency of the airway does not guarantee adequate ventilation. The chest wall, lungs, and diaphragm must be inspected, palpated, auscultated, and percussed to identify five immediately life-threatening thoracic injuries.

Assessment Parameters

Inspect chest movement for bilateral expansion and asymmetry. Auscultate breath sounds in the high anterior chest (apices) and mid-axillary lines (bases). Palpate for rib crepitus, sternal instability, and subcutaneous emphysema. Observe respiratory rate, depth, effort, and continuous pulse oximetry.

Immediately Life-Threatening Thoracic Injuries

1. Tension Pneumothorax: Caused by a one-way valve air leak from the lung or chest wall, leading to progressive intrapleural air accumulation, complete lung collapse, mediastinal shift, and vena cava compression.
   • Clinical Signs: Respiratory distress, absent breath sounds on affected side, hyperresonance to percussion, hypotension, jugular venous distension (JVD), and late tracheal deviation away from the affected side.
   • Immediate Intervention: Needle Decompression (14-gauge, 3.25-inch angiocatheter inserted into the 2nd intercostal space at the midclavicular line or 5th intercostal space at the anterior axillary line) to convert tension into an open pneumothorax, followed immediately by tube thoracostomy (28–36 Fr chest tube).
2. Massive Hemothorax: Rapid accumulation of > 1,500 mL of blood or > one-third of the patient's blood volume in the pleural cavity.
   • Clinical Signs: Severe shock, absent breath sounds, dullness to percussion on the affected side, flat neck veins (due to hypovolemia).
   • Immediate Intervention: Large-bore tube thoracostomy, auto-transfusion, volume replacement with blood products, and urgent surgical consultation for emergency thoracotomy (indicated if initial drainage is > 1,500 mL or ongoing drainage > 200 mL/hour for 2–4 hours).
3. Open Pneumothorax ("Sucking Chest Wound"): Large chest wall defect (> two-thirds the tracheal diameter) causing air to enter the pleural space via the chest wall rather than the trachea.
   • Clinical Signs: Visible chest wall defect, bubbling/sucking chest wound, severe dyspnea, hypoxia.
   • Immediate Intervention: Apply a three-sided occlusive dressing (flutter valve effect: allows air to escape during expiration but blocks air entry during inspiration). Securely taping four sides risks creating a tension pneumothorax. Follow with tube thoracostomy away from the wound site.
4. Flail Chest: Occurs when two or more contiguous ribs are fractured in two or more places, creating a free-floating segment.
   • Clinical Signs: Paradoxical chest wall movement (segment moves inward during inspiration and outward during expiration), severe chest pain, underlying pulmonary contusion leading to hypoxemia.
   • Immediate Intervention: Supplemental oxygen, analgesia (epidural or regional blocks), positive pressure ventilation (NIV or endotracheal intubation) if respiratory failure develops.
5. Cardiac Tamponade: Fluid/blood accumulation in the pericardial sac restricting ventricular filling and reducing stroke volume.
   • Clinical Signs: Beck’s Triad (hypotension, JVD, muffled heart sounds), pulsus paradoxus (> 10 mmHg drop in SBP during inspiration), Kussmaul’s sign.
   • Immediate Intervention: Pericardiocentesis (preferably ultrasound-guided) as a temporizing measure, followed by surgical thoracotomy or sternotomy for definitive repair.

---

Circulation with Hemorrhage Control (C)

Uncontrolled hemorrhage is the leading cause of preventable trauma death. The resuscitation protocol mandates controlling catastrophic bleeding immediately (C-A-B-C-D-E in massive exsanguination).

Hemorrhage Control & Resuscitation

• External Bleeding: Apply direct, firm manual pressure over the bleeding site. If extremity bleeding is refractory to direct pressure, apply a commercial windlass tourniquet 2–3 inches proximal to the wound (never over a joint), tighten until bleeding stops and distal pulse disappears, and clearly record the application time on the patient's forehead/tag.
• Internal Bleeding: Recognize occult sites of massive hemorrhage: "blood on the floor plus four spaces" (Chest, Abdomen, Retroperitoneum/Pelvis, Long bones). Apply a pelvic binder centered over the greater trochanters for suspected unstable pelvic fractures.
• Vascular Access: Establish two large-bore peripheral IV lines (14-gauge or 16-gauge in the antecubital fossae) or rapid intraosseous (IO) access in the proximal humerus or proximal tibia.
• Resuscitation Strategy: Implement Permissive Hypotension in non-TBI trauma patients (maintaining SBP 80–90 mmHg or MAP ~50 mmHg until active bleeding is surgically controlled to prevent disrupting early blood clots). In traumatic brain injury (TBI), maintain SBP ≥ 110 mmHg to preserve cerebral perfusion pressure.
• Massive Transfusion Protocol (MTP): Activated when blood loss > 150 mL/min or anticipated replacement of > 10 units of PRBCs in 24 hours. Administer uncrossmatched O-negative (or O-positive for adult males) PRBCs, Fresh Frozen Plasma (FFP), and Platelets in a balanced 1:1:1 ratio. Administer Tranexamic Acid (TXA) 1 gram IV over 10 minutes within 3 hours of injury, followed by a 1-gram infusion over 8 hours.

---

Disability: Neurological Evaluation (D)

Rapidly quantify central nervous system function to detect intracranial pathology and baseline deficits.

• AVPU Scale: Alert, responds to Voice, responds to Pain, Unresponsive.
• Glasgow Coma Scale (GCS): Evaluate Eye Opening (1–4), Verbal Response (1–5), and Motor Response (1–6). Scores range from 3 to 15. Severe TBI is defined as GCS ≤ 8.
• Pupillary Assessment: Check size, symmetry, shape, and light reactivity. A unilaterally dilated, unreactive pupil ("blown pupil") signals uncal transtentorial herniation causing third cranial nerve compression.
• Herniation Signs: Unilateral blown pupil, decerebrate (extension) posturing, and Cushing's Triad (widened pulse pressure/hypertension, bradycardia, irregular respirations).

---

Exposure & Environmental Control (E)

• Complete Exposure: Undress the patient completely by cutting away clothing to inspect the entire body surface for occult wounds, impaled objects, or bleeding.
• Hypothermia Prevention: Hypothermia degrades the coagulation cascade, worsening the Trauma Triad of Death (Hypothermia, Coagulopathy, Acidosis). Keep the resuscitation room warm (80°F / 26.6°C), remove wet clothing immediately, apply forced-air warming blankets, and infuse all IV fluids and blood products through blood warmers set to 39°C (102.2°F).