The Vitals: The Trauma Primary Survey for the Non-Trauma Doc

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Picture of Shyam Murali
Shyam Murali
Fellow in Trauma and Surgical Critical Care - University of Pennsylvania, Senior Editor - CriticalCareNow.com, Writer - RebelEM.com, Saxophonist, EDM remixer, husband, puppy father, and new human father
Picture of Rahel Gizaw
Rahel Gizaw

Emergency Medicine Resident and MedED Enthusiast. Learning and teaching medicine one doodle at a time!

The Pre-brief

The ABCs of trauma have been ingrained into emergency medicine and surgery residents during their training. In fact, most can recite the primary survey in their sleep…but the trauma patient can be daunting for other learners and new attendings. Those of you in the non-surgical world may be thinking: “I’m never going to have to take care of a trauma patient! Why do I need to know this??” Perhaps you don’t take care of trauma patients on a day-to-day basis, but what if you were called in to help during a mass casualty incident? What if you happened to be on the scene of a car accident and just wanted to help first responders? You never know when these skills and knowledge can come in handy.

So let’s go through a crash course on the Primary Survey, courtesy of my dog, Bentley.

The Primary Survey

The Primary Survey of Advanced Trauma Life Support (ATLS) is designed to catch the most common life-threatening conditions found in trauma and treat them rapidly within the first few minutes of evaluation and resuscitation. At each step, the clinician is supposed to evaluate and assess for pathology and treat that pathology immediately before moving on to the next step. While ATLS breaks this process down into very basic concepts, there is truly a massive amount of nuance to the trauma survey, and we will certainly cover those in future posts. This order is hotly debated and some trauma experts recommend different approaches such as the CABC or MARCH paradigms. However, here is the basic algorithm of the Advanced Trauma Life Support (ATLS):

  • Airway
    • Is your patient’s airway patent? To assess this, start by asking their name.
      • If they answer you appropriately, their airway is likely clear and they are able to ventilate and maintain their airway appropriately.
      • If they do not answer appropriately, consider the following:
        • Are there obstructions in the airway? Blood, teeth, debris, etc.
        • Are there any facial fractures that prevent normal speech? Are there any facial fractures that are obstructing respiration?
        • Is there a CNS issue (ICH, toxins, etc.)? Poor mental status can lead to problems with maintaining the airway.
      • This is the first treatment decision point. Does this patient need an artificial airway placed in order to continue ventilating?
      • With few exceptions (which we’ll cover in future posts), ATLS recommends intubation at this time before moving onto the next step.
Bentley Airway
Bentley’s airway looks pretty clear if you ask me…
  • Breathing
    • Listen to both sides of the chest to assess for breath sounds. Do they sound equal? Is one diminished or absent compared to the other side? Are you unable to hear lung sounds on either side?
      • Equal lung sounds bilaterally? On to the next step.
      • Absent on one side? This may be the time to place a needle thoracostomy or perform a finger thoracotomy.
        • Consider diaphragmatic injury causing translocation of the bowel into the chest cavity. This can cause decreased or absent breath sounds. If you have suspicion for this (obvious abdominal bruising from a seat belt, severe abdominal and chest pain, etc.) consider getting a chest x-ray first.
  • Circulation
    • Immediately control external bleeding. In some trauma algorithms, this is the first step, even before assessing the airway. Consider direct pressure vs. wound packing vs. tourniquet use. Check out this post for more information on controlling bleeding.
    • Check DISTAL pulses (radial and dorsalis pedis). If you can’t find distal pulses, move more centrally. This does two things:
      • Gives you a rough estimate of SBP. Although many studies have found low or no correlation of presence of distal pulses to specific SBP targets, the absence of a pulse should certainly worry you. Presence of a distal pulse should not necessarily reassure you that your patient is out of the danger zone.
      • Gives you an idea of whether an extremity has a severe vascular injury (transection vs. dissection vs. obstruction; think knee dislocation or extremity fracture causing vascular injury).
    • Note the heart rate and blood pressure
      • Quickly calculate a shock index (HR/SBP, shock index >0.8 can portend some badness in hemorrhaging patients)
    • Consider whether your patient needs blood products or even a massive transfusion protocol. Your patient is not bleeding normal saline, so avoid giving too much crystalloid fluid (anything more than 1L in a trauma patient is too much; in very sick patients, even 1L can be far too much). In trauma, move to blood early.
  • Disability
    • GCS
      • GCS<8, Intubate….maybe? This is controversial and out of the scope of this post. It is safe to say that you should consider intubation in patients with low GCS as they have decreased ability to control their airway and breathing. Any episode of hypotension or hypoxia in these patients can be extremely detrimental.
    • Pupils
      • The window to the brain. Abnormally dilated? Unreactive? In conjunction with the vital signs, consider the presence of significant brain bleed with mass effect and possible herniation.
Bentley Eyes
  • Exposure
    • Undress the patient and examine the skin of the torso and extremities. Look for wounds on the front and back and be active, not reactive, about controlling external bleeding.
    • As soon as possible, cover the patient with warm blankets. Don’t put them at higher risk for Trauma-Induced Coagulopathy.

The Debrief

  • The trauma Primary Survey is meant to catch common trauma-induced life-threatening injuries and treat them immediately.
  • The Primary Survey consists of evaluating: Airway, Breathing, Circulation, Disability, and Exposure
  • This is just a framework to use when approaching trauma patients and there are many nuances that we will cover soon.

 

And I’ll just leave this one right here for you…

References

  1. Campos-Serra A, Montmany-Vioque S, Rebasa-Cladera P, Llaquet-Bayo H, Gràcia-Roman R, Colom-Gordillo A, Navarro-Soto S. The use of the Shock Index as a predictor of active bleeding in trauma patients. Cir Esp (Engl Ed). 2018 Oct;96(8):494-500. English, Spanish. doi: 10.1016/j.ciresp.2018.04.004. Epub 2018 May 31. PMID: 29778416.

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