Primary Survey in Emergency Medicine

Framework: ABCDE

Although presented sequentially, a well-functioning trauma team executes these simultaneously under a team leader. - Current Surgical Therapy, 14e

A - Airway (with Cervical Spine Protection)

• Agitation, belligerence, anxiety (early hypoxia)
• Use of accessory respiratory muscles
• Stridor, hoarseness, gurgling
• Inability to make verbal response / altered consciousness

• Jaw thrust maneuver (preferred over head-tilt in trauma - preserves C-spine)
• Insert oral or nasal airway as temporizing measures
  • Oral airway: avoid if gag reflex intact
  • Nasal airway: avoid if basilar skull fracture suspected
• Definitive airway: Rapid Sequence Intubation (RSI) via translaryngeal endotracheal intubation is the method of choice
• If RSI fails: surgical airway (cricothyroidotomy)
• Confirm tube placement with end-tidal CO2 and pulse oximetry, then chest X-ray

• All blunt trauma patients require cervical spine immobilization until injury is excluded
• Hard collar or sandbags + tape; soft collars are insufficient
• Use two-person technique: one maintains in-line stabilization while the other manages the airway
• For penetrating neck wounds, cervical collars are NOT recommended - they provide no benefit and interfere with assessment
• Schwartz's Principles of Surgery, 11e; Current Surgical Therapy, 14e; Tintinalli's Emergency Medicine

B - Breathing and Ventilation

• Bilateral auscultation of breath sounds + inspection of chest rise
• Check for right mainstem intubation post-RSI (equal breath sounds)
• Bedside ultrasound: absence of pleural sliding = pneumothorax

Patients presenting in extremis may benefit from bilateral finger thoracostomies for rapid chest evaluation. Pneumothoraces can expand with positive-pressure ventilation - always reassess after intubation. - Current Surgical Therapy, 14e

C - Circulation with Hemorrhage Control

• Weak/absent peripheral pulses
• Cool, pale skin with decreased capillary refill
• Tachycardia (often the only early sign)
• Hypotension (a late sign - the body compensates until ~30% blood loss)

• SI > 0.9 is highly suggestive of critical bleeding
• Note: SBP alone is unreliable in early shock

1. Control external bleeding first - direct compression or tourniquet
2. Two large-bore IVs (above the diaphragm preferred in pregnancy/abdominal trauma); if difficult access, use intraosseous (IO) route
3. Fluid resuscitation with isotonic crystalloids; for hemodynamically unstable patients - Type O-negative packed red blood cells until type-specific blood is available
4. Activate Massive Transfusion Protocol (MTP) for ongoing instability: 1:1:1 ratio of RBCs:Platelets:Fresh Frozen Plasma
5. Tranexamic acid (TXA) - administer within 3 hours of injury to reduce bleeding and mortality
6. Balanced resuscitation: use TEG/ROTEM to guide targeted therapy

Attempting to intubate severely shocked patients before hemorrhage control can precipitate cardiac arrest - the primary problem is brain hypoperfusion, not a primary airway issue. - Current Surgical Therapy, 14e

D - Disability (Neurological Status)

1. Glasgow Coma Scale (GCS): Motor + Verbal + Eye components
   • GCS ≤ 8: intubate to protect the airway and prevent secondary brain injury from hypoxemia
   • Motor score may identify spinal cord injury
2. Pupils: Size, symmetry, reactivity
   • Unilateral fixed/dilated pupil = transtentorial herniation until proven otherwise
3. AVPU (quick alternative to full GCS):
   • Alert, Voice responsive, Pain responsive, Unresponsive
4. Consider blood glucose - hypoglycemia can mimic neurological injury

• Harriet Lane Handbook, 23e; Tintinalli's Emergency Medicine

E - Exposure and Environment

• Completely expose the patient - remove all clothing and debris to identify all injuries (including the back - logroll the patient)
• Screen for medication overdose or drug intoxication associated with the trauma
• Prevent hypothermia - hypothermia worsens the "lethal triad" of coagulopathy, acidosis, and hypothermia
  • Use warm blankets, warm IV fluids, warm the environment

Special Modifications

Cardiac Arrest (Non-Traumatic)

Military/Tactical Setting (MARCH)

• M - Massive hemorrhage control
• A - Airway
• R - Respiratory
• C - Circulation
• H - Hypothermia prevention / Head injury
• Tintinalli's Emergency Medicine

Trauma in Pregnancy

• Left lateral tilt 15-30 degrees (or manual uterine displacement) after 20 weeks to relieve IVC compression
• Fetus can be compromised even when maternal BP appears normal (expanded circulating volume)
• Uterine fundal height in cm = gestational age in weeks
• Fetal viability threshold: approximately 22-24 weeks
• Rosen's Emergency Medicine

What the Primary Survey Is NOT

• Detailed head-to-toe physical examination (that is the secondary survey)
• Imaging studies (though eFAST ultrasound is now integrated during circulation assessment)
• Definitive diagnosis
• Detailed history (SAMPLE history belongs to secondary survey)

Key Life-Threatening Conditions Identified During Primary Survey