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Primary Survey and Resuscitation

Principles

The primary survey is a structured, rapid assessment to identify and manage immediately life-threatening injuries.
Assessment and resuscitation occur simultaneously, following the ABCDE sequence.
Treat the greatest threat to life first and do not delay lifesaving interventions for diagnostic tests.
Reassess continuously—if deterioration occurs, repeat the entire primary survey.

Airway with Cervical Spine Protection

Assessment

  • Determine if the patient can speak; the ability to talk implies a patent airway.
  • Look for stridor, gurgling, noisy respirations, blood, vomitus, or facial trauma.
  • Assume cervical spine injury until proven otherwise.

Interventions

  • Maintain manual inline stabilization (MILS) at all times.
  • Suction blood and vomitus immediately.
  • Perform chin lift or jaw thrust (avoid head tilt).
  • Insert airway adjuncts as indicated:
  • Oropharyngeal airway: if unresponsive and without gag reflex.
  • Nasopharyngeal airway: if gag present and no basilar skull fracture.

Definitive Airway Indications

  • GCS ≤ 8.
  • Airway obstruction or severe facial/neck trauma.
  • SpO₂ < 90% despite high-flow oxygen.
  • Apnea or hypoventilation.

Definitive Airway Techniques

  • Orotracheal intubation with inline stabilization (preferred).
  • If unable to intubate or ventilate, perform surgical or needle cricothyroidotomy.

Key Principle: Always maintain cervical spine protection during airway management.

Breathing and Ventilation

Assessment

  • Inspect for symmetrical chest expansion, wounds, and deformities.
  • Auscultate both lungs for air entry.
  • Percuss for dullness or hyperresonance.
  • Observe respiratory rate, effort, and SpO₂.

Immediate Life-Threatening Conditions

  • Tension pneumothorax: needle decompression (14 G at 5th ICS AAL or 2nd ICS MCL) → chest tube.
  • Open pneumothorax: apply three-sided occlusive dressing → chest tube.
  • Massive hemothorax: chest tube; if >1500 mL initial output or >200 mL/hr × 4 hr → thoracotomy.
  • Flail chest: oxygen, analgesia, and ventilatory support as needed.
  • Cardiac tamponade: pericardiocentesis and urgent surgical exploration.

Oxygenation Targets

  • SpO₂ ≥ 94%, RR 10–30/min, PaCO₂ 35–40 mmHg.
  • Avoid prophylactic hyperventilation.

Key Principle: Diagnose and treat tension pneumothorax clinically—do not delay for imaging.

Circulation with Hemorrhage Control

Assessment

  • Palpate central pulses and assess skin color, temperature, and capillary refill (<2 sec).
  • Control external bleeding with direct pressure or tourniquet if needed.
  • Consider internal bleeding in chest, abdomen, pelvis, or long bones.

Access and Monitoring

  • Insert two large-bore (14–16 G) IVs or IO access.
  • Draw blood for type and cross-match.
  • Initiate continuous ECG, BP, SpO₂, temperature, and urine output monitoring.

Resuscitation

  • Class I (<15% loss): monitor; fluids usually not required.
  • Class II (15–30%): give 1 L warmed isotonic crystalloid → reassess.
  • Class III (30–40%): initiate massive transfusion (1:1:1 PRBC:FFP:platelets).
  • Class IV (>40%): immediate transfusion and operative control.

Targets

  • SBP ≥ 100 mmHg (<65 yr) or ≥110 mmHg (≥65 yr).
  • MAP ≥ 65 mmHg.
  • Urine output ≥ 0.5 mL/kg/hr (adult), 1 mL/kg/hr (child).
  • Lactate < 2 mmol/L and Base deficit > –6 mEq/L indicate adequate perfusion.

Adjuncts

  • Apply pelvic binder if pelvic instability suspected.
  • Perform FAST or DPA for internal hemorrhage assessment.

Key Principle: Assume hypotension is due to hemorrhage until proven otherwise.

Disability (Neurologic Evaluation)

Assessment

  • Determine GCS (E4 / V5 / M6).
  • Examine pupils for size, symmetry, and reactivity.
  • Evaluate motor and sensory function in all extremities.

Management

  • Prevent hypoxia and hypotension; maintain SBP >100 mmHg.
  • Treat seizures promptly.
  • If GCS ≤ 8, secure a definitive airway and maintain PaCO₂ 35–40 mmHg.

Red Flags

  • Unequal pupils or lateralizing signs suggest intracranial mass lesion → urgent neurosurgical consultation.

Key Principle: A single episode of hypotension or hypoxia worsens outcomes in TBI—prevent both.

Exposure and Environmental Control

Actions

  • Fully expose the patient; inspect front, back, axillae, perineum.
  • Prevent hypothermia:
  • Use warm blankets or forced-air warmer.
  • Warm IV fluids and blood products.
  • Maintain ambient temperature >26 °C.

Key Principle: Hypothermia contributes to coagulopathy—actively prevent heat loss.

Adjuncts to the Primary Survey

  • Continuous ECG, SpO₂, and EtCO₂ monitoring.
  • Obtain portable chest and pelvic x-rays and FAST as indicated.
  • Insert urinary catheter unless urethral injury suspected (blood at meatus, perineal bruising, high-riding prostate).
  • Insert gastric tube (orogastric if facial trauma).
  • Draw baseline labs: CBC, type & cross, lactate, base deficit, ABG, coagulation profile.

Reevaluation

  • Repeat ABCDE after each major intervention or change in status.
  • If deterioration occurs, restart at Airway.
  • Document all findings and responses.

Transfer and Communication

  • Stabilize airway, breathing, and circulation before transfer.
  • Maintain oxygen, IV access, and monitoring during transport.
  • Communicate physician-to-physician with the receiving trauma center.
  • Do not delay transfer for imaging that will not alter immediate management.

Documentation

  • Record time and response for every intervention.
  • Document vital signs, GCS components, airway procedures, fluids, blood products, and reassessments.

References

  • Advanced Trauma Life Support (ATLS®) 10th Edition, American College of Surgeons Committee on Trauma.
  • Vanderbilt University Medical Center Trauma PMG Format.