What are the findings of the primary survey in a patient involved in a motor vehicle accident (MVA) with a head-on collision?

From the Guidelines

The primary survey in a patient involved in a motor vehicle accident with a head-on collision should begin with assessing the patient's airway, breathing, circulation, disability, and exposure (ABCDE approach), while maintaining cervical spine immobilization due to the mechanism of injury, as recommended by the guidelines for field triage of injured patients 1. The assessment of the patient's airway, breathing, and circulation is crucial in identifying life-threatening conditions that require immediate intervention. According to the guidelines, the patient's vital signs, including systolic blood pressure, respiratory rate, and level of consciousness, should be measured to determine the need for transport to a trauma center 1.

• Key components of the primary survey include:
  • Assessing the patient's airway for patency and obstruction
  • Evaluating breathing by observing chest rise, respiratory rate, oxygen saturation, and auscultating breath sounds bilaterally
  • Checking circulation by assessing pulse rate and quality, blood pressure, capillary refill time, and looking for external hemorrhage
  • Assessing the patient's disability using the Glasgow Coma Scale to determine their level of consciousness, pupillary response, and motor function
  • Completely exposing the patient to identify any additional injuries while maintaining their dignity and preventing hypothermia The guidelines also recommend assessing the anatomy of injury, mechanism of injury, and special patient or system considerations to determine the need for transport to a trauma center 1.
• Special considerations include:
  • Older adults, who are at increased risk of injury or death
  • Children, who should be triaged preferentially to pediatric capable trauma centers
  • Patients with head injury, who are at high risk for rapid deterioration
  • Patients with anticoagulants and bleeding disorders
  • Pregnant women > 20 weeks During the primary survey, immediate interventions should be ordered as needed, such as supplemental oxygen for hypoxemia, IV access with crystalloid fluids for hypotension, direct pressure for external bleeding, and pain management with titrated doses of fentanyl or morphine 1. The patient should be transported to a trauma center if they meet any of the criteria outlined in the guidelines, including a Glasgow Coma Scale score ≤13, systolic blood pressure <90 mmHg, or respiratory rate <10 or >29 breaths per minute 1.

From the Research

Primary Survey Findings in Motor Vehicle Accident (MVA) with Head-on Collision

• The primary survey in a patient involved in a motor vehicle accident (MVA) with a head-on collision is crucial in identifying potential injuries and determining the appropriate course of treatment 2.
• A study published in the Emergency Medicine Journal in 2001 reported a case of a 26-year-old motorcyclist who was involved in a head-on collision with a motor vehicle and presented with a normal primary survey, but was later found to have a Brown-Sequard syndrome and unilateral Horner's syndrome due to a contusion of the left half of the spinal cord 2.
• The study highlights the importance of a thorough examination of the central and peripheral nervous system, even in the absence of radiographic abnormality and neck pain, in patients with suspected spinal injury 2.

Cervical Spine Injury and Clearance

• A national survey of trauma centers in the United States found that the overall incidence of cervical spine injury (CSI) was 4.3%, and that the incidence of CSI without spinal cord injury was 3.0% 3.
• The survey also found that there was no difference in the incidence of CSI overall or by subtype based on trauma center level or type, but that injury severity score correlated with incidence of CSI without cord injury 3.
• Another study published in 2017 found that computed tomography (CT) scan was highly accurate and reliable for identifying clinically significant spine injuries in intoxicated patients, and had a 100% negative predictive value for identifying unstable injuries 4.

Respiratory Exacerbation in Acute Traumatic Cervical Spinal Cord Injury

• A study published in 2021 found that copious airway secretion (CAS) was an independent predictor of respiratory exacerbation (RE) in patients with acute traumatic cervical spinal cord injury, and that timely intubation based on close attention to CAS during the acute phase may prevent RE 5.
• The study also found that motor-complete injury above C5 was not a significant predictor of RE, and that routine intubation may not be necessary in all patients with motor-complete injury above C5 5.

Intracranial Hemorrhage After Minor Head Injury

• A study published in 2020 found that the rate of intracranial hemorrhage after minor head injury was 8.5%, and that older age and male gender were associated with positive computed tomography (CT) scans 6.
• The study also found that the most common findings were subdural hematomas, traumatic subarachnoid hemorrhages, and cerebral contusions/intraparenchymal hematomas 6.