What are the key steps in a primary survey in trauma?

Primary Survey in Trauma: The ABCDE Approach

The primary survey in trauma follows the ABCDE approach to quickly identify and address immediate life-threatening conditions, including airway with cervical spine protection, breathing and ventilation, circulation with hemorrhage control, disability assessment, and exposure/environmental control. 1

The ABCDE Sequence

A: Airway with Cervical Spine Protection

• Assess airway patency while maintaining cervical spine immobilization
• Clear visible obstructions and secretions
• Consider advanced airway management if needed (intubation, supraglottic devices)
• Apply cervical collar or manual in-line stabilization until spine cleared

B: Breathing and Ventilation

• Assess respiratory rate, effort, and symmetry
• Look for signs of respiratory distress: accessory muscle use, paradoxical breathing
• Auscultate lung fields bilaterally
• Immediately identify and treat life-threatening conditions:
  • Tension pneumothorax
  • Open pneumothorax
  • Massive hemothorax
• Provide supplemental oxygen as needed

C: Circulation with Hemorrhage Control

• Control obvious external bleeding with direct pressure
• Assess pulse quality, rate, and blood pressure
• Evaluate skin color, temperature, and capillary refill
• Establish large-bore IV access (two lines if possible)
• Begin fluid resuscitation targeting systolic BP 80-100 mmHg until major bleeding is controlled 1
• Identify potential sources of internal hemorrhage

D: Disability (Neurological Status)

• Assess level of consciousness using AVPU (Alert, Voice, Pain, Unresponsive) or GCS
• Check pupillary size and reactivity
• Evaluate for signs of increased intracranial pressure
• Perform brief neurological examination (motor and sensory function)

E: Exposure/Environmental Control

• Completely undress the patient to identify all injuries
• Prevent hypothermia with warming blankets and warmed fluids
• Log roll to examine posterior surfaces
• Implement warming strategies based on core temperature 2

Implementation and Evidence

The systematic ABCDE approach is a priority-based consensus approach for the primary assessment of all critically ill or injured patients 3. This structured approach has been shown to potentially improve patient outcomes when properly implemented. A recent study found that the application of a structured approach by checklist may improve adherence to guidelines during resuscitation and might lead to a reduction in mortality among severely injured patients compared to clinical examination (Adjusted OR 0.51; 95% CI 0.30-0.89) 4.

Advanced Trauma Life Support (ATLS) courses provide standardized training in this approach, though observational studies have demonstrated that healthcare professionals do not always adhere to these guidelines 2. Adherence to the ABCDE approach varies widely, ranging from 18-84% in clinical practice 3.

Diagnostic Adjuncts During Primary Survey

Several diagnostic tools should be integrated during the primary survey:

• FAST (Focused Assessment with Sonography for Trauma) to detect free fluid in chest, abdomen, and pericardium 1
• Chest and pelvic X-rays for immediate identification of life-threatening thoracic injuries and unstable pelvic fractures 1
• Point-of-care ultrasonography to detect pneumothorax, hemothorax, hemopericardium, and free abdominal fluid 1

Common Pitfalls and Caveats

1. Failure to reassess: The primary survey is not a one-time assessment. Continuous reassessment is essential to identify deterioration.

2. Distracting injuries: Obvious injuries may distract from identifying more serious occult injuries. Maintain systematic approach.

3. Hypothermia: Prevent hypothermia which can worsen coagulopathy and increase mortality. Core temperature should guide warming strategies 2.

4. Pediatric considerations: Children are not just small adults. Anatomical, physiological, and emotional differences require specialized equipment and approach 5, 6.

5. Team leadership: The presence of a designated team leader who facilitates clear communication improves adherence to the ABCDE approach 3.

The primary survey should be completed rapidly (within minutes) before moving on to the secondary survey, which involves a more comprehensive head-to-toe examination to identify non-life-threatening injuries 1, 4. Following this structured approach ensures that life-threatening conditions are addressed in order of priority, maximizing the patient's chance of survival.