Initial vs. Secondary Survey in the Emergency Room
The primary survey is a rapid assessment focusing on immediately life-threatening conditions following the ABCDE approach, while the secondary survey is a comprehensive head-to-toe examination performed after stabilization to identify all injuries or conditions that were not detected during the primary survey. 1, 2
Primary Survey
The primary survey is designed to rapidly identify and address life-threatening conditions using the ABCDE approach:
- A - Airway: Assessment and management of airway patency 1
- B - Breathing: Evaluation of respiratory function and management of life-threatening chest injuries 1, 3
- C - Circulation: Assessment of hemodynamic status and control of major bleeding 1
- D - Disability: Brief neurological assessment 1
- E - Exposure/Environment: Complete exposure of the patient while preventing hypothermia 1
During the primary survey, life-threatening conditions that require immediate intervention are identified and treated. These include what some literature refers to as the "Lethal Six":
- Airway obstruction
- Tension pneumothorax
- Cardiac tamponade
- Open pneumothorax
- Massive hemothorax
- Flail chest 3
The primary survey is conducted immediately upon patient arrival and focuses solely on detecting conditions that pose an immediate threat to life. Point-of-care ultrasonography (POCUS), including FAST (Focused Assessment with Sonography for Trauma), is recommended during this phase for patients with thoracoabdominal injuries 1.
Secondary Survey
The secondary survey is a comprehensive head-to-toe examination performed after the primary survey and initial resuscitation when the patient is relatively stable:
- Detailed history (using the SAMPLE approach: Signs/symptoms, Allergies, Medications, Past medical history, Last oral intake, Events leading to injury) 1
- Complete physical examination from head to toe 1
- Appropriate diagnostic imaging based on clinical findings 1
- Laboratory investigations as indicated 1
The secondary survey aims to identify all injuries or conditions that were not detected during the primary survey, including what some literature calls the "Hidden Six":
- Thoracic aortic disruption
- Tracheobronchial disruption
- Myocardial contusion
- Traumatic diaphragmatic tear
- Esophageal disruption
- Pulmonary contusion 3
Key Differences
Timing and Priority:
Scope:
- Primary survey: Limited to ABCDE assessment
- Secondary survey: Complete head-to-toe examination 1
Imaging and Diagnostics:
- Primary survey: Limited to essential imaging (e.g., FAST scan)
- Secondary survey: Comprehensive imaging (e.g., contrast-enhanced whole-body CT) 1
Duration:
- Primary survey: Rapid (minutes)
- Secondary survey: More time-consuming (can take hours) 2
Clinical Pitfalls to Avoid
Skipping components: Research shows that healthcare professionals do not always adhere to guidelines, with resuscitation tasks associated with both the primary and secondary surveys often being skipped or performed incompletely 1.
Missing injuries: Studies have shown that approximately 9% of injuries are missed during initial assessments, highlighting the importance of a thorough secondary survey 4.
Premature secondary survey: Conducting the secondary survey before stabilizing the patient can lead to missed life-threatening conditions 1, 2.
Failure to reassess: Patients' conditions can change rapidly; regular reassessment is essential 1.
Overlooking tertiary survey: Some centers now implement a tertiary trauma survey, which is a comprehensive re-examination performed after the secondary survey, typically before ambulation or upon regaining consciousness in head-injured patients 4.
The use of a structured approach with checklists during trauma resuscitation has been shown to improve patient outcomes and reduce mortality among severely injured patients (Adjusted OR 0.51; 95% CI 0.30-0.89) compared to non-structured clinical examination 2.