What is the approach to assessing disability in a primary survey?

Primary Survey Disability Assessment

In the primary survey, disability assessment follows the ABCDE approach and focuses on rapidly evaluating neurological status using the AVPU scale (Alert, Voice, Pain, Unresponsive) or Glasgow Coma Scale, checking pupillary response, and identifying gross motor deficits to detect life-threatening neurological emergencies requiring immediate intervention. 1

Systematic Approach to Disability Assessment

Initial Neurological Evaluation

• Assess level of consciousness immediately using either the AVPU scale (Alert, responds to Voice, responds to Pain, Unresponsive) for rapid bedside assessment, or the Glasgow Coma Scale for more detailed evaluation in the primary survey 1, 2
• Evaluate pupillary size, symmetry, and reactivity to light bilaterally, as abnormal findings may indicate elevated intracranial pressure, herniation syndromes, or focal brain injury requiring urgent intervention 2
• Check for gross motor function and symmetry by assessing limb movement and strength bilaterally to identify lateralizing signs suggesting stroke, spinal cord injury, or mass effect 2

Critical "Must-Not-Miss" Pathologies

• Identify signs of elevated intracranial pressure and herniation including deteriorating consciousness, asymmetric pupils, posturing, or Cushing's triad (hypertension, bradycardia, irregular respirations) 2
• Screen for acute stroke symptoms using rapid assessment tools, as time-sensitive interventions may be indicated 2
• Assess for spinal cord compression by checking for sensory level, motor weakness in specific distributions, and sphincter dysfunction 2
• Evaluate for ongoing seizure activity including subtle signs of non-convulsive status epilepticus in patients with altered consciousness 2

Integration with Overall Primary Survey

Sequence and Timing

• Complete disability assessment only after securing airway (A), ensuring adequate breathing (B), and establishing circulation (C), as these take priority for immediate survival 3, 1
• Perform the disability assessment rapidly as part of the initial primary survey, recognizing that detailed neurological examination comes later in the secondary survey 1, 2
• Reassess neurological status frequently during resuscitation, as changes may indicate evolving pathology or response to interventions 2

Documentation Elements

• Record specific findings systematically including exact GCS score (or AVPU), pupil size in millimeters and reactivity, and specific motor deficits rather than vague descriptors 2
• Note the time of assessment as neurological deterioration or improvement over time guides management decisions 2

Common Pitfalls to Avoid

• Do not attribute altered consciousness to intoxication or metabolic causes without first excluding structural brain injury, especially in trauma patients 2
• Avoid performing detailed neurological examination during the primary survey when life-threatening ABC problems remain unaddressed 1
• Do not delay urgent neuroimaging in patients with abnormal disability findings, as time-sensitive neurosurgical interventions may be needed 2
• Remember that normal initial neurological assessment does not exclude serious pathology, particularly in patients with lucid intervals before deterioration 2