ABC

Primary survey
Secondary survey
History
Others

PRIMARY SURVEY & RESUSCITATION

During the initial assessment, as one moves sequentially through the mnemonic ABCDE, life-threatening
conditions are diagnosed and corrected at each stage.

A - Upper airway is established and maintained with cervical spine control

B - Breathing (or the adequecy of air exchange) is evaluated and established
C - Circulation - BP is evaluated and corrected, and bleeding is arrested
D - Deficits of neurologic function are identified, and treatment is initiated (AVPU)
E - Exposure is obtained by completely undressing the patient

(See summary)

A - Upper airway is established and maintained with cervical spine control

Cervical spine control
All patients presenting with abnormalities of mental status after trauma, however subtle, must be assumed to
have injuries to the cervical spine  hard cervical collar & manual maintenance of the head in the neutral
position. Immobilization must be maintained until radiologic visualization of C1-C7 (and T1?) is complete and
determined to be normal. Commonly, an initial view of the cervical spine demonstrates only the more proximal
vertebrae; this must never be interpreted as a normal study, and an additional view must be taken while
downward traction is applied to the forearms. If the distal vertebrae remain nonvisualized with this maneuver, a
swimmer’s view should be obtained.

Airway intervention
Determine whether the patient can speak normally; if so, a reasonable airway probably exists, and other
priorities can be assessed.
 Unconscious patients without inspiratory effort  intubation
 Patients with inspiratory effort but without adequate ventilation require a rapid and directed assessment of
the pharynx to exclude local obstruction related to posterior movement of the tongue or the presence of
swelling or hemorrhage, blood, secretions, or gastric contents. Rigid suction and manual extraction should
be used to clear the pharynx of any foreign material. Obstruction of the airway due to posterior movement
of the tongue is particularly common in lethargic or obtunded patients and may be quickly corrected by the
insertion of an oral or nasal airway and/or the chin lift or jaw thrust maneuvers. Patients with extensive
facial or neck injuries in whom intubation of the trachea is impossible require needle or surgical
cricothyrotomy to secure the airway; in children <12 years of age, needle cricothyrotomy is indicated.
When these techniques are unsuccessful, Ambu-bag-assisted ventilation with 100% oxygen and an oral or
nasopharyngeal airway may provide temporary oxygenation

Contraindications to nasal airway:

Suspicion or demonstration of a basilar skull fracture
CSF otorrhea @ rhinorrhea
Significant maxillofacial or perinasal injuries

Note : The physician must always remember that there are a number of common, rapidly reversible etiologies of
CNS or respiratory depression that commonly precipitate trauma by interfering with consciousness; these
include hypoglycemia, opiate overdose, and Wernicke’s encephalopathy. These disorders must be considered
and presumptively treated in all patients presenting with abnormalities of mental status after trauma even when
other explanations seem both obvious and adequate to explain the clinical presentation (e.g., head injury, alcohol
ingestion, severe hypotension). Treatment includes the rapid IV administration of 1 ampule of 50% dextrose,
0.4-2.0 mg of naloxone, and 100 mg of thiamine.

B - Breathing (or the adequacy of air exchange)

After the airway is secured and ventilation with oxygen initiated, the adequacy of air exchange must be assessed
by inspection, palpation, percussion and auscultation of the chest  bilateral and symmetric breath sounds
should be present immediately after intubation or other airway establishment.
Problems?
 Placement of the endotracheal tube in the esophagus is the most common cause of failure to ventilate
the patient adequately following intubation, and this may be diagnosed by auscultation over the
stomach during ventilation. The tube may then be repositioned after a period of Ambu-bag-assisted
ventilation with 100% oxygen and an oral airway.
Failure to appreciate breath sounds on the left or reduced breath sounds on the left is often explained by
the presence of the ET tube in the right mainstem bronchus; this is easily corrected by simply pulling
the tube back 2-4 cm and reauscultating the chest.
When the above problems are excluded and ventilation or oxygenation remains inadequate, hemothorax, simple
pneumothorax, and tension pneumothorax must then be considered and corrected if present. Flail chest and
pulmonary contusion are additional diagnoses that may explain persisting hypoxia in the traumatized patient but
initially remain diagnoses of exclusion.

C - Circulation
BP evaluation + arrest bleeding
Control of bleeding
External bleeding should be controlled by direct pressure. If an extremity is involved and direct pressure is
unsuccessful, elevation followed by the application of a proximal BP cuff inflated above systolic pressure may
be used temporarily while other care is rendered.

 Direct pressure
 Elevation
 Pressure points
 Tourniquet (a last-resort method)

Intravenous access
Established with two 14- @ 16-gauge short peripheral lines (through which, after insertion, a 50-ml syringe may
be used to aspirate blood for type and cross matching and other studies, and Ringer’s lactate solution then
rapidly infused.

Initial fluid challenge

Adults presenting with significant blood loss or established or evolving shock should be reated initially with 2
liters of Ringer'’ lactate solution; this may be given as rapidly as possible, usually over 5-10 minutes; children
may be given 20 ml/kg over a similar interval.

Blood replacement
Although subsequent therapy will be dictated by the patient’s response to the initial fluid challenge, most
patients presenting with significant hypotension will requrie blood replacement, and a minimum of 4 unites of
packed cells should rapidly be made available. Although cross-matched blood is clearly preferable, its
preparation requires between 50-70 minutes, and in many patients presenting with exsanguinating hemorrhage
or severe hypotension, an abbreviated type and cross match (which requires 15-20 minutes), type-specific blood
(which requires approximately 10 minutes), or 0-negative blood (which should be available immediately) must
be transfused.
Cross-matched blood = 50-70 minutes
Abbreviated type and cross match = 15-20
Type-specific blood = 10 minutes
0-negative blood = available immediately
Flow and tissue oxygenationare optimized at hematocrits around 30.

Assessment of response to initial fluid challenge

In general, patients who rapidly respond to the initial fluid challenge with a normal BP and who remain stable
may be assumed to have lost relatively little blood (<15-20%) and will generally not require additional fluid
challenges or blood replacement. Hospital admission for observation is required, and a minimum of 4 unites of
packed cells should remain available for emergency transfusion. Patients in whom only a transient increase in
BP is noted require rechallenge with Ringer’s lactate solution and rapid blood replacement, since greater initial
blood losses have occurred or blood loss is ongoing. If patients exhibit little or no response to the initial fluid
challenge, either blood loss was extensive or continuing, or the diagnosis of hypovolemic shock was in error. If
the initial diagnoses is correct, blood replacement must be aggressively undertaken and plans for possible
surgical intervention pursued. Evidence of elevated right-sided pressures a/w systemic hypotension suggest that
hypovolemic shock may have been at least an incomplete if not an incorrect diagnosis; one should immediately
consider cardiac tamponade, tension pneumothorax, massive hemothorax, and congestive heart failure in these
patients. These two groups may be differentiated by physical examination and by measurement of CVP: It the
diagnosis of hypovolemic shock is corret, CVP will be low, whereas if any of the other conditions exist, CVP
will be elevated.

D - Deficits of neurologic function

During the initial assessment, the patient’s overall neurologic status is grossly assessed and may simply be
characterized as:
A - Alert
V - Responsive to Verbal stimuli
P - Responsive to Painful stimuli
U - Unresponsive to all stimuli

Rapidly reversible causes of CNS depression, including hypoglycemia, opiate overdose, and Wernicke’s
encephalopathy, must be considered intially and prophylactically treated in all patients. Similarly, seizure may
have precipitated trauma, and clearly the postictal state may produce persisting abnormalities of consciousness
as well as focal neurologic findings; a past history of seizure (Medic Alert bracelet) or evidence of recent seizure
(tongue laceration, loss of continence) should be noted. Excluding the above, persisting abnormalities of mental
status at a time when BP is normal or relatively normal should suggest cerebral injury, and treatment must be
rapidly undertaken; the usual modalities for reducing intracerebral pressure (restriction of fluid administration,
furosemide, mannitol) must be abandoned, however, in the context of hypovolemic shock and the deficit in
intravascular volume corrected aggressively and routinely.

Spinal shock
Spinal shock, which must always be a diagnosis of exclusion (to the extent that the physician must prove that
hemorrhage does not explain the patients’ hypotension), may be noted immediately after injury to the spinal
cord. Most patients present with:
Systolic BP in the 70-90 mm Hg
Warm extremities
Normal or only slightly elevated pulse
All of the above is not an expected finding in patients with hemorrhagic shock.
Additionally helpful findings include:
Neck pain
Flaccid areflexia including the rectal sphincter
Diaphragmatic breathing or apnea,
Priapism
A sensory level
Facial gesturing in response to painful stimuli above the level of the clavicles but not below them

E - Exposure
Obtained by completely undressing the patient to allow a complete evaluation.

Summary - The Primary survey addresses the:

A - Airway with cervical spine control
B - Breathing
C - Circulation with hemorrhage control
D - Disability (neurologic status)
E - Exposure with environmental control

A - Airway with cervical spine control

Stabilize spine - hard cervical collar
In conditions like:
Head & neck injuries
Loss of consciousness
High speed injuries
Clearance
Finger sweep
Suction - mucus, vomitus, phlegm, blood
Maintenance
Jaw-thrust maneuver @ Head-tilt Chin-lift maneuver
Oropharyngeal/Nasopharyngeal airway

B - Breathing
Finger & ear for air movement
 Chest movement
Trachea
If deviated + hyperresonant + absent breath sounds  tension pneumothorax
Insert No. 14 GA catheter - mid-clavicular line, 2nd ICS

C - Circulation with hemorrhage control

Carotid pulse, radial pulse - rate, volume
Also:
Blood pressure
Skin perfusion - temperature, capillary refill
Organ perfusion - mental status, urine flow
Stop bleeding
Massive external hemorrhage - Direct pressure
Internal hemorrhage - Stabilization of fracture

D - Disability
AVPU (note : essentially the criteria in eye response of GCS)
A - awake/Alert
V - open eyes to voice
P - open eyes to pinaful stimulus
U - Unarousable/unconscious
Check pupils

E - Exposure + environmental control

Take off clothes
Inspect front
Inspect back - Log-rolling
Inspect perineum - splay legs
Warmed fluids
Warm blankets or a “ hot air” heating blanket

SECONDARY ASSESSMENT
Following primary survey and resuscitation, the next priority is to conduct a complete head-to-toe examination
of the patinet. The purpose of this secondary survey is to inventory all injuries completely. For this reason, the
secondary survey often is described as a head-to-toe examination, with insertion of a finger or tube into each
orifice.

HISTORY
AMPLE
A - Allergies
M - Medications
P - Past medical history
L - Last oral intake
E - Events surround the injury
Nature of accident
When
Where
How
What
Who
CNS
Amnesia
LOC
Seizure
Otorrhea, rhinorrhea
 ICP
Headache, nausea, vomiting, blurring of vision

After primary survey, secondary survey, history, investigation, what to do?

ATT
Antibiotics
Assess patient again (Frequent reassessment)