Primary Survey

Nicole Smith Clinical Nurse Unit Manager Nepean Hospital Sydney Australia

What we will cover: �  Indonesian population growth

�  Local stats on trauma

�  Defining trauma

�  Mechanism of Injury

�  The purpose of a primary survey

�  Primary Survey

Indonesian Population growth

Total population in Indonesia 2015 is 256 009 297 people, with a 1.24% growth from the previous year.

The growth rate is positive with 5 250 751 births compared to 1 835 587 deaths in 2015.

The sex ratio is males 994 to women 1000.

The average life expectancy is male 68.8 years and females 74 years.

Indonesian statistics on trauma

Total population in Indonesia 2015 was approx 256 009 297

1.24% growth from the previous year.

Causes of traumatic deaths

Road traffic accidents: 44 594 deaths

Falls: 12 858 deaths

Other injuries: 18 475 deaths

Fires: 6 251 deaths

Drowning: 6 122 deaths

Violence: 3 414 deaths

Total = 91 714 deaths from trauma 2014/15

(World ratings: World Health Organisation. May 2014)

Trauma and high risk mechanism of injury

Trauma = An insult that creates the sudden onset of severe injuries that require immediate medical attention.

High risk:

High speed MVA >60km / hr

Major deformation of the vehicle

Fatal injury in the same vehicle as the patient

Fall from >5m

Patient has been ejected out of the vehicle

Multiple injuries on body from a single accident

Pedestrian or cyclist hit by a car travelling >30km / hr

Comprehensive history

Detailed history – either from patient, family or bystander

Identify the mechanism of injury

Communicate and document

Mechanism of injury can predict actual and associated injuries

following a trauma

Purpose of a Primary survey

�  Crucial element of the “Initial assessment” of a seriously injured patient

�  Identify life threatening conditions

�  Assessment and treatment are based on the patients injuries, stability of vital signs and mechanism of injury

�  The primary assessment is quick but efficient, resuscitation of vital signs and treatment of the patient begins

Important!

The primary survey must be done in a sequenced order

You should not move on to the next assessment until it has been assessed and cleared

During the primary survey life threatening conditions are identified and management is begun simultaneously

Primary survey sequence

A.  Airway with Cervical spine control

B.  Breathing

C.  Circulation

D.  Disability

E.  Exposure

A. Airway The key = Look, Listen, Feel

Ensure the airway is open

Nil obstructions, airway is clear

Trachea is midline

Mandibular or maxillofacial fracture

Jaw thrust maneuver

Jaw thrust maneuver

Cervical spine control Assume a cervical spine injury with any multisystem trauma, especially with an altered level of consciousness or blunt injury above the clavicle.

Maintain the neck in a neutral position

✔

✗

Secure the spine

B. Breathing

The key = Look, Listen and Feel

For gas exchange to occur adequate function of the lungs, chest wall and diaphragm; each component must be examined.

The chest should be exposed to view respiratory function properly.

Pneumothorax Tension pneumothorax is life threatening. Immediate concerns are reduced gas exchange and reduced venous return to the heart.

Pneumothorax on CXR �  Deviation of the trachea away from the the side of

the tension

�  Shift of the mediastinum

Flail chest

C. Circulation

�  Blood volume and cardiac monitoring - key elements that will provide a good examination tool are pulse and level of consciousness

�  Bleeding – external and severe hemorrhage is identified and controlled in the primary survey

�  20-25% total blood volume can be lost before a person begins to show physical signs of blood loss for example, tachycardia and hypotension = approx 900mls

Major sites for potential blood loss

�  External injuries

�  Thoracic cavity

�  Abdominal cavity

�  Retro peritoneum

�  Pelvis

�  Long bones

Hypovolemic shock Hemorrhage

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Hypervolemia

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Decreased systemic filling pressure

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Decreased venous return

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Decreased cardiac output

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Decreased blood pressure

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Decreased systemic blood flow

If left untreated = certain death will occur

Circulatory system

Identify and Control the bleeding Identify:

�  Chest – Chest x-ray

�  Abdomen – FAST

�  Retroperitoneal – CT scan

�  Extremities – femurs, pelvis x-ray

Control:

�  Theatre

�  Embolisation

�  Pressure

�  Reduction & stabilisation

FAST Focused Assessment with Sonography for Trauma

An ultrasound used to assess 4 areas for free fluid:

1. Liver + Hepto-renal space

2. Spleen

3. Pericardium

4. Pelvis

Positive FAST views

Positive FAST views

D. Disability A – Alert

V – responds to Verbal stimuli

P – responds to Painful stimuli

U – Unresponsive

Baseline and monitoring GCS

General rule GCS <8 requires airway control

FAST if GCS <8

Beware of obvious head injury

D. Identify any threat to the limbs

Looking for: color, warmth, movement and sensation

Compare with unaffected limb

E. Exposure/Environmental control

You want to be able to view and fully assess your patient but prevent hypothermia

If the person has a wound that is covered, remove it and view the wound

Hypothermia is poorly tolerated in trauma

Points to remember �  Primary survey is the initial assessment of the

trauma patient

�  Identify life threatening issues

�  Is a quick but efficient examination

�  Follow the sequence of A. B. C. D. E

�  Do not move to the next sequence until it is safe to do so

�  Secure the spine and neck until cleared by a Senior Physician and documented

References:

Chest Trauma pneumonthorax – tension. Retrieved: www.trauma.org/archive/thoracic/CHESTtension.html

FAST. Retrieved: www.trauma.org/index.php/main/article/214

Indonesian Population. Retrieved: www.countrymeters.info/en/Indonesia

The Primary Survey. Retrieved: www.evidencebased.net/ce/case1/primarytext.html

World Rankings Indonesia: WHO. May 2014

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