What is a primary survey in the emergency department?

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• The Primary Survey, or initial assessment, is designed to help the emergency responder detect immediate threats to life. Immediate life threats typically involve the patient's airway, breathing or circulation, and each threat is corrected as it is found. Life threatening problems (e.g. catastrophic haemorrhage) MUST be identified first.

Patient Factors & Considerations

• Always ensure scene safety prior to approaching patient to being primary survey
  

AIM: To detect and correct life threatening illness or injury.

Danger

Position the ambulance appropriately, taking into consideration patient access and egress.

• Don appropriate PPE.
• Approach scene cautiously.
• Assess for dangers to self, partner, bystanders and patient. Look, listen and smell to identify potential or existing hazards present. Evaluate risks and negate danger if safe to do so.
• Consider need for other emergency services required to ensure scene safety (WA Police, DFES, SES).
  • If the patient is in immediate danger and they can be moved safely, do so at this stage, regardless of injury.
• Do not enter scene until deemed safe.
• If multi-casualty incident is evident, refer to the Emergency Management Guidelines

Response

• Perform a brief neurological assessment to establish patient’s conscious state (AVPU).
  
  • Alert = Describes a patient who is spontaneously awake and aware of their surroundings.
  • Verbal = Describes a patient who responds to verbal stimuli i.e. when spoken to in a loud voice.
  • Pain = Describes a patient who responds to touch or a painful stimuli (trapezius squeeze only)
  • Unresponsive = Describes a patient who does not respond to verbal or painful stimuli.

Send for Help

• Establish need for emergency services back-up:
  
  • Consider how many patients there are at the scene, and their condition
  • Are additional ambulances required?
  • Are the Police and/or Fire/Rescue services required to help manage scene safety?
• Establish need for Clinical Support to assist with patient management: 
  • Clinical Paramedic: Contactable 24/7 in State Ambulance Operations Centre – referred to as CSPSOC.

Airway

• Open mouth using cross-finger technique.
  
• Inspect oral cavity for any obstruction and/or fluid.
• Clear airway with lateral position to assist drainage, finger sweeps, and/or suction.
• Open the airway by performing an appropriate airway manoeuvre:
  • Triple – non injured adult patient
  • Double – spinal injured adult patient
  • Neutral alignment – Paediatric patient
• Maintain: Consider Oropharyngeal Airway (OPA) or Nasopharyngeal Airway (NPA) if unresponsive/appropriate.
• Place in lateral position if unconscious, once signs of life have been confirmed.

Note: Consideration of c-spine injury should take place during airway assessment and management. If injury is suspected, positioning and immobilising of the head in neutral alignment is indicated, but not at the expense of the airway.

Breathing

• Assess breathing for adequacy. Look, listen and feel for 5-10 seconds:
  
  Look:
  • Equal rise and fall of chest wall
  • Rate, regularity and effort of breathing
  • Accessory muscle use
  • Cyanosis (Blue tinge, commonly seen at the finger nails and lips)
  • Tripod positioning
  • Recessive breathing in paediatrics (sucking-in of chest wall)
  Listen:
  • Abnormal noises associated with breathing (wheezes, crackles)
  • Ability to talk in full sentences
  Feel:
  • Rise and fall of chest
  • Breath on cheek (unconscious patients only)
• Apply SpO2 monitoring if trained and authorised.
  
• Record dyspnoea score
• Correct any breathing problems encountered according to relevant CPGs or Skills (e.g. Ventilation).
• If patient is not breathing/not breathing normally, commence resuscitation.

Circulation

• Assess for bleeding and control any life threatening haemorrhage according to relevant skill/CPG.
• Palpate a pulse for 5 seconds. Note characteristics such as speed, regularity and strength.
  Common pulse sites and situations include:
  • Carotid (unconscious patients, or conscious patients where radial pulse is difficult to locate)
  • Brachial (infants)
  • Radial (conscious adult patients)
  • Apical (newborns)
• Assess capillary refill.
• Assess skin temperature and colour (useful in identifying shocked patients).
• Correct any life threatening circulatory problems according to relevant CPG.
• Where CPR is indicated and chest compression initiated, attach defibrillator as soon as possible to assist with restoration of circulation as per cardiac arrest CPG.

Disability

• Rapid assessment of brain function:
  • Assess conscious level (AVPU/GCS)
  • Assess pupil reaction to light (PERL)
  • Assess neurological limb function (sensation, movement and strength)
  • Perform BGL where patient is not fully alert and orientated to time, place and person
  • Perform FAST test where stroke is suspected.
    • If FAST positive, complete RACE evaluation
  • Consider temperature where suspected of causing reduced conscious level
  • Correct life threatening disability problems according to relevant CPG

Exposure & Evaluation

• Perform brief systematic head to toe evaluation:
Expose:
• Potential injury/illness sites, manage according to relevant CPG
• Consider exposure to the elements, don’t leave exposed unnecessarily.
Evaluate:
• Treatment/interventions provided
• Time critical status

Note: Any patient exhibiting significant primary survey problems is deemed time critical and requires urgent transportation to the nearest receiving hospital under Priority 1 conditions. Constant reassessment, life-saving interventions and a pre-alert/notification should be carried out en-route.

Head of Clinical Services

The Primary Survey, or initial assessment, is designed to help the emergency responder detect immediate threats to life. Immediate life threats typically involve the patient's ABCs, and each is correct as it is found.

Life threatening problems MUST be identified first. This is to be completed in an order of priority to ensure the most important steps are undertaken in a logical order ensuring nothing is missed. This systematic approach uses the acronym DRABC.

D: Danger:

• Ensure safety for yourself and any others. Do not put yourself at risk.
• Remove danger or move the patient.
• Find out what has happened from witnesses if possible. Get information.

R: Response:

• Assess the patient’s level of consciousness using the AVPU score (see levels of response AVPU).

Note: The presence of dementia in the elderly patient can make it hard to accurately assess the mental status and the responder should utilise family/carers to obtain baseline information.

A: Airway:

• Look into their mouth, if any liquid is found place the patient on their side and drain the liquid (postural drainage).
• Place patient back onto their back and open the airway using a head tilt/chin lift techniques.

B: Breathing:

• Place your ear over the patient's mouth and look, listen and feel for 10 seconds.
• Ask yourself is the patient breathing normally, and not taking occasional gasps of air.
• If patient is breathing normally carry out a secondary survey.
• If in any doubt patient is breathing normally dial 999.
• Asses the patient's circulation (pulse and bleeding) if needed start chest compressions or defibrilation (see below).

C: Compressions

• Start chest compressions. Depth 5-6cm. Rate of 100-120 per minute combined with two mouth-to-mouth inflations.
• Continue at 30 compressions then two mouth-to-mouth inflations (mouth-to-mouth is still the gold standard treatment).
• If unwilling to or unable to perform mouth-to-mouth continue with chest compressions only, until paramedics arrive.
• Remember that the elderly often have an irregular pulse which is rarely life threatening, however the speed of the pulse i.e. too fast or too slow, can be life threatening.

Defibrillator:

• Attach an AED (Automatic External Defibrillator) as soon as it arrives, if available at your workplace. Follow voice prompts.

IMPORTANT:

• Patient should be on a hard surface to allow you to perform quality chest compressions, beds are not ideal. Be careful not to injure yourself removing then from a bed.

REMEMBER:

Any resuscitation is better than no resuscitation at all.

SECONDARY SURVEY

A focused history and physical exam should be performed after the initial assessment. It is assumed that the life threatening problems have been found and corrected. If that process involved CPR you may not get to this stage.

The focused history and physical exam includes examination that focuses on specific injury or medical complaints, or it may be a rapid examination of the entire body as follows, which should take no more than 3 minutes.

The secondary survey is a systematic approach to identify any bleeding or fractures. This system starts at the head and works down to legs.

• Bleeding: Carryout out a head to toe check for bleeding.

• Head & Neck: Clues to look out for are: bruising, swelling, deformity or bleeding (See Spinal Injuries).

• Shoulders & Chest: Place both hands on opposite shoulders, run them down comparing both sides of the body. (See Fractures & Dislocation).

• Abdomen & Pelvis: Place palm of hand onto abdomen and push gently checking for painful responses from patient.

• Legs & Arms: Using both your hands compare both arms and legs for fractures, dislocations, look also for medic alerts.

• Pockets: Look for clues, ID medical jewellery, such as medic alerts which might indicate any existing medical condition. 

• Recovery Position: If patient is unconscious place them in the recovery position (see Recovery Position).

It also includes obtaining a patient history and vital signs and the acronym used for this is SAMPLE:

• S = Signs & symptoms.
• A = Allergies.
• M = Medications.
• P = Pertinent past medical history.
• L = Last oral intake.
• E = Events leading to the illness or injury.

We hope you find this article useful. This is one in an alphabetical series of articles addressing various symptoms and their first aid treatments. If you would like more information on related resuscitation and first aid training, please get in touch.

You might also be interested in our blog. In this particular post, Sheila Mitchard explains why being a paramedic is like being a detective inspector.

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