Primary and secondary survey in trauma

What it is

Trauma is approached in a fixed order, not by the injury that looks worst. The order runs: preparation, then the primary survey with resuscitation, then the adjuncts of the primary survey, then the detailed secondary survey, then the adjuncts of the secondary survey, then definitive care. Re-evaluation is not a step at the end of that chain; it runs through all of it.

Causes and risk

The first thing to know in any trauma patient is the mechanism of the trauma, which is divided into blunt, such as an MVC or a fall from height, and penetrating, such as a gunshot or a stab. The mechanism decides part of the management: a cervical collar is put on in blunt trauma, and is not put on in penetrating stab trauma in the chest.

How it is diagnosed

The primary survey is ABCDE: airway with c-spine protection and protection of the spinal cord, breathing and ventilation, circulation with haemorrhage control and bleeding control, disability and neuro status, and exposure with environmental control and prevention of hypothermia. Five initial steps are taken for any trauma patient: attach the patient to a monitor, 100% oxygen, two 16 G cannulas in the ACF, blood for cross match, CBC and coagulation profile, and a 1 L IV bolus. The adjuncts of the primary survey are the CXR, the pelvis x-ray and FAST, and FAST is always done after resuscitation. The detailed secondary survey then picks up what the primary survey does not cover, such as a swollen lower limb. If the patient deteriorates, or the clinical status changes at any point, during the secondary survey or while definitive care is being given, the primary survey is repeated: that is the re-evaluation.