The key to saving a trauma victim is to understand the whole concept of the primary survey. The primary survey means – save a life, save a life over a limb, a limb over vision. I know you have heard of – ABCDE of the primary survey. Today you are going to learn beyond it & its insight.

What is Primary survey? 

The primary survey is the identification and simultaneous management of life-threatening injuries. The most important thing is to adhere to – ABCDEs.

What is ABCDE?

A – Airway maintenance and restriction of cervical spine motion.

B – Breathing and ventilation

C – Circulation and haemorrhage control

D – Disability (Neurological assessment)

E – Exposure & Environment control (Prevention of hypothermia)

Well, you know that right? Now the next question is why you should stick to the sequence of A – B – C – D – E?

First thing first

• The threatened airway can kill a patient in a few seconds, maybe in the next 10 seconds it can cause cardiac arrest ….. yes, in the next 10 seconds. One patient in cardiac arrest – had a decreased chance of survival as it was 10 seconds before. So identify threatened airways and secure them faster to save your patient.
• Breathing (chest trauma) and Ventilation can kill your patient in a few minutes may be in the next 5 minutes – be aware of tension pneumothorax and cardiac tamponade. These patient dies fast and can be saved faster. So learn to identify the killer. Here a wide-bore needle can save your patient. How we will learn soon in other chapters.
• Now Circulation – nonetheless trauma means haemorrhage. Haemorrhage sometimes bluffs from reality. Sometimes distracts us from critical intervention & sometimes hides what kills your patient from the inside. Active bleeding distracts us – from securing an airway, which is more lethal, whereas concealed abdominal bleeding gives us false hope that everything is okay.
• Remember – circulation never kills a patient directly – it is always by threatening the airway. So, in doubt secure the airway first, then control bleeding. Here parallel resuscitation plays a vital role to save patients.
• Next is Disability, most of the time residents are confused with a physical disability but it’s a neurological disability.  The parameter which can alter the level of consciousness should be examined now e.g. Head injury, Hypoglycemia, intoxication, and associated poisoning.
• Exposure & environment control – It’s neither description of your clinical examination nor exposure to the patient. it’s basically for reminding you -don’t expose your patient to extreme temperatures, especially hypothermia. Later in this book, you will get to know how it kills a patient.

I hope you understand well, why you should adhere to the fact of ABCDE. It’s like playing chess – when you are planning to kill a peon, they kill your queen, and you lose the game. So don’t distract yourself follow the rule. Following the primary survey is proven to save the trauma victim and has the highest possibility to save a life than any other means especially in critically ill patients.

We wise, don’t follow non-sense instructions from remote & non-utilized clinical skills to save a life. Put your brain into gear and act fast and wisely. It’s good to take an expert opinion, from an experienced person, and use your brain too. You might project false information to the expert person if you don’t know how to examine or approach a trauma victim. So keep your senses alert and have a good piece of knowledge and learn skills every day. Learn from seniors, enquire bluntly and be curious.

Primary Survey

Airway maintenance and cervical spine restriction

The earliest priorities in managing the injured patient are to ensure an intact airway and recognize a compromised airway – ATLS

As we already discussed, the importance of the airway and its role in life-saving manoeuvres.

Now the question is how to secure airway in trauma victims – a stepwise approach.

1. Assessment of airway in trauma – whenever you receive a trauma patient immediately assess the airway, and keep the mind cervical spine stabilises.

Trauma Dictum – “Any polytrauma patient who is unconscious – consider cervical spine injury until proven otherwise”

• 10 seconds Quick assessment – this is an easy and quick process to assess your patient. Ask three questions.
  • Identify themselves – what is your name?Identify place & Person – where are you now? & Who is he or she (known relative)?
  • Remember the incident – what happened?

These three questions will tell you about – almost 80% severity of the patient.

Interpretations of the questions

1. If a patient is able to answer three questions properly – means patient is having patent airway, no breathing problem, and enough brain perfusion to think and analyse.
2. If a patient is answering but taking breaths in between sentences (tachypneic) and confused in your questions (inadequate brain perfusion or head injury)
3. If the patient is not able to answer your question at all – needs urgent attention & may be collapsed in a few minutes.

So, 10 seconds quick assessment – quickly tell us about airway, breathing, circulation and disability. If practice it in day-to-day life you will be a master and can about the severity of the patient just in 10 seconds. How it exactly works you should understand from basics. If any person has a patent airway – means nothing in between the trachea and the oral cavity, which will produce normal sound. If the lungs are not compromised (pneumothorax or hemothorax) and have a good perfusion ventilation ratio, will take normal breath and will be able to complete their sentences without breaking into pieces. If circulation or perfusion to the brain is intact, will be able to answer your questions normally – they will not be confused. Here is the trick – this is not only applicable to trauma patients bit Its applicable to all critically ill patients.

• Category of airways – you should categorize your patient into three categories
  • Patent airway – Normal, patient is taking normal breaths and is alert.Compromised airway – means the patient is maintain saturation but is not able to protect their airway in case of vomiting or bleeding. These patients need to have definitive airways before proceeding with any investigation and procedure.
  • Threatened airway – means the patient is not able to maintain his/her airway. Saturation is falling and needs urgent intervention other patients may collapse in a few seconds/ minutes.

Airway Management

Whenever you read about airway management – first you should know which category and why? this book is not a textbook it’s the discussion between you and me. Every word is meaningful if you are not able to understand then read it again and again.  So, we were talking about the management of the airway, there are three categories – patent, compromised and threatened.

1. Patent – Only needs to put on an O2 mask if needed. Sometimes bleeding / head injury patients have patent airways at presentation but deteriorate fast if not managed properly.
2. Compromised airway – here most of the resident takes chance and utilized their unutilized brain and behave as they want. Saturation is normal then why intubate? They don’t find the reason and leave the patient in their own condition – if the patient vomits, has minor oral/nasal bleeding, having ongoing oral secretions patient lands up into a threatened airway and collapsed if remains unrecognized.
3. Threatened itself means threatened – leading to death.

Now how will you react after the categorization of your patient’s airway? At this point, you need to understand the types of airway management.

Types of Airway Management

Keeping the mind categories there are two types of airway management – Definitive / Non-definitive (temporary). Stay focused here. Whenever you feel tired or not in the mood to read, leave and read again whenever you are free-minded to assimilate the content.

So. Come to the important part of the types.

1. Definitive Airway – remember 5 points to define a definitive airway
   1. A tube below the vocal card the tube should be cuffed – should not allow it, as the content goes into trachea. Should be connected to O2 rich source.Should be connected to mechanical ventilation
   1. Should be secured from the outside.

Anything which is not fulfilling the above criteria is not a definitive airway and the most important component is the cuffed tube. There are two types of definitive airways

1. Non-Surgical definitive airway – includes orotracheal or nasotracheal intubation.
2. Surgical definitive airway – cricothyroidotomy (Needle/ open) or tracheostomy (open/per-cutaneous)

• The definitive airway is the indication for all threatened airways. The most frequently performed intervention is orotracheal Intubation – it is the fastest and safest way to secure the airway.
• In any case, orotracheal intubation is not possible – one should on to a surgical airway. Meanwhile one can take help from non-definitive airways.
• In emergency scenarios – open cricothyroidotomy is preferred if intubation fails.
• One should not try – tracheostomy (open / percutaneous) in emergency set-ups, because it consumes lot of time and required complete asepsis (with expert hands tracheostomy takes 10-15mins) considering everything is ready in emergency. While surgical cricothyroidotomy takes 1-2 mins in expert hands and required only surgical blade and tracheostomy tube.
• I am not going to tell you how to intubate – its skilled procedure, be curious and learn from expert around you.

• Non-definitive airway – frequently useful in elective procedures to secure airways, and often used in emergency. An intelligent resident never underestimates the use of non-definitive airways.

Now the question is what non-definitive airways. Which is not definitive is – non-definitive airway.

1. Airways – they provide temporary patency of airway,
   1. Oropharyngeal Airways (Guedels airway) – Prevent tongue fall, in intubated patients they prevent tube biting. Should only be used in where GCS is less than 8
   1. Nasopharyngeal airways – provide patent airways and can be used in GCS more than 8.
2. Supra-Glottic Devices – if you want to talk then there many devices known to as supraglottic devices and if you want to know then only few useful and they are
   1. LMA (Laryngeal Mask Airways) – first you need to understand that – all non-definitive airways are only useful in compromised airway in emergency.
   1. I-Gel – its advanced supraglottic device equivalent to LMA – non-inflatable cuff made up of thermoplastic elastomer. Its easy to use than LMA.
   1. Combitube airway – it’s not typically supraglottic device but its very useful in emergency scenarios. Combitube can be placed blindly its double lumen tube – one for esophagus and another is for supraglottic area (trachea).

To secure airway in emergency – first you need to identify threatened or compromised airway, then react fast as possible.

In emergency set-up, few things are very important because results are time bounded. Understanding difficult airway and preparation is important.

Difficult Airway

Identification of difficult airway is important part of successful management of airway. Difficult airway means where you can fail with normal approach or need accessories.  As soon you see the patient just have a look like an expert & Remember – LEMON criteria.

L – Look externally: see the patients face, abnormal swelling (Hematomas), growth (Malignancy), fracture mandible or maxilla especially bilateral, congenital deformity. Any visible deformity is direct indicator for difficult airway.

E – Evaluate the 3-3-2 rule:  It’s rule to identify alignment to airway

1. Distance between the patient’s incisor teeth should be at least 3 finger breadths
2. The distance between the hyoid bone and chin should be at least 3 finger breadths
3. The distance between the thyroid notch & floor of the mouth should be at least 2 finger breadths

M – Mallampatti: Classification is based on visibility of hypopharynx, and better useful in awake patient than unconscious patients

O – Obstruction – Any short of obstruction in the oral cavity or hypopharynx can create difficult airway in emergency. 

N – Neck mobility – Follow the Dictum – “All unconscious polytrauma patients have cervical spine injury – until ruled out”.  Stabilization of neck is important component while securing airway.

Second difficult neck is short neck – while pushed Adam’s apple anterior and make difficult visualization of vocal cards (Use of airway accessories like stylets or gum elastic bougie)

Breathing and ventilation

Any patient arrived in the emergency department with having low spo2, patient might have

• Compromised airway
• Extreme shock led to cold extremities which reduces sensitivity of SpO2 probe – gives false reading (Most common)
• Chest trauma – pneumothorax & hemothorax.
• Known case of pulmonary diseases – COPD, asthma, or parenchymal diseases. 

Stepwise approach

• A polytrauma patient with low SpO2 examined the patient for compromised airway – never skip airway first approach. Once airway is secured – move to breathing (keep in the mind probe and monitor should properly functional).
• Examine the patient’s chest
  • Look – external injuries, surgical emphysema, flail chest & open wound.
    • First site of surgical emphysema is the indirect indicator of site of breach of pleaura. If surgical emphysema first appeared on chest which indicates breach in thoracic wall & if first appeared around neck which indicates Neck or bronchial injury.
    • Fast progressive surgical emphysema around neck or to whole body is indicates active air leak from lung or trachea.
  • Listen – Bilateral air entry, added sounds and heart sound
    • If external injury corresponds to reduced air entry – patient might have ipsilateral side hemo or pneumothorax.
    • Muffled heart sound (called distant heart sound) – needs a silence to listen heart sounds is pathognomic feature of cardiac tamponade.
    • Reduced air entry on left side – without external injury, look for displaced endotracheal tube (pushed into right bronchus).
    • Reduced air entry on right is always pathological – right hemothorax, pneumothorax, mucous plug, pneumonia, or other lung pathology to be ruled out.
    • Coarse crepts – suggestive of aspiration (food or blood)
    • Active air leak is suggestive of breach to lung & thoracic wall, airway – trachea or bronchus.
    • First site of surgical emphysema is the indirect indicator of site of breach. If surgical emphysema first appeared on chest which indicates breach in thoracic wall & if first appeared around neck which indicates Neck or bronchial injury.
    • Fast progressive surgical emphysema around neck or to whole body is indicates active air leak from lung or trachea.
  • Feel
    • Palpate the chest wall – both hands from front then bimanually one chest at a time to ribs fracture and relative movement in chest wall.
    • Examine the clavicle bilaterally.
• In case of hemo/pneumothorax, immediate treatment is decompression of chest – means placement of intercostal tube drainage (ICD).
• In an Emergency, placement of ICD doesn’t require any definite investigation if the patient is unstable. Direct clinical signs of chest trauma indicate the procedure. 

Circulation and hemorrhage control

• Most common preventable cause of death in trauma is hemorrhage. Any patient in shock is considered to be in hemorrhagic shock until prove otherwise. Always remember hemorrhage control is the part of circulation, if patient is not stable – needs urgent hemorrhage control – just do it. Which may include emergency laparotomy or emergency thoracotomy.
• Any patient arrive in trauma emergency with shock – consider: hemorrhagic shock until ruleout. Bleeding can be revealed or concealed. Revealed bleeding always distract to budding surgeon from securing airway and breathing. Your patient might have revealed or concealed even both bleeding simultaneously.
• External bleeding can be controlled by direct pressure, external compression and torniquet application. Concealed bleeding best assessed in Emergency Department (ED) by ultrasonography.

The first step in the initial management of shock is to recognize its presence. – ATLS

• Any trauma patient arrive in emergency with shock – follow ABCD protocol. Control external hemorrhage and resuscitate with 1.5 liter of warm lactated ringer’s solution (RL). Identify the source of bleed and control. On arrival blood pressure less than 90mm Hg with on going blood loss consider for blood transfusion immediately.
• After transfusion of 1 Liter of warm crystalloid, blood pressure remains same or drop – consider for surgical intervention to stop bleeding and activate MTP (Massive Transfusion Protocol).
• If blood pressure increases, and pulse rate reduces, move to disability part of primary survey.
• Common type of shock in trauma

Type of Shock	Clinical signs	Pathogenesis	Treatment
Hypovolemic/Hemorrhagic (Most common)	Low BP High pulse rate Fall in GCS	Excessive bleeding (external or internal	Hemorrhage control, Fluid resuscitation, blood transfusions
Obstructive shock	Low BP, High Pulse rate and distant heart sound (cardiac tamponade) and absent air entry (tension pneumothorax)	Only 2 causes of obstructive shock – tension pneumothorax and cardiac tamponade	Decompression Needle decompression Pericardiocentesis.
Neurogenic Shock	Low BP, Low Pulse rate associated with spinal cord injury.	Spinal cord injury at level of cervical or upper thoracic leads to cut off of sympathetic outflow	Don’t overload with fluids. Start inotropic support. (Noradrenaline – maintain mean blood pressure 65mm Hg)

Cardiogenic and septic shocks are rare in trauma victims, until they have previous overlapping disease with trauma.

Since the management of the shock varies – next step is identifying probable cause of the shock and management.