ABCD

Airway


Inspection (foreign bodies, facial, mandibular fractures)
Chin lift or jaw thrust maneuver
If patient communicates verbally, airway not likely to be in immediate jeopardy.
If GCS <8 they need definitive airway


Prevent excessive movement of spine.
Protect spine with immobilisation devices

Breathing and ventilation 

Chest exposed

Inspect
Auscultate
Palpated

Injuries that can impair ventilation include
Tension pneumothorax
flail chest and pulmonary contusion
massive hemothorax
open pneumothroax


Circulation with haemorrhage control 

Blood volume and cardiac output 

Hypotension must be considered hypovolemic in origin until proved otherwise
Clinically: Level of consciousness, skin colour, and pulse. (could be assessed within seconds)

(Elderly limited physiological reserve, Children have abundant reserve)



Level of consciousness:
blood loss, impaired cerebral perfusion, altered level of consciousness.

Skin colour:
Pink skin in face and extremities rarely has critical hypovolemia.
Ashen, gray facial skin, white extremities.

Pulse
Assess for quality rate and regularity.
Rapid thready pulse, is sign of hypovolemia.
Abscent central pulse necessitate immediae resuscitative action


Bleeding

External haemorrhage
manual pressure on the wound
Pneumatic splinting devices
Tourniquet
Hemostats

Disability

Rapid neurological evaluation
Level of consciousness
Pupillary size and reaction, lateralizing signs, and spinal cord injury.
GCS (best motor response)


Exposure

Complete exposure
Warm blankets
External warming device
IV fluids warmed
Warm room temperature


Resuscitation 


Airway

Jaw thrust or chin lift
If unconscious and no gag reflex then oropharyngeal airway can help temporarely (Guedel)
Intubation if not maintaining

Breathing/Ventilation/Oxygenation 

Intubate if compromised airway due to mechanical factors, ventilatory problems or unconscious.
Surgical airway if intubation not possible
Chest decompression immediately if tension pnumothorax is suspected

Suplemental oxygen
If not intubated should have mask-reservoir device to achieve optimal oxygenation.
Pulse oximeter to monitor

Circulation and bleeding control 

Two large caliber intravenous (IV) catheters shold be introduced.
Draw blood for type and crossmatch baseline hematologic studies including pregnancy test

Definitive control of hemorrhage is essential
Operation, angioembolization and pelvic stabilization.

IV fluid with crystaloids
1-2 litres of isotonic solution to acheive an appropriate resonse in the adult patient
shold be warmed
if unresponsive to bolus IV therapy, blood transfusion may be required.

Be aware of hypothermia.


Adjuncts to primary survey

ECG
Urinary catheter
gastric catheter
Ventilatory rate
ABG
Pulse oximetry
Blood pressure
X-ray examination


ECG
Tachycardia, AF, Premature ventricular contractions, ST changes can indicate blunt caridac injury.
PEA can indicated cardiac tamponade, tension pneumothorax, profound hypovolemia.
Bradycardia, aberrant conduction and premature beats indicated hypoxia and hypoperfusion

Urinary catheters 
Urine output
contraindicated in suspected urethral injury (blood at meatus, perineal ecchymosis, blood scrotum, high riding prostate, pelvic fracture), retrograde urethrogram should be done if suspected before insertion of catheter.

Gastric catheters 
Reduce stomach distention and decrease risk of aspiration

Other monitoring

Ventilatory rate and ABG
Adequacy of respiration

Pulse oximetry 
Measures the oxygen saturation of haemoglobin, but not the partial pressure of oxygen. value should be compared with ABG reading.

Blood pressure 

X-ray examination and diagnostic studies. 

AP chest and pelvic films.
FAST and DPL are useful for detection of occult intraabdominal blood.


Secondary survey