The primary survey is the rapid, systematic process used by emergency medical personnel to assess and manage immediate life-threatening conditions in a patient, whether due to trauma or a medical emergency. This initial assessment provides the framework to prioritize interventions and ensure patient stability during the earliest phase of care. The procedure is designed to be completed in minutes, with the goal of identifying the most urgent problems and beginning treatment immediately to improve the chance of survival.
Prioritizing Safety and Initial Patient Status
The patient assessment process begins with ensuring the safety of the scene. Rescuers must first confirm that the environment poses no threat to themselves, the patient, or bystanders before initiating care. This preliminary safety check, along with the appropriate use of personal protective equipment (PPE), is a necessary precursor to all medical steps.
Once the scene is safe, the first physical step is to establish the patient’s level of consciousness and responsiveness. This is often done using the AVPU scale: Alert, responsive to Verbal stimuli, responsive only to Painful stimuli, or Unresponsive. A patient who is alert and speaking coherently is generally considered to have a patent airway, providing a positive indicator of their initial status.
If the situation involves a suspected trauma mechanism, such as a serious fall or car crash, in-line stabilization of the cervical spine is initiated immediately. This manual maneuver helps prevent further injury to the spinal cord until an immobilization device can be applied. Determining the patient’s initial status and ensuring safety guide the subsequent, more detailed assessment of life-sustaining functions.
The Systematic Life Threat Assessment (ABCDE)
The core of the primary survey is the systematic, sequential assessment known as the ABCDE approach. Each letter represents a function that must be checked and managed before proceeding to the next. The overriding principle is “treat as you go,” meaning any life-threatening problem identified must be corrected immediately before moving to the next step. This structured method prevents rescuers from getting distracted by obvious but non-immediately lethal injuries.
Airway with Cervical Spine Protection
The first priority is the Airway, ensuring the patient can move air freely, as total obstruction can lead to death in less than five minutes. The rescuer assesses for patency by listening for breath sounds, looking for chest movement, and checking for foreign objects or swelling. If the airway is compromised, immediate interventions like a jaw-thrust or chin-lift maneuver are performed, or a temporary airway adjunct may be inserted. For a trauma patient, all airway maneuvers must be performed while maintaining manual in-line stabilization of the neck to protect the cervical spine.
Breathing and Ventilation
Once a patent airway is confirmed, the focus shifts to Breathing and the effectiveness of gas exchange. This assessment involves visually checking the chest for symmetrical rise and fall, observing the respiratory rate and effort, and listening for breath sounds. A rapid respiratory rate (tachypnea) or the use of accessory muscles are signs of respiratory distress requiring immediate attention. Conditions like a tension pneumothorax or a massive hemothorax, which compromise lung function, must be identified and treated immediately with interventions like needle decompression or chest tube insertion.
Circulation with Hemorrhage Control
Circulation addresses the heart’s pumping function and blood volume status, emphasizing control of catastrophic bleeding. The rescuer checks the pulse rate and quality, assesses skin color and temperature, and looks for external hemorrhage that must be stopped immediately with direct pressure or a tourniquet. Suspected internal bleeding, particularly into the chest, abdomen, or pelvis, is a major concern influencing fluid resuscitation decisions. Establishing large-bore intravenous access is a priority to allow for the rapid administration of blood products or warmed intravenous fluids if the patient is in shock.
Disability (Neurological Status)
The brief neurological assessment, labeled Disability, gauges the patient’s level of consciousness and brain function. This is most commonly done using the AVPU scale or a rapid check of the pupils for size and reactivity to light. Any sudden change in neurological status, such as a patient becoming unresponsive, signals a potentially life-threatening problem like increasing pressure inside the skull. This check helps the team determine the urgency of advanced neurological imaging or intervention.
Exposure and Environmental Control
The final step, Exposure and Environmental Control, requires the rescuer to fully expose the patient by removing clothing to identify any hidden injuries. While exposure is necessary, preventing hypothermia is equally important, as a low body temperature significantly worsens outcomes for critically ill or injured patients. After the examination, the patient must be covered immediately with warm blankets or warming devices to maintain a normal core temperature. This comprehensive visual inspection ensures that no life-threatening injury is overlooked.
The Transition to Detailed Care
The primary survey is complete after all immediate life threats have been identified, managed, and the patient’s condition stabilized. This marks the transition to a more detailed and less time-sensitive phase of assessment and treatment. At this stage, the team gathers a comprehensive patient history, often using the standardized mnemonic SAMPLE (Signs/Symptoms, Allergies, Medications, Past medical history, Last oral intake, and Events leading up to the injury).
The next step is the secondary survey, a methodical, head-to-toe physical examination to find injuries or conditions that were not immediately life-threatening. While the primary survey focuses on immediate survival, the secondary survey aims to detect significant but not immediately fatal injuries, such as fractures or minor internal bleeding. Continuous monitoring of the patient’s vital signs and level of consciousness is maintained to ensure the stability achieved during the primary survey is not lost. The information gathered guides decisions regarding definitive treatment, such as surgery, and preparation for transfer to a higher level of care.