The Primary Survey

Concepts of ATLS
Treat the greatest threat to life first
The lack of a definitive diagnosis should
never impede the application of an indicated
treatment
A detailed history is not essential to begin the
evaluation
ABCDE approach
Identify sources of
bleeding that may be
contributing to
hypotension
Sequential step-wise approach
for single provider in rural setting
Find a problem =
fix-it

45 yr male
high speed MVA
ejected through
windshield.

Arrives c-spine
immobilized.
Intoxicated.
Alert, but
belligerant.
Multiple facial
lacerations.
Temp: 99.1
HR: 124
Resp.rate: 25
BP: 100/70
O
2
Sat.: 94%
What are the management priorities at this
time?

What are this patients possible injuries?

What are the interventions that need to
happen now?
Simultaneously
A
G
F
D
E
C
B
L
Neuro.
Before
Airway
Head-of-the-bed-guy:
GCS, assessing airway and potential for difficult airway,
and can they move all 4 extremities
(no sensory exam needed)
Eyes? Motor? Voice?
Hey buddytalk to mesqueeze my hand .

EYE VERBAL MOTOR
Spontaneous 4 Oriented 5 Obeys 6
Verbal 3 Confused 4 Localizes 5
Pain 2 Words 3 Flexion 4
None 1 Sounds 2 Decorticate 3
None 1 Decerebrate 2
None 1
Lung Guy:
Evaluating the
breath sounds
Are bilateral breath sounds reassuring?
Needs Positive Pressure Ventilation

Lung Guy:
and palpating
the chest wall
Lung Guy:
Lung Guy:
Lung Guy:
Lung Guy:
Team Leader: (no procedures)
Feeling the feet, Check the pelvis
and Feel the belly
Where is the injury?
Where is the injury?
Lung Guy:
1. Armpits
2. Back
3. Butt cheeks
4. Sack
Look for distension, tenderness, seatbelt marks, penetrating
trauma, retroperitoneal ecchymosis
Be suspicious of free fluid without evidence of solid organ
injury
Focused Abdominal Scanning in Trauma
5 views: Cardiac, RUQ, LUQ, suprapubic + LUNG
Goal: evaluate for free fluid
Trauma is best managed by a team approach
(theres no I in trauma)
A thorough primary and secondary survey is key to identify
life threatening injuries
Once a life threatening injury is discovered, intervention
should not be delayed
Disposition is determined by the patients condition as well
as available resources.
Airway
Breathing
Circulation
C-Spine
Disability
Decon
Expose
Foley
Fluids
Girl = HCG
Glucose
History
Hang Antibiotics
Head-to-Toe Exam
and prevent

Inject Pain Meds
Inject tetanus
Next: OR, CT or stabilized and start secondary survey
Mark P. Brady PA-C
Dept.of Emergency Medicine
Cambridge Health Alliance
Cambridge, MA