Last updated 11/11/23

Primary & Secondary Survey - History & Record Taking - an overview

Setting the scene

When taking a history, the trick is to obtain enough information to enable you to quickly and correctly identify all the important problems (e.g. fractured ankle plus mild hypothermia plus a few cuts and bruises) without getting bogged down in superfluous detail e.g. what their granny's parrot died of. You will then be able to decide what the problems are and deliver the appropriate management. The most important things must be given the highest priority.

At what stage you take a history and in how much detail varies from rescue to rescue. You always need an initial "one liner" that summarises why you have been called. This may come from the casualty e.g. "I slipped on some wet grass and now my ankle hurts and I can't walk" or from a witness, if the casualty is unable to answer e.g. "He said he felt faint and then passed out." In cases of serious illness or injury, it would be more appropriate to briefly ask the casualty or witnesses what happened and then concentrate on the Primary Survey to identify any immediately life-threatening problems and undertake their treatment before trying to take a thorough history. In really sick casualties, it would make more sense for one person to start the Primary Survey whilst a second takes and records the history from a bystander, if possible. 

Important principles

• A good history will lead you directly to the correct diagnosis in almost all cases.

• You need to be able to take a history in two ways

  • When there is no great urgency and you have time to get lots of information, you can be fairly relaxed about it.

  • You need to be focused and move quickly when it is not possible to ask everything e.g. because time is short (e.g. due to the urgency of the situation, the casualty is losing consciousness), conditions prevent good communication (e.g. stormy day, loud river nearby), or there are verbal communication problems (deafness, non-English speaker). In these cases, you must have a way of identifying only what is absolutely essential and getting the information quickly. This takes practice.

• Be structured and organised. Resist the temptation to keep switching between topics otherwise you will forget where you were up to and end up wasting time covering ground again. If the casualty wanders off the subject, politely bring them back.

• Document as much as you can (ideally everything). This is because you (or someone else) may need to refer to the information later when the casualty may have become unable to provide any information. Also, it demonstrates that you were being thorough, should any questions be asked in the future.

• Unless you have an excellent memory, do not try to remember loads of acronyms about all the details you could need to ask. History taking is amenable to the application of common sense. If you do need an acronym, just have one that makes sure you will cover all the important headings e.g. SAMPLE.

• If there is any doubt about the ability of the casualty to give an accurate story, ask witnesses for their version.

• Finally, casualties will mention diseases and drugs that you have never heard of before. Don’t guess because some drugs have very similar names, as do some diseases, so if you guess the wrong one, you will send everyone off on a wild goose chase. Ask the casualty if they can spell the disease/drug. If not, use a text description to indicate its existence e.g. drug for blood pressure, blood problem causing low platelet numbers etc.

Work your way along this pathway starting with the most important

1. The first question is usually “What are you complaining of?” This identifies the main reason why you were called. However, subsequent questioning and examination may show that this is actually not the most urgent problem e.g. facial lacerations are obvious, but the appearance of those may mask an accompanying problem e.g. the seizure that made the person fall in the first place. Get details about how and when it occurred, the casualty’s status when it occurred (which could be different from when you arrive), and how it is affecting them now. Remember to ask about any treatment that has been attempted prior to the Team’s arrival and how successful it was.

2. You can then ask “If it wasn’t for this, would you be absolutely fine?” If the answer is ‘yes’, you can focus on the main problem (but always remain vigilant). If ‘no’, you know you will have to enquire about other things.

3. If a number of things are going on (e.g. head injury + fractured femur + chest injuries), you must prioritise them.

4. Factors that could influence your choice of management e.g. allergies and medication. Knowing about medication is helpful because regardless of what previous illnesses the patient has had in the past, the ones to particularly worry about are the ones that need ongoing treatment. If you know what drugs they take, it is possible to work out what illnesses they have without them telling you. Many casualties do not know the names of the drugs they are taking. In that case, write down what they are taking them for e.g. something for blood pressure, something to thin the blood, etc.

5. Other important previous illnesses or operations e.g. coronary artery stenting.

6. Relevant social habits that could affect treatment (or your safety) e.g. recreational drugs.

7. With children, ask their age. It is possible to calculate drug dosages, blood volume and normal parameters (e.g. BP) from that.

8. If there is time, you can also list insignificant injuries e.g. cuts.

General skeleton for questions about specific symptoms

Although many symptoms are possible, there are certain things you need to know in all cases. This list of questions works for just about everything including pain, breathlessness, convulsions, nausea, vomiting, palpitations, dizziness, pins and needles, inability to move, feeling faint, bleeding, etc.

1. When it started

2. What was the casualty doing when it started, or how were they feeling just beforehand (e.g. felt dizzy and then fell off the crag)?

3. Speed of onset (sudden or gradual)

4. Have they ever had this before? If so, what was it called and how was it managed?

5. What makes it worse (e.g. position, movement, breathing, etc)?

6. What makes it better (e.g. position, stopping movement, etc)?

7. Has the casualty already tried anything to improve the situation (e.g. taking their inhaler, analgesics, GTN)?

8. Severity. Mild, moderate or severe will do (+ see below for a comment about pain scores).

9. Is it getting worse, better, or no change? This indicates any trends. If it is getting worse, you will need to act more quickly and the situation could get out of control e.g. escalating cardiac chest pain.

10. Associated symptoms e.g. light-headedness, palpitations, nausea, etc. If a patient with chest pain also has palpitations, this may indicate an unstable cardiac rhythm.

11. Any significant negatives e.g. breathlessness without concomitant chest pain decreases the likelihood of a cardiac cause.

Specific questions about trauma

See below in the section on SAMPLE

Specific additional questions about pain

• A description of the pain (sharp, stabbing, dull, burning, etc).

• Radiation e.g. chest pain radiating to the neck, jaw or arm.

• For headache, does the light bother them? That’s called photopobia and it can be a bad sign.

• Severity. Mild, moderate, or severe will do. Pain scores are fine in a fully conscious and co-operative patient before administering analgesia and afterwards to assess its effectiveness, but in the first instance for speed, a verbal description will do.

• You can get them to compare the pain to others they have had. A good one for women is labour pains. If the pain they now have is worse than labour pains, it is pretty bad!

Specific additional questions and observations about breathlessness

• Can they speak a full sentence without stopping to take a breath?

• Any cough?

• Coughed up any blood?

• Any pain when breathing?

Specific additional questions about bleeding

In addition to the general skeleton outlined above, you could ask about:

• Are they known to have a problem with bleeding?

• Are they on medication that could prevent the blood from clotting normally (e.g. warfarin)?

Specific additional questions and observations about nerve injuries

• Weakness

• Altered sensation

• Urinary or bowel incontinence if there could be spinal injury

Observe the casualty when you take the history

• Some people play down their symptoms, and if you take them at their word, you may not move quickly enough.

• It will make it easier for you to identify any deterioration or improvement.

• Can the casualty speak a full sentence without stopping to take a breath?

• Are they using accessory breathing muscles whilst they are talking?

Final essential question

"Is there anything else that I might have forgotten to ask you that you think is important?” You will be surprised what can crop up sometimes.

Ongoing history while the casualty is in our care

Don’t forget that once you have the basic story of symptoms (i.e. what the casualty complains of) and clinical signs (e.g. skin colour, Cap Refill, pulse rate, etc.), you should observe if/how these change over time and in response to any treatment you might deliver.

Patient confidentiality

As we work in a public setting, some people may not wish to disclose past injuries and illnesses, medications or any illicit substances they have taken, in front of friends, family or the general public.  Before discussing these matters with them, ask if they're happy to discuss their medical history in front of people and if not, ask bystanders to give you the space necessary to discuss things in private.

S.A.M.P.L.E.

The mnemonic acronym SAMPLE and the cas card can be used to remember the key questions. NB SAMPLE does not have to be followed in order. It’s simply an acronym to remind you what questions to ask, but you must go through it before giving any drugs.

The order in practice needs to be in relation to importance. For example, events is more important than when they last ate. The information below is in the order you are more likely to ask the questions, not in ‘SAMPLE’ order:

Events/Mechanism of Injury (E)

To some extent, this is covered above in the section on General Points for all histories. However, in trauma cases, it is useful to try to gain as many details about the mechanism of injury as possible:

• Where they fell

• Did they move/have they been moved? This is important for three reasons: (1) If they are not where the injury actually occurred, what is the terrain like where it did happen? (2) if they were able to move themselves, it says something about the severity of their injuries; (3) It’s not unknown for injuries to deteriorate on movement e.g. exacerbating a spinal injury. This is not only critical for the on-site management but it could avoid the Team being criticised for bad management.

• What they landed on (grass, rock, mud.....)?

• How they fell: forwards, backward or just crumpled down?

• Did they tumble or roll afterwards?

• What caused the fall (was it a slip, trip, poor landing, faint or blackout)?

• How did they land (which parts of there body made contact with the ground, which hit first, which took the main impact)?

• Did their limbs twist or rotate as they hit the ground?

• Did they feel or hear any snapping, tearing or grating as it happened?

• Did they hit their head or back?

Ask anyone accompanying them if they witnessed the fall and how they would describe it.

Remember - there may be more than one thing going on. Always check for other causes which may have precipitated the injury e.g. a seizure causing a fall, etc.

Symptoms (S)

Ask the casualty about symptoms they may have including:

• pain

• feeling sick

• can't walk

• feeling cold

• feeling dizzy

• feeling weak

Past Illnesses/Injuries (P)

Check for past or ongoing illnesses, in particular:

• Diabetes

• Heart problems e.g. MI

• Epilepsy

• TIA or stroke

• Asthma or bronchitis

• Impaired liver or kidney function

• Stomach ulcers (might be contraindication to aspirin and diclofenac)

• Depression

Medications (M)

Ask if they are currently taking any regular medications or have taken anything since the incident started. Check for common medications of particular concern:

• Drugs affecting blood clotting e.g. warfarin

• Diabetic drugs e.g. insulin

• Aspirin

• Pain killers e.g. paracetamol, ibuprofen, diclofenac, codeine, tramadol

• Drugs for epilepsy

• Drugs for heart disease or high blood pressure. The group of drugs called beta-blockers is important because these drugs stop the heart from beating fast. People taking these drugs will have a slower heart rate than you would otherwise expect, and they will struggle to cope with conditions that need a fast heart rate such as haemorrhage.

• Anti-depressants (get medical advice if giving Fentanyl)

Allergies (A)

Ask the casualty about any relevant drug allergies they suffer from. Other things such as hay fever or an allergy to goats isn't normally relevant. This is particularly relevant if we could want to give them drugs whilst we are caring for them. Remember:

• Penicillin or cephalosporin antibiotics.

• Aspirin (NSAIDs)

• Ibuprofen (NSAIDs) (brand name Nurofen)

• Paracetamol

• Morphine

• Wool (the new cas bag is merino wool)

• Adhesive used on plasters

Last meal (L)

Ask when and what they last ate and drank. This is especially important when considering the possibility of hypoglycaemia, angina (it can be brought on by exercising after a big meal), heat illnesses (dehydration) and suspected heart attack (could also be indigestion).

N.B. - the receiving hospital will treat any casualty they receive from us who requires immediate surgery as having a full stomach.

Pain Score

Pain scores are a useful diagnostic tool, especially in cases of trauma. Because they're seeking relief, it's often something a casualty is keen to tell you about, and whilst you shouldn't get drawn into thinking about or attempting to manage their pain too early, it is appropriate and natural to ask about pain after events in SAMPLE.  

Pain is highly subjective and unique to each casualty.  Some people are in agony with a scratch, whereas for others, their arm could be hanging off and they just say “it’s a bit sore, doc”. Pain is influenced by a wide range of factors e.g. cause, location, social, cultural, prior history of pain, age, gender, fear, anxiety....). One person’s 10 may be another person’s 6.  Studies have shown even trained professionals are poor judges of their patient’s pain, usually underestimating it. Unless there are reasons to believe the casualty is being disingenuous, we should treat according to the reported pain score.

Start by ask the casualty to rate their pain on a scale of 0-10 with 0 being no pain at all and 10 being the worst imaginable.  Also enquire about the nature, duration, location and radiation of the pain, as described above.

Ask them to:

• rate the pain now

• at the time of the incident

• how it has changed

• if anything provokes an increase in pain e.g. movement or weight bearing.

Pain scores should be repeated after interventions e.g. splinting or packaging, and periodically during the evacuation.  Repeat their previous score to them before asking for their current score.  The trend in scores is scores is a more important indicator of the effectiveness of treatment than the absolute scores.

See pain management for details on how to take a pain score.

The Cas Card

 The Cas Card is the primary record of treatment undertaken by the team. In all cases, it is essential to record as much detail as possible. Meticulous record keeping, including documenting the time for all events (arrival on scene, when drugs were given, critical events such as cardiac arrest), is very important. Precise records are essential to evaluate the casualty's needs, clinical status and treatment given in the prehospital setting. This is not only provides us with an important way of determining if the casualty is improving, stable or deteriorating, but is also extremely useful for the receiving ambulance crew and hospital. In addition, medico-legal problems can arise following an accident or incident that we are involved with and so precise records are helpful to record what care was carried out by LAMRT. It should therefore be seen as a legal document.

A person should be assigned to fill out the Cas Card in as much detail as possible.  This person should stay close to the casualty and team members administering treatment throughout to ensure an accurate record is taken.

Consent will be gained by the Cas Carer for any treatment given, if this is refused then this must be recorded on the Cas Card to show that we had attempted to undertake that assessment or administer a particular treatment. Always remember to write neatly (printing is best). If there isn’t enough room on one cas card, start a second one. It is especially important to record any drugs given to the casualty, including the amount and time given.

The person filling out the card is also responsible for ensuring the card goes with the casualty to hospital by handing it over to the ambulance crew.  Where possible photographs of both sides of the casualty card should be taken for team record keeping purposes. If we handover the casualty at LAMRT Base, photocopy the cas card and give the copy to the ambulance staff. We can then keep the original for our records.

Incident Card

The incident card contains a more limited record of what has occurred and is designed to be retained for team record keeping purposes.  If possible the person filling out the Cas Card should also make a record on the incident card, which is kept in the red folder with the Cas Card.

Handing Over To The Ambulance Service

When transferring a casualty to the ambulance service, use the Cas Card as a prompt, giving:

• a brief summary of the incident, including the casualty’s name, age, the time that the incident occurred and the time we were on scene

• your assessment and treatment

• anything you are particularly worried about and would want them to look at quickly

• Finally, ask them is there anything else they need to know.  

Don't forget the casualty. It's important to include them in the conversation, if they are well enough, when you are having the discussion with the paramedic. Don't rush the handover but be concise. By following the A.T.M.I.S.T. mnemonic, you can ensure all the basic elements are covered in a logical manner. 

Here is an example of a handover using ATMIST:-

Age

This is Alice Smith. She is 75yrs old

Time of incident

She tripped and fell at 1600.

Mechanism

She was walking on a rocky path and her right foot went down a hole and she heard her ankle crack.

Injuries

She is unable to weight bear on her right leg. 

Signs/Symptoms

She had intense pain in the ankle area when we arrived on scene (pain score 6 at rest and 8 when trying to move it). The ankle was swollen on the lateral (outer) side and painful on touch. The foot was warm and pink and there was a foot pulse present. The foot was in a neutral position. Additional information from SAMPLE history: she has no allergies, is a mild diabetic on diet alone; her BM was 6, no other medical problems or illnesses. She last ate at 1300.

Treatment

We gave her Entonox for pain relief while we removed the boot and splinted the leg. She continued to use this occasionally on the carry out. We have also given her ibuprofen 400mg and paracetamol 1g at 1630hrs. At the moment her pain score is 5.  

Is there anything else you would like to know? The Cas Card with all this information documented is then handed over to the paramedics.