Last updated 13/10/24

What is Primary Survey?

Casualty Care is a structured system that enables non-medical people to safely and reliably assess and deliver essential treatment to any casualty they might encounter on the hills. The keyword is structure because without an organised system, the rescuer is very likely to miss out some things and more importantly, fail to give the highest priority to the most life-threatening problems. The structure is built around the Primary Survey, taking a history and the Secondary Survey. Other pre-hospital services e.g. ambulance and helicopter paramedics also use this system and allows us to hand-over to them in a structured way that they can easily relate to. 

LAMRT has developed a comprehensive book which covers all you need to know for casualty care on the hill. Each team member is given their own copy and the Team has shared this with MR teams across the country. This is updated as necessary. A downloadable copy is on this website.

 

Primary Survey

The Primary Survey is the first and most important part of casualty assessment. 

During the Primary Survey, the aim is to identify life-threatening injuries as quickly as possible and take the necessary steps to treat them (or at least improve the situation).

Everything else can wait, so do not get involved with anything that will distract you from this main aim

Other injuries may be more obvious and painful, but the identification of life-threatening problems always take precedence during the Primary Survey. Similarly, it is not necessary to attach monitors to the casualty during the Primary Survey. It takes time to do this and in some cases, such as pulse oximetry (Sp02), you might not get a reading quickly, if at all, causing unnecessary delays. You can do a perfectly good Primary Survey with just your hands, eyes and ears and a wristwatch.

The concept behind the Primary Survey comes from the Advanced Trauma Life Support (ATLS) programme now adopted worldwide.  it emphasises that the lack of a diagnosis and a detailed history should not slow the treatment of life-threatening injury, with the most time-critical interventions performed early.

Only when the Primary Survey has been completed and any essential interventions have been undertaken can the Secondary Survey begin and a full history be taken. The Secondary Survey is a head-to-toe evaluation of the casualty, including a complete history and physical examination, and reassessment of all vital signs. Each relevant part of the body must be fully examined. If at any time during the Secondary Survey the casualty deteriorates, another Primary Survey is carried out as a potential threat to life may have emerged and reassessment is needed.

The Primary Survey is split into sections based upon the bodily system involved. The order reflects the speed with which problems can kill a casuatly . A simple mnemonic, DRcABCDE, is used as a memory aid for the order in which problems should be addressed.  This refers to the following, which are explained in their own pages:

There are two important things to appreciate when doing the Primary Survey:

  1. The order - Airway before Breathing before Circulation before Disability – is deliberate. It indicates how quickly a problem can be fatal. Thus, if untreated, a blocked airway is fatal in minutes whereas a head injury, unless massive, may take several hours before the person dies. Therefore, we attend to the problem that is most rapidly lethal and work our way down the list.

  2. How long it takes - Although the Primary Survey should be done as quickly as possible, one cannot say exactly how long it will actually take. If something is particularly problematic, then you must not move on until it has been sorted. Thus for example, in a casualty with a difficult airway, you may spend 10 or 15 minutes clearing it and keeping it clear before moving on to breathing. In a team situation, assessments can be carried out simultaneously – a “Pit Crew” Primary Survey.

More recently, in some books you will see C-ABCDE. The first C refers to ‘catastrophic haemorrhage’, which is bleeding that is so severe that the casualty will bleed to death within minutes if not treated. This modification of the basic ABCDE mnemonic was developed in the military to deal with victims of blast and missile injury. In theory, management of this should come first. In practice, it will rarely be an issue in MR unless you are on scene when the incident occurs. This is because the casualty will have died before the team arrives.

By the time you have finished your Primary Survey you should have undertaken all indicated interventions before protecting the casualty from the environment and moving on to the Secondary Survey.

For an overview of how to perform a Primary Survey, take a look at this excellent video featuring Olly.



History taking during the Primary Survey

Because it is important to identify and treat life threats as soon as possible, you should not get into discussions about anything else at this stage, but only ask any questions that are part of essential information gathering to help you decide what’s going on and if specific life-saving treatment is required. The best example of that is chest pain, to help decide if it could be cardiac pain, when you would have to give aspirin and possibly GTN during the Primary Survey. Other examples are asking about the presence of pelvis or thigh pain at ‘C’, in case there are major fractures there, and spine pain when you get to ‘D’, so that you are alert to the possibility of spinal damage. But don’t suddenly interrupt the flow e.g. to ask an isolated question about pain score or some other non-critical matter.  For further information on history taking look at the history taking section.



Secondary Survey

The secondary survey is a complete front and back examination of the casualty from top to toe, but is only undertaken if time allows, and only after the Primary Survey has been completed.

This website explains the Primary Survey and Secondary Survey used by LAMRT in their longest forms. Depending upon the circumstances, it can be acceptable and appropriate to designate some items as ‘not applicable’ in the Primary Survey. For example, if a casualty is sitting up and talking normally, they can be assumed to have a fully open airway and reasonably normal respiratory rate, so you do not need to check in the mouth. The decision not to assess items in the Primary and Secondary Surveys can only be made on a case by case basis.

 

Primary Survey in more detail

The primary survey is to quickly identify and treat/stabilise any life-threatening conditions. Everything else can wait. Do not get distracted by spectacular-looking injuries.  

Not all steps will be necessary for all casualties e.g. checking the airway of a casualty who is talking and whose voice sounds normal. Part of being a good Casualty Carer is learning what you can omit in the circumstances or leave to the secondary survey. If in doubt about whether something is necessary, err on the side of caution and check. 

NB Perform any indicated interventions before moving on to the next step

If an intervention requires your continuing attention e.g. maintain the airway manually because they won't tolerate an NPA, OPA, i-gel or assisted breathing with a Bag-Valve-Mask, you should continue that intervention and only move on once someone becomes available to take over from you.

The fact that you treat something doesn't mean that it will remain ok. Therefore, you should check periodically to ensure that the situation hasn't deteriorated. 

Any primary survey problems warrant immediate evacuation by air.

Only when the primary survey has been completed and any indicated interventions undertaken can the secondary survey begin if time allows.
N.B. anaphylaxis should be treated as soon as it is identified during the primary survey.

Cas card - Make sure this is completed by a team member as interventions are carried out and vital signs are recorded as a baseline. Information about the casualty must be recorded clearly as an important record of the care delivered by the team as well as all the relevant information about the incident and the casualty’s personal details.

Consent: This is assumed if the casualty is unconscious. If they are conscious, ask if you can treat them before starting.

 

 Danger and Safety

This is covered elsewhere in more depth but here is a brief summary. 

  • Gloves (always)

  • Helmet

  • Sharps (lying around)

  • Ropes

  • Crampons

  • Ice axe

  • Swift water gear

  • Avalanche

  • Dangerous animals

  • Lightning

  • Violent individuals

Ask yourself if it is safe to approach?

 

 Reading the Wreckage

  • Where - which Fell, what are the ground conditions like

  • When - time of day and time of year

  • Weather - hot/cold, raining/dry, windy/still, snow and ice

  • Who - age, gender and general appearance

  • Gear - is it appropriate for the conditions

  • Witnesses - what happened, does the casualty have a history of anything similar happening, have they moved them, have they given them anything

  • What's around them - do they have bag, is there anything relevant in it, are there object, rocks or equipment near them


Catastrophic Bleeding

This is major ongoing bleeding that will kill the casualty in minutes. It is rare for us to encounter this in MR because by the time we arrive on scene, the casualty will have died. However, we may encounter it if we are nearby e.g. on a training session, when the accident occurs or if a MR colleague is the casualty. Look for major bleeding and attempt to control it via direct pressure, packing, haemostatic dressing and elevation of the limb.

Response

Look for a response as you walk in. Hand on forehead in case of C-Spine problem. “Hello can you hear me?’ If no response, consider whether cardiac arrest possible. Do not waste time if not a normal response, this will be checked more fully in Disability.

Airway + Cervical Spine

Remember that these two go hand-in-hand. Think “C spine” in every case. Then you won’t forget to do it in the cases that really matter.

C Spine
Does the mechanism of injury indicate C spine support? If so, if possible, approach the casualty from a direction that will not encourage them to turn their head to see you. If the casualty is conscious, ask them to keep their head still as you approach. When you arrive, stabilise the C Spine before doing anything else.  

Airway

  • In the apparently unconscious, check for a response using the shake and shout

  • Temporarily open the airway via either a head tilt chin lift or jaw thrust if there is the possibility of a C spine problem

  • Check the airway for objects, fluids and the tongue position

  • Clear the airway using body positioning, careful finger sweep (don't get bitten), suction or Magill forceps as appropriate. Take care not to push any foreign objects further in.

  • Secure the airway - NPA, OPA, i-gel or recovery position


Breathing

  • Check for breathing (ten seconds)

  • If breathing is present, count respiratory rate (15 or 30 seconds)

  • Assist breathing if necessary (rate 8/min or less, unless severe hypothermia)

  • Check for life-threatening chest and neck injuries (e.g. tension pneumothorax) using the TWELVE mnemonic if it helps you remember.

    • Tracheal deviation

    • Wounds on the front, sides and back. Look also for bruising and abrasions.

    • Emphysema (air in the tissues that makes the skin feel crackly when you press on it)

    • Laryngeal trauma (look for bruising or injury around the Adam's Apple area)

    • Vein distension in the neck (bulging neck veins - can be difficult to detect, especially if the casualty has a fat neck))

    • Evaluate chest injuries (see below)

  • Check the chest using the F.L.A.P. acronym

    • Feel the chest wall

    • Look for signs of injury, including Armpits

    • Palpate (i.e. feel) the back, front and Sides of the chest

  • Start oxygen in any severe illness (trauma or medical). You can always discontinue it later if indicated by Sp02 reading. Consider the flow rate and available supply. For example, although it is often stated that you would use a high oxygen flow rate (15 litres/minute), you will soon empty the oxygen cylinder at that rate. It would therefore be better to use a lower flow i.e. a little extra oxygen for a long time is better than a lot for a short period and then have to revert to air.


Circulation

  • Look for and control obvious significant external bleeding

  • Assess the pulse for rate

  • Check central capillary refill time

  • Don't worry about measuring the blood pressure at this stage. It takes time and doesn't add a lot to the care at this stage. If you can feel a radial pulse, that is an indication that the BP is acceptable at this stage.

  • Look for less obvious bleeding - one on the floor and four more

    • One on the floor is any obvious pool of blood

    • The four more are the long bones, pelvis, and the chest and abdominal cavities (Note: long bones includes the tibias as well as femurs since a fracture of both tibias can lose almost as much blood as one femur)

  • Treat pelvic and femoral fractures with splinting

  • Consider the possibility of shock and treat if present e.g. raise the legs, IV fluids (if possible)


Disability

This refers to impaired conscious level

  • Rate on the ACVPU scale

  • Indicate whether they are agitated or confused

  • Head Injury

  • Assess the pupils (size in mm and reaction to light)

  • Take a BM and treat reduced readings immediately

  • Take a temperature if this could be contributing to reduced conscious level


Environment

  • Protect the casualty from the environment using the group shelter. Apply heat or cooling if needed.

 

Secondary Survey in more detail

During the secondary survey get down to skin and work methodically from head to toe, 

The elements of the secondary survey are:

  • History - SAMPLE

  • Pain score - now, when it happened, has it changed, does anything make it worse. See Pain Management section.

  • Check the head - look for injuries hidden by hair, bleeding/fluid from the nose/ear, raccoon eyes, Battle's sign

  • Assess the pupils for size and P.E.A.R.L. (if not already done during the primary survey)

  • Glasgow Coma Scale (GCS) - using this scale when ACVPU does not provide an adequate assessment. Observation of trends using this scale.

  • Temperature - hypothermia, heat exhaustion or heat stroke? (If not already done during the primary survey)

  • Assess C-spine using NEXUS

  • SpO2- consider use of oxygen

  • Blood Pressure (BP)

  • Blood glucose monitoring (BM) If not already done during the primary survey.

  • Check the body

  • ECG - is the rhythm normal? Take a recording

  • Check the limbs - expose the limbs, identify and locate potential injury sites, assess the distal limb for MSC (motor, sensation and circulation), consider ischaemia, compare with the other limb.

  • Working Diagnosis