The primary survey, whether for an arrest, trauma, or other situation, is designed to detect life-threatening changes requiring emergent (i.e. as they arise) correction. In a non-arrest situation, as you plan for or work through the ABCDEs of your primary survey, consider the SHAVED acronym for any immediate interventions that may be indicated. In a cardiorespiratory arrest, consider the 4Hs and 4Ts. Prepare for and manage accordingly.
As you follow the protocol, focus first on the derangement in physiology, responding to that, rather than looking to make a specific diagnosis.
DANGER: look for potential dangers (water, fire, biohazards, etc.)
RESPONSE: Use the acronym AVPU to recall the two extremes of the spectrum; i.e. alert (A): eyes are spontaneously open ( they’re breathing); or unresponsive (U): check that they are breathing. A patient who is breathing but not alert will respond either to your voice (V) or to a painful stimulus (P). The colloquial reminder sometimes used here is that if the patient is in the PU (“poo”) part of AVPU spectrum, they will likely need help with their airway. be prepared to intubate that patient.
SEND for Help:
AIRWAY (incl. Oxygen and C-spine): Manual inline stabilisation (MILS) + Jaw Thrust (JT) or if no risk to cervical spine, Head Tilt (HT) + Chin Lift (CL).
Measure for (fingers breadth from angle of neck to angle of jaw) and place a hard collar. Any foreign body (FB) in the mouth? Lay them on their side and suction if post-ictal. Consider nasopharyngeal airway (NPA) unless evidence of head injury (C/I: base of skull #) or oropharyngeal airway (OPA) or laryngeal mask airway (LMA).
Consider the need for a definitive airway:
- Insertion of Endotracheal Tube (ETT) under Direct Laryngoscopy (with/without use of bougie or stylet)
- consider need for sedation/paralysis, RSI (rapid sequence induction)
If you have had two, or your best, attempt/s at any of the devices above and can not establish an airway, you have entered a CICO (cannot intubate, cannot oxygenate) scenario and a surgical airway is indicated. Do it:
- Surgical cricothyroidotomy: feel the cricothyroid membrane and steady the larynx with your non-dominant hand below, go straight down onto the cricothyroid membrane with a 15 blade and cut horizontally across it towards you (turning the blade sideways at the last instant), thread the bougie into the larynx and down the trachea, railroad a narrow-gauge endotracheal tube over the bougie and while holding the tube firmly, remove the bougie and inflate the ETT cuff. Ventilate with a bag-valve and tie the tube in place.
BREATHING: Look, Listen, and Feel for breathing; if none, commence CPR. Use Bag-valve-mask (BVM) ventilation. Ensure the chest rises bilaterally symmetrically. Check that the trachea is midline. Percuss and auscultate the chest. (A deviated trachea and hyper-resonance to percussion with absent breath sounds is an indication for emergent needle thoracostomy in the second intercostal space at the mid-clavicular line. This should be quickly followed by the insertion of a thoracostomy drain at the ipsilateral fifth intercostal space in the mid-axillary line, connected to an underwater seal drain.)
CIRCULATION: Look at skin colour and check capillary refill time (CRT); in a breathing patient check PR and BP; put defibrillator leads on the chest. Insert two large bore intravenous cannulas (IVC) at each cubital fossa, taking blood for bedside sugar (BSL), and also for haematology and biochemistry (± cardiac markers, G&H or Cross Match). Give a bolus of 20 mL/kg Normal Saline. If you can’t get access consider venous cut-down or interosseous needle.
DISABILITY: Run through AVPU again or calculate a Glasgow Coma Scale (GCS). Check the pupils. Do a quick neurological assessment. [“DEFG”: Don’t Ever Forget Glucose. If you haven’t already done a BSL, do it now.] If there is suspicion of raised intracranial pressure (e.g. closed head injury) nurse about 15-30 degrees head up.
EXPOSURE: uncover and look for bleeding sites or evidence of injury, infection, rash etc. Check the temperature. Start to warm or cool the patient accordingly.
[Reassess]
Sugar: 50 mL 50% Dextrose for an adult (5 ml/kg 10% Dextrose for a child)
Haemorrhage: direct pressure bandage, splint
Anaphylaxis: 0.5 mL 1:1000 adrenaline IMI lateral thigh in an adult (0.01 ml/kg 1:10,000 for a child)
Ventricular Fibrillation: DC shock 4J/kg (continue compressions)
Epilepsy: Midazolam 0.1 mg/kg IV (can give midazolam PO or PR at slightly higher doses)
Drugs/Toxins: consider specific anti-toxins
[Reassess]
Hypoxia: attention to Airway and Breathing, high-flow oxygen
Hypovolaemia: Normal Saline 20 mL/kg bolus +/- repeat; consider packed cells
Hypo/hyper-kalaemia: Insulin/Dextrose for raised K+ (KCl for low K+)
Hypothermia: warm
Thrombin (clot): Thrombolytics or Percutaneous Intervention (STEMI) or for Pulmonary Embolus
Tamponade: needle pericardiocentesis
Tension pneumothorax: needle decompression of chest
Toxins: specific antidotes
[Reassess]
Perform a Secondary Survey, including 12-lead ECG, and consider a diagnosis and differentials. Consider any investigations, such as POCUS (Point-of-care Ultrasound) or Radiography. Consider referral, patient disposition, transfer or admission.
[Reassess]
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The primary survey, perhaps somewhat modified, is useful in recognition also of the deteriorating patient, allowing interventions to reverse the patient’s clinical trajectory and prevent an arrest. Hypoxia and hypotension are common findings in deteriorating patients, with tachypnoea usually the earliest sign of deterioration before the arrest or even pre-arrest situation. Nurse concern is also an important predictor of patient deterioration. Also note the patient’s temperature.
Assess the patient from afar: How are you?
- Airway: if they answer you then their airway is fine and, by the time you get to the bedside, you have already moved to “B” for breathing
- Breathing: use R.A.T.E.S
- Respiratory Rate
- Auscultation
- Trachea
- Effort of Breathing
- Saturation O2
- Circulation: think causes of shock
- hypovolaemia
- cardiogenic
- obstructive – emboli, pneumothorax, tamponade
- distributive – sepsis, anaphylaxis, drugs or toxins
- Drugs
References
- Rural Emergency Skills Training (REST) Manual, 5th Edition – Australian College of Rural and Remote Medicine
- Procedural sedation in the Acute Care Setting – AFP, 2005 (available as pdf)
- Comparison of propofol/fentanyl versus ketamine/midazolam for brief orthopedic procedural sedation in a pediatric emergency department, Godambe et al – Pediatrics. 2003 Jul;112 (1 Pt 1):116-23.
