Primary Survey of Resuscitation

During the primary survey, the critical therapeutic efforts of resuscitation are initiated. At the same time, the signs of the various shock states are unmasked and clues to the underlying diagnosis may be elicited. Although a definitive diagnosis is often not made initially, it is almost always possible to direct resuscitative efforts toward a particular class of shock.

When problems are encountered in the primary survey, they should be addressed immediately. Each element may be managed with either temporizing or definitive maneuvers. For example the airway may be temporarily managed with the chin-lift and bag-valve-mask ventilation, or definitely managed with enforceable intubation.

A�Airway
When approaching the airway, the clinician ensures that cervical spine precautions are in place if trauma is a possibility and determines whether the airway is patent, protected and positioned adequately. The clinician: Observes for level of consciousness, drooling and secretions, foreign bodies, facial burns,
carbon in sputum
Palpates for any facial or neck deformities and checks for a gag reflex, and Listens for hoarseness or stridor.

Findings	Diagnostic Implication
Drooling, stridor	Upper airway obstruction
Decreased level of consciousness	Unprotected airway
Diminished gag
Facial burns	Unstable airway (potential obstruction)
Facial instability

Airway management in the primary survey may be as simple as positioning of the airway using the chin lift or jaw thrust maneuvers (used when cervical spine instability is a concern). It may also involve the placement of nasopharyngeal or oral airway devices and the application of supplemental oxygen. In cases of obstruction, foreign bodies may need to be dislodged using basic life support maneuvers or manually with suctioning and Magill forceps. Definitive airway intervention, such as oral endotracheal intubation (with or without rapid sequence technique), nasotracheal intubation or a surgical airway (e.g., cricothyroidotomy) may be required.

B�Breathing

To assess the adequacy of the breathing apparatus, the clinician:

• Observes for signs of tracheal deviation, jugular venous distention (JVD), Kussmaul�s sign (increased JVD with inspiration), respiratory distress (such as indrawing, splinting and use of accessory musculature) and trauma (contusions, flail segments, open wounds)

• Palpates for bony crepitus, subcutaneous air or tenderness
• Auscultates to assess air entry, symmetry, adventitial sounds (crackles, wheezes and rubs), and
• Percusses, if necessary, for hyperresonance or dullness on each side.

Findings	Diagnostic Implication
JVD, unilaterally absent	Obstructive shock
breath sounds	(tension pneumothorax)
JVD, clear lung fields	Obstructive shock
	(cardiac tamponade, massive pulmonary embolism)
	Cardiogenic shock
	(right ventricular myocardial infarction)
JVD, diffuse crackles	Cardiogenic shock (cardiogenic pulmonary edema)
JVD, diffuse or localized wheezes	Status asthmaticus, COPD exacerbation, aspiration syndrome
Kussmaul ("air hunger") breathing	Metabolic acidosis
Chaotic, irregular breathing	Central nervous system insult
Abdominal breathing, failure of chest expansion	High spinal cord injury

Possible interventions during the breathing segment of the primary survey include bag-valve mask ventilation, the administration of naloxone for narcotic induced apnea, placement of thoracostomy needles and tubes and the application of positive pressure ventilation, by either non-invasive or invasive means.

C�Circulation

To assess the circulation, the clinician:

• Palpates the pulse for rate, regularity, contour and strength. Pulses should be checked in all four extremities, and if absent, central pulses (femoral and carotid) are palpated. Also, palpates the skin for temperature, moisture and the briskness of capillary refill in the extremities.
• Observes for signs of obvious hemorrhage such as visible exsanguination, a distending abdomen, an unstable pelvis or long bone deformities.
• Measures the blood pressure, notes pulse pressure, and if necessary, compares BP among the extremities.
• Auscultates the precordium for the clarity of heart tones, listening for any extra sounds, murmurs, rubs or Hammon�s crunch (pneumomediastinum)

Interventions during the circulation segment of the primary survey include placing the patient on a cardiac and pulse oximetry monitor and the establishment of vascular access. They may also include the administration of fluids and blood products, electrical and pharmacological therapy for dysrhythmias, pericardiocentesis and, in some cases, such as penetrating trauma, emergency thoracotomy.

D�Disability

Disability represents the neurological assessment in the primary survey. If at all possible, it is desirable to obtain a cursory assessment prior to use of paralyzing agents. The clinician:

• Assesses the level of consciousness, using the Glasgow Coma Scale.

  	Eye Opening	Motor	Verbal
  1	None	No movement	No sounds
  2	To pain	Decerebrate postutre	Moans
  3	To command	Decorticate posture	Words
  4	Spontaneous	Withdrawal from pain	Confused
  5		Localize to pain	Oriented
  6		To command

  Minimum Score = 3 (severe coma); Maximum Score = 15

• Observes the pupils for size, symmetry and reactivity to light, and observes all four extremities for their gross movement
• Palpates rectal tone by digital examination

Findings	Diagnostic Implication
Coma, unilateral dilated pupil, hemiparesis	Cerebral herniation
Pinpoint pupils	Opiate, cholinergic or clonidine overdose Pontine lesion
Dilated, reactive pupils	Sympathomimetic overdose
Dilated, unreactive pupils	Anoxia Anticholinergic overdose
Deviation of eyes to one side	Ipsilateral cortical lesion Contralateral brainstem lesion
Decreased rectal tone	Spinal cord injury Other neurological insults, seizures, toxins
Rigid extremities	Neuroleptic malignant syndrome Serotonin syndrome Tetanus, strychnine poisioning

Interventions in the disability segment of the primary survey are often limited to airway, breathing and circulation, as these all affect neurological function. Once these are addressed, attention can be directed toward interventions such as cranial CT, the administration of mannitol and hyperventilation for suspected acute brain herniation, and surgical decompression. Pharmacologic therapy is directed at causes of altered levels of consciousness, such as the administration of glucose for hypoglycemia, naloxone for suspected opiate overdose and thiamine for Wernicke-Korsakoff syndrome.

E�Exposure

Often described as "strip, flip, touch and smell", exposure means not only completely undressing the patient, but also looking for other important clues. The clinician should:

• Expose the entire surface area of the patient
• Inspect and palpate the back for abnormalities, using cervical spine precautions to roll the patient if there is a possibility of trauma. Also, inspect the skin for rashes, other obvious lesions and signs of trauma
• Note any particular odors about the patient, and
• Measure a rectal temperature

Findings	Possibile Diagnostic Significance
Hyperthermia/Hypothermia	Hypovolemic (severe dehydration) Distributive shock (e.g., septic) Cardiogenic shock
Unsuspected wounds (especially in axilla, back, neck, perineum)	Hypovolemic shock (hemorrhagic shock from occult trauma)
Odors:
Fetid urine	Distributive shock (urosepsis)
Bitter almonds	Cyanide toxicity
Garlic	Organophosphate or arsenic toxicity
Fruity	Ketoacidosis, isopropyl alcohol toxicity
Alcohol	Complications of alcohol abuse (trauma, multiorgan toxicity)
Track marks of IV drug use	Distributive shock (sepsis) Cardiogenic shock (valvular disease) Opiate overdose Non-cardiogenic pulmonary edema
Dialysis shunt (AV fistula)	Cardiogenic shock (volume overload) Obstructive shock (pericardial tamponade) Hyperkalemia Uremic encephalopathy
Cullen�s or Gray-Turner signs	Hypovolemic shock
(periumbilical or flank ecchymosis)	(retroperitoneal hemorrhage from ruptured aortic aneurysm, ectopic pregnancy, hemorrhagic pancreatitis and other abdominal catastrophes)
Diffuse purpuric rash	Distributive shock (meningococcal sepsis)
Diffuse maculopapular rash	Distributive shock (toxic shock syndrome)
Unilateral lower extremity edema	Obstructive shock (massive pulmonary embolism)

The most important intervention in the exposure segment of the primary survey is often the measurement of rectal temperature and the maintenance of euthermia. This may be as simple as placing a warm blanket on the patient or as involved as invasive rewarming procedures in the unstable hypothermic patient. In resuscitations overview, hypothermia may be maintained or deliberately induced. Hyperthermic patients may simply receive acetaminophen, or, in the case of severely elevated temperatures (>105� F), aggressive mechanical cooling measures may be necessary. Sterile dressings should be applied to patients with burns.