Primary survey or ABCD

Begin the primary survey as soon as you see the patient. A

quick look can tell you a lot. Are they breathing? Do they look at you? Is the cervical spine immobilized?

Airway

Is the airway preserved? If not, correct with positioning (chin lift and jaw thrust), oral airway, suction and if necessary intubation (with in-line immobilization to protect the cervical spine).

Ask 'How are you'? If the patient responds in a clear voice, the airway is patent—at present. A clear voice, quiet respirations and a normal mental state rule out significant obstruction.

Listen: snoring sounds suggests obstruction, while gurgles suggest secretions, vomit or blood in the airway. These sounds indicate the need to clear the airway, usually followed by intubation. Hoarseness or pain with speaking may indicate laryngeal injury, which can result in airway obstruction. Agitation can be due to hypoxia. Altered conscious level may be due to carbon dioxide retention.

Assess future risk to the airway by looking for foreign bodies or loose teeth, and test for a gag reflex if unconscious.

Breathing

Is the patient breathing adequately? If not administer 100% oxygen and mouth-to-mouth resusitation or other ventilation.

If the patient's respirations are not obvious to you, put your ear to the patient's mouth. While watching the chest for movement, listen and feel for the motion of air on your cheek. Assess the rate of respirations and their depth: listen to the chest for breath sounds

Circulation

Is it adequate? What is the pulse and BP? Is there obvious volume loss, active bleeding? Obtain venous access, give fluids, start external cardiac massage if no output. Monitor the patient's circulation with ECG and frequent measurements of pulse and BP. Stop any active, external bleeding by applying pressure directly over the wound.

If shock is present give fluids and consider underlying causes, such as hypovolaemia, pericardial tamponade or tension pneumothorax.

Hypovolaemia or shock may produce apprehension, drowsiness and even unresponsiveness. The peripheries may be pale, cold and bluish or mottled.

Examine for peripheral pulses.

Examine pulse rate and rhythm, BP, heart sounds and JVP.

Immobilize the head and neck, and maintain the cervical spine in a neutral position. Assume a cervical spine injury is present until proven otherwise.

Disability (conscious level) (or disorders of the CNS)

What is the conscious level? Use the Glasgow Coma Score to document. Examine pupil size, equality and reactivity.

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