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The Primary Survey

The Primary Survey is a crucial element in the initial approach and assessment of each patient that paramedics encounter.  This clinical practice guideline (CPG) recommends general key actions, but it is essential and expected that professional paramedics will adopt their approach to match the requirements of each unique patient in the unique setting in which they are found.  This survey is intended to assist paramedics with their clinical approach, not to prescribe a mandatory check-list that must be precisely complied with, in its entirety, for every patient encounter.  The primary survey should be conducted in a ‘find it, fix it, move forward’ pattern.

 

  1. Take universal / standard precautions prn (gloves, eye protection, helmet, safety gear, etc.)

  2. Before approaching the patient, be aware of, and accommodate for, any factor in the environment which could be a potential danger to yourself, your team, or your patient.

  3. Determine the nature of the incident, if possible, before the patient encounter (old versus young, trauma versus medical, etc.) and prepare yourself and your equipment appropriately.

  4. Determine the number of patients as soon as possible.

  5. Activate additional medical teams or other useful resources if available and required.

  6. Upon arrival, if there is a single patient, ensure that the cervical spine is immobilized before any excessive manual handling or extrication of the patient occurs.  If there are multiple patients, ensure that a ‘multi casualty incident’ is declared and accommodated for.

  7. Upon arrival, if there is a single patient, obtain a ‘general impression’ of the patient, which usually includes their approximate age, their apparent gender, the location and position in which they were found, their level of awareness, and their apparent level of distress.  If there are multiple patients then a ‘METHANE’ update should be reported to central communications, which consists of the following:

    • M: a ‘Mass casualty’ is declared

    • E: the Exact location of the incident

    • T: the Type of incident is described, with details including vehicles, buildings, etc.

    • H: any Hazards that are currently or possibly an issue

    • A: the best Access and egress routes

    • N: the approximate Number of casualties

    • E: Emergency services currently present, and those that are still required

  8. Before assessing the patient’s ABCs a final quick assessment of the people, objects, places and environment (POPE) of the situation should be performed to ensure the safety of yourself, your team, and your patient.  The paramedic should then consider treating any obvious and immediately life-threatening emergencies point (e.g. traumatic amputation, uncontrolled bleed, etc.)

  9. The airway should be assessed to determine if it is patent, if it requires care, and if there are any current or impending obstructive difficulties.  The paramedic should then consider: positioning, suctioning, foreign body airway removal, basic airway adjuncts (oro/nasopharyngeal airway, laryngeal mask) and advanced airway adjuncts (endotracheal intubation +/-pharmacological assistance), surgical airways for the ‘can’t intubate – can’t ventilate’ (CICV) patient.

  10. The patient’s breathing should be assessed by looking, listening and feeling for ventilations, rapidly auscultating for bilateral air entry, and potentially assessing oxygen saturation and end tidal carbon dioxide levels.  The paramedic should then consider: positive pressure ventilation, oxygen administration, chest needle decompression or finger thoracotomy (as per scope of practice)

  11. The patient’s pulse should be assessed to determine whether it is present or not, and to estimate the general rate, strength and regularity.  Simultaneously a perfusion assessment should be performed to determine adequate versus inadequate perfusion status.  The paramedic should then consider: cardiopulmonary resuscitation, establishing an intravenous line, obtaining an electrocardiographic reading.

  12. The patient should be assessed to determine whether or not they have any significant medical or traumatic disabilities.  The paramedic should then consider: benzodiazepine treatment for prolonged seizures, adrenaline for life threatening bronchospasm, naloxone for narcotic overdose, glucose for hypoglycaemia, defibrillation, cardioversion or trans-thoracic pacing for life-threatening dysrhythmias, or rapid immobilisation, haemorrhage control, and transport for any life-threatening traumatic injury.

  13. The situation should be assessed for environmental and extrication considerations.  The paramedic should then consider: protection from heat/cold/rain/sun or impending dangers, the most appropriate extrication priority and method, whether additional medical or transport support is required, and the most likely appropriate transportation method and destination.

 

This primary survey can be remembered using the mnemonic ‘SAFETY FIRST GET ABCDEs’1:

 

SAFETY           personal protective equipment
 

F                      Fears (dangers on scene)

I                       nature of the Incident

R                      numbeR of patients

S                      Send for help

T                      Trauma to the c-spine, or, Triage of a multi-casualty incident
 

G                     General impression of the patient or situation

E                      Estimate levels of awareness

T                      any immediate Threats to you, your team, or the patient
 

A                      Airway

B                      Breathing

C                      Circulation

D                      Disabilities

E                      Extrication

 

 

 

References:

 

1.        Colbeck, M. A. et al. International Examination and Synthesis of the Primary and Secondary Surveys in Paramedicine. Irish J. Paramed. 3, 1–9 (2018).