In many aspects of first aid, there are often variations in approach depending on the likely context the first-aider will be operating in, as well as the level of training and equipment that the first-aider has received. An example of this could be regarding airway management, someone who has taken a basic first aid certificate might be trained how to perform airway maneuvers such as the head tilt-chin lift, whereas a member of a mountain rescue team might be trained in the use of airway adjuncts. Therefore there are often “basic” and “advanced” versions of the same process, such as the Primary Survey, depending on the skills and equipment available to the responder.
The Primary Survey is a rapid assessment of a casualty to determine if there are life threatening injuries or a condition that needs addressing immediately. In this article we’ll run through the more advanced version of the Primary Survey covered by DRCABCDE. This version is not appropriate for those with only basic first aid knowledge and is instead designed for those with advanced training and equipment. If you’re looking for a simpler version, we’ve covered that in a previous post.
The Primary Survey
The basic Primary Survey has the following steps: Danger, Response, Airway, Breathing, Circulation. However, this more advanced version expands this to include Catastrophic Bleeding, as well as Disability and Exposure/Extraction. If an issue is found at any stage, return to the start of the Primary Survey, to ensure the casualty condition has not degraded.
Danger
Before approaching the casualty, assess the scene for danger. You should look for potential dangers that could present a risk you as a responder. For example, out on the hills if someone has fallen, you may need to consider the risk of falling rocks. In the event of a road traffic accident, the risk could be from traffic. You may need to lay out warning lights or a warning triangle.
At this point you should consider PPE. In almost all circumstances this will at least involve putting on nitrile gloves. However, you may require additional personal protective equipment such as a face mask, goggles, a helmet, and warm or waterproof clothing.
Response
Check is the casualty is responsive. When approaching the casualty, call out to them and let them know who you are. Expect that the casualty may be in shock or may be confused, so telling them who you are and that you are there to help is important. Ask them what has happened. You must call out to the person before touching them. If there is no response and you are required to touch the casualty, beware of the potential for a c-spine injury. If you have an assistant with you, ask them to control the c-spine until you have chance to clear it as a concern. If you do not have an assistant, place a hand on the casualty’s forehead to prevent neck movement.
If the casualty is not immediately alert, move through the “ACVPU” system. Be aware that this may cause them to become alert and attempt to sit up. You should warn the casualty not to move until you have established the circumstances and have cleared the c-spine.
Send for Help
Send for Help
If you are alone, do not leave the casualty. If you are with another person, delegate communicating to emergency services to them. Give direct and short commands. Contact Control or Emergency Services as appropriate. Be prepared to give your exact location. Be prepared to request additional equipment as required.
Catastrophic Bleed
Check for major bleeding that is an immediate threat to life. Look for spurting arterial bleeds, blood soaked clothing, or pools of blood collecting on the floor. Once a large amount of blood is lost (approximately three litres) it can be too late to address through intravenous fluids and a blood transfusion may be ineffective. A lacerated femoral artery can bleed as much as 1 litre per minute. Therefore, rescuers should aim to control a massive bleed within one minute.
Bleeding may be controlled by direct pressure, wound packing with a haemostatic agent, or applying a tourniquet.
Airway with C-Spine
If the casualty is responsive, remind them frequently to remain still and not to move their head or neck. If the casualty is unresponsive, control the c-spine.
Clear, open, and maintain the airway. The airway can be cleared using suction or forceps. Once cleared the airway can be opened with an airway manoeuvre. If the c-spine has not been cleared then a jaw-thrust should be used, otherwise a head tilt-chin lift may be used. If the casualty cannot maintain their airway then an airway adjunct can be used, such as a nasopharyngeal airway (NPA) or an oropharyngeal airway (OPA). The OPA may also be called a Guedel Airway, which is the name of a common type of OPA. The airway adjunct should be lubricated prior to insertion.
An NPA can be used for unconscious or semi-unconscious casualties that does not have a risk of a basal skull fracture. The NPA is sized from the tip of the casualty’s nose to the tragus of the ear. The average female will require a 6mm and the average male will require a 7mm.
An OPA can be used for an unconscious casualty and may be used in conjunction with an NPA. The OPA is sized from the casualty’s jawbone to the centre of the incisors. For an adult: invert, insert with care, and rotate. For a child, the OPA is not inserted in the inverted position.
Breathing
Check for breathing by placing your ear near to the casualty’s nose and mouth and placing your hand on the stomach of the casualty. Listen, Watch, and Feel for breathing. Check for 10 seconds to establish if the casualty is breathing. Check for a pulse.
If no signs of breathing and no palpable pulse, start CPR. Do not stop CPR until help arrives or you become exhausted. If you have an assistant, tell them to prep an AED if there is one available. If you have an assistant available, prepare to take turns giving CPR.
If no signs of breathing, but there is a palpable pulse, consider using a Bag-Valve Mask (BVM).
If the casualty is breathing, check for 30 seconds to determine their respiratory rate. A normal rate is 12-20 breaths per minute. Check for respiratory distress, such as noisy breathing, use of accessory muscles, obvious distress.
Perform a thorough check of the chest for life-threatening injury. Start at the larynx and continue checking to the bottom of the rib cage for abnormalities. Observe the breathing pattern. Look at the chest wall (front, back, sides, and armpits) for uneven shape, bruising, lacerations, holes, or flail segment. Feel the chest for tenderness, emphysema, or deformity. Check for puncture wounds and consider using a chest seal.
If an injury of condition is encountered, treat appropriately and restart the primary survey. Oxygen may be given if required, at 15l/m, via a non-rebreathing mask with reservoir bag. Ensure the reservoir bag is full before using.
Circulation
Assess the pulse for rate, rhythm and strength.
Perform a capillary refill test, ideally on the forehead or centre of the chest. Hold for 5 seconds, 2 seconds or less refill time is normal.
Check for major internal or external haemorrhage. “One on the floor (external bleeding) and four more (internal bleeding)”
External Haemorrhage: Check under casualty and inside their waterproof jacket if worn. If major bleed found, control the bleed with pressure, wound packing with haemostatic agent, or applying a tourniquet.
Internal Haemorrhage: Check the chest, abdominal cavity, pelvis, and long bones. Consider the possibility of a major bleed with all chest injuries, if the abdomen is tender or firm, if there is evidence of major pelvic trauma, or major trauma to the long bones (look for shortening, abnormal leg position, thigh deformity, and visible bone.
If an injury of condition is encountered, treat appropriately and restart the primary survey.
Disability
Any altered consciousness level should be assessed at this stage. Initially with a quick “ACVPU” assessment. If any result other than fully alert, consider the following:
Potential Head/Brain Injury due to trauma.
Stroke: Check “FAST”
Check pupils with “PEARL”
Check blood glucose, if indicated by insulin-dependent diabetic, or unconsciousness of unknown cause.
Check temperature, if cold or heat could be the cause of reduced conscious level
Consider other causes such as seizure, lightning strike, drugs, alcohol, or major bleeding.
Environment and Extract
Once you have completed your Primary Survey and you have addressed any conditions or injuries likely to present an immediate threat to life, you may continue to the Secondary Survey. Continue communicating with Control or Emergency Services, and prepare the casualty for hand over upon their arrival.
