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Part 7: TRAUMA
Chapter 28
Trauma: Primary and Secondary Survey
LTC John Holcomb, MC, USA & CPT Robert Mabry, MC, USAPrimary Survey
The standard ABC approach as outlined in civilian models provides an excellent methodology for addressing
life-threatening injuries in systematic fashion. The “ABC” pneumonic prioritizes the search for injuries in
accordance with their potential to kill the patient; it is simple to remember and it provides an anchor point from
which patients can re-assessed if they deteriorate. This system may require some modification in a tactical
setting. For example, in a mass casualty situation, the SOF medic may need to address the ABCs of several
patients at once. Simply asking the casualties where they are injured can do this. Those casualties who
answer the question appropriately have an intact airway, are breathing and are conscious. The medic should
then focus his attention on those casualties who are unconscious or in obvious distress. Meanwhile, the
medic can direct the lightly injured casualties or non-medical team members to assist in controlling the
bleeding of those patients with active hemorrhage, thus addressing the circulation step.
During combat, moving the patient to a safe location takes priority over the Primary and Secondary Survey
unless a rapid maneuver can be performed for an obvious life-threatening injury, i.e., the application of a
tourniquet. Rapid control of hemorrhage is a mainstay of combat casualty care.
Airway: A conscious spontaneously breathing patient requires no immediate airway intervention. If the
patient is able to talk normally his airway is intact. If the patient is semi-conscious or unconscious, the flaccid
tongue is the most common source of airway obstruction. The chin lift or jaw thrust maneuver should be
attempted and should readily relieve any obstruction created by the tongue. Once the airway is opened
or if further difficulty is encountered, a nasopharyngeal or oropharyngeal airway should be inserted. The
nasopharyngeal airway is better tolerated in the semi-conscious patient and the patient with an intact
gag reflex. If the above measures fail to provide an adequate airway or if the patient is unconscious,
unresponsive and apneic, orotracheal intubation should be considered. Orotracheal intubation done on a
trauma patient with an intact gag reflex without the use of pharmacological sedation and paralysis will be
difficult and may cause additional complications such as vomiting, airway trauma and increased intracranial
pressure, and thus should be avoided except as a last resort. If the patient is breathing and definitive airway
control if needed, blind nasotracheal intubation (BNTI) may be attempted. Severe facial fractures and basilar
skull fractures are relative contraindications to BNTI.
Other adjuncts to airway management can and should be used if available and if the medic is skilled in their
use. Other possible adjuncts to airway management include the Laryngeal Mask Airway (LMA) the Intubating
LMA, the Combitube, and the Lighted Stylet.
If the patient has obvious maxillofacial trauma with signs of airway compromise or if orotracheal intubation
fails, then a surgical cricothyroidotomy may be a necessary and lifesaving maneuver (see Procedure:
Cricothyroidotomy). The most common mistake when performing a surgical airway is delaying too long before
starting the procedure.
Civilian models of trauma care include cervical spine control and immobilization with airway management.
Few if any battlefield casualties with penetrating trauma will have associated injury to the cervical spine
unless they have combined blunt injuries from vehicle or aircraft crashes, falls or crush injuries, or penetrating
injury to the spinal cord. Meticulous attention to presumed cervical spine injury on the battlefield is not war-
ranted if penetrating trauma is the obvious mechanism. Furthermore, the medic or the casualty may sustain
additional injury if evacuation from the battlefield, and/or treatment of other injuries such as hemorrhage is
delayed while the cervical spine is immobilized.