The primary survey is the initial assessment and management of a trauma patient.

Use a systematic approach based on <C> ABCDE ^{10, 11} to assess and treat an acutely injured patient. The goal is to manage any life-threatening conditions and identify any emergent concerns, especially in a neurotrauma patient who may present with other multisystem injuries.

• Catastrophic haemorrhage
• Airway with in-line spinal immobilisation
• Breathing
• Circulation
• Disability (neurological)
• Exposure and environment

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Catastrophic Haemorrhage

Assess for catastrophic haemorrhage

• Identify any large volume external blood loss.
• Provide immediate management as required, consider: direct pressure, haemostatic dressings, and tourniquets.

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Airway with cervical spine protection

Assess for airway stability

• Attempt to elicit a response from the patient.
• Look for signs of airway obstruction (use of accessory muscles, paradoxical chest movements, see-saw respirations).
• Listen for any upper-airway noises, breath sounds. Are they absent, diminished, or noisy?
• Assess for displaced dentures, especially in the older persons cohort.

Assess for soiled airway

• Haemorrhage, vomiting, and swelling from facial trauma are common causes of airway obstruction in patients with TBI.
• Attempt simple airway manoeuvres if required:

• Open the airway using a chin lift and jaw thrust whilst avoiding neck extension in order to protect the C-spine.
• Suction the airway if excessive secretions are noted or if the patient is unable to clear their airway independently. Prolonged suctioning can lead to an increase in intracranial pressure (ICP) so be mindful to limit duration.
• Insert an oropharyngeal airway (OPA) if required.

Caution: Nasopharyngeal airways (NPA) should not routinely be inserted in patients with a head injury in whom a base of skull fracture has not been excluded ¹⁴. In the setting of airway obstruction, or failure to oxygenate, then an NPA can be inserted if delay to definitive airway management.

Secure the airway if necessary (treat airway obstruction as a medical emergency)

• Consider intubation early if there are any signs of:

• A decreased level of consciousness GCS <9 (severe TBI), unprotected airway, uncooperative/combative patient leading to distress or further risk of injury.
• Hypoventilation, hypoxia, or a pending airway obstruction such as stridor or hoarse voice.

• Assist ventilation with a bag and mask while the airway clinician is setting up for intubation.
• It is vital that intubation is conducted by a person skilled in airway management. Intubation may cause a transient increase in ICP, which may contribute to secondary brain injury. Attempts at intubation can also result in hypoxia, so preference is for a rapid sequence induction with sedation and paralysis by the most skilled operator available.

Maintain full spinal precautions if indicated

• Suspect spinal injuries in polytrauma patients, especially where TBI is involved. Ensure cervical collar, head blocks, or in-line immobilisation is maintained throughout patient care.

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Breathing and ventilation

• Assessing for adequate ventilatory effort is essential in the initial stages of TBI.

Administer oxygen and record the saturation (SpO₂)

• Adequate oxygenation to the brain is an essential element in avoiding secondary brain injury.
• Administer O2 and maintain SpO₂ 94-98%. Saturations below this range are associated with poorer outcomes ⁶.

Assess the chest

• Be mindful that thoracic injuries may have also occurred.
• Count the patient’s respiration rate and note the depth and adequacy of their breathing.
• Auscultate the chest for breath sounds and assess for any wheeze, stridor, or decreased air entry.

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Circulation with haemorrhage control

Assess circulation and perfusion

• Check heart rate and blood pressure.
• Maintain an SBP > 110 mmHg in order to sustain cerebral perfusion and prevent further brain injury.
• Inspect for any signs of external haemorrhage and apply direct pressure to any wounds.
• Consider the potential for significant internal haemorrhage, which may lead to signs and symptoms of shock.
• Insert two large-bore peripheral intravenous (IV) cannulas. If access is difficult consider intraosseous insertion (IO) if the equipment/skills are available.
• If a pelvic fracture is suspected, apply a pelvic binder if there are no contraindications.
• Commence fluid resuscitation as indicated.
• If signs of shock are present, establish a cause and commence appropriate treatment to raise the blood pressure and improve cerebral perfusion. Hypotension is not generally associated with isolated head Injury. If hypotension is present, identify the cause.

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Disability: neurological status

Assess level of consciousness

• Complete an AVPU assessment (Alert, responds to Voice, responds to Pain, Unresponsive). A more detailed neurological assessment using the GCS will be performed in the secondary survey.
• Refer to Appendix 1: Adult neurological observations chart.

Check pupillary size and responses

• Unequal or unresponsive pupils may be an indication of severe TBI and raised intracranial pressure. It will be important to note if the pupils change during the patient’s re-assessments.

Test blood sugar levels

• Ensure that any alterations in the patient’s level of consciousness are not related to a metabolic cause. Identify and correct hypoglycaemia.

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Exposure and environmental

• Remove all clothing from the patient and assess to ensure there are no other obvious, life-threatening injuries present.
• Keep the patient normothermic through passive re-warming with blankets and a warm environment.