Surgical Critical Care,  Trauma Surgery

The Five Letters on Which Trauma Stands – Part 2

Primary Survey Overview

Last time we have left the patient on his way to our hospital after being involved in a motor-vehicle accident. In this post we are going to explain the basis of the primary survey.

So then, what is the primary survey?

ATLS, as mentioned in the previous post, gives you a method to manage trauma, and this method is structured basically into two parts: the primary and the secondary survey.

The primary survey consists in the initial approach to a traumatized patient and is divided into five parts: the famous ABCDE.

The aim of the primary survey is to identify and treat all the life-threatening injuries. All other injuries can be safely evaluated and managed in a second moment (i.e. during the secondary survey).

This five-letter system relies upon four laws:

  1. The sequence order cannot be changed
  2. The following point (aka “letter”) cannot be evaluated if the previous one is not solved
  3. If something happens during the evaluation, you start again from the beginning (from A)
  4. Trauma is a disease in evolution: repeat the sequence every time something changes or at predetermined short intervals

Let’s go back to our patient…

After the phone call with the paramedic, you decide to prepare the Shock Room and to activate the Trauma Team. Unfortunately, the Shock Room in your hospital has just one bed and it’s occupied by a patient with a massive heart attack. Needless to say, the anesthetists on call is busy with the cardiac patient.

Now you are in a small room with the orthopedic and two nurses. After 5 minutes the patient arrives and the paramedic you talked to starts the handover.

Do you remember the ATMIST formula? Let’s refresh it…

“Kenneth McCormick, man, 45-year-old. [A] About half an hour ago [T] he hit a car with his motorbike. He was thrown for about 10 meters. He was wearing his helmet, which didn’t fly away with the impact. We checked it and it was intact when we arrived on the scene. On the contrary, the motorbike was destroyed, and even the car wasn’t in good shape. [M] He reported a loss of consciousness for a couple of minutes, but he remembers everything else, even if he’s a little bit confused. The shock, I think. He has an open mid-shaft fracture to the right femur, some superficial excoriations, and nothing more. [I] The vitals have been stable the whole time. Blood pressure has been around 130/80, heart rate between 110-120, saturation about 96% in room air, and Glasgow Coma Scale 14/15, because of the confusion. [S] We’ve inserted an 18 Gauge IV-line on the left arm and started infusing Ringer Lactate. We gave him about 1 L. We removed the helmet on the scene and put him on the spinal board and Philadelphia collar. We have splinted the fracture and gave him morphine 5 mg IV. [T]

Remember: this is just a clinical case. It doesn’t mean that everything has been done correctly.

Now you are alone with the patient. Ah, yes… The orthopod and the two nurses… Well… Tonight is your night: the orthopod will retire in 2 weeks and he has never managed anything else than fractures, the younger nurse was hired one month ago and this is the first trauma she’s ever seen, and the other nurse, a big hairy guy, is a good man, but as stupid as hell.

We know this is a little bit exaggerated, but you must prepare yourself for the worst-case scenario… Always… Not only in trauma… Otherwise, it’s all vane… You cannot always rely on others to do things. I’m not saying you need to know everything. However, if you want to be a good acute care surgeon, you need to know at least how to save a patient in an emergency situation.

Basically, you are the only useful doctor for our motorcyclist… Up to now, we want you to be able to survive alone. After you have grounded in your mind how to work alone, we’ll see how the work changes when you’re in a team!

So, what to do next? Nothing more than the five-point four-rule method: ABCDE.

A Check for the airways, check if they are patent or not. Check the mouth for blood, vomit, or whatever that may obstruct them. Check the neck for tracheal deviation, hematomas, or subcutaneous emphysema. Don’t forget to control the spine movements while restricting them!

B Is the air arriving at the lungs? Is the thorax expanding equally? Are the lungs working properly? Is there a hemothorax or a pneumothorax? How are the lungs and heart sounds? What’s the finger saturation of your patient?

C Search for bleeders. Trauma patients bleed in 5 places: “on the floor and four more”! Remember we are searching for major bleeding sites (we are speaking about 2-3 liters of fresh blood)! They are the external bleeder (on the floor) plus thorax, abdomen, pelvis, and long bones (the four more). in this phase you also have to start treating them: get the venous line, blood tests, ABG, monitor (BP and HR), liquids and blood transfusions, coagulation support, ROTEM, etc…

D Three things to check: Glasgow Coma Scale, pupils and lateralizing signs.

E Exposure and environmental control (temperature and more), log-roll, catheters, orogastric tube (yes ORAL)…

Once the patient has been evaluated and treated properly (now he should be in a stable condition with normal physiology) you can move on with your resuscitation: adjuncts as eFAST, X-Ray of thorax and pelvis.

After them, the secondary survey time will come. But let’s save this for another post.

To better focus on the primary survey, the next posts are going to emphasize every single letter of the primary survey! Up to now, you have to remember to strictly follow them, do not jump from A to C because the patient looks like he is breathing properly!

There is only ONE way to do it properly: A → B → C → D → E !
Moreover, go to the following letter only after you have treated and solved the letter you’re in! We know it is difficult to imagine. You must have seen people mixing the evaluation and treatments of the letters. We hope those people were highly trained and their resuscitations were so fast you couldn’t follow the ABCDE line; otherwise, they were just messing it up.

Now that you should have understood how the primary survey works, let’s try to apply it to our Mr. McCormick! We’ll start easy!

Mr. McCormick has been moved on your trauma bay, undressed and he’s ready for your evaluation.

Up to now let’s forget about the orthopedic so we can focus on a one-man resuscitation. On the other hand, we’ll have to use the nurses in our team.

We start giving some simple orders to our team:

  • Nurse 1: connect our monitor.
  • Nurse 2: insert a second IV line, throw blood for tests, type&screen, ABG, and check if the previous (field) line is working.

What about us? get close to our patient:

A – “I’m your doctor. How are you?” If he answers, that means he speaks, opens the mouth, and vocalizes. The trachea is not deviated, there are no hematomas or emphysema. The collar is open with the help of the orthopedic to get C-Spine immobilization and then closed again after the neck evaluation.

B – “Take a couple of deep breaths.” The thorax expands equally, lungs sounds are normal anteriorly, and posteriorly bilaterally, he accuses a bit of pain on the right thorax. Saturation is 97% in room air.

C – BP 120/75 mmHg, 90 bpm; good distal pulses, refill time 2,5 sec. No external bleeding can be seen. The abdomen is not tender, the pelvis is stable and not painful. Left lower limb is fine; the right one is already splinted, no blood can be seen from the midshaft fracture of the femur; the distal pulses are present. The patient already receiver 1 L of Ringer. If we want to continue with fluids, we should use blood. So up to now, we decide to not give any more fluids.

D – How’s the GCS? He has spontaneous open eyes, moves all limbs (except the splinted one but he can move the foot), he seems confused and repetitive = Eyes 4/4; Verbal 4/5; Movements 6/6. We’ll write it down as GCS 14/15 (E4 V4 M6). The pupils are equals and reactive to lights (PEARL). Mr. McCormik can feel at his extremities and can move them – no lateralizing signs.

E – Temperature is 36,5°C. Let’s prepare for the log-roll using our entire team: no pain on the cervical-thoracic-lumbar spine; at the digital rectal examination (this is not sadism, believe us!!!) normal anal tone, no blood on the finger, regular prostate; some excoriations on the back. Cover him with a heather blanket to keep him warm. Do we need a urinary catheter? Maybe not now.


  • eFAST: no free fluid in the pericardium, thorax bilaterally, right upper quadrant, left upper quadrant, and pelvis. Lung sliding is present bilaterally.
  • Chest X-Ray: regular trachea, no pneumothorax, no free fluid, regular cardiac shadow, regular diaphragm, three fractured ribs on the right.
  • Pelvic X-Ray: no deformation of the inner or outer rings, proximal femurs seems regular, the ischiatic branches are normal.

Up to now, we have a so-called “stable” patient… Actually, it is better to say that he has normal vital signs (remember that the most stable patient is the dead one). On our primary survey, Mr. McCormick has a midshaft femur fracture and a minor traumatic brain injury.

We still miss a lot of information about him (ABG and blood tests results and more…), but for today is enough.

Or maybe not… We want to confuse you a bit more… We have to! 

It has to be said that recently this 5-point sequence has been questioned. In fact, some military doctors believe that this sequence should include a sixth point to be inserted in the first position. Thus, the new sequence should appear as cABCDE, with the “new c” standing for “catastrophic hemorrhage”. This 6-point sequence is the one used by the battlefield ATLS (BATLS). The reason is that the first cause of death in bleeding traumatized patients is not airway obstruction, but severe hemorrhage. And, in most cases, it was seen that these hemorrhages could be stoppable with simple maneuvers. Because of this and of the increasing number of penetrating injuries in the civil setting, the American College of Surgeons Committee on Trauma created a new course: Stop the Bleed. This course is directed to both health practitioners and common people, with the hope that in the event of a mass casualty incident, normal people can at least stop bleeding patients from dying until professional help arrives… But we will talk about that in the future…

To be continued… Namasté!

  1. Advanced Trauma Life Support: Student Course Manual. 10th Ed. Chicago, IL: American College of Surgeons; 2018.
  2. Hodgetts TJ, et al. ABC to <C>ABC: redefining the military trauma paradigm. Emerg Med J. 2006;23:745-6.
  3. Clough RAJ, et al. Initial CABC: Advances that have led to increased survival in military casualties. Trauma. 2019;21:247-51.
How to Cite This Post

Marrano E, Bellio G. The Five Letters on Which Trauma Stands – Primary Survey Overview. Surgical Pizza. Published on June 28, 2020. Accessed on January 15, 2023. Available at [].