RECMOD2 Primary and Secondary Survey

REMOTE EMERGENCY CARE (REC)
MODULE 2
Primary Survey + Secondary Survey
Acknowledgement
CRANAplus acknowledges the Aboriginal and Torres Strait Islander peoples as the
traditional custodians of Australia, many of whom live in remote and isolated areas, and we
pay our respect to their Elders both past and present.
Copyright
The contents of this module are protected by copyright law as prescribed by the Copyright
Act 1968 (Cth).
Copyright in this material resides with CRANAplus Incorporated or other various rights
holders, as indicated.
Disclaimer
This training program has been designed to assist health care practitioners in remote and
isolated health services to provide a basic emergency care service.
It is a guide only and does not replace clinical judgment. It is essential that in each
situation relevant legislation and local policies/procedures are applied as appropriate.
Development and review of clinical content

Its always risky to list names in a document such as this as so many others have responded
to our call when we need clarification on clinical points. To those many valued
contributors we thankyou.
This module has been reviewed by:

1. Wendy Bowyer
2. Lyn Byers
3. Elizabeth Bowell
4. Sue Crocker
CONTENTS
The remote context 5
Primary survey: What are your learning needs? 7
Secondary survey: What are your learning needs? 8
Our goals for this module 11
Primary Survey 12
Why the DRABCDE approach? 13
Preparation is key 14
D: DANGER 15
R: RESPONSE 16
A good place to start assessing response 16
What is responsive? 16
Overview of ABCDE assessment 17

Some tips for ABCDE assessment 17
A: AIRWAY (with cervical spine control) 18

Causes of airway obstruction 19
Airway principles 20
Flow chart: sequence of questions 20
Adult airway management 22
Cervical spine 24
Managing a choking client 25
Paediatric airway management 27
Pregnant women and airway considerations 28
B: BREATHING (with oxygen) 29

Two goals of assessment 29
Assessing breathing: Look, Listen and Feel table 30
Assessing breathing: Look, Listen and Feel flowchart 31
C: CIRCULATION (with haemorrhage control) 32

Blood pressure 33
Capillary return 33
Haemorrhage control 34
Resuscitation fluids 34
Permissive hypotension 35
CONTENTS (cont’d)
D: DISABILITY 36
Always look at the trend 36
E: EXPOSURE / ENVIRONMENTAL CONTROL 37
DRABCDE complete, now what? 38
Self-assess your knowledge and confidence 39
Secondary survey in the remote context 41
F: FULL SET OF VITAL SIGNS, FOCUSED INTERVENTIONS, 42

FACILITATE FAMILY PRESENCE
1. Full set of vital signs 42
2. Focused interventions 43
3. Facilitate family presence 43
G: GIVE COMFORT 44
Assessing pain 44
Pain management strategies 45
H: HISTORY and HEAD TO TOE 46

1. History 46
2. Head to toe 47
3. Look, Listen and Feel table 48
I: INSPECT POSTERIOR SURFACES 49
J: JOT IT DOWN 50
Remember 51
Review your learning 52
References 53
Remote Emergency Care
The remote context

§ REC has been designed by remote health practitioners for remote health practitioners.
§ It covers the core principles of emergency care and management in the remote
context.
§ Interventions must be within the context of the emergency, and the policies of the
employing health service.
§ Preparation and diligent monitoring underpin each part of remote emergency care.
§ Remote practitioners often have to prepare clients for transfer to definitive care.
§ An important part of improving our emergency care is critical self and team reflection
at an appropriate time after the emergency situation.
The primary survey is the initial assessment and

management of a trauma or critically ill client.
It is a systematic way of detecting and treating
actual or imminent life threats and preventing
further complications.
In single responder settings the primary survey is addressed in a linear, or step by step way.
However, when a team is assembled, elements can be addressed simultaneously.
The secondary survey is commenced after the

primary survey has been completed: immediate
life threats have been identified and managed,
and the client is stable.
It involves a more thorough examination, and
the aim is to detect other significant but not
immediately life-threatening
injuries/conditions.
REC REMOTE EMERGENCY CARE Module 2 © CRANAplus Inc. 2019 Page 5

Do not start Monitor your client
the secondary vigilantly.
survey until you
If there is any
have identified
deterioration, the
and treated life
ABCs must be
threatening
repeated., and the
problems and
cause of the
your client is
change identified
stable.
and managed.

PRIMARY SURVEY: WHAT ARE YOUR LEARNING NEEDS?
Why do you need to know about this?
A systematic
A systematic approach is recommended for all life
threatening presentations whether trauma or medical. process helps you
to stay focussed
Having a simple approach that follows the alphabet helps and organised so
you to focus on the situation at hand and address things you don’t miss
that can potentially lead to deterioration of a client’s vital clues.
condition.
D Danger
R Response
A Airway with cervical spine control if story indicates
B Breathing with oxygen
C Circulation with haemorrhage control
D Disability with neurological and blood glucose management
E Exposure / Environmental Control
What do you need to know about?

§ Potential hazards and risks at scenes.
§ Mechanisms of injury.
§ Signs and symptoms of a range of presentations.
§ Basic interventions (and equipment) to stabilise the client.
§ Signs of deterioration.
What do you need to be able to do?

1
Use a primary survey to assess, identify and manage life threatening conditions in
severely ill or injured clients.
2
Use appropriate interventions to establish a client’s airway, support breathing,
maintain circulation and assess disability.
3 Document and communicate your primary survey.

SECONDARY SURVEY: WHAT ARE YOUR LEARNING NEEDS?
Why do you need to know about this?
A systematic approach is recommended for the secondary
A systematic process
survey so that you can further clinical information, provide
pain relief, and conduct a comprehensive physical helps you to conduct a
assessment to identify and treat other injuries. comprehensive
assessment, manage
Having a simple approach that follows the alphabet will life threatening
help keep you focussed, ensure nothing is missed and will injuries and gather a
make it easier to communicate your findings and full story to ensure you
interventions. don’t miss injuries.
F Full set of vitals, Focussed interventions, Facilitate family presence

G Give comfort
H History and Head to Toe
I Inspect posterior surfaces
J Jot it down
What do you need to know about?

§ How to systematically conduct a secondary survey.
§ How to obtain a detailed history and establish mechanism of injury.
§ How to identify and manage problems that may worsen or become life threatening
and/or limb threatening.
§ Symptoms/signs of injuries or illness that need intervention.
§ Appropriate and adequate pain relief.
§ Ensuring family are considered in the care of the client.
§ How to follow a thorough systematic approach when documenting and consulting
with a Medical Officer.
What do you need to be able to do?

1
Conduct a secondary survey to assess, identify and prioritise injuries/conditions in
severely ill or injured clients.
2
Use appropriate interventions to ensure best practice comprehensive care is
provided to clients in low resourced centres.
3 Document and communicate your secondary survey.

Take a few moments to think about your own experiences.
Have you worked with clients who presented with life threatening
conditions?
Did you work through a primary survey and a secondary survey?
Is there a situation where you didn’t get to the secondary survey because of
the life threatening nature of the injury?
Is there one experience in particular that stands out?
1. What happened? How did the client come into

your care? Were you at the clinic or elsewhere?
2. How did you feel when you realised that the

client had a potentially life-threatening
condition?
3. What actions did you take? What was the

outcome? Did you conduct a primary survey?
What do you think you did well? Was there
anything you could have done better?
4. Did you conduct a secondary survey? What was

done well and what could have been improved?
5. What else could have been done? What did you

learn? What did your team learn? Would you feel
confident if the same situation occurred?
6. What steps did you take to address any personal

or system deficits?

How do you rate your current knowledge, skill and confidence
when conducting primary and secondary surveys?
How do your rate yourself out of 5 for your knowledge, skills and
confidence when conducting primary and secondary surveys
with severely ill or injured clients?
Be honest with yourself. Think about your range of experience.
Can you identify any gaps in your knowledge, skills and confidence?
What do you need to focus on in this course?
Primary Survey and Secondary Survey Knowledge Confidence

& skill / 5 /5
Mechanisms of injury and associated signs and symptoms.
D: Identify and manage hazards and risks at the scene.
R: Assessing client’s response and determine if you need to call for help.
A: Assessing client’s airway and if not patent how to establish and

manage an airway with simple manoeuvres and adjuncts.
Use of spinal precautions if story suggests potential of spinal injury.
B: Assess client’s breathing status, exclude the five life-threatening

chest conditions and support breathing as necessary.
C: Assess circulatory status and identify (and stop) the presence of
bleeding.
Establish intravenous or intraosseous access and commence fluid
resuscitation.
D: Use AVPU and assess pupil size and symmetry.
E: Expose client’s body in stages and prevent hypothermia.
F: Take a full set of vitals. Conduct focussed interventions such as Spo2,

cardiac monitoring/ECG, blood pathology, indwelling catheter, naso-
gastric. Facilitate family presence.
G: Provide comfort including appropriate pain relief.
H: Conduct a thorough head to toe assessment, identifying and treating

findings appropriately. Take a thorough history using AMPLE. Establish
vaccine status including Tetanus
I: Log roll client if necessary and inspect posterior surfaces to identify
injuries.
J: Jot everything down systematically so that you can document and
communicate your assessment, interventions and requests.

Our goals for this module:
Assist you to be even more knowledgeable, skilful and confident
when you conduct primary and secondary surveys by:
• Providing you with the underpinning theoretical content and
rationale for each part of primary and secondary surveys.
• Describing what you need to be thinking about at each stage of
primary and secondary surveys.
• Outlining the actions that you need to take at each stage of
primary and secondary surveys.
By the end of this online module and the face to face workshop, it is expected
that you will be able to:
1 Apply your knowledge about primary and secondary surveys to case scenarios in the
following modules:
Module 3: The Trauma Patient
Module 4: Respiratory Emergencies
Module 5: Cardiac Emergencies
Module 6: Neurological Emergencies
Module 7: Gastrointestinal Emergencies
Module 8: Spinal Emergencies
Module 9: Burns
Module 10: Toxinology, Bites and Stings
2 Answer questions at the end of each module. (They are on the Moodle Site).
3
Demonstrate how to conduct a primary survey in a simulated scenario during the
face to face workshop.
It’s important that you work through the content in this

module so that you can get the most out of the rest of the
modules in this course and will be well prepared for the
workshop.
The workshop content is an extension of the work covered
in the online modules. You’ll have the opportunity to work
with industry experts in the face to face workshop, so jot
down any questions you want clarification on or want
explored further. Industry experts will guide you through
skills stations to further hone your knowledge and skills and
help you to develop your confidence.

Remember
ABCDE should be done within the first 5 minutes and
repeated anytime the client’s condition deteriorates.
Initial assessment and management of the major trauma client is designed to identify
any actual or imminent life threats and to treat them immediately to ensure optimum
resuscitation.
Avoidance of hypovolaemia in trauma is a cornerstone of management.
Trauma Victoria

The initial assessment and management of the seriously injured client is both
challenging and anxiety-inducing for many clinicians. It is an undertaking that requires
a cool head, systematic approach, speed, and good clinical judgement.
The Initial Trauma Assessment Part 1 – The Primary Survey, Medical Exam Prep, 2018
Why the DRABCDE approach?

It is systematic and leads practitioners to:
ü identify and assess danger / risk.
ü call for help early.
ü approach every client in a systematic way.
ü recognise life-threatening conditions early.
ü do the most critical interventions first: fix
problems before moving on.
ü Re-assess regularly.
ü communicate with others effectively.
In a single responder situation DRABCDE need to be addressed

in a step by step way. However when there is more than one
practitioner, they can be addressed simultaneously. Clear and
concise communication between you and your colleagues is vital.
§ The term ‘survey’ is somewhat misleading in that it implies that only assessment is
occurring; however any problems are addressed/rectified as they are identified with
the client being regularly re-assessed.
§ The rule of thumb: assess priority areas in the alphabetical order and do not progress
onto the next letter until it has been corrected.
§ Use the simplest treatment possible to stabilise your client’s condition. Competence
in simple manoeuvres is more important than using more advanced interventions.
§ Always be aware of co-existing distracting injuries (for example, pain from a nasty
fracture), influence of drugs and alcohol, and heightened emotional states of
responders, bystanders or family members.)
§ If your client’s condition deteriorates at any time, immediately return to the top of
the systematic process and quickly rectify the cause, ensuring that there is an
appropriate response. Only then resume your survey.

Preparation is key
1. Prepare yourself
§ Know local protocols and national standards.
This is the ‘go to’ site for all health
§ Know about your local community.
professionals in Australia for the most
§ Use the systematic approach. current resuscitation information.
§ Know how to use equipment.
2. Prepare other staff

§ Know who is available and how to assign roles, direct protocols and equipment.
§ Have call out lists that are current and accessible.
§ Practice emergency response scenarios.
§ Never drive to an emergency without letting responsible others know where you are and
how to contact you.
3. Prepare your facility

§ Know your equipment and stocks and where to reach for them.
§ Ensure that personal protective equipment (PPE) is where you will reach for it.
§ Look at your layout and plan a workable flow in your emergency, room (consider your
access to clients, their privacy, and have an escape route).
§ Look at phone placement and documentation.
4. Prepare your equipment

§ Make sure that there are lists of contents attached to emergency bags/kits (e.g. Parry
packs, Thomas packs) and have a system to ensure that they are stocked according to the
lists. If there are additional bits and pieces that you like to have available, pack them
separately. Do not mess with the integrity of the kit.
§ Have a system in place to regularly check the contents of packs and function of
emergency equipment.
§ Ensure that vehicles are always maintained and fueled up.
For more information about general management of an emergency,

read ANZCOR Guideline 2 Managing an Emergency

D R A B C D E
DANGER
I need to protect
In any emergency it is important that you
myself, the client and
protect yourself, the client and others from
others from danger.
potential hazards.
The hazards will vary depending on the
location; however, the one constant hazard
I scan the environment
is blood and body fluids.
for hazards and risks.
Remember to treat all blood and body What can I see, smell,
fluids as being potentially infectious and and hear?
wear personal protective equipment (PPE).
This includes gloves, goggles, mask, and
gown or plastic apron. I make a decision:
Is the scene safe?
If it is likely that you will need to attend Am I safe?
rescue breathing it is a good idea to carry a
mouth–to–mask device.
When approaching a client regardless of the setting,
remember to think as you approach, are you safe? Is the scene
safe?
If attending an emergency at the scene be aware of
environmental hazards like fire, fumes, other vehicles, live
wires and so on.
If attending an emergency at the roadside, remember to do these things.
How many hazards can you think of for each of these situations? Click on them
to see some examples.
Environmental
Vehicle crash Crime scene
dangers
Hazards within
In the clinic
structures

D R A B C D E
RESPONSE
Patient Response + Your Response (call for help)
If this is an emergency situation and you are by yourself calling for help is a
priority!
1. As part of your preparation, be aware of resources available in person, by phone, and
by radio or video link up.
2. Do a quick assessment of the scene and basic overview of the story to ensure the
appropriate resources are mobilised to assist.
At this point of the primary survey, all you want to know

is:
1. Is this client responsive (conscious and awake) or
not?
2. If so, what is their response?
A good place to start assessing response

Ask: “How are you going?” or “What’s your name?”
• If they don’t respond, pinch their ear lobe or gently shake their shoulders, or with a
child - tap their shoulder, and with a baby - tap their foot. If they still don’t respond,
then you can presume they’re unresponsive and move on to the next stage: Airway.
• Clients who do not respond may have a life-threatening problem.
• Unresponsiveness is considered a life-threatening emergency due to the potential
threat to the airway. Any reduction in level of responsiveness may indicate
deterioration in the client’s condition.
What is responsive?
• A person who is unable to talk might still be able to move and this is classified as being
responsive.
• A person who cannot talk/move may have a spinal cord injury, but still be able to signal
by blinking their eyes in response to questions and this is classified as being
responsive.
• A person who fails to respond or shows only a minor response, such as groaning
without eye opening, should be managed as if unconscious (ANZCOR Guideline 3:
Recognition and First Aid Management of the Unconscious Person).

Overview of ABCDE assessment
Some people prefer to get an overview of the whole process first before going through
the step by step content.
This short clip (4.55 mins) provides a brief overview of the ABCDE
assessment.
This longer clip (10.17 mins) provides a more comprehensive overview.
Some tips for ABCDE Assessment

1. You are not alone: ask for help (colleagues, phone MO,
bystanders).
Assess
2. Talk out loud to help you stay focused.
â
3. If you are working simultaneously with a colleague, clearly Address
communicate who is taking care of which parts of the â
primary survey.
Advance
4. Assess, Address and only then Advance
5. Look, Listen and Feel.
6. Use the simplest treatment possible to stabilise a client’s
condition.
7. Do not start the secondary survey until you have completed
the primary survey.
8. Constantly reassess client for response to treatment, if
condition deteriorates go back to the top and reassess ABCD.
Principles of managing trauma/critically ill children are the same

as for adults: Follow the primary survey process.
(The differences: mechanism of injury, patterns of injury and

anatomical differences.)

D R A B C D E
AIRWAY (with cervical spine control if story indicates)
The airway has priority over other aspects of resuscitation in clients with life threatening
illness or injury.
If you don’t have a patent airway
You are assessing for:
(A) do not proceed (BCDEF).
• inhalation injury
• penetrating injury
• partial or complete obstruction Airway status can change at any
• severe allergic reaction moment; you need to be alert
• altered consciousness and ready to intervene.
Do you know how to assess airway and the 4 airway interventions?
Airway Airway
Assessment Interventions
What are you What are the
looking and 4 main
listening for? interventions?
How did you go?

How would you rate your knowledge about airway assessment and airway
interventions? Is there anything you need to ‘brush up on’?

Causes of airway obstruction
A compromised airway can be a secondary effect of many serious and life-threatening
conditions.
Following a systematic approach helps identify early in the assessment whether an
airway is compromised and/or whether there is potential for the airway to deteriorate.
For example if a person walks into your clinic and says they are allergic to bees, usually
carry an epi pen and was stung by a bee 15 minutes earlier, you would ensure there is
ongoing assessment and monitoring of their airway.
Let’s revise some of the more common causes of airway obstruction or compromise.
Jot down as many causes of airway obstruction / compromise as you can in

each of the categories below and then click on the shapes to compare your
responses. The numbers show how many causes the CRANAplus team
identified.
Life-threatening
upper airway causes Life-threatening
(5) pulmonary causes (8)
Life-threatening
cardiac causes (8)
Life-threatening Life-threatening
toxic & metabolic causes neurologic causes (2)
(7)
Life-threatening
miscellaneous causes
(7)
How did you go? How would you rate your knowledge about causes of airway
compromise?

Airway principles
1. Be aware of the unconscious client - all muscles relax
increasing the risk of the tongue falling back and
obstructing the airway.
2. Unconscious clients cannot clear their airway of No sound or feel

foreign material such as vomit. of breaths =
complete airway
3. Vomiting or aspiration of a foreign body may cause
muscle spasm or stridor which may lead to a partial obstruction
or complete airway obstruction.
4. A compromised airway may present in several way

including: shortness of breath, stridor, drooling or
obvious facial injuries such as swelling or bleeding.
5. A stridor is usually heard on inspiration and is Laboured and/or

indicative of partial airway obstruction.
noisy breathing
6. A person who cannot protect their own airway is at = partial airway
risk of aspiration. obstruction
7. If an unconscious a person is breathing normally then

they may be left in a recovery position on their side
with an appropriate head tilt to ensure airway
remains open.
8. Anyone with a compromised airway must be

monitored and not left unattended.
9. Infants and children differ from adults in significant

ways: smaller physiological reserves and increased
risk of dehydration, hypoglycemia and hypothermia.
Flow chart: sequence of questions

Look at the algorithm on the next page for the
sequence of questions to ask and actions to take.

Is the person conscious?
Notify MO
YES NO asap.
Is person Is person having trouble breathing?

talking?
YES NO
Airway is Perform age appropriate Monitor

most likely airway manoeuvre to airway and
clear. open airway. continue
assessment.
Jaw thrust or chin lift
(consider story: trauma).
Continue
assessment.
Suction if needed,
consider rolling client
into recovery position if
If person is talking, but not no spinal concern.
normally:
• Listen for abnormal
sounds suggesting
obstruction. Insert basic airway
• Look and listen for fluid in adjunct (oropharyngeal
the airway. or nasopharyngeal).
• Look for foreign body,
swelling around airway or
altered mental status.
Consider insertion of
advanced airway adjunct
(LMA).
Monitor airway and

continue assessment.

Adult airway management
This brief clip (6.23 mins) provides a quick overview of airway management.
JUST A REMINDER: In the face to face workshop you’ll have the opportunity to develop
skills and confidence in the management of simple adult and paediatric airways and
insertion of LMAs. Please make sure you understand the theory in preparation for this.
1. OPEN the airway

Airway management is required to provide an open airway when the person:
is unconscious, has an obstructed airway or needs rescue breathing.
Jaw Thrust
The jaw thrust manoeuvre is an effective technique,
particularly when there is a concern about spinal injury.
This manoeuvre moves the tongue anteriorly with the
mandible, minimising the tongue’s ability to obstruct the
airway. Click here for detailed instructions.
Head Tilt/Chin lift

The head tilt/chin lift is the primary manoeuvre used in any
client in whom cervical spine injury is NOT a concern.
Click here for detailed instructions.
2. CLEAR the airway: suction

Need a refresher? Watch this short clip (45 seconds).
3.1 ESTABLISH A PATENT AIRWAY: SIMPLE AIRWAY ADJUNCTS
Oropharyngeal airway (OPA)

OPAs should only be used with deeply
unresponsive clients who are unable to
maintain their airways. It should not be used
in conscious clients as it stimulates the gag
reflex and can cause vomiting and
aspiration.

3.1 SIMPLE AIRWAY ADJUNCTS (Cont’d)
Nasophayrngeal airway (NPA))

Clients tolerate NPAs more easily than OPAs, so NPAs
can be used when, for example, a client’s jaw is
clenched or the client is semiconscious and cannot
tolerate an OPA or there is oral trauma.
This airway adjunct should be avoided in the presence
of maxillary or base of skull fractures.
3.2 ESTABLISH A PATENT AIRWAY: ADVANCED AIRWAY ADJUNCTS
Laryngeal mask (LMA)

The LMA provides a safe and swift airway which is more
secure than an oropharyngeal airway with less dead
space. It should only be used when reflexes are sufficiently
depressed.
Go to page 49 of the CRANAplus Clinical

Procedures Manual for Remote and Rural
Practice (2017) 4th Edition for more
detail.
This more comprehensive clip (2 parts: 9.52 mins and 9.32 mins) provides information and
demonstrations about assessing and opening/clearing the airway, the cervical spine,
airway adjuncts, manual ventilation, LMAs and Positive End Expiratory Pressure (PEEP)
valves.
Part 1: https://www.youtube.com/watch?v=etPa9oxVWyU
Part 2: https://www.youtube.com/watch?v=pqw_7K3Mz8M&t=18s

4. MONITOR AIRWAY
Simple rule of thumb:

If you have to intervene to establish or maintain an airway,
then it remains a priority to monitor it.
Someone must stay with the client at all times.
Unconscious clients with unsecured airways

should be managed on their sides.
Protect the spine if there is concern
about the possibility of spinal trauma.
Cervical spine
Have a high level of ‘spine awareness’ with clients who are at risk of spinal injury.
These presentations are considered to be at risk of spinal injury:
§ Blunt multisystem trauma, e.g. pedestrian vs car, high impact falls/collisions.
§ Significant injury above the level of the clavicles.
§ Impaired level of consciousness.
§ New neurological deficit.
§ Midline cervical tenderness.
If you are by yourself you might decide to apply temporary steps such as encouraging
client to lie still and sandbags or rolled up towels either side of the clients head.
Clinical Protocol Difference

The CARPA Manual recommends the use of manual in-
line immobilisation until able to fit apply a semi rigid
collar. On the other hand, the Primary Clinical Care
Manual recommends in-line immobilisation only.
Managing potential spinal emergencies is covered in more detail

In Module 8: Spinal Emergencies.

Managing a choking client
Choking due to a foreign body can be a life-threatening airway emergency. Techniques to
relieve the obstruction should be implemented as a priority. Sometimes more than one
method may need to be initiated.
According to the Australian Resuscitation Council (ARC) guidelines

removal of a foreign body using the methods outlined in the flow chart
remain controversial due to the lack of scientific evidence.
The consensus remains however, that back blows, chest and abdominal
thrusts should continue to be used. In the event of an unconscious client
CPR should be commenced.
If the client is conscious with an effective cough, encourage coughing in an effort to

dislodge the foreign body.
If head tilt/chin lift has not cleared the airway and foreign body aspiration is suspected,
use back blows and chest thrusts, as per standard ARC/BLS guidelines. Refer to the
ANZCOR choking flow chart.
Choking adult or child

1. If standing/sitting and conscious Give up to 5 blows with an
open hand between shoulder blades (interscapular).
2. Check to see if the technique has relieved the obstruction.
3. Do not remove foreign bodies with a blind ‘finger sweep’ as this may push an object
further down or cause trauma and bleeding. Use direct vision (and/or) laryngoscope, if
necessary.
4. If these strategies don’t work give up to 5 standing chest thrusts.
Watch this short clip (22 secs) to see how to deliver standing chest thrusts
from behind.
Stand behind person with their arms raised, your chest pressed into area between
shoulder blades. Place clenched fist on their chest covered by your other hand in same
position as CPR:1 thrust per second.
If client is on the ground but still conscious: give up to 5 chest thrusts. Compress central
sternum as for CPR.

Choking child
• If the child is conscious with an effective cough, encourage coughing in an effort to
dislodge the foreign body.
• If head tilt/chin lift has not cleared the airway and foreign body aspiration is suspected,
use back blows and chest thrusts, as per standard ARC/BLS guidelines.
• Do not remove foreign bodies with blind ‘finger sweep’ as this may push an object
further down or cause trauma and bleeding. Use direct vision (and/or laryngoscope), if
necessary. The same applies to suction.
Choking infant
Sit or kneel. Support infant across thigh or lap in head
down, face down position and give up to 5 blows with an
open hand between the shoulder blades (interscapular).
If this doesn't work, roll infant over to face up position

with head in neutral position and give up to 5 chest
thrusts, central sternum, sharper than CPR, every 2
seconds.
If this doesn't work and infant is

conscious alternate between 5
back blows and 5 chest thrusts.

Paediatric airway management
Most common airway issues
1. Obstruction from foreign body (complete or partial)
2. Inflammation – stridor (partial) – croup, epiglottitis, anaphylaxis
3. Apnoea
Children aged 1-8 years are managed in the same way as for adults.
Anatomical differences
How do these anatomical differences between children and adults impact on airway
management?
If you’re not sure, click on them to find out. Superior laryngeal position.
Large, floppy epiglottis. Larger tonsils and adenoids.
Funnel-shaped airway. Narrow trachea.

Prominent occiput.
Large tongue. Shorter trachea.
This is a terrific article by Harless, Ramajah and Bhananker (2014) about paediatric
airway management.
ANZCOR Guideline 4: Airway also provides an overview of airway management, for both
adults and children
Open the airway

Awake children with airway obstruction e.g., croup, will adopt a comfortable position for
themselves, usually sitting up. Don’t force them to lie down.
Positioning may require experimentation.
• Position the infant/child into sniffing position, open the airway using jaw thrust or chin
lift (often easy method in small children or infants).
• Avoid touching the soft neck area under the floor of the mouth as this can obstruct the
airway further.
• For infants (<1 year), head

position may need to be
neutral rather than tilted. A
towel may need to be
placed under the shoulders
to achieve this.

Paediatric airway management (cont’d)
Unconscious children usually require intubation. Simpler devices (OP or NP airways, LMA)
can assist maintaining the airway in the meantime.
To insert simple airway adjunct:
• OPA – choose correct size (measure as in adults), push tongue gently downwards with
wooden spatula and insert OPA straight over the tongue (<2 years of age).
• NPA – choose correct size (measure as in adults), lubricate and slide into nostril.
Once the child’s airway is open, clear, secure and monitor the airway as you would with
adults.
Pregnant women and airway considerations

There are anatomical and physiological changes that occur during pregnancy and labour
that can impact on airway breathing and circulation.
These changes start to occur from 12 weeks gestation.
Anatomical differences
§ Large tongue
§ Large breasts
§ Mucosal and airway oedema of the oropharynx, vocal cords and larynx (due to increased
circulatory volume)
In pregnant women:
§ There is a 20-30% higher oxygen consumption in the last Respiratory
trimester due to increased work of breathing and
increased foetal requirements. adaptations to
pregnancy, result in a
§ Compliance of chest is reduced due to the displacement
pregnant woman
upwards of abdominal contents to make way for the
uterus and potentially increased breast size. In a supine having lower oxygen
position this can cause concerns for airway and reserves making both
breathing and risk of aspiration of stomach contents. her and the foetus
§ Increased progesterone levels relax the oesophageal susceptible to
sphincter along with slowing gastric motility. hypoxia.

D R A B C D E
Breathing with oxygen
Breathing function should only be assessed and
managed after airway has been assessed as adequate.
look
A patent airway does not mean a client can breathe listen
effectively or efficiently.
feel
Breathing is assessed to detect signs of respiratory
distress or inadequate ventilation.
Please note: We are having only a brief look at the assessment and
management of breathing here because the signs, symptoms and
management of breathing emergencies are explored in more detail
in Module 4: Respiratory Emergencies.
Please make sure you look at Module 4, because acute shortness of

breath can be life-threatening and chest trauma accounts for 20-
25% of trauma related deaths.
Two goals of assessment

1. Ensure the client is breathing adequately.
2. Diagnose and treat life-threatening conditions (for example, acute severe asthma,
pulmonary oedema and the 5 life trauma chest conditions on the next page.
What constitutes adequate breathing?

LOOK LISTEN FEEL
Is there movement of the chest or For the escape of air from For movement of air at the
upper abdomen nose and mouth mouth and nose
Colour Soft tissue and bony wall integrity

Retractions (Chest
retractions are a sucking in of the
skin in between or around the
Count the rate: very fast or very bones of the chest when
slow? inhaling. Retractions may occur
Normal rate is 12-20 breaths per in several areas of the chest and
min. are a sign of increased use of
If >25 min or increasing rate is a the chest muscles for breathing.
warning that client may deteriorate This usually is a sign of difficulty
suddenly. Auscultate lung fields (2 point breathing.
auscultation only in primary https://medlineplus.gov/ency/art
survey to confirm breath icle/003322.htm
sounds present).
Breath sounds equal?
Flail segments (when multiple
adjacent ribs are broken in
multiple places, separating
a segment, so a part of
Depth of each breath? normal or the chest wall moves
shallow? independently).
https://www.merckmanuals.com
/home/injuries-and-
poisoning/chest-injuries/rib-
fractures
Any chest deformity? • Absence of breath sounds

Tracheal position? on one side? Does trachea feel midline?
Symmetry- equal rise and fall of • Dull sound with percussion
chest? to the same side?
Raised jugular venous pulse (JVP).

Indicates possible acute severe
asthma or a tension pneumothorax.
Audible breath sounds
Work of breathing (WOB) (wheeze, grunt, rattling noises
• Accessory muscle work? indicating secretions caused
• Chest indrawing? by client being unable to
• Nasal flaring in infants? cough sufficiently or to take a
• Abnormal chest wall movement? deep breath, noisy breathing
that you are unsure of).
Visible injury (bleeding, bruising, flail Crepitus, cracking and popping

chest, imprints, seatbelt marks, with palpation.
penetrating injuries, burns).

Assessing breathing: Look, Listen and Feel flowchart

D R A B C D E
Circulation with haemorrhage control and IV fluids
§ The focus is on detecting and managing shock or reduced tissue perfusion.
§ The most common cause of shock in trauma clients is hypovalaemic shock from blood
loss.
We are looking at an overview of the key points of

assessment and management of circulation here.
Hypovalaemic shock is explored in more detail in

Module 3 The Trauma Patient.
Fluid resuscitation is looked at in more depth in
Module 9 Burns.
There are two parts to the assessment and management of circulation: look
1. Assess circulatory status.
2. Identify (and stop) the presence of bleeding (external or internal). listen
To assess circulation follow the same pattern used for assessing airway
and breathing. feel
Look for
• Colour of hands and
digits: blue, pink,
mottled?
• State of the veins: may be Feel for
underfilled or collapsed • Cold extremities.
when hypovolaemia is • Weak pulse or tachycardia Listen for
present. (suggesting a poor cardiac • Heart sounds: does it
• Capillary refill > 3 secs. output). sound normal? Are
• Sweating. • Bounding pulse (may the sounds difficult to
• Distended neck veins. indicated sepsis). hear?
• Burns. • Damp clothing: sweat / • Count heart rate.
• Internal and external bleeding. • Does the audible
bleeding. • Tenderness or guarding of heart rate correspond
• Reduced consciousness. abdomen. to the pulse rate?

Historically, health practitioners relied on the vital signs (specifically blood pressure)
together with other physical findings to determine if a client was in hypovolemic shock.
Blood pressure (BP)

A formal BP reading is not done until secondary survey especially if working by yourself.
See F: Full Set of Vital Signs (page 42).
• Traditionally we were taught that the presence of peripheral pulses in various
locations reflects systolic blood pressure. Although seemingly sound it wasn’t
scientifically proven.
• Considering the differences between clients with BMI and pre-existing vascular disease
it is now thought that palpability of pulses may be affected. However, it is implied that
where a location of a pulse can be found in a trauma client, for example, carotid vs
radial it does give some indication to the level of hypotension.
• If you’re interested, read Mistovich’s article, “Blood pressure assessment in the
hypovolemic shock client”, and Rezaie’s article, “Is ATLS wrong about blood pressure
estimates”.
• With that considered, blood pressure is a poor indicator of circulatory status as more
than a 30% reduction of blood volume needs to occur before the systolic blood
pressure will fall. This is especially applicable to pregnant women, children and
athletes.
• Pulse pressure may narrow prior to onset of hypotension, i.e. diastolic BP rises, and
systolic BP stays the same.
Capillary return
Normal values of capillary refill time, based on observation of thousands of persons,

average approximately 2 seconds. Women have slightly longer times compared with
men, and capillary refill times normally increase in elderly clients and in cooler
ambient temperatures.
S McGee (2018) Peripheral Vascular Disease in Science Direct
• To test capillary return, a nail bed should be pressed with the finger for five seconds
(to blanche it), and then released.
• In infants and small children press on the chest or abdomen.
• Record capillary return as less than or greater than 2 seconds. (Two seconds can be
measured by the time it takes to say ‘capillary return’.)
Go here to see a short clip (27 secs) of some examples of testing capillary
return.

Every drop of blood lost is gone forever for a client.
Haemorrhage control
§ Stopping further blood loss is an early priority in resuscitation.
§ Large volumes of blood may be hidden in thoracic, abdominal and pelvic cavities or
from femoral shaft fractures (you may need to splint a possible femur fracture or
apply a pelvic binder to possible pelvic fractures).
§ Direct pressure, elevation and rest are usually adequate, although a pressure
bandage may be used if all else fails, for example, in an amputation.
§ The final strategy that may be used to control haemorrhage, particularly in the case
of amputation, is the use of a tourniquet. It is important to record the time of
application and ensure that those taking over the care of the client are aware.
Consult with the referral medical officer as an urgent priority if you apply
tourniquets.
Read more about applying tourniquets.
Resuscitation fluids
The assessment of hypovolaemic shock is
Goals: difficult during the early phase of major
1. Avoid hypovolaemia. trauma care. The clearest signs of end-
2. A balanced approach to preserve vital organ hypoperfusion include decreased
organ function until bleeding can be urine output, acidosis, altered conscious
controlled. state and elevated lactate level.
Trauma Victoria
§ For volume expansion use the same fluids in children as in adults.

§ Normal Saline is preferred, but Hartmann’s (also known as CSL) is acceptable.
§ Hartmann’s is always used for burn injuries.
§ Colloids have not been shown to be advantageous over crystalloids.
§ Non-responders and transient responders need blood.
If the source of bleeding cannot be controlled, e.g. penetrating abdominal trauma, the
aim is to limit fluid resuscitation, at least until haemorrhage is controlled – by natural
haemostasis, external pressure or surgery.

Permissive hypotension
Traditionally, “early and aggressive” fluid administration was applied to clients with severe
trauma, in order to restore their circulating blood volume and maintain tissue perfusion.
However it’s been determined that this treatment approach may have adverse effects,
including:
§ increasing hydrostatic pressure in injured vessels
§ dislodging hemostatic blood clots
§ inducing dilutional coagulopathy
§ hypothermia
Permissive hypotension refers to restricting the amount of fluid resuscitation administered

while maintaining blood pressure in the lower than normal range if there is still active
bleeding during the acute period of injury.
Although this treatment approach may avoid the adverse effects of early and high-dose
fluid resuscitation, it carries the potential risk of tissue hypoperfusion.
For more detail, read this article by Kudo, Yoshida and Kushimoto (2017)
Titration of initial fluid therapy (250 ml boluses) to a lower than normal systolic blood
pressure (SBP) i.e. target SBP > 100 mmHg (conventional) or target SBP of 80–90 mmHg
(low) ensuring that there is end organ perfusion urine output of 1ml/kg/hour.
Frequent reassessment is essential to gauge the clinical response and determine the
amount of fluid to be used.
It is not advised to run a permissive hypotension resuscitation unless you do this in

consultation with a medical officer who requests you to do this.
The exceptions are clients where the aim is to normalise the BP with 1-2L boluses.
• over 65 years
• with IHD
• with head injuries
Children are given bolus fluids at 20mls/Kg.

D R A B C D E
DISABILITY with neurological and blood glucose measurement.
DISABILITY refers to the brief assessment of neurological response (alertness). It should
follow once airway, breathing and circulation have been assessed and interventions
implemented.
Common causes of unconsciousness include: profound hypoxia, hypercapnia, cerebral
hypoperfusion or the recent administration of sedatives or analgesic drugs.
In the primary survey, the AVPU scale can be used

as a quick assessment in addition to checking of the
pupil size and reactivity.
What we want to know in the primary survey is
whether the client is conscious or not and if not
where do they register in the AVPU scale.
Assessment of pupils is done in conjunction with
AVPU to look at pupil size and symmetry.
Whilst AVPU is a simple tool it may be less sensitive in a small baby especially < 1 month
of age. It is important to engage a carer in this assessment as this may help you to get a
more accurate response.
Always look at the trend

An initial AVPU score of P or U may improve with resuscitation; a deteriorating AVPU
demands reassessment of the ABC’s and interventions to maximise brain perfusion and
oxygenation and avoid secondary brain injury.
In the presence of other evidence for head injury (i.e. altered AVPU/GCS), a dilated pupil
is usually a sign of a haematoma on the same side.
This is an appropriate time to check the BGL particularly in a client who is unconscious
due to an unknown cause, or a known diabetic, or any infant or small child. Follow local
protocols for management of hypoglycaemia. Repeat BGL to monitor effects of
treatment.
AVPU is followed up in the secondary survey by the more detailed

Glasgow Coma Score (GCS).
The GCS and the Paediatric Coma Scale are explored in Module 6:
Neurological Emergencies.

D R A B C D E
Exposure/Environmental Control
By the end of the primary survey your critically ill or injured client should be fully exposed
to ensure that no injuries posing an immediate life threat are missed.
The examination must be handled with sensitivity and respect for the client’s privacy and
culture, and it should be done in a way that reduces exposure to the elements. Exposure
may need to be done sequentially, uncovering one body region at a time.
Avoid inducing hypothermia, especially in burns victims. Turn off the air-conditioning if
necessary.
Trauma clients are prone to hypothermia, so once you have completed the primary survey,
cover your clients with dry warm blankets.
All intravenous fluid or blood should be warmed prior to administration if a fluid warmer is
available.
In trauma the whole body including the back and Potentially life threatening
genitals must be examined to exclude life- injuries can be missed if you
threatening injuries and to check for signs that don’t examine:
would indicate a contraindication to inserting an
indwelling urinary catheter. Back of head
Back
Buttocks
Perineum
Axillae
Skin folds
Most commonly the client is log rolled during the
secondary survey as part of the head to toe
examination.
Only log roll your client in the primary survey if:

§ the condition of the client requires it to be done
during the primary survey (i.e. large amounts of
blood underneath the client, disruption to
sensation or movement).
§ there are enough people to do a log roll.

This clip (15.5 mins) shows a nurse conducting a primary survey.
This is a simulation in a British clinic setting so some of the
suggested assessment tools and interventions are not the same as
those used in Australia. However, it highlights the complete
primary survey assessment, quick interventions and further
management strategies and demonstrates some techniques.
This clip (6.45 mins)shows a simulation of a critically ill client in a

hospital setting. The Nurse has called for the Registrar who then
conducts a primary survey.
This publication by the NSW Health Dept provides a good

overview of clinical practice guidelines for emergency assessment
and management of paediatric clients.
DRABCDE complete, now what? Do not start the

Having completed the primary survey, quickly recount the secondary survey until
information you have so far and reassess ABCD before you have identified
moving on. and treated life
Always treat life threatening injuries as you identify them. If threatening problems
the client deteriorates at any stage during your assessment and your client is
go back and check ABCD! stable.

Self-assess your knowledge and confidence…
1. What are the 7 key components of the primary survey?
2. Can you explain to others why it’s imperative to have a structured approach in the
primary survey of clients?
3. How would you approach airway assessment and maintenance?
4. How would you manage a choking infant?
5. What are you looking, listening and feeling for when you assess breathing?
6. What are your focusing on when you are assessing circulation with haemorrhage
control?
7. How would you quickly assess a client’s neurological status?
8. What do you need to be mindful of when exposing a client?
How do your rate yourself out of 5 for your knowledge and

confidence when conducting a primary survey with severely ill or
injured clients?
Can you identify any gaps in your knowledge, skills and

confidence?
You’ll get lots of practice with

applying a primary survey to a range
of presentations.
Is there anything you need to focus

on specifically as you work through
the modules?

Secondary Survey
Full set of Focussed

Family
vitals interventions
Give comfort
History Head to toe Inspect
Treatment and Documentation
Monitor your client vigilantly as deterioration

in a client’s clinical condition can be swift.
If there is any deterioration, the ABCs

must be repeated., and the cause of the
change identified and managed.

e
Secondary survey in the remote context ote E m e rgency Car
Re m
In the primary survey you quickly identified
and addressed life-threatening problems and
stablilsed your client.
However you don’t have a full story and you
haven’t detected other injuries nor taken care
of other interventions that are not life-saving,
such as dressings and splints.
Generally clients who are injured or critically
ill will require transfer to definitive treatment.
Clearly now you need more information to start to put a story together, to communicate
with the client’s family, provide pain relief and be able to competently and confidently
consult with a Medical Officer.
F
1. Full set of vital signs
2. Focused interventions
3. Facilitate family presence
G
The importance of frequent
Give comfort reassessment cannot be over-emphasised.
Clients should be re-evaluated at regular

intervals as deterioration in a client’s
H 1. History
2. Head to toe
clinical condition can be swift.
This will be evident in their vital signs

and level of consciousness.
I Inspect posterior surfaces If in doubt, repeat ABCDE
J Jot it down


The secondary survey begins with a full set of vital signs.
Read this article to refresh why vital signs are so important.
1. Jot down a list of actions you would take to obtain a full set
of vital signs.
2. When should you do neurovascular observations?
3. When should you include a GSC?
REMEMBER it is the trend that is all-important.
1. What is one of the earliest signs of shock?

2. What should you do if there is any deterioration in a
parameter?
Major trauma clients may present with significant challenges and induce substantial
stress on staff, with a loss of situational awareness resulting in key indications for
escalation being missed.
Studies have shown that multi-tasking and task switching can lead to missed indicators
of client deterioration and that clear charting methods, using easily identifiable
thresholds for escalation, can reduce adverse events in client care.
Trauma Victoria
Trauma Victoria provides a useful table of early and late warning signs
of client deterioration and recommends eight important clinical
processes to be in place at healthcare services.

The focused interventions are procedures or tests that might be performed if appropriate to
the client’s condition and injuries, orsuspected injuries.
The interventions may include:
§ Pulse oximetry
§ Cardiac monitoring/12 lead ECG
§ IDC (if not contraindicated)
§ Gastric tube (oro or naso – remember the contraindications for any nasal tube)
§ Istat pathology if available (CG4, chem 8, troponin if indicated)
§ Laboratory specimens (urine, blood, swabs)

§ Once the client’s condition is stabilised, and before proceeding, it may be appropriate
to attend to any family present at this time.
§ Depending on your work location it may be culturally important to allow certain family
members in whilst you continue with your assessment and interventions.
§ If available, a member of staff should be delegated to talk to family to provide them
with information about the condition of their loved one, the injuries and treatment
received and the plan for ongoing management.
§ If possible, a short visit to the client by a family member will be reassuring for both
parties.
§ The family may also be able to provide information about the client which can help to
guide consultation with other health professionals and ongoing management.
§ If family members are not present or not aware of the situation, it’s important that
efforts are made to contact them and inform them of the situation. Resources other
than the clinical staff can be used, for example, local staff and the police.
The recent focus on family centred care has resulted in much discussion about the
presence of family during resuscitation. The US Emergency Nurses Association has
developed a Clinical Practice Guideline. Access it here.
Go here for more research articles on this topic.

G Give comfort
Pain relief is often forgotten in the chaos that
can accompany emergency situations, however,
there is no reason to delay giving pain relief if
the client’s BP is acceptable.
The term “Give comfort” refers to providing the client with some form of pain relief. This
also provides reassurance to the client and family.
Goals of pain relief:
1. Alleviate/control pain.
2. Prevent a recurrence of the pain.
3. Correct pathology.
4. Achieve physiological advantages (HR, O2).
5. Prevent chronic pain syndromes.
Assessing pain
1. Listen to your client.
2. Listen to parents/guardians of your client.
3. Watch your client’s behaviour (grimacing, guarding of an area, reduced movement,
pallor, diaphoresis and anxiety).
Pain assessment tools Remember that pain is

An effective tool needs to:
• be simple and quick to use.
subjective and clients’
• take into account both the client’s own assessment of perceptions of pain may
pain as well as observational data including: be influenced by their
ü Posture culture, previous painful
ü Anxiety level experiences, beliefs,
ü Emotional state mood and their ability to
ü Vital signs
cope in this instance.
The Numerical Rating score

This is a simple and effective pain assessment tool
that is regularly used for triage. It can be used with
adults and children from about age 6 years.
The Wong Baker faces are suitable for children and those from NESB.
The FLACC scale can be used for babies and preverbal young children.
The Abbey Pain Scale can be used for those with dementia and/or cognitive deficits.

Pain management strategies
1. Pharmacological pain relief
Titrated narcotic analgesia is the initial approach to pain

management in trauma.
Intravenous administration is the most effective route.
Administer as per local protocols and titrate to effect.
Analgesia should be administered prior to wound or fracture
care as treatment and dressing of wounds or fractures can be
particularly painful.
Prophylactic antiemetic administration prior to transfer and
retrieval is recommended.
Trauma Victoria
2. Physical pain relief

§ Splint fractures (back slabs, box splints, inflatable splints,
specialised splints, bits of wood, pillows, and rolled up
paper).
§ Cool/hot packs, cold water.
§ Dressingstoopenwounds/burns.
§ Touch (stroking, massaging).
§ TENS.
3. Other non-pharmacological pain relief

These are often useful in the initial phases of client management
(the resuscitation phase).
The goal is to quickly develop rapport to overcome cultural,
environmental and relationship/role barriers.
§ Reassurance(aboutthesituation,planoftreatment andfamily).
§ Informationandexplanation(to reduceanxiety).
§ Presence of family/friends allowing choices and control (where
possible).
§ Diversion/relaxation strategies (for example: deep
breathing/controlled breathing, mediation, imagery and music).

H 1. History
2. Head to toe
Although history focuses on the specific injury
or chief complaint, it should be complete.
1. History
Obtaining your client’s history starts as soon as your assessment starts or from the phone
call you may have received alerting you to the event.
It is something that builds throughout the assessment and as family members or others
from the scene can give more detail.
It’s important to find out about the client’s medical history especially of there are co
morbidities that may impact on their condition or treatment. Increasing access to
electronic notes has made it easier to access history earlier in the assessment.
With a responsive client you may be able to talk with To obtain a good descriptive
the client to gain the information required. history, do not ask questions
With an unresponsive client, talk to family members that can be answered with
or bystanders about what they know or saw. a simple yes or no.
Find out about:
• Mechanism of injury (to anticipate probable injuries).
• Use of protective devices (for example, seat belt, helmet, child seat).
• The time elapsed before the client received medical attention.
• Injuries sustained or suspected by first responders. Initial responsiveness any loss of
consciousness, any seizure activity. Vital signs: What were the prehospital vital signs?
Treatment: What treatment did the client receive before arriving at the clinic and what
was their response to those interventions?
• Medic alert bracelet or other medical identification. If you are at the client’s home, look
for medication bottles.
• The client’s age and previous general state of health.
The easiest way to be thorough is to

use the tools that help you
remember to ask the vital
questions. CRANAplus recommends
using the commonly used DeMist
and AMPLE mnemonics.
DeMIST is useful for looking at the

acute incident that brought the client
to the clinic.
AMPLE is useful for gaining critical

information to guide your care.

2. Head to toe
A systematic head to toe physical examination is required.
Deformities
In a secondary survey you are looking, listening and feeling Contusions
for burns, penetrating injuries, lacerations, loss of
Abrasions
peripheral pulses, swelling, deformity, pain or discomfort,
impaired movement and body fluid leaks. Rashes
Punctures
Document injuries and give required treatment such as Pain
covering wounds, managing non-life-threatening bleeding
and splinting factures. Pulses
Burns
The head-to-toe assessment begins with assessment of Tenderness
the client's general appearance, including body position or Lacerations/Leaks
any guarding or posturing.
Swelling
Work from the head down, systematically assessing the Needle marks
client one body area at a time.
Be situationally aware.
Be systematic and organised.
Whist examining your client, always

maintain communication.
Explain what you are doing and ensure

your client’s privacy and dignity.
Observe the client’s reaction to the

examination, looking for signs of pain
and discomfort.

LOOK LISTEN FEEL
HEAD: • Lacerations • Crepitus
general • Deformities • Bony tenderness
• Facial muscles • Subcutaneous emphysema
• Asymmetry • Jaw fracture
• Position of nasal septum, flattening or
angulation of the norse
EYES • Pupils - size, equality and reactivity to Orbit - is there a palpable step,
light or numbness under the eye?
• Periorbital bruising - Raccoon eyes
(suggesting base of skull fracture)
• Contact lenses
• Double or blurred vision
EARS • Blood or cerebrospinal fluid in canal
• Evidence of Battle’s sign -
bruising/haematoma behind the ear
indicating base of skull fracture
NOSE • Deformity or epistaxis
MOUTH/ • Loose teeth

ORAL • Bite occlusion (mandibular fracture?)
CAVITY • Airway/tongue swelling
• Foreign material
NECK • Deformity, laceration or raised Jugular Hoarseness • Tracheal position
veins • Bony tenderness
• Bruising, swelling, wounds, impaled • Carotid pulse
objects • Subcutaneous emphysema
• trachea midline or deviated, • Lymphadenopathy
CHEST • Expansion • Heart sounds • Tenderness
• Paradoxical movement • Air entry • Subcutaneous emphysema
• Accessory muscle use • Breath sounds • Bony crepitus
• Lacerations or deformity • Additional • Apex beat
sounds
ABDOMEN • Laceration, bruising Bowel sounds • Tenderness
• Distension • Guarding
• Priapism (spinal trauma) • Rigidity
• Rebound tenderness or
masses
PELVIC • Laceration, bruising or deformity • Bony tenderness
REGION & • Bleeding at urethral meatus or from
GENITALS rectum
• Incontinence
LIMBS • Laceration, bruising, deformity • Colour, warmth, movement,
• Shortening sensation
• Rotation • Pulse
• Compromised skin • Bony tenderness or crepitus
• Partial amputations • Motor strength
• Range of movement (active
and passive)

2. Head to toe (cont’d)
Trauma Victoria provides a more detailed head to toe

assessment.
If you’d like more information about conducting a head to toe

assessment on children, go to Royal Children’s Hospital
Melbourne site.
Adjuncts to assessment:
§ CXR, ECG and oximetry where available for continuous
monitoring.
§ If available, a series of three X-rays can be performed - AP
chest/AP pelvis/ Lateral cervical spine. Otherwise X-Rays
will be performed once transferred to definitive care.
I Inspect posterior surfaces
§ Log-roll your client so you can examine the entire posterior

surface from the head to the heels.
§ Maintain in-line stabilization.
§ Look for abrasions, lacerations, bleeding or penetrating
injuries. Listen to lung fields.
§ Palpate the spine for any tenderness or steps between the
vertebrae.
If there are insufficient people to allow for a log roll, slip

gloved hands under the back in those areas which allow it e.g.
under the back of the neck, the small of the back and under
the knees.
Check for blood on withdrawing the hands. Take care in the
presence of glass or other sharp objects.

J Jot it down
Studies have shown that multi-tasking and task switching can lead to missed
indicators of client deterioration and that clear charting methods, using identifiable
thresholds for escalation, can reduce events in client care.
The initial clinical management of a major trauma presentation needs to rely on both
the collection of concise data and on astute observations gained from clinical
examination of the client to relay to consulting team members.
Trauma Victoria
As well as being a legal requirement, Vital signs and trends are important
documentation is vital to accurate, indicators to the client’s condition but
ongoing assessment and care.
can only be seen if you are diligent in
your documentation.
Documentation should include:
ü Date & time.
ü Demographic information (name, DOB, address, gender etc.).
ü A short history (story) from DeMIST and AMPLE.
ü Primary survey (findings and interventions).
ü Secondary survey (findings and interventions).
During the secondary survey:

ü Injuries are detected are accurately documented.
ü Urgent treatments, such as covering wounds and splinting fractures are provided.
ü Appropriate analgesia, antibiotics or tetanus immunisations are ordered.
Following the secondary survey:

ü Go back to the top and reassess ABCD and vital signs. This needs to be an ongoing
process.
ü Continual monitoring.
ü Priorities for further investigation and treatment may now be considered and a plan for
definitive care established.

Remember…
Do not start Monitor your client

the secondary vigilantly.
survey until you
If there is any
have identified
deterioration, the
and treated life
ABCs must be
threatening
repeated., and the
problems and
cause of the
your client is
change identified
stable.
and managed.

Review your learning
At the beginning of this module you were invited to assess

your knowledge, skill and confidence with respect to
conducting primary and secondary surveys.
This module has provided you with the theoretical concepts

that underpin primary and secondary surveys.
1. Have you refreshed that underpinning knowledge?
2. Have you learned anything new? Is there anything you
can share with your team?
3. Have you jotted down questions to take to the face-face
workshop?
4. Have you identified what you need to focus on in the face
to face workshop with respect to further developing your
skill, knowledge and confidence?
What’s next?
If you are new to remote emergency If you are aware Skim and scan
care or consider that you have lots to of specific gaps in through the
refresh, you’ll probably want to work your experience, modules in a
systematically through Modules 3-10. perhaps go to way that works
those modules best for you.
first.

References
Australian Resuscitation Council (n.d) Retrieved from
https://resus.org.au/
Australian Resuscitation Council (n.d) Guidelines. Retrieved from

https://resus.org.au/guidelines/flowcharts-3/
Brouhard, R (2019) The Myth of Tourniquets Damaging Limbs verywell health. Retrieved
from
https://www.verywellhealth.com/understanding-tourniquets-1298289
Centre for Remote Health (2017) CARPA Standard Treatment Manual 7th edition. Retrieved
from
https://docs.remotephcmanuals.com.au/review/g/manuals2017manuals/d/20318.html
?page=1
Cranaplus (2017) Clinical Procedures Manual Clinical Procedures Manual for Remote and
Rural Practice (2017) 4th Edition. Retrieved from
https://docs.remotephcmanuals.com.au/review/g/manuals2017-
manuals/d/20326.html?page=1
Cranaplus (2013) Remote Emergency Care (REC) course manual 6th edition.
Emergency Nurses Association (n.d) Clinical Practice Guideline: Family Presence During
Invasive Procedures and Resuscitation. Retrieved from
https://www.ena.org/docs/default-source/resource-library/practice-
resources/cpg/familypresencecpg3eaabb7cf0414584ac2291feba3be481.pdf?sfvrsn=9c1
67fc6_16
Expert in my pocket (2014) Oropharyngeal Suction. Video. Retrieved from

https://www.youtube.com/watch?time_continue=4&v=dV1Sy44gqH4
Hammett E (2017) The Truth About Tourniquets. First Aid for Life Retrieved from
https://firstaidforlife.org.uk/tourniquets/
Harless J, Ramajah R and Bhananker SM 92014) Pediatric airway amangement Int J Crit Illn
Inj Sci. Jan-Mar, 4(1): 65-70. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3982373/
Hoptry, A (2013) 4 2 oxygen via non-rebreather mask Video only. Retrieved from
https://www.youtube.com/watch?v=s7jg3BGhHFk
Kudo D, Yoshida Y and Kushimoto S (2017) Permissive hypotention/hypotensive

resuscitation and restricted/controlled resuscitation in clients with severe trauma.
Journal of Intensive Care. Retrieved from
https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-016-0202-z

References (cont’d)
KP20001000 (2018) Nursing students ABCDE assessment framework. Video only. Retrieved
from
https://www.youtube.com/watch?v=6yb9QzsTv1Y
McGee, S (2018) Peripheral Vascular Disease ScienceDirect Retrieved from

https://www.sciencedirect.com/topics/veterinary-science-and-veterinary-
medicine/capillary-refill
Medical Exam Prep (2018) The Initial Trauma Assessment Part 1 – The Primary Survey.
Medical Exam Prep Retrieved from
https://www.medicalexamprep.co.uk/the-initial-trauma-assessment-part-1-the-
primary-survey/
Medline Plus (n.d) Intercostal retractions. Retrieved from

https://medlineplus.gov/ency/article/003322.htm
Mistovich J (2009) Blood pressure assessment in the hypovolemic shock client. Retrieved
from
https://www.ems1.com/ems-products/Ambulance-Disposable-
Supplies/articles/479223-Blood-pressure-assessment-in-the-hypovolemic-shock-client/
NIRSM (2018) ABCDE Assessment in Short Nursing Theory. Video only. Retrieved from
https://www.youtube.com/watch?v=OBidolWhb6g
NIRSM (2018) ABCDE Assessment Practical Skill Guide Nursing Theory. Video only.
Retrieved from
https://www.youtube.com/watch?v=HOux2n4LETs
NSW Health Department (2011) Recognition of the sick baby or child in the emergency
department, clinical practice guidelines, 2nd edition. Retrieved from
https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2011_038.pdf
PRRAPID (2015) Capillary Refill Time. Video only. Retrieved from

https://www.youtube.com/watch?v=sYmSH6mYdzU
ResusCouncilUK (2017) RC (UK) ABCDE assessment demo. Video only. Retrieved from
https://www.youtube.com/watch?v=KNqoXboSVUI
Rezaie, S (2013) Is ATLS wrong about blood pressure estimates? Retrieved from
http://rebelem.com/atls-wrong-palpable-blood-pressure-estimates/
St John New Zealand (2010) Basic Airway Management 1. Video only. Retrieved from
https://www.youtube.com/watch?v=etPa9oxVWyU
St John New Zealand (2010) Basic Airway Management 2. Video only. Retrieved from
https://www.youtube.com/watch?v=pqw_7K3Mz8M&t=18s

References (cont’d)
Singapore Civil Defence Force (2013) Chest Thrust (Choking Steps) Video only. Retrieved
from
https://www.youtube.com/watch?v=o5jX54TJ2UE
The Department of Health (2013) FLACC pain scale. Retrieved from

https://www1.health.gov.au/internet/publications/publishing.nsf/Content/triageqrg~tri
ageqrg-pain~triageqrg-FLACC
The Royal Children’s Hospital Melbourne (n.d) Primary and secondary survey. The Royal
Children’s Hospital Melbourne. Retrieved from
https://www.rch.org.au/trauma-service/manual/primary-and-secondary-survey/
Trauma Victoria (n.d) Early Trauma Care. Trauma Victoria. Retrieved from
https://trauma.reach.vic.gov.au/guidelines/early-trauma-care/key-messages
Trauma Victoria (n.d) The deteriorating trauma client. Trauma Victoria. Retrieved from
https://trauma.reach.vic.gov.au/guidelines/the-deteriorating-trauma-client/key-
messages
University of South Wales (2016) Basic Airway Management – Clinical skills for student
nurses. Video. Retrieved from
https://www.youtube.com/watch?v=rOJqWt-GhKA
Weiser TG (2018) Rib Fractures MERCK MANUAL Consumer Version. Retrieved from
https://www.merckmanuals.com/home/injuries-and-poisoning/chest-injuries/rib-
fractures
Wells J (2017) Do Vital Signs Wrong and Pay Ultimate Price American Council on Science
and Health. Retrieved from
https://www.acsh.org/news/2017/01/06/do-vital-signs-wrong-and-pay-ultimate-price-
10689
Wong Baker Faces Foundation (N.d) Wong-Baker FACES Pain Rating Scale. Retrieved from
https://wongbakerfaces.org

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REMOTE EMERGENCY CARE (REC)

Development and review of clinical content

This module has been reviewed by:

Primary survey: What are your learning needs? 7

Secondary survey: What are your learning needs? 8

Our goals for this module 11

Overview of ABCDE assessment 17

A: AIRWAY (with cervical spine control) 18

B: BREATHING (with oxygen) 29

C: CIRCULATION (with haemorrhage control) 32

E: EXPOSURE / ENVIRONMENTAL CONTROL 37

DRABCDE complete, now what? 38

Self-assess your knowledge and confidence 39

Secondary survey in the remote context 41

F: FULL SET OF VITAL SIGNS, FOCUSED INTERVENTIONS, 42

H: HISTORY and HEAD TO TOE 46

I: INSPECT POSTERIOR SURFACES 49

Review your learning 52

The remote context

The primary survey is the initial assessment and

The secondary survey is commenced after the

REC REMOTE EMERGENCY CARE Module 2 © CRANAplus Inc. 2019 Page 5

REC REMOTE EMERGENCY CARE Module 2 © CRANAplus Inc. 2019 Page 6

What do you need to know about?

What do you need to be able to do?

3 Document and communicate your primary survey.

REC REMOTE EMERGENCY CARE Module 2 © CRANAplus Inc. 2019 Page 7

F Full set of vitals, Focussed interventions, Facilitate family presence

What do you need to know about?

What do you need to be able to do?

3 Document and communicate your secondary survey.

REC REMOTE EMERGENCY CARE Module 2 © CRANAplus Inc. 2019 Page 8

1. What happened? How did the client come into

2. How did you feel when you realised that the

3. What actions did you take? What was the

4. Did you conduct a secondary survey? What was

5. What else could have been done? What did you

6. What steps did you take to address any personal

REC REMOTE EMERGENCY CARE Module 2 © CRANAplus Inc. 2019 Page 9

Primary Survey and Secondary Survey Knowledge Confidence

Mechanisms of injury and associated signs and symptoms.

D: Identify and manage hazards and risks at the scene.

A: Assessing client’s airway and if not patent how to establish and

B: Assess client’s breathing status, exclude the five life-threatening

E: Expose client’s body in stages and prevent hypothermia.

F: Take a full set of vitals. Conduct focussed interventions such as Spo2,

H: Conduct a thorough head to toe assessment, identifying and treating

REC REMOTE EMERGENCY CARE Module 2 © CRANAplus Inc. 2019 Page 10

It’s important that you work through the content in this

REC REMOTE EMERGENCY CARE Module 2 © CRANAplus Inc. 2019 Page 11

REC REMOTE EMERGENCY CARE Module 2 © CRANAplus Inc. 2019 Page 12

Why the DRABCDE approach?

In a single responder situation DRABCDE need to be addressed

REC REMOTE EMERGENCY CARE Module 2 © CRANAplus Inc. 2019 Page 13

2. Prepare other staff

3. Prepare your facility

4. Prepare your equipment

For more information about general management of an emergency,

REC REMOTE EMERGENCY CARE Module 2 © CRANAplus Inc. 2019 Page 14

REC REMOTE EMERGENCY CARE Module 2 © CRANAplus Inc. 2019 Page 15