Scene Size-Up Before Patient Contact
Before approaching any patient, complete a scene size-up. Ensure body substance isolation (BSI) and appropriate personal protective equipment (PPE) are in place. Evaluate scene safety for hazards such as traffic, fire, hazardous materials, violence, or unstable structures. Determine the mechanism of injury (MOI) or nature of illness (NOI). Assess the number of patients and request additional resources if needed. Identify the need for spinal motion restriction based on MOI. This step is not part of the primary survey itself but must be completed before patient contact begins.
X: Exsanguinating Hemorrhage
The X in XABCDE stands for controlling life-threatening external hemorrhage as the very first priority. This reflects the updated emphasis from military and civilian tactical medicine that massive hemorrhage is the most rapidly correctable cause of preventable death in trauma. Scan for and control any major external bleeding immediately using direct pressure, tourniquet application, wound packing, or hemostatic agents as appropriate. Address this before moving to airway assessment. This step should take only seconds and targets arterial bleeding or major venous hemorrhage that will lead to death before airway management can make a difference.
A: Airway with Cervical Spine Protection
Assess the airway while maintaining cervical spine stabilization in trauma patients. Look, listen, and feel for adequate air exchange. Listen for abnormal airway sounds: stridor suggests upper airway obstruction, gurgling indicates fluid in the airway, and snoring suggests soft tissue obstruction. If the airway is not patent, use a jaw thrust maneuver (preferred in trauma) or head-tilt chin-lift (if no suspected spinal injury). Suction the airway if needed. Insert an OPA or NPA as appropriate. Clear visible foreign bodies with finger sweeps only in unconscious patients when the object is visible.
B: Breathing and Ventilation
Assess breathing by looking at chest rise for symmetry and adequacy, listening to breath sounds bilaterally, and feeling for air movement. Note the respiratory rate, depth, and effort. Look for signs of respiratory distress including accessory muscle use, nasal flaring, intercostal retractions, paradoxical chest wall movement (flail chest), and cyanosis. Auscultate lung sounds in at least four fields: bilateral anterior and bilateral mid-axillary. Absent or diminished sounds may indicate pneumothorax, hemothorax, or bronchial obstruction. Provide supplemental oxygen for any patient with respiratory compromise. Assist ventilations with BVM if the rate is below 10 or above 30 breaths per minute, or if tidal volume is inadequate. Apply a pulse oximeter to monitor SpO2.
C: Circulation
Assess circulation by checking the pulse for rate, rhythm, and quality. A rapid, weak, thready pulse suggests shock. Check skin color, temperature, and moisture. Cool, pale, diaphoretic skin indicates poor perfusion. Assess capillary refill time (normal is less than 2 seconds). Check for additional sources of bleeding not identified in the X step. Establish IV access if within scope. Begin fluid resuscitation per protocol for signs of shock. Reassess vital signs including blood pressure. In trauma patients, anticipate the need for blood products at the receiving facility and communicate this during your hospital notification.
D: Disability (Neurological Status)
Perform a rapid neurological assessment using AVPU (Alert, responds to Verbal stimuli, responds to Painful stimuli, Unresponsive) or Glasgow Coma Scale (GCS). Assess pupil size, equality, and reactivity to light. Check for lateralizing signs such as unilateral weakness or unequal pupils, which may indicate increased intracranial pressure or herniation. Assess blood glucose to rule out hypoglycemia as a cause of altered mental status. Document baseline neurological status for comparison during transport. A GCS of 8 or less indicates the patient cannot protect their own airway and requires advanced airway management.
E: Exposure and Environment
Expose the patient as needed to identify injuries not visible through clothing. Cut away clothing to visualize the entire body, including log rolling to examine the posterior surfaces. Maintain patient dignity and privacy as much as possible. After exposure and examination, immediately cover the patient to prevent hypothermia, which worsens coagulopathy and outcomes in trauma. Use blankets, reflective sheets, or warming devices. Note the environmental conditions and address temperature extremes. Document all injuries found during exposure.
SAMPLE History
SAMPLE is a mnemonic for obtaining a focused patient history. S stands for Signs and Symptoms, including what the patient is experiencing and what you observe. A is Allergies, particularly to medications, foods, and environmental allergens. M is Medications, including prescription, over-the-counter, herbal supplements, and recreational drugs. P is Pertinent Past Medical History, including surgeries, hospitalizations, and chronic conditions. L is Last Oral Intake, noting what and when the patient last ate or drank, which is important for surgical planning. E is Events Leading Up To the incident, including what the patient was doing before the injury or illness and any prodromal symptoms. Gather SAMPLE history from the patient if able, or from bystanders, family, or medical alert jewelry.
OPQRST Pain Assessment
OPQRST is a mnemonic for obtaining a detailed pain history. O is Onset, asking when the pain started and what the patient was doing at the time. P is Provocation/Palliation, asking what makes the pain worse or better. Q is Quality, asking the patient to describe the pain in their own words (sharp, dull, pressure, burning, tearing, cramping). R is Radiation, asking if the pain moves or spreads to other areas. S is Severity, typically rated on a 0 to 10 scale where 0 is no pain and 10 is the worst pain imaginable. T is Time/Temporal pattern, asking how long the pain has been present, whether it is constant or intermittent, and whether it has changed since onset. Document the OPQRST findings and reassess after interventions to determine if treatment is effective.