clinical home > primary survey


This page does not review a full respiratory examination; it focuses on the "breathing" part of the primary survey

In the primary survey determine:
1) Is breathing present or not?
2) If present is breathing abnormal?
3) If present is there an immediately life threatening problem?

Once you have confirmed there is air moving through the airway (which you will have before getting to the B bit of the primary survey) the rate and depth of respiration are checked - this is often easier if you put a hand on the front of the chest over the sternum (make sure the casualty is happy for you to do this, especially if they are female).

Absent breathing

Rescue breathing (or BVM ventilation if the equipment is available) is needed.
In some settings a decision may be made that attempts at Basic Life Support are futile.
Video showing mouth to mouth technique (NB we don't want to use head tilt-chin left after trauma, but airway patency and adequate ventilation take priority over possible c spine injuries - in this case the smallest possible movement at the neck for ventilation is made)

Bag valve mask ventilation

More effective and aesthetically so much more appealling than mouth to mouth exhaled air ventilation, BVM is the usual initial means of supporting absent or inadequate breathing.
Although skilled operators can successfully use a bag valve mask device on their own (ie hold mask on airway with one hand and squeeze the bag with the other) most people will ventilate much more effectively if they adopt a 2 person technique - one holds the mask on the wairway and the other squeezes.
When holding the mask a better seal is obtained if you try to pull the face up to the mask rather than push the mask onto the face - this is aa skill that needs to be learned hands-on.
Remember not to overventilate! (12 per minute will be fine)

Abnormal breathing

Breathing can be abnormally slow (<10/minute) or fast (>29/minute).
When fast, there may be other signs of respiratory distress: accessory muscle use, nasal flaring, intercostal & subcostal recession.
Treat with oxygen (when available) & monitor pulse oximetry when possible.
When the breathing is too slow - < 10/minute - or shallow to be effective support the breathing with rescue breaths.
Remember abnormal breathing may be due to a non-respiratory problem: shock, acidosis, head injury, drugs.

Life threatening problems

Immediately life- threatening chest injuries mnemonic: "ATLS failed to complete"
Aortic dissection
Tension pneumothorax
Large haemothorax
Sucking chest wound
Failed (to)
Flail segment
Cardiac tamponade

The main non-traumatic life threatening problem is bronchospasm from asthma or as part of anaphylaxis.

Diagnosis and treatment of the life threatening problems is:

1) Aortic dissection

is often caused by rapid deceleration (e.g. in RTC).
There may be a difference in BP between the arms but this is not invariable.
The treatment is surgery so rapid evacuation is required.
This will be suepceted from the mechanism of injury (sudden deceleration) but the assessment of pulses in both arms is part of the C assessment, rather than of B.

2) Tension pneumothorax

causes tachypnoea, the casualty often says "I can't breathe" (and may get the reply "yes you can"!), the trachea is deviated away from the pneumothorax, the percussion note is resonant on the side of the pneumothorax and the breath sounds are absent.
Initial treatment is often needle thoracocentesis (to reduce the pressure in the pleural space), though this is slightly controversial.
Definitive management is intercostal drainage - remember that underwater seals are not practical in a remote setting.
Needle thoracocentesis and chest drain

video of needle thoracocentesis

Securing a chest drain using Prusik knot:

3) Large haemothoraces

will present as dull percussion note and decrease/absent breath sounds +/- signs of shock.
They are managed with intravenous access +/- fluid for shock (and evacuation).
After life threatening inuries have been addressed consideration needs to be given to intercostal drainage - the decision about the timing of this in the remote setting will be governed by the likley time to definitive care as well as the patient's status. The usual management would be to delay intercostal drainage until after arrival at definitive care. Drainage may increase bleeding. A minority bleed sufficiently to require cardiothoracic surgery.

4) Sucking chest wounds

need to be treated with something that prevents air getting into the pleural cavity from outside the chest but which allows air to enter (so avoiding a build up in pressure).
Much has been written about dressings sealed on three sides but the Asherman chest seal is custom designed for the job and, threfore, preferred. The Bolin seal has valves that are less likely to become obstructed (the flutter valve in the Asherman seal can be kinked and therefore obtructed) - see video below.

Asherman chest seal with one way valve

Intercostal drainage is likely to be needed as well - usually after arrival at definitive care.

5) Flail segment

There is little specific treatment for a flail segment , but it is important to recognise their presence. One should anticipate substantial pulmonary damage deep to the chest wall injury. Analagesia should be provided, oxygen saturation monitored if an oximeter is available and oxygen provided when possible. Evacuation is needed.

6) Cardiac tamponade

classically presents with hypotension, distended neck veins and muffled heart sounds.
The latter is will often be difficult to detect in a remote setting so: shock + distended neck veins = tension or tamponade.
Needle pericardiocentesis is recommended as the treatment for tamponade. While this is usually done with ultrasound guidnace in hospitals it may be necessary to do it "blind" if the patient's condition is deteriorating rapidly.
Like the aortic dissection, this is a doagnosis to consider under "C" - it is a cause of shock with distended neck veins.

7) Life threatening bronchospasm

is treated with oxygen when available, bronchodilator drugs (especially inhaled/nebulised beta2 agonists), and, on occasion, adrenaline. If steroids are available they should also be given though they will not act quickly.

The assessment of B

Assess rate and depth of respiration
Inspect the chest for sucking chest wounds and for flail segment (the latter will exhibit paradoxical movement) - look at the back!
Check the tracheal position (in case of tension pneumothorax)
Percuss both sides of the chest (high and wide) - hyperresonant with pneumothorax, dull with haemothorax.
Listen on both sides of the chest "high and wide": at the apices at the front and as far back in the axilla as possible (air rises so breath souonds are absent at the front of the chest with a pneumothorax, and at the back if there is a haemothorax)
Listen also for wheeze, but remember the absence of wheeze may indicate preterminal airway obstruction in bronchospasm.

Examination of the chest in the primary survey must be sufficiently thorough to detect the abnormalities listed above.
A common error is to examine only the front of the chest.
Some of the B assessment is difficult/impossible in a noisy environment - in this case much more care must be taken when using the other senses: vision and touch.

Life threatening chest injuries