clinical home > primary survey

Disability

In the primary survey you are looking for evidence of a significant brain injury/CNS problem - in a remote setting this is something that will (with the exception of hypoglycaemia) need urgent evacuation, if possible.

To do this:
  1. speak to the patient and assess their conscious level
  2. assess the pupils
  3. assess movements of fingers and toes (looking for loss of movement)
  4. if there are problems with any of these check the capillary blood glucose if you have the equipment to do so

Speak to the patient & assess consciousness

If they answer you do NOT need to assess their reaction to pain (I've seen it happen!).
If the patient does not reply to your speech, ask them to obey a simple command ("wiggle your fingers, wiggle your toes" - covers another part of the assessment at the same time)
Pressure on the supraorbital nerve is the painful stimulus of choice (find the small dip in thebone under the eyebrow and rub with the end of the finger or thumb - try it on yourself before doing it to a casualty)

AVPU

can be used for a quick assessment of conscious level:
A = alert (able to have a coherent conversation)
V = response to voice (no coherent conversation but able to follow commands)
P = responds to pain (does not obey commands but responds/moves in response to pain)
U = unresponsive (no response to pain)
score the best that the patient can do

avpu.jpg

Assess pupils

Assess pupil size (very small, normal, very big is enough detail - you do not need to measure then with a ruler), symmetry and reactions to light.
When shining the light into the eyes:
1) Do NOT shine a really bright light into the eye - you may damage the retina
2) Shine the light obliquely into the eye - the source of the light should NOT be directly in front of the eye.

Assess limbs - ask patient to wiggle fingers and toes

Assess quickly whether the casualty has weakness in the limbs (not caused by direct limb trauma).
Do not assess power by placing your fingers in the patient's palm and asking them to squeeze your fingers: in some head injured patients this squeezing will happen because of a primitive reflex (the grasp) and it does not then indicate an ability to obey commands.

If there are any problems at all with any of these then measure capillary blood glucose
Remember that any neurological deficit may be the result of hypoglycaemia.
ALWAYS exclude hypoglycaemia as the cause of neurological impairment - even in the presence of an obvious head injury.

The assessment above does NOT consititute a full neurological examination - that comes later within the secondary survey.