The Primary survey has long been something that is done after arrival and before CT. It comes from the ALTS model of trauma management. The idea is to identify immediately life threatening injuries that require attention or intervention. This has been historically done by clinical examination alone and there is an understanding that this is very insensitive and unspecific in the diagnosis of these conditions, and so there is a time pressure to get to CT. Ultrasound is another method of diagnosis, unfortunately I often hear at traumas “We are going to CT do not do the FAST as it will delay things” this is said after someone has vaguely listened to heart sounds to see if they are muffled, listened and tapped on a chest in a loud resus to see if there is a pneumo or haemothorax and then prodded the belly to see if they can tell, by feel, whether there is blood in the abdomen. This form of a Primary survey to me seems like the “delay”, most of this clinical examination is frankly a waste of time. However all is not lost, we can simply do the primary survey with Ultrasound: 

The patient arrives, the Survey Doc has the probe in hand set up and ready to go. The Anaesthetist assesses the airway while the survey doc visually checks the trachea and chest and places the US on the chest while palpating (our stethoscope has been replaced by something modern). The US of both sides of the anterior chest gives us immediate diagnosis of a pneumothorax, studies show the sensitivity is close to CT at 99% which is far better than a CXR or a bloke with a stethoscope and finger. The probe now goes the upper flanks, haemothorax YES/NO, if its significant it will be visible on US, again far easier than the block with the stethoscope and finger. This is done at each side and at the same time we can look for free fluid in the RUQ and LUQ, the probe is also good at picking up peritonism as you effectively poking them in the belly. Now you can have a look at the heart and IVC, is the patient full or empty? is there a pericardial effusion? The pelvic gutter can also be viewed for free fluid. Then you can continue with standard clinical examination of the pelvis and limbs. 

This US primary survey may take slightly longer but in trained hands can be done in under 2mins and can gain actual useful clinical information that is also conveniently visible to the entire team. I see no reason why the US probe has to wait for a traditional assessment. Lets integrate them and get the most out of both clinical examination and US.

Steve Young