Primary Survey
Injured or critically ill players should be assessed and their treatment priorities established based on their injuries, vital/physiological signs and/or on the mechanism of injury. The player’s vital signs must be assessed quickly and efficiently with management consisting of a rapid primary survey including resuscitation of problems as they are identified and rapid re-evaluation.
This process constitutes of the ABCDEs of immediate care and identifies life threatening conditions by adhering to the following sequence.
- Catastrophic bleeding management
- Airway maintenance with C-spine protection
- Breathing with adequate ventilation
- Circulation with haemorrhage control
- Disability: neurological status
- Exposure & environment control
During the primary survey life threatening conditions should be identified and management commenced simultaneously. The assessment steps are presented sequentially in order of importance, for example a breathing problem should be managed before moving onto a circulation assessment?. If there are a number of care providers, these steps are frequently accomplished simultaneously.
Catastrophic haemorrhage control
In the very rare circumstance of an player presenting with catastrophic haemorrhage the application of a pressure dressing should be considered in attempt to arrest the bleeding before moving to assess and maintain the player’s airway.
Airway maintenance with C- spine protection
In a suspected injured player if there is any possibility of a cervical spine injury, the neck must be controlled by manual in-line immobilisation as part of the initial approach. The airway assessment begins by assessing if the player can respond with a clear verbal response to voice commands. This indicates they have a clear airway, are breathing and have a sufficient blood pressure to adequately perfuse their brain. Listening to the quality of their voice may give information about the airway status and a clue to any impending problems.
If there are any concerns about the player’s airway, this must be assessed and managed according to the principles outlined in the airway chapter of this text.
It is essential to identify airway compromise early and manage this appropriately to minimise hypoxia and hypercarbia. It is also important that the airway is regularly re-evaluated as some airway problems are progressive in nature and may not be obvious during the first primary survey.
Breathing with adequate ventilation
The next priority is to assess the player’s breathing. It is important to determine the respiratory rate and to check for equal expansion of the chest wall. A brief palpation of the chest wall at this time will reveal any areas of crepitus or tenderness. It is unlikely that a player will sustain an immediately life-threatening injury on the pitch but if respiratory distress is identified a further assessment is required.
The more detailed assessment of breathing will normally take place in the medical room or ambulance where inspection of the thorax, respiratory rate, expansion, percussion, auscultation, and examination for tracheal deviation or cyanosis are undertaken.
Life threatening conditions should be identified, and appropriate immediate treatment delivered if trained to do so, appropriate help is summoned urgently or the player is taken at the earliest opportunity to the appropriate secondary care facility/hospital. This is discussed in detail in the Breathing and Chest Trauma chapter. All players with critical injury or illness should be provided with oxygen in the pre hospital environment using a non-rebreathe (trauma) mask with high flow oxygen (10-15L/min).
Circulation with haemorrhage control
The next priority is to assess the player’s circulatory status. This assessment includes:
- Pulse – presence of the radial pulse
- Pulse – rate and volume
- Colour of the player – noting pallor
- Mental status - conscious level and agitation
- Evidence of external bleeding
- Evidence of internal bleeding
The presence of a radial pulse indicates probable end organ perfusion. It is used as a guide to whether intravenous fluids should be administered to a player who has received blunt thoracic or abdominal trauma. More information about this can be found in the circulation chapter.
The presence of external haemorrhage should be managed by direct pressure to the wound and the application of dressings to stem the bleeding. If a player has clinical evidence of shock, it is important that all major areas of occult bleeding are assessed (the chest, abdomen, retroperitoneum, pelvis and long bones).
Disability: neurological status
The on-pitch baseline observation of the neurological status of the player involves the use of the ACVPU system:
- A = Alert
- C = Confusion
- V = Responding to voice
- P = Responding to pressure stimulus
- U = Unresponsive
If there is any suspicion of a spinal cord or head injury a check of the player’s peripheral neurology should be undertaken. This will also be required  as part of clearing the player's spine.
Once in the medical room a more detailed neurological examination should be undertaken using the Glasgow Coma Scale (GCS). This should be repeated frequently and recorded along with all observations in the primary survey to identify improvement or deterioration in the player.
In addition, there should be a quick check of the player’s eyes to see if the pupils are equal, pupil size and if they react equally to light.
Exposure & environment control
For the initial on-pitch assessment, there should be limited exposure and the player protected from the environment. Once the primary survey is completed, any immediately life-threatening issues identified have been treated, and the player has been re-evaluated and the condition improved, , the player should be moved to the medical room or ambulance using the correct equipment and personnel.
Once in a more protected environment, the player will need to be exposed facilitating a thorough examination and assessment if time allows. Do not delay transfer to definitive care. Care should be taken to cover the player at the earliest opportunity to respect their dignity and protect them from the elements.