NAEMT’s new 9th edition of PHTLS has altered the Primary Survey mnemonic from <C>ABC to XABC. Now the substance remains the same; it’s just a different presentation (eXsanguinating/eXternal instead of Catastrophic haemorrhage). Personally, I like it. But more importantly, I think it’s crucial and good practice to develop the habit of following a Primary Survey thoroughly and systematically with ANY PATIENT, regardless of your clinical skill level. Doing so greatly enables you to deliver effective and appropriate care, and to address anything life-threatening in a timely manner.
PROs of XABC
- Exsanguinating/external accurately describes what is occurring, rather than the potential outcome. We now arguably have the clinical capability to prevent these compressible haemorrhages from being catastrophic.
- Having an X conveys the severity of the stage, as many things marked X are often severe and significant.
- It diminishes any confusion people face from having 2 Cs in the Primary Survey algorithm, as is often the case with people who prefer the MARCH mnemonic from Tactical Combat Casualty Care.
CONS of XABC
- Extensive literature from the last 15 years has written of CATASTROPHIC HAEMORRHAGE, and this change may lead to confusion.
- Why change the mnemonic if there is no change in the substance of this step?
Principles and Preferences
Make your own choice on what you follow, and how your put this into practice, but always remember to be thorough and systematic. Address one step of the Primary Survey (i.e make any life-saving interventions – LSIs) before proceeding to the next. There’s no point addressing any compromise of a patient’s AIRWAY + BREATHING if there is no circulatory volume to oxygenate in their body due to an EXSANGUANATING HAEMORRHAGE. Addressing an internal haemorrhage and associate hypoperfusion of a patient’s CIRCULATION before their AIRWAY + BREATHING will be futile if they are hypoxic.
It is also, of course, possible to simultaneously evaluate and manage each component of the Primary Survey, but this should not take precedence of being thorough. Doing so would elevate the risk of you missing key elements of the component you are surveying. However, if there are two or more of you together as a team, one could complete the survey whilst the other(s) could implement the necessary interventions identified. You will need to repeat a Primary Survey frequently with a patient, but you want to get it right the first time to FIND ALL THE INJURIES PRESENT immediately. But remember, quality over time (quantity), and with experience and practice you will find that you become more expedient anyway.
Get it right for your patients. Strive to provide the very best care for your patients.
Finally, for all the critics out there of PHTLS being American, there are many UK providers who do a great job of adapting the course to the prehospital context of the UK, and NAEMT will soon be releasing a 9th edition UK edition of their manual. In the meantime, ask yourself, do you always do a proper primary survey with every patient you encounter? Can your primary survey be improved? Get it right for your patients. Strive to provide the very best care for your patients.
Extract from the PHTLS Manual
“Our patients did not choose us, we chose them. We could have chosen another profession, but we did not. We have accepted the responsibility for patient care in some of the worst situations imaginable: when we are tired and cold, when it’s were and dark or even when we cannot predict which situations we shall encounter. We must either accept this responsibility or surrender it. We must give to our patients the best care possible – not while we are dreaming, not with faulty or unchecked equipment, not with inadequate supplies and most importantly, not with yesterday’s knowledge.
We cannot know what medical information is current and we cannot profess to be fully prepared to care for patients if we do not continue to update and take on board teachings each day. The PHTLS course provides a part of that knowledge to the working Pre-Hospital responders but, more importantly, it ultimately benefits the person who needs our very best – The Patient.”
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