Redefining the Primary Survey: A Smarter Approach to First Aid

By Paul Howes, Former Police Firearms Officer, Firearms Instructor & Police Firearms Medic Instructor Published by Management Solutions and Training Ltd

Why It’s Time to Rethink the Traditional First Aid Sequence

For decades, the Primary Survey has been the foundation of first aid response—a step-by-step method designed to help responders assess casualties and provide potentially life-saving interventions. In low-risk environments, this structure has served its purpose. But as the nature of emergencies evolves—and with increasing incidents involving trauma, violence, and mass casualties—it’s clear that our approach to first aid must evolve too.

Drawing on years of frontline experience in tactical policing and firearms operations, I’ve seen first-hand how catastrophic bleeding, if not treated immediately, can claim a life in under three minutes. That’s faster than a compromised airway or stopped breathing can kill. Yet, traditional first aid training doesn’t reflect this urgency.

The Traditional Primary Survey: Time for an Update

The current first aid model follows this sequence:

D – Danger

R – Response

S – Shout/Call for Help

A – Airway

B – Breathing

C – Circulation

While it provides a logical and structured approach, it assumes a relatively safe environment and overlooks the immediate threat posed by major external bleeding—the kind commonly seen in stabbing incidents, gunshot wounds, explosions, and high-impact trauma.

In high-threat settings, we need a system that mirrors the realities of modern emergencies.

Introducing the Revised Primary Survey

Inspired by principles used in military medicine and tactical emergency care, the revised Primary Survey sequence places catastrophic bleeding control before responsiveness and airway assessment.

Here’s the proposed structure:

D – Danger. First, assess your environment. No matter how urgent the injury appears, scene safety is paramount. Never approach unless it's safe to do so.

C – Catastrophic Bleeding: Look for major bleeding immediately. This includes limb trauma, arterial sprays, or deep wounds.

• Apply direct pressure.
• Use haemostatic dressings if available.
• Apply a tourniquet for life-threatening limb bleeds (if trained).

R – Response: Check for responsiveness only after addressing catastrophic bleeding. Use the AVPU scale (Alert, responds to Voice, responds to Pain, Unresponsive).

S – Shout/Call for Help: Call 999 or direct someone else to do so. Give clear information about the number of casualties, visible injuries, and location details.

A – Airway: Ensure the airway is open and unobstructed. Use head-tilt-chin-lift or jaw-thrust techniques as required.

B – Breathing: Look, listen, and feel for normal breathing. If absent, and no catastrophic bleeding is present, begin CPR or ventilation as trained.

C – Circulation (Non-Catastrophic): Check for signs of shock or internal bleeding. Monitor skin colour, temperature, and capillary refill.

Why This Matters

The reality is this: you cannot resuscitate a person who is bleeding out. CPR won't help a casualty who’s lost critical blood volume. That’s why tactical medics and armed police are trained to deal with catastrophic haemorrhage first.

Civilian first aid training is catching up, but more needs to be done. In the wake of violent incidents—from terror attacks to workplace accidents—early intervention by trained members of the public has already saved lives. But only when they knew what to do, and in what order to do it.

Conclusion: Smarter First Aid Saves More Lives

We must begin to treat first aid not just as a civilian skill, but as a tactical one—capable of making the difference between survival and tragedy. Redefining the Primary Survey is a step in the right direction.

At Management Solutions and Training Ltd, we integrate this modern approach into our first aid courses—blending proven clinical techniques with real-world operational insights.

By updating the Primary Survey to prioritise catastrophic bleeding, we arm people with the tools and mindset needed to act effectively when it matters most.

Consider refreshing your first aid training. Learn how to stop catastrophic bleeds, manage trauma, and take control in high-stakes situations. Because when the clock is ticking, knowledge and action save lives.