Primary/Secondary Survey of the Casualty

Objectives Discuss the importance of the primary/secondary survey Outline how ATLS applies to the casualty

Time of death

Primary/Secondary Survey Why is it important? What and where are the wounds? What resuscitation is required? Mode of EVAC? Why is it important? What and where are the wounds? What resuscitation is required? Mode of CASEVAC?

Will this approach work in firefight? What is the Approach? ATLS Created by surgeons for the non-surgeon Designed in the urban environment Performed in the hospital setting Requires a lot of high tech resources This is our classical training platform Will this approach work in firefight?

How Do We Develop Our Approach? What are we going to see? Injury patterns Civilian trauma? Firefight trauma?

How Do We Develop Our Approach? Civilian trauma Trimodal death distribution First peak Death results in the pre-hospital setting from massive head injury and massive vascular injury. Second peak Death in the first few minute of arrival to the hospital and due to massive head, chest and abdominal injury Third peak Post resuscitation/operative complications Firefight Trauma We don’t know the death distribution It is believed that if the casualty can arrive alive and relatively stable to the ER…they will live.

How Do We Develop Our Approach? ATLS Based on urban injury patterns Primary Survey A-Airway/c-spine control B-Breathing C-Circulation D-Disability E-Exposure Detailed secondary survey Head-to-toe exam

How Do We Develop Our Approach? The Firefight Casualty Slightly different injury pattern-in this order! Penetrating extremity trauma Tension pneumothorax Loss of airway Instead of ABCs……think CBAs

The Firefight Casualty Primary Survey Assess for hemorrhage first Intervene for life threatening bleed only! Then, assess for tension pneumothorax Then, assess for an airway Utilize a Combitube or surgical airway Rarely a need for c-spine control

The Firefight Casualty Primary Survey D-disability- decision to evacuate E-exposure Explore ideas on how to expose your casualty while protecting them from the environment Hypothermia is BAD Remember, they may need that kevlar!!!

Heat loss during transport

Hypothermia

The Firefight Casualty Secondary Survey Occurs after you have performed your primary survey and appropriate interventions Head-to-toe exam along ATLS guidelines. Be very thorough-many injuries are subtle!

Commonly used acronyms DCAP-BTLS- deformities, contusions, abrasions, penetrations, burns, tears, lacerations, swelling. TIC- tenderness, instabilities, crepitus. TRD- tenderness, rigidity, distension PMS- pulse, motor, sensory

Head exam DCAP-BTLS Pupils Raccoon/Battle signs Mid-face instability

Neck exam Step-off Tracheal deviation Jugular vein distention

Chest exam DCAP-BTLS TIC Auscultation Percussion

Abdominal/Pelvic exam DCAP-BTLS TRD-P Pelvic instability Priapism Scrotal/labial hematoma/blood at the meatus

Extremity exam DCAP-BTLS TIC PMS

Posterior Thorax Log roll casualty Spine DRE DCAP-BTLS Tenderness/step-off DRE Gross blood only

Questions?