Primary/Secondary Survey of the Casualty

ObjectivesObjectives

Discuss the importance of the Discuss the importance of the primary/secondary surveyprimary/secondary survey

Outline how ATLS applies to the casualtyOutline how ATLS applies to the casualty

Time of deathTime of death

33355

3

12

20

25

44

Immediate 5-30Mins 2Hrs-6Hrs

1D-1W

Killed in Action

Died of Wounds

Primary/Secondary SurveyPrimary/Secondary Survey

Why is it important?Why is it important?– What and where are the wounds?What and where are the wounds?

What resuscitation is required?What resuscitation is required?– Mode of EVAC?Mode of EVAC?

What is the Approach?What is the Approach?ATLSATLS– Created by surgeons for the non-surgeonCreated by surgeons for the non-surgeon– Designed in the urban environmentDesigned in the urban environment– Performed in the hospital settingPerformed in the hospital setting– Requires a lot of high tech resourcesRequires a lot of high tech resources

–This is our classical training platformThis is our classical training platform

Will this approach work in firefight?Will this approach work in firefight?

How Do We Develop Our How Do We Develop Our Approach?Approach?

What are we going to see?What are we going to see?– Injury patternsInjury patterns

Civilian trauma?Civilian trauma?

Firefight trauma?Firefight trauma?

How Do We Develop Our How Do We Develop Our Approach?Approach?

Civilian traumaCivilian trauma– Trimodal death distributionTrimodal death distribution

First peakFirst peak– Death results in the pre-hospital setting from massive head injury Death results in the pre-hospital setting from massive head injury

and massive vascular injury.and massive vascular injury.

Second peakSecond peak– Death in the first few minute of arrival to the hospital and due to Death in the first few minute of arrival to the hospital and due to

massive head, chest and abdominal injurymassive head, chest and abdominal injury

Third peakThird peak– Post resuscitation/operative complicationsPost resuscitation/operative complications

• Firefight TraumaFirefight Trauma– We don’t know the death distributionWe don’t know the death distribution

• It is believed that if the casualty can arrive alive and relatively stable It is believed that if the casualty can arrive alive and relatively stable to the ER…they will live.to the ER…they will live.

How Do We Develop Our How Do We Develop Our Approach?Approach?

ATLSATLS– Based on urban injury patternsBased on urban injury patterns

Primary SurveyPrimary Survey– A-Airway/c-spine controlA-Airway/c-spine control– B-BreathingB-Breathing– C-CirculationC-Circulation– D-DisabilityD-Disability– E-ExposureE-Exposure

Detailed secondary surveyDetailed secondary survey– Head-to-toe examHead-to-toe exam

How Do We Develop Our How Do We Develop Our Approach?Approach?

The Firefight CasualtyThe Firefight Casualty– Slightly different injury pattern-in this order!Slightly different injury pattern-in this order!

Penetrating extremity traumaPenetrating extremity trauma

Tension pneumothoraxTension pneumothorax

Loss of airwayLoss of airway

– Instead of ABCs……think CBAsInstead of ABCs……think CBAs

The Firefight Casualty Primary The Firefight Casualty Primary SurveySurvey

Assess for hemorrhage firstAssess for hemorrhage first– Intervene for life threatening bleed only!Intervene for life threatening bleed only!

Then, assess for tension Then, assess for tension pneumothoraxpneumothorax

Then, assess for an airwayThen, assess for an airway– Utilize a Combitube or surgical airwayUtilize a Combitube or surgical airway– Rarely a need for c-spine controlRarely a need for c-spine control

The Firefight Casualty Primary The Firefight Casualty Primary SurveySurvey

D-disability- decision to evacuateD-disability- decision to evacuateE-exposureE-exposure– Explore ideas on how to expose your casualty while Explore ideas on how to expose your casualty while

protecting them from the environmentprotecting them from the environmentHypothermia is BADHypothermia is BAD

– Remember, they may need that kevlar!!!Remember, they may need that kevlar!!!

Heat loss during transportHeat loss during transport

HypothermiaHypothermia

The Firefight Casualty The Firefight Casualty Secondary SurveySecondary Survey

Occurs after you have performed your Occurs after you have performed your primary survey and appropriate primary survey and appropriate interventionsinterventions

Head-to-toe exam along ATLS Head-to-toe exam along ATLS guidelines.guidelines.– Be very thorough-Be very thorough-many injuries are many injuries are

subtle!subtle!

Commonly used acronymsCommonly used acronyms

DCAP-BTLS- deformities, contusions, abrasions, DCAP-BTLS- deformities, contusions, abrasions, penetrations, burns, tears, lacerations, swelling.penetrations, burns, tears, lacerations, swelling.

TIC- tenderness, instabilities, crepitus.TIC- tenderness, instabilities, crepitus.

TRD- tenderness, rigidity, distensionTRD- tenderness, rigidity, distension

PMS- pulse, motor, sensory PMS- pulse, motor, sensory

Head examHead exam

DCAP-BTLSDCAP-BTLS

PupilsPupils

Raccoon/Battle signs Raccoon/Battle signs

Mid-face instabilityMid-face instability

Neck examNeck exam

Step-offStep-off

Tracheal deviationTracheal deviation

Jugular vein distentionJugular vein distention

Chest examChest exam

DCAP-BTLSDCAP-BTLS

TICTIC

AuscultationAuscultation

Percussion Percussion

Abdominal/Pelvic examAbdominal/Pelvic exam

DCAP-BTLSDCAP-BTLS

TRD-PTRD-P

Pelvic instabilityPelvic instability

PriapismPriapism

Scrotal/labial hematoma/blood at the Scrotal/labial hematoma/blood at the meatusmeatus

Extremity exam Extremity exam

DCAP-BTLSDCAP-BTLS

TICTIC

PMSPMS

Posterior ThoraxPosterior Thorax

Log roll casualtyLog roll casualty– SpineSpine

DCAP-BTLSDCAP-BTLS

Tenderness/step-offTenderness/step-off

– DREDREGross blood onlyGross blood only

Questions?Questions?