The rapid trauma assessment – part I

hurricane-katrina

The hurricane came in off the Atlantic and slammed into the Carolina coasts at 2am on Thursday. For once, the weather forecasters were right, and it did not weaken to a Category 4 from a Category 5 as it got closer to shore. In the inky blackness of night, the hellstorm tore its way inland from Myrtle Beach and carved a path of total destruction as it howled all the way up to Asheville before it transmogrified into a tropical storm that flooded 18 inches of rain on the wreckage it sowed.  Regardless of the preparation taken by the local, state, and federal emergency management agencies, millions were now without shelter, water, electricity, or help. The country had not seen anything like this, ever. It was the Galveston Hurricane of 1900, the San Francisco earthquake of 1906, and Hurricane Katrina combined into one. Whole towns – gone. Contact with the coasts – lost. Staged preparations – missing. As the sun rose from the east, the horrors of what nature had wrought would make the most hardened man tremble.

Bill Parker was lucky. As dawn illuminated what was left of his house, three walls and half a roof, he realized how lucky he was to even be breathing. His kids were terrified and still crying. His wife was stoic in her comforting of them, but he saw in her eyes the recognition of the desperation that lay ahead. But Bill Parker was lucky. Nobody in his house was seriously hurt.

katrina01

The NOAA radio was still receiving and the computer voice had been replaced by the voices of actual humans giving instructions. There were repeated warnings to not touch downed power lines and to shelter in place until help could arrive.  The police scanner revealed chaos. Not so much crime, but frustrated fire and EMS resources unable to access areas because of downed trees and power lines. Other than that, there was very little information. Bill, his family, and his neighborhood, were on their own.

Bill went through the Rule of Threes and assessed his situation. He sort of had shelter. He had three weeks worth of water and food. All good and well for a power outage alone, but this was different. He knew that people were going to need to help, and that included what he set aside to keep his family alive.

Bill knew right away that he needed to get his wife’s and kids’ minds occupied with the duties of staying alive lest they get paralyzed with fear. He got the kids to find and set up the tents, and his wife began to set up field sanitation and hygiene equipment. A camp had to be built and life, in its new reality, must continue.

He powered up his hand held ham radio and checked in to his local Amateur Radio Emergency Service frequency with a welfare message.

“Do you have injured or need immediate medical assistance?” asked the coordinator.

“Not sure yet. My family is fine, but I am going out into my neighborhood to start checking.” Bill replied.

“Acknowledged. Please monitor this frequency for further instructions and advise if you need help.” The coordinator checked out. He sounded busy.

Bill checked out and switched his radio to the frequency that he and Charlie Franklin use as the unofficial neighborhood watch.

“This is KXXXX calling KYYYY, do you copy?” Bill called out every ten seconds. On the third try, a response came through.

“KYYYY receiving KXXXX. Bill, it’s Charlie. Are you guys OK?” Bill heaved a sigh of relief that his buddy and co-conspirator was still breathing.

“Yeah Charlie, we’re OK. Not much house left, but everyone is OK. What’s your status?”

“We need some help. Eileen is unconscious and I can’t wake her. I’m pretty sure my leg is broken and am having trouble moving around. Haven’t made it outside yet. We had a tree come down on the house last night. It’s bad.” Bill could hear the fear in his voice. This was not like him.

“Stay put Charlie, I’m on my way over. KXXXX out.”

With that, Bill put his wife in charge of getting camp set up and settled. He gave her a radio tuned into the neighborhood watch frequency with instructions to call if anything came up. He grabbed his medical kit and made his way to Charlie’s. There was destruction everywhere. Power poles were snapped in half and wires covered the ground. His neighbors were slowly making their ways out of their bombed-out homes. It felt like he was in a movie, it was all so unreal. Looking at the carnage, he knew that Charlie and his wife were only two of many that were going to need help. It was going to be a very long day.

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No matter what situation you find yourself in, knowing how to give the right assessment is critical. Trauma is all about finding life threats and fixing them immediately. The rapid trauma assessment is designed to do just that. This will follow the civilian model of Airway, Breathing, Circulation, Disability, and Exposing the patient to find injury.

Before we go any further, there are all kinds of assessments that are tailored to the situations at hand. Check out Doc Grouch’s primer on History and Physical Exam. What works well in an on-scene trauma scenario is not going to be really smart to do in the grid-down clinic with an ambulatory patient that has a dull stomach ache that’s been bothering him for a week.

Furthermore, the Tactical Combat Casualty Care assessment in the Care Under Fire phase is barely an assessment at all other than figuring out if the guy next to you is dying and if he can either help himself or you can do something while simultaneously engaging in a gunfight. We’re not going to cover that today. A good TCCC primer can be found at Max Velocity’s site. Max is 68W-qualified, so he’s up to speed. Check it out.

Now let’s continue, shall we?

We are looking for deformities, contusions, abrasions, penetrations / punctures, burns, tenderness, lacerations, and swelling in our patient that are LIFE THREATS. The mnemonic for this is DCAP-BTLS. If you ever say to a medic or a doctor “I’m looking for DCAP-BTLS” you better know what they stand for or you will be doing pushups.

If your patient has a deep laceration on his calf that’s already clotted, we don’t care about that right now, he’s not dying from that. If your patient has a deep laceration on his calf that is spurting bright red blood in a three foot stream, we care about that, because that will kill him.

So, let’s talk about bleeds. (WARNING: GRAPHIC CONTENT AHEAD)

  • Arterial bleed: Bright red (oxygenated) blood and lots of it pulsing out in streams. If you see this, you better move fast and get the bleeding stopped.
  • Venous bleed: Dark red (deoxygenated) blood and lots of it oozing out rapidly depending on the site of the wound. Not a great sign. The bleed in the video below looks like a small vein, so it’s more about the color of the blood and the constant flow.
  • Capillary bleed: Bright red blood slowly oozing out from a wound. This is not life threatening. Not a big deal. No need to do anything right away.

Here’s a video that’s somewhat relevant, and fun, because it’s from the 70s. Don’t do everything they do in here. That’s old medicine. Like Ringer’s Lactate and NaHCO3 as an automatic for altered patients.

If you have time, get some nitrile gloves and some eye pro on, because it’s going to get messy.

If you suspect any cervical spine, head, or back injury, immobilize the patient’s head and neck to prevent any further injury. You’re going to need help to do this and assess the patient. We’re talking neck and head right now and not the full body spinal immobilization. Here’s a very textbook video of the full spinal immobilization skill. For now, focus on manual c-spine stabilization with your hands and a c-collar. Then skip the rest and do the rapid trauma assessment.

What is his mentation at this stage? Conscious, alert, and obeying commands? Conscious and alert, but mumbling and reciting multiplication tables? Barely awake? Knocked out? Whatever it is, make note of it. A patient’s mental status is a key indicator of his level of perfusion and his priority. The mnemonic here is AVPU, which stands for:

  • Alert: Patient is awake and alert. He may or may not be making sense, and may or may not be following your commands. Be watchful if he starts slip-sliding down the scale.
  • Verbal Stimuli: The patient responds to verbal stimulation. Chances are his eyes are closed and they open when you call his name. Same thing applies in making sense and following commands as above. The less he do, the worse he may be.
  • Painful stimuli: The patient responds to painful stimulation. A rub on the sternum with your knuckles. Pinching his fingernail bed between your finger and a pen. Note how he responds. Do he localize the pain and grab at where you are stimulating? Does he have a general response that is non-specific? The difference is a key distinction between levels of brain injury. The less specific the response, the worse he is.
  • Unresponsive: Exactly what it means. This is where it is important to gauge the patient’s ability to breathe on his own in a MCI or Care Under Fire situation. It he cannot breathe on his own, he is Expectant. Move on to other patients. If he is breathing on his own, he is Immediate. Treat accordingly.

Check the airway – is it open / patent? If not, stop the assessment and get it open with a head-tilt chin-lift, or if cervical spine injury is suspected, a modified jaw-thrust maneuver. You can consider using an oropharyngeal airway if the patient’s tongue is blocking his airway and he has no gag reflex. If the patient is awake or does have a gag reflex, you can try a nasopharyngeal airway as well. Here’s a video on how to do both. In either case, don’t take forever doing this. The key word here is “rapid.”

We’ll talk about some more advanced airway stuff in a later post. The key here is to make sure the guy can move air. The modified jaw thrust is a beast of a move and you will burn out your fingers keeping tension on the patient’s jaw. Be prepared to switch people out or start thinking about an advanced airway, since having to do this maneuver implies that his airway is compromised.

Check the breathing – is it adequate? If it’s under 8 or over 30 respirations (in an adult) per minute, assist ventilations with a bag-valve mask (BVM) and 15LPM 100% O2 if you have it. Your ventilations should be 12-20 a minute, with an emphasis on 12. All you are looking for is chest rise and fall for each ventilation given. You do NOT need to empty the entire contents of the BVM into your patient’s lungs.

Bag valve mask. Get one if you don’t have one already.

Note the resistance – or compliance – when ventilating. If there is a lot of resistance, there could be a pneumothorax, or an intrathoracic bleed that’s increasing intrathoracic pressure, or some other kind of really bad thing. A helper for pacing your ventilations is to say “BREATHE one thousand, two one thousand, three one thousand, four one thousand, five one thousand, BREATHE one thousand, two one thousand, three one thousand, four one thousand, five one thousand” and squeeze the BVM slowly over “BREATHE one thousand.” That gets you about 12 ventilations a minute. Chances are you’re going to be excited, so work hard at not counting too fast. If you think there is some kind of chest injury that is preventing your patient from breathing adequately, then stop the assessment, remove the clothing from his thorax, find what’s wrong and fix it right then and there. This could be dressing a flail segment, putting a chest seal / occlusive dressing on a sucking chest wound, and /or decompressing a tension pneumothorax. We will cover those skills in the more detailed trauma assessment post coming later.

Check radial – i.e. wrist – pulses, BOTH WRISTS at the same time. If they are present, then your patient has a systolic BP somewhere in the neighborhood of 80mmHg (please check out Doc Grouch’s post on getting blood pressures sans equipment, too). Note the pulse rate. Your count doesn’t have to be perfect. At this point “Wow, that’s really fast” or “Seems normal” is adequate for quantifying pulse rate. If there is a pulse in one wrist but not the other, make a note, as that is an ominous sign. Note the location of the radial and ulnar arteries in the illustration below. If you find a pulse in either, use a Sharpie and mark the location of the pulse on the patient. This is important for reassessing the patient or if you transfer care to another person. It’s poor-man’s telemetry, if you will.

If no radial pulses are present, go to the carotid artery in the neck.

carotid pulse

Carotid artery pulse location.

If you feel a pulse, the patient’s systolic pressure is at least 60-70mmHg. Chances are his heart rate will be high because he’s in compensated shock. If you feel barely any to no carotid pulse, chances are this guy is expectant and hopefully you were able to ask him if there was anything he wanted to say to his wife before he died.

A good medic or EMT can do almost all of this at once if the patient is conscious. Have a conversation with the patient while you are feeling his radial pulses. If pulses are present, he can converse normally and speak in full sentences, then you know you have a good airway, adequate breathing, and good circulation. If any of those basic things are off, you know something is up and you need to be highly alert.

ALWAYS use your patient as a diagnostic tool. He’s going to provide you great info about his status. Ask him what hurts, if he has numbness or tingling anywhere, if he lost consciousness, ask his name, his birth date, the day of the week, his current location, and finally ask him to wiggle his fingers and toes. With that, you’ve just done a field expedient neurological exam and can check off AVPU. Note any deficits.

Continue the assessment by doing a blood sweep by running your hands down the patient’s head, torso, and legs. After each major area, check your gloves. If you see blood, stop and assess the wound. Cut away anything that gets in your way. If it is a life threatening bleed, stop the assessment and control the bleeding with direct pressure, a hemostatic agent (CELOX, Combat Gauze, QuickClot, etc.) and/or a tourniquet. DON’T use hemostatic agents on any wounds outside of the extremities, and for God’s sake, don’t stuff a tampon in a chest or abdomen wound. Continue the blood sweep. If no other bleeding is found, continue on. One thing, the blood sweep should be fast, like 5-10 seconds fast.

Cool gear evolution note: The abdominal aortic tourniquet stopping junctional bleeds is getting some good press lately and may be something that we’ll be seeing in the future.

AAT-cropped

It reminds me of the old MAST device. We’ll see.

If you suspect shock, starting treating the patient for shock by elevating the feet, keeping him warm, and giving oxygen if available.

CONGRATULATIONS. You have completed the rapid trauma assessment. If you did it in 90 seconds or less, you are a stud. Under three minutes? Not bad. You now know your patient’s mental status, airway status, breathing status, and circulatory status. You can now form your treatment priority for this patient. In a grid-up world, this is the point where we decide to “load and go” and resuscitate the patient while doing whatever further assessment we can en route to the trauma center, or we continue the detailed rapid trauma on scene for a more complete picture. All-in-all, we want to be off scene in a trauma in under ten minutes from patient contact. In a grid-down world, our options are a little more ominous, and you may be resuscitating a patient in some pretty austere conditions.

monty-python-black-knight

A little common sense. If you walk up to a patient that has half an arm missing and is spurting blood from the stump, go ahead and get a tourniquet on it and control the bleeding right away, then do your assessment.

Part II on the rapid trauma assessment will be more detailed and have more how-to’s with skills. Then we’ll look at the Subjective, Objective, Assessment, and Plan (SOAP) method for documenting your assessment.

Keep in mind that everything we are doing here is based on a functioning rapid transport system as well as access to Level I trauma centers. In the scenario above, those things are in short supply and you will not be getting your patient off scene in under ten minutes or under a surgeon’s knife in under 60 minutes. TCCC has been successful because it also hinges on rapid transport (CASEVAC) to definitive care.

Homework

Here is the National Registry EMT-B trauma assessment skill sheet. Download it. Read it. Learn it. Grab your SO and make her or him your “patient.” Feel around. Put Barry White on. Can’t get enough of your love, baby. Yeah. Who said it can’t be fun?

16 responses to “The rapid trauma assessment – part I

  1. Pingback: Hogwarts: The Rapid Trauma Assessment – Part I | Western Rifle Shooters Association·

  2. Excellent read will go thru it repeatedly,though still a bit confused as to how the weed trimmers will help,guess that is where improvisation comes into play,as for the night,”Tis merely a flesh wound!”I will say the one thing folks do on island were my mom lives if folks OK but bad storm is clear roads with chainsaws while watching for wires ect.,lets you or others perhaps get in quicker to help or allows vehicles to leave,a few hurricanes down there while she has lived there,though not really bad hits does show the value of being as ready as one can.

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  3. Reblogged this on Freedom Is Just Another Word… and commented:
    As a medic/educator found this for you all! Read it! Just remember MARCH (Massive Bleeding, Airway, Respiration, Circulation, Head Injury/Hypothermia) is what the Military teaches and our Medical Director is a strong advocate of it.

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  4. Mike great job on laying out a rapid trauma assessment for the layman to use, hope you will forgive my insisting that the old ABCs still being taught are great for a clinic with ambulatory patients but in most scene trauma responses a different plan is needed and I think you are illustrating this idea.
    For a grid-down emergency medical response I have my own mnemonic. Its a combination of ATLS, TCCC and Mass Casualty
    initial assessment and works in just about any situation.
    A….Assess scene safety
    A…..AVPU
    M….Massive Hemorrhage
    A….Airway
    R….Respirations
    C….Circulation
    D….Disability/deformity
    Its a little unwieldy to pronounce it but that’s OK because you are reciting it in your head while you are working anyway.
    The reasoning behind treating massive hemorrhage ahead of airway,
    regardless of whether its caused by a GSW or an MVC is that you can live longer without an adequate airway than you can a severed major artery pumping your blood onto the ground. The CROC devices for junctional and abdominal hemorrhage have had limited use in the field but are showing some good early successes. I think they are way too expensive for the average person to get.
    Even though AVPU is the second one listed, it doesn’t mean I am going to stop and treat whats making him unconscious. Its just to see if he can aid in his care and rescue. And to have someone to talk to while Im doing the rest of the assessment.
    Airway is fourth on the list in my book and in situations where you are the lone provider with numerous patients, deserves no more than, positioning, check mouth for objects and finger sweep if needed and move to the next patient..
    As in all multiple casualties, use AAMARCD to treat the worst first unless they obviously have zero chance of survival.
    A simple mnemonic will not fit every scene or situation, thats where the judgement and experience of the provider comes in. I have witnessed too many cases where following protocols or “the book” cost
    people’s lives. Conversely not having a solid skill set and plan will cost patients and providers their lives unnecessarily.

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  5. Nicely broken down. Trauma Assessment and Medical Assesment are the only skills I’m feeling iffy on and more so Medical than Trauma since I’ve seen this I take the hands on test for the national registry this coming Tuesday. Thank you for the break-down!

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  6. Every one has thier own Kata on the primary trauma survey. Most are quite similar. Although all are good, I dont prefer a linear aproach but do several things at once in a set sequence that is super well rehersed. If I get knocked off track I start over. Hands on takes about 1 min per patient, 40 sec if they are minimaly injured. up to 3-5 min if interventions are needed.

    Heres my 2 pennies worth. Again its just an overview of what I do.

    step one is to prepare with training, aid bags packed daily, rehersals, vehicles maintained and fueled, gloves, knee pads, full kit etc…
    Gather information on the scene from the initial call on location, patients quantity and main issues, mechanism.

    example: Grid XX 666 666 – 3 green 2 red hemodynamic unstable GSW.
    litter vs ambulatory and interventions applied, complex extraction needs, and security/hazard info are also helpfull.

    If I am on scene at the time of injury its more obvious, If running search paterns I use red green and blue LED triage lights when pts are found or IR as apropriate. I dont use yellow. I mark distance and direction from a central point. If I cant get to the patient then I try to assess with verbal or binoculars at a distance. The assessment is continuous and fluid based on what info I can access. Remenber the first report is alwase wrong. be prepared to change expectations on the fly.

    On arrival to the patient its asess safety and mechanism on aproach, check own pulse so to speak and walk the last few steps. Ensure my weapon is accessable but out of the way. Ensure that the patients weapon or demo or attitude is not a hazard. Disarm and restrain patient with overwatch if needed. We have to solve the tactical or safety problem first that put the patient there. Thats usually the best medicine.
    Initial touch is the radial pulse and a question re where does it hurt, assesing pulse quality and rate, skin temp, cognition (avpu and do they track and make sense), airway, breathing effort, skin color, obvious major bleeding, mechanism clues like burnt eyebrows etc… immediately address obvious critical issues and reassess, Quick interventions like reposition airway and TQ take little time and are done on discovery of issues. Chest decompression or packing a wound may also be done at this time based on severity. Only life critical interventions that take under 1 min are done at this point.
    blood sweep- I touch press (crepitus check) and rub fingers to check for fluid in the following sequence.
    Face, scalp, neck, armpits and upper back, sternal press, flanks, belly press, illiac crest press, glutial fold thigh leg, oposite leg, cross leg, arms, one person roll to side with c spine in line sweep back again , triage marker light and location, move to next patient.
    The sequence of assess again, vs move to the next patient or start moving pt to the casualty colection point/evac staging area is based on situation, when in doubt do a slower more detailed patient survey, and reasess the patient.
    I ask further pertinant questions while doing the survey.

    If needed I anotate pt triage color and location on a 3″ tape strip on my left thigh. Right thigh is pt data from the secondary survey, and gets stuck on the patient.

    I personaly dont use dcap btls etc as I dont need to think about all those names while doing an assessment. Im looking for anything wrong and adressing it when apropriate based on how life threatening it is. They are great for the initial school house indoctrination.

    For training we put KY on the skin under clothing and try to find it on a primary survey.
    A dime taped to skin should be found on a secondary survey.
    Filming the survey alows the individual to see what they can do better.
    doing it filmed blindfolded with a verbal patient also brings out weak areas

    In the end the decision to evac or treat in place needs to be made. Again situation dependant.
    The book says send the most critical first. I try not to send all the reds at once. If you give 4 reds to a single medic on a truck he will be overwhelmed. Send 2 reds with 2 greens to help the medic. Heck put another least injured green in the front seat as codriver. Consider things like distance and road conditions, medic skill level, anticipated time till the next platform arriving etc before just loading reds up.

    In the above example treat in place will likely be the only available option for a few days.
    Based on the description plan on the items to bring or scrounge enroute. Im thinking Husband Splint and ABO for the leg, pain meds, crutches.
    For the wife medical or more likely trauma causes of LOC. anticipate an assessment, and based on that be prepared to move the patient to shelter to maintain warmth while maintaing spine precaution as possible. If you have the skills, (read neuro surgery in the tropics and do a good neuro trauma rotation in the developing world or in a pinch with a vet) bur holes may be indicated to decompress, possibly a flap.
    lack of a pulse or perfusion, lack of respirations without drowning or electrocution and CPR would not be very benificial.

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    • Love this. Definitely a better approach for people with more experience that can sense a bad patient from six feet away from prior experiences. The weapons thing is a big one. Nothing like a combative TBI in your own group waving a carbine around.

      Thanks for your contributions pa4ortho, this is great stuff.

      Drop a line at: Headmaster_at_Hogwarts@hotmail.com if you get a chance. Thanks!

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  7. PA excellent systematic approach for quick treatment in hostile environment. Hogwarts seems to be attracting some great talent for the mission. One point I would like to repeat that was mentioned, in hostile environments, disarm the patient only if NEEDED. That is almost always someone who has been given morphine or narcotic pain-killer and someone with a TBI, who is showing cognitive impairment, i.e. lethargy, unusual anxiety or non-recognition of people/surroundings. In a hostile environment you need every shooter armed and ready, that includes the patient if necessary. Just because you have the situation somewhat under control does not mean you can not get hit again while you are distracted with medical care. And lastly, Medical decisions NEVER take precedence over .tactical decisions. Here is a real time TCCC video from a couple of years ago.
    These guys had prior TCCC training but it is hard to remember some of the POL when bullets are zinging around you. Warning; Graphic Army language content.
    http://spec-opsmedic.blogspot.com/2013/07/firefight-while-waiting-for-medevac.html

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  8. Like the man said. Everyone has their own kata for survey. My Primary Survey is usually done before I get to the vic. Airway, breathing, profuse bleeding are USUALLY visible on the way in. Interventions at that point tend to be profuse bleeding first, then airway, because you can bleed to death MUCH faster than your brain dies from cardiac or breathing interruptions..(+/-45 secs for a femoral lac against 4-6 mins from resp or cardiac interruptions)

    Then I run a head to toe survey that can take around a minute. You touch everything on the way down, scalp, eyes, nose, mouth skull, neck (palpation only), shoulders arms hands (skin temp, color, cap refil presence of radial pulse) check for an extra elbow, and chest/abdomen feeling for unusual discontinuities etc, feeling for lumps in the abdomen, etc.
    Press pelvis for crepitus and continue down the legs looking for discontinuities an extra knee, etc.
    This is also where you want to be aware and careful in looking for a femoral fracture with partially tamponaded femoral bleed (thigh muscles can absorb a unit or two of blood which never gets out of the body) This would require an intervention right now.
    You do reach under to palpate the spine and posterior chest as you come down.

    Takes longer to type than it does to do…
    BUT it is systematic, and you need to practice it on someone until it’s something that is as natural as breathing

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  9. Pingback: The rapid trauma assessment – Part II | Hogwarts School of Grid-Down Medicine and Wizardry·

  10. Pingback: Rapid trauma assessment – Part III: You need some SOAP | Hogwarts School of Grid-Down Medicine and Wizardry·

  11. Pingback: Hogwarts: Rapid Trauma Assessment – Part III | Western Rifle Shooters Association·

  12. Pingback: Burns | Hogwarts School of Grid-Down Medicine and Wizardry·

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