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Medical Education Division |
Operational Medicine 2001
Field Medical Service School
Student Handbook
Casualty Assessment
FMST 0422 17 DEC 99
TERMINAL LEARNING OBJECTIVE: 1.
Given a casualty in a combat environment
(day and night) and the standard Field Medical Service Technician
supplies and equipment, perform casualty assessment survey, per the references.
(FMST.04.23) ENABLING LEARNING OBJECTIVES: 1.
Without the aid of reference materials, identify from a list the correct
purpose of performing an accurate primary and secondary survey, per the student
handout. (FMST.04.23a) 2.
Without the aid of reference materials and given a list, select the six
sequential steps of a primary survey, per the student handout. (FMST.04.23b) 3.
Without the aid of reference materials and given a FMST MOLLE Medic bag
and a simulated casualty, perform a primary and secondary survey in less than 7
minutes, per the student handout. (FMST.04.23c) OUTLINE: A.
PRIMARY SURVEY
a.
Combat Primary Survey 1.
Definition The combat primary survey is a method of identifying and
treating all major life threatening injuries while in under effective fire
conditions. a)
The combat primary survey usually involves treating numerous casualties. b)
Procedures performed are for rapid, life saving interventions. Definitive treatment will be rendered during subsequent
assessments at higher echelons of care. 2.
Procedural Steps for Performing a Combat Primary Survey a)
Area Security make sure that the area is secure before entering b)
Scene Size Up A quick analysis of the scene to determine what type of
injuries to expect c)
Determine Responsiveness of the Patient 1)
AVPU Examination
Figure 1 AVPU Examination d)
A1 Airway Assessment and Management 1)
Does the patient have an open airway? (a)
Head tilt / Chin lift maneuver (b)
Jaw Thrust maneuver (c)
Safety pin through the tongue maneuver 2)
Look, listen, and feel for respirations (a)
Listen for a minimum of 05 to 10 seconds (b)
Gives a rough estimate of respiratory rate of the patient 3)
Insert an appropriate airway if required (a)
Oropharyngeal Airway only in unconscious patients (b)
Nasopharyngeal Airway may be utilized in all patients e)
B1 Breathing Assessment and Management 1)
Inspect Thorax (a)
Watch for bilateral symmetry during inspiration / expiration (b)
Observe obvious signs of thoracic trauma wounds, ecchymotic areas (1)
Occlude any open wounds with either 3 or 4 sided occlusive dressings 2)
Auscultate Thorax (a)
Listen over one lung field bilaterally on the anterior chest wall (b)
Listen to heart tones at the 5th intercostal space,
midclavicularly. (1)
Known as the Point of Maximum Impulse (PMI) (2)
Note rate, rhythm, and character of heart tones 3)
Mark the position of the trachea 4)
Palpate Thorax (a)
Anterior Thorax (1)
Check for flail chest segments (2)
Check for bony crepitus (b)
Posterior Thorax (1)
Can palpate or rake the posterior thorax checking for injuries (2)
Place an unopened abdominal dressing on any posterior sucking chest
wounds (occlusive dressing) 5)
Percuss Anterior Thorax (a)
Hyper-resonance indicates an accumulation of air (b)
Dull indicates an accumulation of fluid 6)
Perform Needle Thoracentesis (if indicated) f)
C1 Circulation Assessment and Management 1)
Check for a pulse (a)
In a combat environment, if a patient has no pulse, it is unlikely that CPR will
be initiated. 2)
Assess for uncontrolled gross bleeding (a)
Identify source of bleeding and type of bleed (1)
Arterial bleeding (2)
Uncontrolled venous bleeding (3)
Amputation (a mixture of #1 and #2) 3)
Control all gross bleeding (a)
Apply an appropriate dressing, pressure dressing, or hemostats to control
the bleeding (b)
Place a loose tourniquet around an amputation to control bleeding
(tighten as needed). Place a 4x4
under the stump to assist in monitoring blood loss. NOTE: In a combat environment, this is all you would treat. You would then move on to your next patient and perform the same assessment until all casualties had been properly treated. b.
Non-Combat Primary Survey 1.
Definition The non-combat primary survey is a method of identifying
and treating all potentially life threatening injuries when there is no
effective fire conditions. a)
The non-combat primary survey focuses on treating one casualty b)
Procedures performed are for establishing definitive treatment methods
for these potentially life-threatening injuries. c)
Many times the non-combat primary survey will be performed once a
casualty has had a combat primary survey performed, or once the casualty has
been removed from the combat environment. 2.
Procedural Steps for Performing a Non-Combat Primary Survey a)
Airway Assessment and Management 1)
Provide the patient a definitive airway (b)
Emergency Cricothyroidotomy (1)
Performed for obstructed airways -or-
(2)
Failed two attempts to endotracheally intubate the patient 2)
Hyperventilate patient with maximum oxygen concentration available 3)
Consider C-Spine precautions (a)
Apply C-collar and long board spine immobilization if available b)
Breathing Assessment and Management 1)
Inspect Thorax (a)
Watch for bilateral symmetry during inspiration / expiration (b)
Effectiveness of chest dressings (c)
Effectiveness of needle thoracentesis 2)
Auscultate Thorax (a)
Listen over two lung fields bilaterally over the anterior chest wall (b)
Listen to heart tones at the PMI, noting rate and rhythm, and character 3)
Assess for tracheal deviation (a)
Perform needle thoracentesis
if indicated 4)
Palpate Thorax (a)
Check for flail chest segments (b)
Check for bony crepitus 5)
Percuss Thorax checking for hyper-resonance or dull sounds (could
indicate pneumothorax or hemothorax) 6)
Logroll patient to inspect posterior thorax for injury (perform same
assessment as on anterior thorax) c)
Circulation Assessment and Management 1)
Assess status of all controlled bleeding (a)
Estimate amount of blood loss (b)
Reinforce saturated bandages as necessary (c)
Tighten tourniquets as necessary 2)
Initiate two large bore IVs (18 gauge or larger).
Titrate fluids to a radial pulse. d)
Disability Assessment (Neurological Exam) 1)
AVPU Exam 2)
Check neurological integrity by having patient wiggle fingers and toes
(if awake). Note patients
response. Also note if patient has
pain or parasthesias. e)
Exposure of Patient 1)
Remove enough clothing to properly treat the patient and conduct further
assessments. 2)
Remember to provide cover for the patient to prevent unnecessary cooling f)
Full Set of Vital Signs (a)
Three methods of obtaining a blood pressure in a casualty: (1)
With a blood pressure cuff if stethoscope and BP cuff available (2)
Palpable blood pressure when stethoscope is not available or
conditions preclude the use of the stethoscope (i.e. in a helicopter) (aa)
Apply a blood pressure cuff and inflate until the brachial or radial pulse
disappears. (bb)
Slowly release the pressure until you feel the pulse return.
(cc)
Pulse return indicates an approximate systolic blood pressure (3)
Pulse pressure if a blood pressure cuff is not available (aa)
Find the patients pedal pulse if present, patient has a systolic blood
pressure of at least 90 mm Hg (bb)
If the patient has no pedal pulse, attempt to find the radial pulse if
present, patient has a systolic blood pressure of at least 80 mm Hg (cc)
If the patient has no radial pulse, attempt to find the femoral pulse if
present, patient has a systolic blood pressure of at least 70 mm HG (dd)
If the patient has no femoral pulse, attempt to find the carotid pulse if
present, the patient has a systolic blood pressure of at least 60 mm Hg. 2)
Pulse note rate and rhythm of pulse 3)
Respirations note rate, depth, and effectiveness of breathing
patterns g)
Go to the beginning and reassess one more time before initiating patient
evacuation or transport B.
SECONDARY SURVEY
a)
Is a systematic evaluation of the patient from head to toe b)
As injuries are identified, proper treatment is rendered c)
Secondary surveys are usually initiated once the patient has been removed
from the combat environment and taken to the Battalion Aid Station (BAS) or a
higher echelon of medical care
a.
To assist in remembering the order of performing a secondary survey, use
the pneumonic HNS CASPER b.
H HEAD AND FACE 1.
Inspect a)
Look for the following: 1)
Bruising (a)
Battles Sign bruising behind the ears.
Can indicate a fracture of the mastoid process or a depressed skull
fracture 2)
Lacerations 3)
Obvious deformities 4)
Drainage or Discharge from
the ears and nose b)
Eye Examination checking for PEARLA, extra-ocular movement is intact,
foreign objets (to include contact lenses), and redness c)
Mouth Examination checking for foreign objects within the mouth
(dentures, broken teeth, etc.), bleeding, or lacerations. 2.
Palpate a)
Place hands over the entire skull and facial regions, checking for
tenderness, deformities, instabilities, or depressions b)
Common injuries include: (1)
Depressed skull fractures (2)
Zygomatic Arch fractures (found underneath the eyes) (3)
Mandibular fractures (4)
Maxillae fractures (cheekbones) 3.
Percuss not applicable during this assessment 4.
Auscultate not applicable during this assessment c.
N NECK 1.
Inspect- a)
Look for: 1)
Distended neck veins may not be significant if distended while the
patient is lying down. If the
patient is sitting upright, may indicate development of a tension pneumothorax. 2)
Lacerations 3)
Bruises 4)
Deformity b)
Trachea Examination - It should be in the midline at the suprasternal
notch. Deviation of the trachea may
indicate tension pneumothorax. 2.
Palpate- a)
Palpate the neck for tenderness or masses (internal bleeding) 3.
Percuss - not applicable during this assessment 4.
Auscultate - not applicable during this assessment d.
S SPINE 1.
Inspect inspect the spinal region for obvious deformities 2.
Palpate gently palpate the entire spinal region for pain or bony
deformities 3.
Percuss not applicable during this assessment 4.
Auscultate not applicable during this assessment e.
C CHEST 1.
Inspect a)
Look for 1)
Chest wall symmetry on inspiration / expiration (a)
Paradoxical chest wall movement could indicate a flail chest (b)
Asymmetry could indicate a pneumothorax, hemothorax, or tension
pneumothorax 2)
Bruising 3)
Obvious deformities to the chest wall cavity 4)
Open wounds or lacerations not previously treated 2.
Palpate a)
Gently press on the rib cage, looking for: 1)
Fractures 2)
Subcutaneous Emphysema air trapped underneath the skin 3.
Percuss a)
Percuss over the lung fields, listening for: 1)
Hyper-resonance 2)
Dullness 4.
Auscultate a)
Listen to all lung fields, both anteriorly and posteriorly. Note rate, depth, pattern, and adventitious lung sounds b)
Listen to the heart tones at all 5 examination points. Note rate, rhythm, and character of the heart tones. f.
A ABDOMEN 1.
Inspect a)
Look for the following: 1)
Abdominal distention could indicate internal damage or bleeding 2)
Abdominal bruising same as above 3)
Wounds or lacerations not previously treated or identified 2.
Auscultate a)
Listen to all 4 quadrants of the abdomen checking for the presence of
bowel sounds. 1)
Absence of bowel sounds could indicate internal damage to the large and
small intestine 3.
Palpate a)
Gently press on the abdomen, checking for: 1)
Tenderness 2)
Rigidity 4.
Percuss a)
Hyper-resonance indicating free air in the abdominal cavity b)
Dull indicating fluid within the abdominal cavity g.
S SHOULDERS 1.
Inspect a)
Looking for: 1)
Obvious deformity 2)
Bruising 2.
Palpate a)
Gently press over the clavicles, looking for: 1)
Tenderness 2)
Crepitus 3)
Step Offs 3.
Percuss not applicable during this assessment 4.
Auscultate not applicable during this assessment h.
P PELVIS 1.
Inspect a)
Look for: 1)
Bruising 2)
Wounds or lacerations 3)
Edema b)
Genitalia, looking for: 1)
Bruising 2)
Wounds or lacerations 3)
Bleeding
from the urethral meatus (in males) 2.
Palpate a)
Compress the pelvis from side to side to determine tenderness and the
presence of crepitus. b)
Compress the iliac crest checking for pelvic stability. 3.
Percuss not applicable during this assessment 4.
Auscultate not applicable during this assessment i.
E EXTREMITIES 1.
Inspect a)
Look for: 1)
Obvious bony deformity 2)
Wounds or lacerations not previously identified or treated 3)
Bruising, abrasions, or other skin impairments 2.
Palpate a)
Gently press on the entire extremity, looking for: 1)
Crepitus 2)
Pain 3)
Check distal pulses in all extremities 4)
Check motor strength in all extremities 3.
Percuss not applicable during this assessment 4.
Auscultate not applicable during this assessment j.
R RECORD ALL DATA 1.
Record all injuries and treatments initiated 2.
Record patients responses to treatments 3.
Record vital signs 4.
Go back to the beginning and reassess your patient. REFERENCE
(S): 1. Tactical Emergency Care
2. Advanced Special Operations Medical Training Course Field Medical Service School
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