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This is designed to elicit all immediately life threatening injuries with the most serious problems identified first. An airway problem can kill you in three minutes, a breathing problem in six, and a circulatory problem in nine. If possible, try to also take a history. Remember their friends or passers-by may be able to provide you with more information than the patient.

Remember DR C ABCDE

D - Danger

Before you approach a casualty situation it's important to ensure that the area is safe before approaching, because the last thing you want is to become a second casualty. For example, if a patient has fallen from a height, is there a risk of falling rocks or masonry? In a road traffic collision, is there any fuel visible leaking out onto the road?

R - Response

As you approach the patient, see whether they're alert and looking around. If not, use the COWS approach;

  • C - Can you hear me?
  • O - Open your eyes.
  • W - What is your name?
  • S - Squeeze my hands.

C - Catastrophic haemorrhage

While Airway and Breathing come before Circulation, if the patient is visibly bleeding at an alarming rate (particularly with a spurting arterial bleed) then you need to try and stop the bleeding as a matter of priority, with direct pressure and if necessary, a tourniquet.

A - Airway

Assess patency of airway and consider the need for an airway adjunct (OPA/NPA). In a casualty with an unknown method of injury always secure their cervical (C) spine. This is the same for any fall greater than head height.

Talking to patients is a good initial way of doing this. Someone who can talk to you clearly has a patent airway, a reasonable respiratory function and decent neurological function.

Airway problems can manifest in a variety of manners, the most notable are noisy breathing, lack of chest movement, poor/uncoordinated respiratory effort and cyanosis

If you suspect there is an airway problem, use one of the following techniques:

  • Simple airway manoeuvres - head tilt, chin lift (not appropriate if suspected c-spine injury); jaw thrust (first two fingers behind the angle of the jaw, pull forwards. This is very difficult on a conscious patient).
  • Insert an airway adjunct - nasopharyngeal or oropharyngeal airway.
  • (Tracheal intubation)
  • (Surgical intubation)

B - Breathing:

Assess general work of breathing. Use the 'RV FLAP TWELV' mnemonic:

  • Rate - how fast are they breathing (normal is 12-20 breaths per minute).
  • Volume - are they getting good breaths, or are they shallow/deep.
  • Feel - respiratory rate, chest expansion, (symmetry) down the ribs, ‘raking’ for holes.
  • Look - wounds, symmetry, flail chest, cyanosis.
  • Auscultate + Armpits - air entry (same on both sides? crackles?), feel and look at armpits for wounds.
  • Percuss + pat the back - ensure you percuss vital areas (2 each side), rake back for wounds.
  • Trachea - central or not? (remember, deviation is a late sign).
  • Wounds - feel and look around neck
  • Emphysema - feel the neck and above the clavicles for surgical emphysema, which gives a ‘bubble wrap' feel.
  • Laryngeal crepitus - feel the larynx for instability
  • Veins - distended? (may not be distended if  hypovolaemic)

C - Circulation

The pulse can give you a general indication of the patient’s blood pressure, if you suspect a they might have a reduced blood volume (hypovolaemia)

  • If the radial pulse is palpable, the systolic blood pressure (sBP) is >80 mmHg
  • If the carotid and femoral pulses are palpable, the sBP is 70-80 mmHg
  • If only the carotid pulse is palpable, the sBP is 60-70 mmHg

Central Capillary Refill Time (CRT) - Feel this by pressing down with a finger on the sternum for 5 seconds and then releasing.  You should be pressing down hard enough to blanche your own fingernail. Normally blood should return to the small capillaries turning the skin pink again in under 2 seconds.  If this is delayed it may indicate circulatory failure. One cause of this is blood loss. It is important to note that in cold conditions CRT can be prolonged normally.

Identifying haemorrhage - blood on the floor and four more. Don’t forget the back, and that waterproof clothing will hide it - this means getting the casualty suitably exposed.

  • Chest - percuss chest and feel around back for any broken ribs.
  • Abdomen- look for bruising on back/ swelling on abdomen.
  • Pelvis - check superior iliac crests are aligned.
  • Long bones - feel down long bones for any breaks.

D - Disability

This really means assessing neurological functioning. Whilst there is little you can do in a remote setting to solve neurological problems knowledge of the problem can highlight areas of concern (e.g. the patient in with a declining neurological status; consider shock due to an occult bleed) and is important for other medical teams to be aware of. There are a two major methods of doing this which are summarised below:

AVPU - this is a basic but thorough method of assessment.

  • A - Alert. Is the patient alert?
  • V - Voice. Does the patient respond to your voice? Don't be shy, be loud!
  • P - Pain. Does the patient respond to a painful stimulus? (e.g. trapezium squeeze, pressing on the supraorbital notch)
  • U - Unresponsive, is the patient unresponsive?

Glasgow Coma Scale (GCS) - this is a more thorough method of examination, however it is more complicated. Whilst used widely by paramedics and emergency care doctors it is not necessary to know. It is marked out of 15 in three domains

1

2

3

4

5

6

Eyes

Does not open eyes

Opens eyes in response to painful stimuli

Opens eyes in reponse to voice

Opens eyes spontaneously

Motor

No response to pain

Extensor response to pain (decerebrate response)

Abnormal flexor response to pain (decorticate response)

Withdrawal from pain

Localises pain

Obeys commands

Verbal

No verbal response

Incomprehensible sounds

Inappropriate speech

Confused conversation

Orientated and appropriate conversation

Pupils

  • Look at the casualties pupils - are they too big/ too small/ symmetrical? (Remember that the pupil on the same size as the lesion dilates.)
  • Light reactivity - using pen torch
    • On each eye test the direct response (does pupil you're shining the light into constrict?)
    • And the consensual response (does the other pupil constrict?)

Motor - Ask patient to wiggle toes and fingers. This shows the casualty is able to follow instructions and does not have limb weakness due to nerve damage.

E- Exposure/Environment

Exposure - In hospital practice the whole patient needs to be exposed for a complete examination. In a wilderness setting, though, it is usual to expose only one part of the patient at a time to limit heat loss. The point is to make sure you haven’t missed anything that could potentially be fatal. Look for life threatening skin conditions (massive burns, non-blanching rash & erythroderma) and injuries. Check the patient's temperature if you have equipment. If there is no thermometer try to gauge the patient's temperature by touching the skin on their trunk (compare with your own and others' if unsure if it is abnormal).

Environment - Do what you can to prevent the environmental temperature causing the patient's temperature to become abnormal. In the UK cold is the main problem - do whatever can be done to insulate the casualty from the ground and to protect them from wind and rain. Hypothermia in trauma casualties increases the mortality rate.

Ways to reduce heat loss:

  • Try to position them away from wind
  • Insulate them from the ground eg. Kneel down and place casualty on knees
  • Erect a group shelter (storm shelter)
  • Remove the wet clothes if there are dry replacements available
  • Place the casualty in a warm casualty bag or improvise with a "hypothermia wrap"
  • Skin to skin contact can help warm up
  • Remember that if the casualty is hypothermic then other members of the same group may well be hypothermic too (or at risk of becoming hypothermic). Look after the rest of the group.

If the environment is one when heat illness is likely to be a problem then the casualty should be moved to shade (if possible) and cooled with evaporative cooling (pour a little water on their clothes at regular intervals). Remove insulating clothing/clothing that will retard heat loss. If there is any breeze or wind place the casualty in a position to take advantage of this if possible. A hammock is ideal for increasing heat loss.

(DEFG)- don’t ever forget glucose!

If there are any issues with any of the above areas, intervene to correct it and then go back to the start and reassess everything. Remember, if in doubt, or anything changes, start again!

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