Primary/Secondary Survey of the Combat Casualty

1. Primary/Secondary Survey of the Combat Casualty CPT Allen Proulx, MPAS, PA-C Tactical Combat Medical Care (TCMC)

2. Objectives • Discuss the importance of the primary/secondary survey • Outline how ATLS applies to the combat casualty

3. Time of death

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

5. 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 combat?

6. How Do We Develop Our Approach? • What are we going to see? • Injury patterns • Civilian trauma? • Combat trauma?

7. 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 • Combat Trauma • We don’t know the death distribution • It is believed that if the casualty can arrive alive and relatively stable to the FST/CSH…they will live.

8. 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

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

10. The Combat Casualty Primary Survey • Assess for hemorrhage first • Intervene for life threatening bleed only! • Then, assess for tension pneumothorax • Perform needle decompression as needed • Then, assess for an airway • Utilize a Combitube or surgical airway • Rarely a need for c-spine control

15. The Combat Casualty Primary Survey • D-disability- decision to evacuate • GCS scoring is appropriate AVPU also appropriate • 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!!! • F-foley • Situational need for urinary catheter • G-gastric tube • Situational need to decompress the stomach

16. Hypothermia is Bad!

17. Rewarming in the trenches of WWI

18. Heat loss during transport

19. Hypothermia

20. Hypothermia

21. The Combat 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!

22. 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

23. Head exam • DCAP-BTLS • Pupils • Otorrhea/Rhinorrhea/Hemotympanum • Raccoon/Battle signs • Mid-face instability

24. Neck exam • Step-off • Tracheal deviation • Jugular vein distention

25. Chest exam • DCAP-BTLS • TIC • Auscultation • Percussion

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

27. Extremity exam • DCAP-BTLS • TIC • PMS

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

33. Questions?