Trauma Primary Survey for Rural and Austere Environments

1. Trauma Primary Survey forRural and Austere Environments William A. Liston MD FACS Capt, MC, USN July 2011

2. Acute Trauma • Leading Cause of Death all over the world in ages younger than 44 • Prevention is the key to improving survival • Safe driving, removing land mines or IEDs • Preventing burns from open flame heat/ cooking • Safe handling of firearms • Safe electrical power/ wiring

3. Primary Survey • Organized approach prevents missing injuries that may cause death • May be done with little or no resources such as X-ray machines, lab tests, sonograph (Ultrasound )machine • Same approach may be useful to triage large numbers of injured patients that require care

4. Primary Survey • Easy to remember method of ABCDE • A = Airway/ the opening from the mouth to the lungs • B = Breathing/ moving air from the mouth to the lungs • C = Circulation/ assess for blood loss • D = Disability/ Is there a head injury and/ or paralysis of any arms or legs • E = Expose or examine the entire patient to not miss any injuries including the back and then cover patient to prevent heat loss

5. Airway • Chin Lift/ Jaw thrust may be enough to allow patient to breath on their own • Rescue breathing position may allow patient to breath that has bleeding from the mouth or is not completely awake • Bag Valve Mask ventilation with oxygen or just room air may be adequate to allow the patient to breathe • Nasal trumpet may assist breathing

6. Breathing • Breathing cannot occur without an open airway • If a patient can talk or moan then they have an open airway and can breathe • Bag Valve Mask can assist with breathing • Endotracheal intubation is not always necessary or available • CPR techniques can include mouth to mouth breathing but the person doing it wears out within 30 minutes at best

7. Circulation 1 • Many injured patients die from hemorrhage/ bleeding • Bleeding can be seen externally from lacerations to the body/ it is hard to guess blood loss from looking at blood on a patient or beside them • Bleeding may going on in the chest, abdomen, pelvis, or in the thigh and not be seen • Pallor, rapid pulse, patient complaining of thirst may be clues they are bleeding internally

8. Circulation 2 • Bleeding may be treated for external wounds by pressure dressing and or tourniquets • Oral fluids with some salt and sugar mixed in may be given to patients that are awake enough to swallow instead of intravenous saline or blood • Patients may survive for long periods of time with severe wounds internally because some times the body will shut down blood flow to non-vital organs to preserve life

9. Circulation 3 • Patients with blood loss that is significant are best treated with blood and intravenous fluids • Tourniquets should not be left on for more than 6 hours if possible to preserve the extremity • Tourniquets may be left on for longer trading an arm or leg for life • Keeping the patient warm with blankets may prolong life while waiting for transportation to a hospital that can treat their injuries

10. Disability 1 • Patients that are struck in the head or have a penetrating head injury from bullets, fragments, IEDs, explosions may have a brain injury that requires CAT scan and neurosurgery • Some patients will survive a brain injury without surgery • Oxygen, when available, may help prevent further brain damage • Unequal pupil size or pupils that do not contract with a light may indicate a brain injury

11. Disability 2 • It is important to exam a patient for paralysis and note the level it is at • Patients that have been paralyzed by the trauma usually have a spinal cord injury • It is important to pad the back with a blanket to prevent sores from developing on the patient’s back, head, neck, or buttocks • It is important to fix the patient to a firm surface/ backboard to stabilize the spine and prevent further injury

12. Exposure/ Environment • It is important to remove all clothing to look for injuries including the back • It is important to cover the patient back up after exam to prevent hypothermia even in a warm climate • Patients lose body heat faster after blood loss • Patients may be completely examined modestly with an attendant/ family member present • It should be stresses to the patient and family how important this exam is so as to not miss an injury

13. Transport • Patients that are severely injured are best cared for at a hospital that treats trauma patients • Patients that are severely injured may survive several hours to days with minimal care so continue to provide care if possible or care not futile • Open skull fracture at top of mountain with no help • Simple splinting and/ or backboard may reduce further injuries during transport

14. Summary • Good care can be provided with little to no resources • Systematic approach can discover most injuries and prevent worse injuries from treatment or lack of good treatment • Remember ABCDE • Patients with severe injuries are best treated at a hospital that cares for trauma patients