Primary/Secondary Survey of the Combat Casualty CPT Allen Proulx, MPAS, PA-C Tactical Combat Medical Care (TCMC)
Objectives • Discuss the importance of the primary/secondary survey • Outline how ATLS applies to the combat casualty
Primary/Secondary Survey • Why is it important? • What and where are the wounds? • What resuscitation is required? • Mode of CASEVAC?
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?
How Do We Develop Our Approach? • What are we going to see? • Injury patterns • Civilian trauma? • Combat trauma?
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.
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
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
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
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
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!
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
Head exam • DCAP-BTLS • Pupils • Otorrhea/Rhinorrhea/Hemotympanum • Raccoon/Battle signs • Mid-face instability
Neck exam • Step-off • Tracheal deviation • Jugular vein distention
Chest exam • DCAP-BTLS • TIC • Auscultation • Percussion
Abdominal/Pelvic exam • DCAP-BTLS • TRD-P • Pelvic instability • Priapism • Scrotal/labial hematoma/blood at the meatus
Extremity exam • DCAP-BTLS • TIC • PMS
Posterior Thorax • Log roll casualty • Spine • DCAP-BTLS • Tenderness/step-off • DRE • Gross blood only