Advanced first aid – Primary survey

An excellent enhancement to training is the introduction of simulated casualties. Not only does this test first aid knowledge, but dealing with the tactical situation is an added stress that puts pressure on the section commander and members of the section. Everyone has a part to play and without teamwork and communication the situation can quickly escalate. This lesson will introduce an advanced primary survey, and teach you new techniques and considerations when dealing with complex casualties. The level of this training is First Responder, and is far more advanced than you will likely have received. Before we start, let’s check your existing knowledge and then work on enhancing it with current protocols and methods.

This is a complex subject. Don’t let it put you off. Take as much or as little from this lesson as you feel comfortable. Unless it is dangerous to do so, never hold back from providing treatment to a casualty even if you don’t think you know what to do. Doing something is better than taking no action at all; even if it is just getting appropriate help. The information given here is for your development, always seek professional and accredited training.

Danger

This is your approach to the situation and to the casualty. Never rush into a scene without first fully appreciating the situation. Should you become a casualty during this process you will become incapable of helping the casualty and you will potentially hinder their treatment. We must consider three things, the three SSS:

• Self – Whatever situation we are entering, we must make sure we do not put ourselves at risk of becoming a casualty.
• Scene – Be aware that a scene is a 3-dimensional environment. Is anything we do going to increase the hazard of the scene?
• Survivors – As a result of our actions, we must not endanger any additional casualties or survivors.

To make sure we consider the situation, we use the SAFE approach:

• Shout, send or signal for assistance (report using METHANE, below)
• Assess the scene, looking for dangers and the potential mechanism of injury
• Free the scene from dangers and find the casualties (there could be more than one)
• Evaluate the casualties (by conducting the primary survey)

METHANE report

Signalling for assistance is crucial to making sure you have assistance on the way before you start treating casualties. In a simple unconscious casualty scenario, we initially shout for help upon establishing the casualty is unresponsive, and then if no help has arrived by the time we check for breathing (which is not normal), this is when we would leave and either phone an ambulance ourselves or summon help. In a multiple casualty situation, this becomes more important. We use the mnemonic METHANE to report the situation and summon assistance.

• Major incident declared – Can you deal with the situation based on your current resources? If not, then this becomes a major incident and assistance is required. This could be declared immediately, or put units on standby if the situation changes.
• Exact location – A grid reference is the usual method of relaying our location. Use local maps or GPS, and include any features of landmarks to help. Make sure you have this ready before making the call.
• Type of incident – Give an overview of your upstanding of the incident, this will help the rescuers deploy a suitable response. Examples could be gun or bomb attack, chemical spill or road accident.
• Hazards – What hazards have you identified, but also what could become a problem in the future, such as the collapse of damaged buildings or ignition of leaking fuel.
• Access and egress – Try to establish safe routes in and out of the scene, and communicate these.
• Number of casualties – How many are there and what is their level of injury.
• Equipment required – Do you need any specialist resources to deal with the situation? Fire brigade to extinguish fires or rescue trapped casualties, or hazardous materials teams to deal with chemical spills.

Primary Survey

Depending on your level of first aid knowledge and training, you should have heard of the primary survey. This is an initial systematic assessment of an individual casualty. This survey is “find and fix” – you must treat each area before moving on to the next. Once the scene is safe to approach, we start with an assessment of a casualties Responses, moving on to the ABC check – Airway, Breathing and Circulation.

Response

The protocol for assessing a casualty’s response level is AVPU. It is a progressive assessment that is repeated through your medium-term treatment of the casualty and can give an indication of any changes in their condition.

• Alert – The casualty is alert
• Voice – The casualty is not fully alert, but responds to voice stimulus. Give them a direct command such as “open your eyes”
• Pain – The casualty has not responded to voice stimulus, but responds to a pain response. In a first aid situation, we do not want to cause a casualty more pain, and we do not want to shake them either. An approach starting with a firm tapping on the shoulders, escalating to a pinch of the earlobe and perhaps to pinching the inside of the arm should be sufficient to initiate a response without causing too much discomfort.
• Unresponsive – If the casualty has not responded to either voice or pain, they are considered unresponsive.

Record or remember the level at which the casualty has responded. This information is useful when handing over a casualty to medical professionals – for example “upon arrival the casualty was responsive to voice, however they now only respond to voice stimulus.”

In first aid, upon discovering an unresponsive casualty we give a shout for “HELP!”

Catastrophic Haemorrhage (Bleed)

An addition to the basic primary survey, is the catastrophic bleed (cat bleed) protocol. With an increase in casualties who have lost their lives due to a delay in treating catastrophic bleeding, this assessment is now done before ABC.

Catastrophic bleeding is severe, sustained, uncontrolled and life threatening. It can occur as a result of traumatic amputation of a limb, as well as penetrating injuries resulting from shrapnel, bullet wounds or stabbings, and can also occur in the abdomen. There are a number of methods we can employ to stem the flow of blood:

• Tourniquets can be applied to the limbs in the event of amputation or a cat bleed. You should seek further training to learn how to apply a tourniquet, I will not cover it in this lesson.
• Haemorrhage control bandages comprise an absorbent dressing and a compression bandage and can be applied to limbs and torso wounds. They are more effective than standard dressings and apply considerable pressure to the wound when applied right.
• Haemostats are novel solutions that assist rapid blood clotting, they can be supplied as a powder, woven into a dressing, or in a gauze for wound packing. They must be used in conjunction with applied pressure.

C-spine

At this stage, we should consider possible upper spine injury, known as the cervical spine or c-spine. This can be as a result of a fall or impact, so an understanding of the mechanism of injury is important. While not life threatening, the consequences of not considering a c-spine injury can be life changing to the casualty. We will consider this when we come to establish the airway.

Airway

In order for us to conduct the breathing assessment, we need to make sure the airway is clear, established and maintained. If the casualty is talking, then it is likely their airway is all three, but be aware of any changes.

So, let’s undertake our airway assessment:

• Check – Visually check the mouth for obstructions, blood or vomit. Find and fix; if any are seen, tilt the head to the side and drain the mouth and airway. If there is a physical obstruction such as dislodged dentures, then you will need to remove them. DO NOT blindly sweep into the mouth with your fingers. Facial injuries may also be causing a problem with the upper airway, in which case you will need to do the best you can to keep it clear.
• Establish the airway – An unconscious casualty lying on their back may have a compromised airway despite not having any trauma due to the limp muscle mass of the tongue blocking their upper airway. There are two methods we can use to establish the airway based on our assessment of possible spinal injuries.
  • Head tilt, chin lift – This is the most common procedure taught in standard first aid courses, and is what you should be familiar with. Keeling beside the casualty in line with their shoulders, one hand grips the forehead, two fingers from the other hand are placed under their chin, and the head is tilted backwards while lifting their chin. Hold this position as you check for normal breathing (next stage).
  • Jaw thrust – This manoeuvre is recommended for casualties with suspected c-spine injuries as it enables better control of the head. However, it is not ideal for single-person first aid and should be maintained once applied. I will not teach this technique in this lesson.

Breathing

In the simplest form, a breathing assessment consists of a look, listen and feel for normal breathing. This check is normally done over 10 seconds, and consists of lowering our check to the above casualty’s mouth to feel for exhaled breaths, and looking down the chest for any rise or fall. But what is considered to be normal breathing?

• Breathing that is noisy
• Snoring sound
• Gurgling
• Sounds when breathing in
• Silence

A healthy adult should have a breathing rate of between 12 and 18 breaths per minute. Anything less than 10 and above 30 would give us cause for concern and not be considered normal.

In our advanced assessment of breathing, we go further than a simple look, listen and feel. ~we examine the chest for injuries. For the purposes of this examination, the check runs from the casualty’s shoulders to the bottom of their rib cage. There are many mnemonics to help guide us, including RESIN, TWELV or FLAPS WET. The one I have modified and chosen for this examination is RESIN:

• Rate of breathing
• Effort required to breath
• Symmetry of the chest – place a hand on each side of the chest and look and feel for the rise and fall
• Injuries around the chest, front, sides and back. You will need to expose the casualty’s chest and both look and feel for blood or tender spots, as well as bruising or any deformities. Roll the casualty over to examine their back. Raise each arm and check the armpits.
• Neck signs – If there is serious internal injury to the chest cavity, there will be signs around the neck. These can be checked using WET:
  • Wounds on or around the neck
  • Emphysema around the top of the chest (air bubbles trapped under the skin. Feels like rice-crispies)
  • Trachea (the wind pipe) is not central

In first aid, upon discovering there is no normal breathing, we would either leave and call an ambulance (if on our own) or start CPR straight away. The protocol for CPR is unchanged at this level, being 30 compressions and 2 breaths, and I will not cover it in this lesson.

Find and fix; cover any sucking chest wounds, and support any segments of broken ribs (flail chest) to ease some pain when the casualty breathes.

Circulation

A casualty who is breathing, should also have signs of circulation. This is the stage where we assess those, as well as looking for non-catastrophic, but still life threatening bleeds. Start by reassessing any cat bleed treatments; checking dressings or tourniquets, if applied.

At this level, we want to check the pulse. Not for signs of life, but as a diagnosis tool. The two areas we take a pulse are the wrists (radial) and the neck (carotid). If a casualty has lost considerable blood volume and their blood pressure is low, it may not be possible to find a radial pulse. We note the following details about pulse and circulation (RRD):

• Pulse rate
• Rhythm of the pulse
• Depth of the pulse (shallow, normal or throbbing)
• Skin colour, temperature to the touch, and clamminess (dry or clammy)

For an adult casualty, a pulse between 50 and 120 beats per minute (bpm) is acceptable.

We move on to look for other bleeding around the body. This is remembered using the saying “blood on the floor, and four more.”

• Signs of external bleeding (“blood on the floor”) including the skull
• 1 – Chest (likely checked during the breathing assessment, if not, do it now)
• 2 – Abdomen, is it rigid, tender or are there signs of bruising or injuries
• 3 – Pelvis, feeling both sides it should be even and not deformed
• 4 – Long bones in the arms and legs, looking for signs of internal bleeding caused by fractures, not concerned about fractures themselves

A capillary refill test (CRT) s a quick and easy method of testing peripheral circulation. A press onto the skin for 2 to 3 seconds will result in blood flow being restricted and the skin turning pale. Lifting your finger off the skin you should see the colour return within a similar time. The slower the refill time, the weaker the circulation. This can also be conducted by pressing a casualty’s finger or toe nails to check circulation at the extremities.

Find and fix; treat any bleeding as you find it, and provide support to a fractured pelvis – not covered in this lesson.

Disability

The disability heading is primarily concerned with assessing head injuries. The mnemonic PERL is used: Pupils Equal in size and Reacting equally to Light. This is typically done with a small pen torch, but opening the eye lids and exposing them to light can have a similar effect. Any casualty who does not respond equally to light is in need of urgent medical attention and this should be communicated as quickly as possible.

Exposure

Any form of casualty will struggle to maintain their body temperature. After your primary survey has been completed, make an effort to cover the casualty to retain body heat. Hypothermia can reduce their chances of survival dramatically.

Handover

As we anticipate evacuation of this casualty pretty soon, we start to prepare for a handover to the emergency services team. For reporting, we only report what is present, not what is not. They don’t need to know that you checked his abdomen and didn’t find anything. Keep it concise and clear. This follows the sequence ATMIST:

• Age / sex
• Time of incident
• Mechanism of injury
• Injuries sustained
• Signs and symptoms
• Treatment given

Flow Chart

Example

The time is 1030 in the morning, and you are driving with a colleague to a remote site to check on a some work. You are driving some way behind a heavy goods vehicle that suddenly swerves across the road, and continues driving. As you approach, you see the lorry has collided with a broken down car at the side of the road. You park your car about 100m behind, put on your hazard lights, get your first aid kit from the boot before approaching on foot. Your colleague comes with you and has brought their phone with them.

We approach the scene on foot, taking in as much information as we can. It sounds as if the engine is running, and we can smell what could be fuel. The car is badly damaged at the rear, and the bonnet appears to be raised. You tell your colleague to hold off, and you continue alone. This reduces the danger to your colleague as you go in to do an initial assessment of the scene.

As you get close to the car, you look in the windows and see that it is empty. The windows have been broken from the impact. You reach in and turn off the ignition and remove the keys. The handbrake is applied. As you walk round the front of the car, you see there is a casualty lying on the ground, half under the car, their eyes are closed. From your approach you do not see any additional casualties. You inform your colleague “One casualty found. Stay there and phone for an ambulance.”

Your report should be sent to the emergency services as soon as possible, but only when you have sufficient information. If you are alone, you will need to get help before you start treatment, but if you have assistance (in the form of your colleague) you can use them. We will not report just yet, but you have already told him to phone for an ambulance.

As soon as you spot the casualty, you start your response assessment. “Hello. Open your eyes.” As you say that, the casualty moans and opens their eyes. They are responsive to voice.

You notice under the car there is a pool of blood by the casualty’s left leg. You assess this as being a potentially catastrophic bleed if not dealt with. You drag the casualty by the shoulders out from under the car, and you can see that they have a partial amputation below the knee that is bleeding severely. As you have the first aid kit with you, you decide a tourniquet is the most effective way to control the bleeding, so you apply one just above the knee. The bleeding has stopped and is now under control. Your colleague informs you they made contact with the emergency services, you give them an initial update on the casualty. “One casualty, responsive to voice, catastrophic bleed, tourniquet applied.”

We do not think the casualty has sustained a c-spine injury due to the main trauma being to their lower limb.At this stage, the casualty is now unresponsive.

A check of the mouth and upper airway doesn’t indicate any obstructions, vomit or blood. We carry out a head tilt, chin lift, and look, listen and feel for normal breathing. We start looking at RESIN – Rate; Over 10 seconds we hear 4 breaths, this equates to a rate of 24 per minute. This is high. Effort; Breathing is not noisy, but rapid and shallow. Symmetry; placing our hands on the casualty’s chest, they rise and fall evenly. Symmetry is good. Injuries; we cut open the casualty’s t-shirt, there are no visible injuries on their chest. We run our hands down the front of the chest, we don’t feel any deformities or depressions, there is no sign of bruising. We do the same but down the side of their chest, removing our hands to inspect for blood signs. There are none. We lift up their arms and check the arm pits for injuries, but none found. We then roll the casualty over, expose their back and do not see any visible injuries. Neck signs; the neck is free form visible injury, there is no sign of emphysema at the top of the chest, and their trachea appears central. We get our colleague to record and report “Breathing rate 24, rapid and shallow. No sign of chest injury, neck signs good.”

We assess circulation, and recheck the tourniquet, it appears to be holding and stopping the bleeding. We can not find a radial pulse, but the casualty has a carotid pulse that is weak and 110 per minute. Their skin is pale and they have a cold, clammy skin. Other than the trauma to the lower left leg, there are no other signs of external bleeding to deal with. Chest has been checked. Abdomen is not rigid and not causing discomfort to the casualty. We feel the pelvis and it seems firm and symmetrical. Checking arms, we notice the left lower arm is fractured with moderate swelling. The right leg is free from major injury. We get our colleague to record and report “Carotid 110 and weak. Skin pale, cold and clammy. Fractured lower left arm.”

We check our casualty’s pupils, and they are equal in size, and respond equally to light. We report and record “Pupils equal and reacting to light.”

We cover our casualty to keep them warm. Our colleague brings a spare coat from the car to lay over the casualty, and we manage to slide a foil blanket under them to insulate them from the cold ground.

Here is an example of our handover:“Male, approximately 30 years old, at 1030, collision with a moving vehicle. Partial amputation lower left leg, broken lower left arm. Unresponsive. Breathing rate 24, rapid and shallow. No sign of chest injury, neck signs good. Carotid 110 and weak. Skin pale, cold and clammy. Pupils equal and reacting to light. Tourniquet applied to left leg.”

Summary

This is an advanced subject, and you should have been able to see that the progression from first aid is primarily concerned with gathering as much diagnostic information as possible. We introduced additional steps in the primary survey protocol, and a number of new mnemonics. Here there are:

• SSS – Self, Scene, Survivors
• SAFE – Shout for help, Assess the scene, Free any dangers, Evaluate the casualties
• METHANE – Major incident declared or standby, Exact location, Time of incident, Hazards, Access and egress, Number of casualties, Equipment required
• AVPU – Alert, Voice stimulus, Pain stimulus, Unresponsive
• RESIN – Rate, Effort, Symmetry, Injuries front and back, Neck signs
• WET – Wounds on the neck, Emphysema under the skin, Trachea aligned
• RRD – Rate, Rhythm, Depth
• PERL – Pupils Equal and Reacting to Light
• ATMIST – Age, Time, Mechanism of Injury, Injuries, Signs and symptoms, Treatments

Follow the protocol in a logical and sequential manner, taking into account your own safety at all times, and the consideration of multiple casualties. And if alone, don’t forget to get help early before you become committed to assessment and treatment.