1. Primary/Secondary Survey of the Casualty

2. Objectives Discuss the importance of the primary/secondary survey
Outline how ATLS applies to the 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 EVAC?
Why is it important?
What and where are the wounds?
What resuscitation is required?
Mode of CASEVAC?

5. Will this approach work in firefight?
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 firefight?

6. How Do We Develop Our Approach?
What are we going to see?
Injury patterns
Civilian trauma?
Firefight 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
Firefight Trauma
We don’t know the death distribution
It is believed that if the casualty can arrive alive and relatively stable to the ER…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 Firefight Casualty
Slightly different injury pattern-in this order!
Penetrating extremity trauma
Tension pneumothorax
Loss of airway
Instead of ABCs……think CBAs

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

15. The Firefight Casualty Primary Survey
D-disability- decision to evacuate
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!!!

16. Heat loss during transport

17. Hypothermia

18. The Firefight 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!

19. 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

20. Head exam
DCAP-BTLS
Pupils
Raccoon/Battle signs
Mid-face instability

21. Neck exam
Step-off
Tracheal deviation
Jugular vein distention

22. Chest exam
DCAP-BTLS
TIC
Auscultation
Percussion

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

24. Extremity exam
DCAP-BTLS
TIC
PMS

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

30. Questions?