Part I: Physiology and pathophysiology of shock
This is the next installment on a series to help people in a SHTF/WROL situation deal with the types of traumatic injuries and concerns they may encounter. The focus is on making the best out of what you have and keeping people alive. Today we’ll focus on triage, treatment, the rapid trauma assessment, and general guidelines to “find it / fix it.”
Triage and treatment
Trauma is a surgical disease. The goal for any trauma patient is to get him, when necessary, into the operating room in 60 minutes or less from the time of injury. This is called “The Golden Hour” and it is the standard that most EMS systems aim for. In a trauma scenario, a patient’s mortality rate goes through the roof if it takes more than 60 minutes to get them under the knife.
This is where I mix it up a little between civilian triage and treatment, and military triage and treatment from Tactical Combat Casualty Care (TCCC). The table below goes over the key differences and treatment protocols with judicious paraphrasing.
|Civilian Mass Casualty Incident (MCI)
|Goal: Get the most critical patients off the scene as fast as possible and into the OR / definitive care.
||Goals: Fight the bastards. Make them stop trying to kill you by killing all of them or by making them go away. Keep as many people in the fight as you can. Stop major bleeding. Self-treatment as able. Administer more advanced care after the fight is over. Try not to get the medic killed.
|Red – Immediate. Unable to walk, does not obey commands, respirations > 30, capillary refill > 2 seconds. Stabilize fast, load and go emergency traffic to trauma centers.
||Immediate – Rapid intervention to save life, limb, or eyesight.
|Yellow – Delayed. Unable to walk, obeys commands. Implies perfusion is adequate enough that mental status is maintained. Stabilize on-scene. Next priority for transport.
||Delayed – Significant injury. Requires stabilization, but PT will not deteriorate for several hours.
|Green – Minor. Walking.
||Minimal – PT is injured but will remain stable for at least 24 hours. Can supply self-aid and buddy-aid.
|Black – Expectant. Unable to breathe on their own. PT is dying or dead.
||Expectant – Injuries incompatible with life. Major treatment withheld until higher-priority PTs cared for. Provide comfort measures as able.
||Stages of care:
|A – Airway: patent?
||Care Under Fire: Fight still going on. Main priority is to stay in the fight. Stop major bleeding as able. Firepower comes first.
|B – Breathing: adequate?
||Tactical Field Care: Fight’s over. Treat with medical equipment on scene.
|C – Circulation: adequate? Capillary refill < 2 seconds? Peripheral pulses? Rate?
||Combat Casualty Evacuation (CASEVAC): Treatment rendered once patient is on board air, ground, or water transport. May be treated at medical personnel staging areas.
|D – Disability: What is the patient’s mental status? Alert? Responsive to Verbal stimuli? Responsive to Painful stimuli? Unresponsive?
|E – Expose: Cut clothes off and conduct the rapid trauma assessment
||C – Circulation: Stop major bleeding with tourniquets, etc. (This is primarily in the Care Under Fire stage).
||A – Airway: patent?
|Red, yellow, and green treatment areas (CCPs) will be identified by tarps of the same color placed on the ground. The treatment section chief coordinates with the transport section chief to get patients cataloged, loaded and transported to the right hospitals via air, land, and/or sea.
||B – Breathing: adequate?
||C – Circulation: adequate? Capillary refill < 2 seconds? Peripheral pulses? Rate?
||D – Disability: What is the patient’s mental status? Alert? Responsive to Verbal stimuli? Responsive to Painful stimuli? Unresponsive?
||E – Expose: Cut clothes off and conduct the rapid trauma assessment
|[i] Casey Bond, MPAS, PA-C, Combat Medic Field Reference (Jones and Bartlett Publishers 2005) 1-3
Here’s the START triage algorithm for adults in a civilian MCI:
Below is an EXCELLENT visual of a civilian casualty collection point (CCP) from the LAX shooting in November, 2013. The tarps are the treatment areas for patients based on the above flowchart. Ambulance Drivers are ready to drink coffee and cruise to the hospital. ‘Cause that’s what we do.
Think about how you might set something like this up for yourselves in a SHTF situation.
The rapid trauma assessment
No matter what situation you find yourself in, this assessment is critical. Trauma is all about finding life threats and fixing them immediately. The rapid trauma assessment is designed to do just that. This will follow the civilian model. In a TCCC mode, find bleeds first.
We are looking for deformities, contusions, abrasions, penetrations / punctures, burns, tenderness, lacerations, and swelling in our patient. The mnemonic for this is DCAP-BTLS. If you ever say to a medic “I’m looking for DCAP-BTLS” you better know what they stand for or you will be doing pushups.
Before we go into it, let’s talk about bleeds.
- Arterial bleed: Bright red (oxygenated) blood and lots of it pulsing out in streams. If you see this, you better haul ass and get the bleeding stopped
- Venous bleed: Dark red (deoxygenated) blood and lots of it oozing out rapidly depending on the site of the wound. Not a great sign. Haul ass on this one too.
- Capillary bleed: Bright red blood slowly oozing out from a wound. This is not life threatening. Not a big deal. No need to do anything right away.
If you have time, get some nitrile gloves and some eye pro on, because it’s going to get messy.
Look at the patient. Is he breathing? If not, do a head tilt, chin lift airway maneuver. Does he start breathing on his own? If yes, this patient is an immediate triage and treatment priority. If no, he’s dead. Move on to other patients and reassess this guy later.
What is his mentation at this stage? Conscious, alert, and obeying commands? Conscious and alert, but mumbling and reciting multiplication tables? Barely awake? Knocked the fuck out? Whatever it is, make note of it. A patient’s mental status is a key indicator of his level of perfusion and his priority. The mnemonic here is AVPU, which stands for:
- Alert: Patient is awake and alert. They may or may not be making sense, and may or may not be following your commands. Be watchful if they start slip-sliding down the scale.
- Verbal Stimuli: The patient responds to verbal stimulation. Chances are their eyes are closed and they open when you call their name. Same thing applies in making sense and following commands as above. The less they do, the worse they may be.
- Painful stimuli: The patient responds to painful stimulation. A rub on the sternum with your knuckles. Pinching their fingernail bed between your finger and a pen. Note how they respond. Do they localize the pain and grab at where you are stimulating? Do they have a general response that is non-specific? The difference is a key distinction between levels of brain injury. The less specific the response, the worse they are.
- Unresponsive: Exactly what it means. This is where it is important to gauge the patient’s ability to breathe on his own in a MCI or Care Under Fire situation. It he cannot breathe on his own, he is Expectant. Move on to other patients. If he is breathing on his own, he is Immediate. Treat accordingly.
Check the airway – is it open / patent? If not, stop the assessment and get it open with a head-tilt chin-lift, or if cervical spine injury is suspected, a modified jaw-thrust maneuver. We’ll talk about some more advanced airway stuff further on down the way. The key here is to make sure the guy can move air. The modified jaw thrust is a bitch of a move and you will burn out your fingers keeping tension on the patient’s jaw. Be prepared to switch people out or start thinking about an advanced airway, since having to do this maneuver implies that his airway is compromised.
Check the breathing – is it adequate? If it’s < 8 or > 30 respirations per minute, assist ventilations with a BVM and 15LPM 100% O2 if you have it. Your ventilations should be 12-20 a minute, with an emphasis on 12. All you are looking for is chest rise and fall for each ventilation given. You do NOT need to empty the entire contents of the BVM into your patient’s lungs.
Bag valve mask. Get one if you don’t have one already.
Note the resistance – or compliance – when ventilating. If there is a lot of resistance, there could be a pneumothorax, or an intrathoracic bleed that’s increasing intrathoracic pressure, or some other kind of really bad thing. A helper for pacing your ventilations is to say “BREATHE one thousand, two one thousand, three one thousand, four one thousand, five one thousand, BREATHE one thousand, two one thousand, three one thousand, four one thousand, five one thousand” and squeeze the BVM slowly over “BREATHE one thousand.” That gets you about 12 ventilations a minute. Chances are you’re going to be excited, so work hard at not counting too fast.
Check radial – i.e. wrist – pulses, BOTH OF THEM at the same time. If they are present, then your patient has a systolic BP of at least 80mmHg. Note the pulse rate. Your count doesn’t have to be perfect. At this point “Wow, that’s fucking fast” or “Seems normal” is adequate for quantifying pulse rate. If no radial pulses are present, go to the carotid artery in the neck. If you feel a pulse, the patient’s systolic pressure is at least 60mmHg, and you are in really deep shit. Chances are his heart rate will be high because he’s in compensated shock. If you feel barely any to no carotid pulse, chances are this guy is expectant and hopefully you were able to ask him if there was anything he wanted to say to his wife before he died.
A good medic or EMT can do almost all of this at once if the patient is conscious. Have a conversation with the patient while you are feeling his radial pulses. If pulses are present, he can converse normally and speak in full sentences, then you know you have a good airway, adequate breathing, and good circulation. If any of those basic things are off, you know something is up and you need to be highly alert.
ALWAYS use your patient as a diagnostic tool. He’s going to provide you great info about his status. Ask him what hurts, if he has numbness or tingling anywhere, if he lost consciousness, ask his name, his birth date, the day of the week, his current location, and finally ask him to wiggle his fingers and toes. With that, you’ve just done a field expedient neurological exam and can check off AVPU. Note any deficits. PS: I always ask who the President of the United States is. Around here, that wakes them right up. It always come with great editorial comments.
Continue the assessment by doing a blood sweep by running your hands down the patient’s head, torso, and legs. After each major area, check your gloves. If you see blood, stop and assess the wound. Cut away anything that gets in your way. If it is a life threatening bleed, stop the assessment and control the bleeding with direct pressure, a hemostatic agent (CELOX, QuickClot, etc.) and/or a tourniquet. DON’T use hemostatic agents on any wounds outside of the extremities. Continue the blood sweep. If no other bleeding is found, continue on. One thing, the blood sweep should be fast, like 5-10 seconds fast.
CONGRATULATIONS. You have completed the rapid trauma assessment. You now know your patient’s mental status, airway status, breathing status, and circulatory status. You can now form your treatment priority for this patient. If you are getting this done in under three minutes, you are doing great. Get your patient to the casualty collection point (CCP) and start treatment. Get your IVs and fluid resuscitation going as indicated.
Next we’re going to do a more detailed assessment if we have the time and the patient is stable enough. The analog to this in TCCC would be the Tactical Field Care phase. We want to get a better – still rapid – look at the patient and find more things to fix if they are life threats. Key point here – TAKE HIS CLOTHES OFF. Seriously. If you can’t see it, you can’t find it, and you won’t fix it. I usually keep my patient’s underoos on if they are 100% conscious, alert, and oriented and inspect “down there” with their permission after a description of what I need to look for and why. If their mentation is altered, the underoos are coming off so I can check the genitalia and rectum for bleeding if there is any thoracic /abdominal trauma or pain in any area that indicates thoracic /abdominal injury.
Head, eyes, ears, nose, and throat (HEENT)
Start at the head and work your way down. Inspect and palpate – which means feel around in vulgar terms – the head and neck. Remember the DCAP-BTLS mnemonic. Key to look out for is fluid coming out of the ears or nose, as it could be cerebral spinal fluid, which indicates a skull fracture of some kind or disruption of the blood / brain barrier. If you see it, dab it with a gauze 2×2 or 4×4. If it looks like a pink blood spot with a halo around it, that’s CSF.
CSF on gauze. Notice the halo.
If you feel bones grinding around – known as crepitus – this is bad, too, as it also indicates skull fracture. Check the pupils and eyeballs. Are they equal, round, and responsive to light? Great. If one or both are dilated and your patient has an altered mental status, you are in deep shit because your patient probably has a bleed going in his brain. If you are out in the middle of nowhere without rapid evac to an OR, this is most likely fatal.
Look for anything in the mouth that can result in an airway threat and take steps to mitigate. Teeth, Copenhagen, soft tissue, etc. The tongue is the most common airway obstruction, and if you hear snoring noises from your patient, most likely his tongue is in the back of his throat. Try basic airway maneuvers to open the airway like the head-tilt chin lift or modified jaw thrust first, and an oropharyngeal airway (OPA) adjunct if the patient has no gag reflex, and a nasopharyngeal airway adjunct (NPA) if he does have a gag reflex. Here’s a nice instructional video for measuring and placing OPAs and NPAs.
If cervical spine injury is suspected, stabilize c-spine and apply a c-collar if available. Inspect and palpate the back of the neck for crepitus or deformity before applying the c-collar. If you don’t have one, use a SAM splint, towels, clothing, and tape to create a hasty c-collar. The goal is to prevent the head from moving around and exacerbating a cervical vertebrae fracture that could slice into the spinal cord. Make sure you’re not restricting circulation in the neck or breathing with the hasty c-collar.
Improvised c-collar. Dig it.
Inspect and palpate the neck. Look for any bruising or open wounds on the neck. If there is a wound near the jugular vein or carotid artery, apply an occlusive dressing like Vaseline gauze, or plastic wrap (a section of MRE rapper, etc.) to prevent air from going into the wound and causing an air embolus in the circulatory system. You may need to position the patient on his left side to mitigate the air embolus from entering the heart. Keep c-spine precautions in place if you do.
If the jugular veins are distended (bulging out), this could be a sign of circulatory compromise, with the right side of the heart failing to move blood adequately. This could be from a pericardial tamponade, which can only be fixed in the hospital, a tension pneumothorax or even a severe hemothorax.
Jugular venous distension. Never fun to see in trauma.
If the patient’s windpipe – i.e. trachea – is deviating to one side, this is an ominous sign of a late stage tension pneumothorax, also known as a collapsed lung.
Tracheal deviation in a tension pneumothorax.
You may need to needle decompress the affected lung, but you’ll need to assess the chest to make the call.
Check the upper chest for little bumps. If you can push down on them and they pop like Rice Krispies, this is probably subcutaneous emphysema, and is a sign that the patient’s airway has been compromised. The larynx, trachea or bronchi may have been damaged and air leaking air into the chest cavity. Look for this sign in pneumothorax as well. Personally, I have never seen this in the field, so who knows what it’s really like.
The other critical findings for a tension pneumo are low blood pressure, tachycardia (pulse > 100 bpm), a narrow pulse pressure (this is the difference between the systolic and diastolic pressures. A normal pulse pressure is 120/80. A narrow pulse pressure with hypotension is 70/60), absent lung sounds on the affected side, fast, shallow breathing, and low O2 saturation. The trachea will deviate AWAY from the side of the collapsed lung. NOTE: Tracheal deviation is a LATE sign in a tension pneumo. Look for the other signs and symptoms first. If you wait for tracheal deviation to show up, you’ve probably killed your patient.
You’ll need a 3.25” 14 gauge need and catheter for decompression. Insert the needle in the second intercostal space just above the third rib at the midclavicular line (in line with the middle of the collar bone) of the affected side. Press hard and remove the needle, and if you do it correctly, you’ll hear a flood of air come out of the catheter. Create a flutter valve with a spare glove fingertip and place it over the top of the catheter. Some of the newer catheters have a one-way valve built in, so what you have already may be adequate.
The 3.25″ needle is preferred, because most likely your tribe is full of studmuffins with 50″ chests who all bench 550lbs easily. The other guys have all the fat dudes with man tits. In either case, that’s a lot of material between the skin and the chest cavity full of air. The shorter needles may not make it all the way through, so keep that in mind.
Press on the clavicles for crepitus. If it is present, note it but keep going. Unless the clavicle is so screwed up that it looks like it is stabbing the the lungs, or you see sign of massive hemorrhage from a nick of subclavian artery and/or vein, it is probably not a life threat.
Press down on the ribs and feel for crepitus. Notice the patient’s work of breathing. Are both sides of his chest rising and falling in unison? That’s good. If you feel crepitus and see a portion of the ribs moving collapsing while the rest of the ribs expand and vice versa, your patient may have a flail segment, which is a section of ribs that have broken completely away from the rib cage. This is a serious sign and should be fixed when found. You want to tape down a folded shirt, saline bag, or bulky dressing over the wound site. Tape it down tightly, because you’re trying to prevent the flail segment for engaging in the paradoxical movement that can compromise breathing. Be highly suspect of a pneumothorax / hemothorax if you see this. This video shows it pretty well. Look how much effort this guy is putting into breathing. If he doesn’t get help soon, he’s going to tire out and crap out.
If you find puncture wounds over the chest, then cover them with occlusive dressings like Vaseline gauze, plastic wrap, or some of the fancy chest seals like the Asherman, Halo, and Bolin. If you are using Vaseline gauze or plastic wrap, tape it down on three sides only and leave one side open to allow for burping the wound.
Vaseline gauze. Cheap and effective.
If the wound is gurgling, then you very likely have a pneumo / hemothorax to deal with. Make sure to count all of the puncture wounds and their locations. If you can, roll the patient on his side and assess the back for wounds and injuries. If there are more holes in the chest / thorax area, count them, note their locations, and get occlusive dressings on them. Don’t worry about exit or entry classifications. What matters is the number of holes in your patient’s body and what the implications are for what’s happening inside where you can’t see.
A quick talk about hemothorax and fluid in the lungs. A hemothorax is blood filling up the space in the chest that once was filled by your now collapsing lung. The space in your chest is big enough to hold 25-40% of your blood supply. Remember the shock table from Part I. 25% of blood volume and above is Stage III and Stage IV hemorrhages. Like a pneumothorax, the blood in the chest cavity prevents the lung from fully inflating, but is less likely to result in the same amount of tension as a tension pneumothorax. Needle decompression will not be an effective treatment for a hemothorax. A chest tube placed on the midaxillary line (think inline with your armpit) in the fifth intercostal space in the ribcage is going to be a better solution in getting the blood out. This is not something that you see done in a prehospital setting. If you know you have a hemothorax in the field and your patient is dying from it, you may need to place your decompression needle in the fifth intercostal while the patient is supine and try to get some of the blood out. If you are having to do this, your day is very, very bad.
Fluid in the lungs is just that. It can be water, blood, vomit, beer, you name it. The fluid fills the alveoli and prevents O2 and CO2 from exchanging at the capillary membrane. Get enough fluid in your lungs and you will not be able to exchange enough gas to stay alive and will die quickly. The alveoli lose their surfactant and collapse, making it impossible for them to continue to hold and exchange air. This condition is called atelectasis and it is very bad. People who survive drownings can have this happen to them days after they are rescued.
DISTURBING CONTENT WARNING. A MAN DIES IN THIS VIDEO
The video below shows a scumbag who got shot for trying to steal. It looks like the guy who blasted him got a good lung shot and hit some blood vessels. Notice the frothy, bright consistency of the blood and how quickly the guy deteriorates once he starts coughing it up. Most likely he aspirated his blood into both of his lungs and ultimately drowned in his own fluids. Not pretty. Fixing this guy would require lots of suction, positive pressure ventilations, endo tracheal intubation, lots of diesel fuel or helicopter fuel to get him to the trauma OR ASAP to get the vessels spewing into his lungs closed. Lesson? Armed robber is a poor career choice.
Inspect and palpate the abdomen. If your patient reports pain anywhere in the abdomen, palpate that area LAST. You are feeling for rigidity and abdominal guarding, where the patient flexes the abdominal muscles when your palpating causes pain over an inflamed or injured organ. Also look for rebound tenderness, which is pain AFTER you take your hands off the abdomen and the abdominal wall returns to its normal position. This could be a sign of something – like blood – irritating the peritoneum, which is the lining of the abdominal cavity. Look for signs of ecchymosis on the skin of the abdomen. It can indicate severe blunt force trauma to the abdomen.
Flank ecchymosis from blunt force trauma to the abdomen.
If you see something pulsating in the patient’s abdomen, DON’T FUCKING TOUCH IT. It could very well be an abdominal aortic aneurysm, which means their descending aorta may burst open at any minute. Find out what this patient wants to say as last words to anyone he cares about, because this finding in the field is very grim. Very carefully load him into a stretcher and take a nice gingerly trip to a vascular surgeon to try and fix it.
Trauma to the patient’s upper right abdomen should make you highly suspicious for a liver laceration or injury. The liver is very vascular and can bleed profusely. Keep a keen eye out for shock in these patients. The same thing holds true for the upper left side of the abdomen with the spleen. Watch for distension in the abdomen and signs of shock, indicating an internal bleed.
If the patient has an evisceration, which is where the intestines herniate through the abdominal wall and the skin, soak a dressing in sterile water or saline and place it over the intestine. Cover that with plastic and tape it down. You want to keep the tissue moist. DON’T shove the intestine back in the hole. It’s already been exposed to germs and dirt on the outside and you can make any rupture of the small bowel worse by spilling gastric contents into the abdomen, thus making a bad situation worse. This is not necessarily a life threatening condition, and you may be able to skip over it to continue your assessment. Let the patient’s condition guide you on this.
Evisceration from a knife wound to the abdomen.
If your patient has been shot in the abdomen, any and all of the above injuries can occur simultaneously. Count the holes, note their positions, and place absorbent dressings over everything to help with bleeding. If you can roll the patient on his side to look for wounds on his back and treat them, do it. DON’T pour hemostatic agents into the wounds. If an evisceration is present, follow the above treatment. Allow your patient to bend his knees when laying supine when he has an abdominal injury. This alleviates some of the pull on the abdominal muscles and wall and alleviates some pain.
The abdomen is a magical, mysterious place where a lot of stuff can go wrong. You have to suspect a lot of different injuries in any kind of trauma because you have different kinds of organs and organ systems all in one compact area. Repeated patient assessments are key with abdominal wounds.
Assess the pelvis by LIGHTLY pressing down on the hip bones (illiac crests) as well as inward. Did I say lightly? If your patient screams at you and tries to choke you out, then there’s probably something wrong. If you feel crepitus with either press, something is VERY wrong and your patient has a fractured pelvis. This is a critical injury because a pelvic fracture can bleed 2000ml of blood in short order. That’s an instant Stage IV hemorrhage with decompensated to irreversible shock as a perverse reward. You’ll need to create a pelvic binder to help stabilize it, reduce bleeding, and reduce the volume of the pelvic cavity for blood to pool. Wrap a sheet, KED, a cut up foam sleeping mat with belt, whatever, under your patient and around his pelvis and secure it so the pelvis cannot be moved around. Very carefully get your patient onto a long board or stretcher and pack voids to minimize movement. Be on high alert for shock and treat aggressively. If there are bullet holes in your patient’s pelvis, the treatment is the same with the additions of counting the wounds, noting their locations, and applying dressings. The video below shows good technique in creating a pelvic binder.
Inspect and palpate your patient’s legs. In the upper legs, we are very concerned about the femoral artery and the femur. Femur fractures can lose 1500ml of blood pretty quickly, so be prepared to aggressively treat for shock if you see deformity and massive bruising. If a femur fracture is found or suspected, treat it when found, as it is a life threat because of the amount of blood that can be lost.
Pic below shows some good bruising:
A closed femur fracture, which means the bone has not penetrated through the skin and is visible, can be treated in the field with a traction splint. These are not things you carry in your daily kit, so the best thing you can do in the field is to supply manual traction. A patient with a broken femur is likely to present with the injured leg shorter than the uninjured leg. The x-ray below illustrates how the now two-piece femur is out of alignment.
Have one of your team members apply traction by grabbing the foot of the injured leg and pulling downward (caudally) to get the bones realigned. This also helps reduce the pain. Have the rest of the team poke around and find materials to make a hasty traction splint, because it’s going to be hard to have someone holding traction on a casualty you need to drag out of the woods. Below is a great example of the hasty traction splint. Be creative, have fun with it.
Key to any extremity injury is to check for pulses in the extremity south of, or distal, the injury site. On this femur fracture, you can check for a popliteal pulse on the back of the knee, or for a posterior tibial pulse just behind the interior ankle bone (aka the medial malleolus). Do this before applying traction, after applying traction, and after applying the splint. Continue to check for those pulses routinely, especially when you are moving your patient across country. Here’s where to find the posterior tibial pulse and the dorsalis pedal pulse as a bonus.
You want to try and keep the tissue distal the injury perfused as much as you can to avoid compartment syndrome from developing. The leg is a big hunk of meat, and if all of the tissue south of the injury gets starved of oxygen and dies, you are going to have a mess of acids, toxins, and the wrong kinds of electrolytes flood back into the bloodstream when circulation is restored. This can cause cardiac arrest. No shit.
If you have an open femur fracture, where the bone is sticking out through the skin, life just got more complicated.
Now THAT is sexy. Doesn’t that look like fun?
In the field, it is highly unwise to put traction on this injury, because you risk causing more damage to the vasculature and nerves in the leg by letting the sharp bones slice their way back through the meat in the leg. Furthermore, you increase the risk of infection. So the thing to do here is to tell your patient “Sucks to be you, brah,” then stop any active, life-threatening bleeding (if you did your blood sweep at the start, you’d have found this already, but we’ll do this anyhow), and now you FINALLY get to use that Tier I, Joint Task Force, Operational, Operating CAT-T, you motherfucking OPERATOR! First – but fast – check for popliteal and pedal pulses distal the injury to see if there is any circulation. This helps you gauge how bad the injury is. If no pulses distal the injury, then we know the tissue has not been getting perfused for a while. Apply your CAT-T until the bleeding stops and you can confirm lack of pulse distal of the injury if it was there before. Here’s a video on application of the CAT-T. Strap your Oakleys and Multicam on and enjoy.
Make sure you mark the time you applied the CAT-T. You can do it on the tourniquet, the extremity, or the patient’s forehead. Example: “T 1345″ means tourniquet applied at 1345 hours.
Next cover the bone ends with dressing soaked in sterile water, then dress the wound and bandage it up. Get the patient loaded up and pack towels, clothing, whatever you can around the leg to immobilize it. A splint may be in order, but again, NO TRACTION. Just try to keep the thing immobilized.
Any amputation occurring at the upper leg will be treated the same way as the open femur fracture. Stop life threatening bleeding with a tourniquet or tourniquets and treat the patient for shock.
If your patient is laying on the ground with one leg shorter than the other with his toes pointing inward (medially) while screaming in pain so loud that you have just alerted the forces of darkness in a 50 mile radius to your location, you may have a dislocated hip on your hands. Quickly expose the leg and look for any injury. If none is found, then you are narrowing it down fast. Check pedal pulses. Check the pelvis for crepitus and palpate the hip area for crepitus as well. If none is felt, you may be OK for treating for a dislocated hip.
While painful, if pedal pulses are present and there is no sign of any injury, this is not a life threatening injury. However, the amount of screaming you will hear from your patient will make you want to fix it to shut him up. Grab an extra cartridge from your kit and give it to your buddy to bite on. He’s going to need it. Here’s the Captain Morgan hip reduction technique.
Now, we’re not supposed to do this as pre-hospital providers, and I sure as hell don’t do this in the course of my job. However, if all that’s left of my hometown is a mushroom cloud and the screaming of my tribe brother is calling the drones of the Geheime StaatsPolizei to come over and Hellfire us out of existence, I’m not worried about getting my patch pulled anymore. In other words, only do this in extreme emergencies where there is no other help available. Otherwise, get the patient to the ER / CCP/ base and let the doc or the PA do the reduction.
Once you do the reduction recheck the pelvis, hip area, and pulses. Assess for any swelling or bruising. Make sure you didn’t break anything by fixing it.
If your patient is lying on his back with one leg potentially shorter than the other and the toes on the injured leg point outward (laterally), suspect a hip fracture. This one is very serious because a hip fracture means a femur fracture, a pelvic fracture, or even both.
Hip fracture. Note the shorter leg and lateral rotation.
You want to immobilize the injured leg and avoid doing anything to it that would open up the fracture even more. Check for distal pulses. Treat with a pelvic binder, packing the voids around the leg, and shock measures.
Further down the leg, you have the tibia (shin bone) and fibula. If these are fractured, you don’t put them in a traction splint like the femur. In the context of a rapid trauma assessment, these may be ugly, but not life threatening. The key is how much the break is bleeding. If it looks like an artery has been damaged because blood is spurting out of it or the calf has swollen into a purple basketball in a closed fracture, you’ll need to fix it right away. If there is minimal bleeding and the patient has other things going on, note the wound and come back to it after you have taken further stabilization measures.
An open tibia / fibula fracture.
In the case of a life-threatening bleed, apply a tourniquet above the knee and tighten it until the bleeding stops and there are no distal pulses. Mark the time, treat for shock, and Charlie Mike.
In a closed tib/fib fracture with obvious deformity, check the distal pulses (noticing a theme here?). If there are none you can try a reduction in the field to get them back – ONCE. Hold the patient’s foot and apply traction by pulling it caudally until it is inline with the upper part of the tib/fib. Check for distal pulses. If you got it right, they’re back. If you missed it, you’re done anyway. Splint the lower leg. Check for pulses after splinting.
Here’s a great example of an improvised splint for the lower leg. Lots of camping gear up on this one. Always be thinking about how you can repurpose your gear for medical use.
An open tib/fib fracture should be treated the same way the open femur fracture was. DON’T perform a reduction. Leave it as is. Check for distal pulses. Stop life threatening bleeds with a tourniquet placed above the knee. Recheck pulses to ensure there are none. Cover the open bone ends with dressings soaked with sterile water or saline. Dress the wound and splint it.
For gunshot wounds and puncture wounds in the legs, if you can control major hemorrhaging with direct pressure, packing the wound with hemostatic gauze and/or hemostatic agents, that is preferable to a tourniquet because you are not cutting off circulation to the entire extremity as you do with a tourniquet. If a tourniquet is your only option or there is just too much bleeding going on, apply the tourniquet above (proximal) the wound site. As before, check distal pulses before and after applying the tourniquet and mark the time it was placed. Dress the wounds with gauze and hemostatic agents. Assess the extremity for motor and sensory by having the patient wiggle his toes. Run a marker or handle of your EMT shears along the bottom of the foot to test for sensory. Note if there are any deficits, as the bullet may have caused some nerve damage.
Checking the arms is very much the same as the legs. You are looking for life threats and need to stop those as they are found. That’s pretty much damage to the axillary, brachial, radial, and ulnar arteries causing a life-threatening bleed. Check for pulses distal to any injuries as well as sensory and motor function. Attempt to control bleeding with direct pressure, wound packing, and hemostatic agents. If that fails, place a tourniquet proximal the injury and tighten until bleed stops and there are no more distal pulses. Mark the time you placed the tourniquet, dress and bandage the wounds.
Open fractures need to be left as-is. Check distal pulses and motor function of the hands. Stop any life-threatening bleed with a tourniquet proximal the wound. Cover the open bone ends with dressings soaked in sterile water and saline, dress the wound, splint it.
After splinting the wound, apply a sling and a swathe to immobilize the arm. If you are dealing with a clavicle fracture from earlier, now might be the time to deal with it. Best treatment for it is a sling and swathe. No splint needed for the clavicle alone.
If the fracture is located in the upper arm, the treatments are the same for open and closed fractures with the major difference in the splinting. You may need to create a long-board splint and then swathe it to your patient’s body. Below is a nice illustration of a long-arm splint.
Once you have assessed the patient and stopped all life threats while he is supine, maintaining cervical spine (c-spine) stabilization (if indicated), you will log roll the patient onto his side and assess his back. The person at the head of the patient maintaining c-spine directs the call on when to roll the patient. While the patient is on his side, expose his back and look for any deformities or injuries. Treat life threats and note the locations of the injuries. Below is an OK video of a log roll and immobilization of a patient to a long board. The assessment of the back is pretty shitty. DON’T be that nonchalant about it. EXPOSE the back and put your hands on the patient to feel for crepitus or vertebrae that are out of alignment.
The SAMPLE history
If your patient is awake, or there are people around who know what happened and/or have knowledge of the patient, use this simple mnemonic to get information.
- S: Signs and symptoms of injury / illness
- A: Allergies to drugs, foods, insects, anything
- M: Medications the patient is currently taking for any chronic malady or short-term condition
- P: Past medical history including chronic conditions like diabetes, hypertension, heart problems, as well as major surgeries like coronary bypass surgery, mastectomies, abdominal surgeries, etc.
- L: Last oral intake, medications, food, drugs – legal and recreational, liquids – virgin and alcoholic, etc.
- E: Events leading up to the event. What was going on before whatever happened, happened?
After this, get a set of baseline vital signs including; AVPU, blood pressure, pulse, respirations, and if you have the equipment to do it, blood glucose level, pulse oximetry (SPO2), and end-tidal CO2 (ETCO2). Recheck vitals and reassess from head-to-toe every five to fifteen minutes depending on the severity of the patients condition.
Even though you’ve stripped the patient down to find wounds, make sure you cover them back up ASAP to keep them warm and continue to watch out for shock.
That pretty much sums up the rapid trauma assessment and the also-rapid follow on assessment. While it is a lot of information, practicing assessments can help you get this entire process down in under ten minutes. The goal on any trauma scene is to get the patient stabilized and in transit in under 10 minutes, with the ultimate goal of getting him on the operating table in under 60 minutes from the time of injury.
In Part III, we’ll go over some philosophy on treatment, training, and what a medical system may look like in SHTF/WROL.
In Part IV, we’ll look at some types of injuries that are most likely to occur in a bullets-flying SHTF/WROL scenario.
In Part V, we’ll get all gear queer and talk medical equipment.