Wednesday, 29 June 2016

First on Scene: Managing traumatic injuries.

Emergency response and civil defence teams will sometimes find themselves at an incident where people have been injured and paramedic and similar care is not available.  When this occurs, it remains possible to respond effectively.  Essentially all responders will have first aid training; this note covers the systems which allow that training to be most effectively deployed.

In preparing this note I have drawn heavily from Wildernessand Remote First Aid (American Red Cross, n.p., 2010) and Ian Dunbar, VehicleExtrication Techniques (Holmatro, n.p., n.d.).

Scene Control

Confirm that the scene is safe (or is made safe) for your crew, the casualty and any bystanders.  Consider whether safety may be affected by daylight, environmental or weather factors.

Establish what happened, how many casualties there are and whether any of them are unconscious (ask bystanders and casualties).  If the incident was a high-impact event (for example, a road accident), it may be worth taking the time to work out the level of force which will have been exerted on a casualty using the formula E = ½M x velocity2, or E (in joules) = ½ mass (in kilograms) x velocity2 (in metres per second).  The greater the energy in joules, the higher the impact on the person, and the more severe their potential injuries.  By way of example, a person weighing 80 kgs who has been involved in a collision at 65 km/h (or 18 metres/second) will have a formula reading E = (½ x 80) x 182 = 12.96 kilojoules.

Consider what resources you have available to care for the casualties and whether further resources will be needed.

Casualty Management

Conduct a primary assessment of each casualty.  If required, also conduct a secondary assessment and take a SAMPLE history.  Document the information you obtain.

Primary Assessment

Assess for life threatening conditions with ABCDE questions –

A – Tilt the casualty’s head back and lift the chin to open the airway.  If the casualty can speak or breathe, their airway is open.
B – Spend ten seconds checking whether the casualty is breathing.  If not, commence cardiopulmonary resuscitation (CPR).
C - Check the casualty’s circulation.  If no pulse is found, commence CPR.  If the casualty is bleeding, expose the wound and apply firm direct pressure.
D – Check for any disability which may have been caused by a spinal injury.  If there appears to be a spinal injury, task a member of your team with ensuring the casualty’s back and neck are kept straight.  If the casualty is face down, use the log-roll technique to turn them face up.
E – Check for indications that the casualty has been exposed to severe environmental conditions, particularly extreme heat or cold.
Logrolling casualty from their chest to their back
Parts A, B and C of the above process are critical, and should be carried out first on unresponsive casualties who cannot communicate their distress.  Two of the greatest contributors to death in the first hour after an accident are loss of an airway and significant internal or external blood loss.
If you identify a life-threatening injury, treat the condition with the resources you have to hand and send for help.  The person sent to get help should be able to advise as to the location of the incident, the casualty’s injuries, any relevant environmental conditions and the resources available at the scene.
If no life-threatening condition is found, conduct a secondary assessment and gather a SAMPLE history.

Secondary Assessment.

A secondary assessment is significantly more detailed.

Hands-On physical assessment

With the casualty’s consent, conduct a hands-on physical assessment.  Look for deformities, open injuries, tenderness and swelling.  Check for circulation, sensation and motion of each limb.  Also check the colour, temperature and moisture of the casualty’s skin.


Responsiveness can be assessed using the AVPU scale –

A – Is the patient alert and able to answer questions?
  • A+Ox4 = Casualty knows who they are, where they are, what day it is and what happened.
  • A+Ox3 = Casualty knows who they are, where they are and what day it is.
  • A+Ox2 = Casualty knows who and where they are.
  • A+Ox1 = Casualty only knows who they are.
V – Responds only to verbal stimuli (if you speak or shout at them)

P – Responds only to painful stimuli (e.g. a pinch)

U – Casualty is unresponsive to stimuli.

Vital signs

Does the casualty have normal vital signs?  For an adult, these signs will be –
  • 12-20 regular and unlaboured breaths per minute.
  • 50-100 strong and regular heartbeats per minute.
  • Skin found to be warm and dry to touch and a colour appropriate for the person’s ethnic background.

Focussed Spinal Assessment

If you suspect that there is a spinal injury but cannot find any signs or symptoms, ask the following questions.  If the answer to each question is ‘yes’, spinal immobilization can be discontinued.
  1. Does the casualty appear to be reliable?  That is, on the AVPU scale, is the casualty at least A+Ox3?  Are they sober and not distracted by injuries or other factors?
  2. Can the casualty move their limbs and do they have normal sensation in them?
  3. Does the casualty have a firm hand grip and can they lift their legs against resistance?
  4. Does their spine have a normal range of motion, and do they deny pain or tenderness in the spine

SAMPLE History

Take a medical history from the casualty by asking the SAMPLE questions.
S – Signs and symptoms.  Ask the casualty what hurts?  Are they suffering pain, nausea, light-headedness or any other abnormal sensations?
A – Allergies.  Do they have any allergies?  Have they been exposed to anything which is likely to cause a reaction.
M – Medications.   Are they taking any medications?  If so, what for and when did they last take it?
P – Past medical history.  Ask if this sort of thing has happened before and whether they are currently seeing a doctor for any significant condition (for example, cardiac or respiratory).  Ask whether they have recently had surgery and (if female) whether they are pregnant.
L – Last intake and output.  Ask when they last ate or drank, and how much.  Are they currently hungry or thirsty, and when did they last relieve themselves?
E – Events leading up to the incident.  Ask how and when the incident happened.
Image from here


A decision will need to be made on whether to remain in place or to evacuate the casualties.  Before deciding, you should weigh up -
  • How severe are the casualties' injuries, and do you have crew and equipment which will allow the casualty to be moved safely?
  • How far will they need to travel, and over what terrain?
  • How long will it be before outside help arrives?
  • Are there particular hazards where you are? (eg rising flood water).  Will the weather be a problem if you do evacuate?

Swift evacuation

If you decide to evacuate, a swift evacuation is required for in cases of –
  1. Worsening vital signs (including an increasing heart rate)
  2. Hypothermia
  3. Head injuries including skull fracture or suspected stroke; seizures which do not resolve within 10 minutes; and altered mental state caused by extreme heat.
  4. Near-drowning causing loss of consciousness or respiratory problems.
  5. Lightning strike.
  6. Anaphylactic reaction (even if treated with an epipen or similar device).
  7. Spinal injury
  8. Heart attack, or chest injury followed by difficulty breathing
  9. Serious infection or serious abdominal problems.
  10. Open or angulated fractures, or fractures of the pelvis, hip or femur.
  11. Injuries causing a loss of sensation, circulation or movement beyond the injury itself.
  12. Any wound that was caused by crushing or impalement; involved ligaments, tendons or a joint space; is deep and affects the face; or was caused by an animal bite or is otherwise contaminated.

Slow Evacution

A slow evacuation is appropriate if the casualty has –
  1. One or more broken ribs.
  2. Persistent abdominal pain.
  3. A first-time joint dislocation, or any injury that prevents use of a limb.
  4. Unresolved heat exhaustion or mild hyponatremia.
  5. A wound which cannot be closed, or an infection which does not improve within 12 hours of treatment.
  6. Mild head injury.
Image from here


If you are in a position to hand over management of the casualty to a paramedic, advise them in the MIST pattern -
M – Mechanism of injury
I – Injuries (both suspected and confirmed)
S – Signs and symptoms
T – Treatment given.

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