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Primary/Secondary Survey of theCombat Casualty

CPT Allen Proulx, MPAS, PA-CCPT Allen Proulx, MPAS, PA-C

Tactical Combat Medical CareTactical Combat Medical Care(TCMC)(TCMC)

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b!ectivesb!ectives

Discuss the importance of theDiscuss the importance of the

primary/secondary surveyprimary/secondary survey

Outline how ATLS applies to the combatOutline how ATLS applies to the combatcasualtycasualty

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Time of deathTime of death

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Primary/Secondary SurveyPrimary/Secondary Survey

Why is it important?Why is it important?

What and where are the wounds?What and where are the wounds?

What resuscitation is reuired?What resuscitation is reuired?

!ode of "AS#$A"?!ode of "AS#$A"?

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"hat is the A##roach$"hat is the A##roach$

ATLSATLS "reated by sur%eons for the non&sur%eon"reated by sur%eons for the non&sur%eon

Desi%ned in the urban environmentDesi%ned in the urban environment

'erformed in the hospital settin%'erformed in the hospital settin%

(euires a lot of hi%h tech resources(euires a lot of hi%h tech resources

This is our classical trainin% platformThis is our classical trainin% platform

Will this approach wor) in combat?Will this approach wor) in combat?

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%o& 'o "e 'evelo# ur%o& 'o "e 'evelo# ur

A##roach$A##roach$

What are we %oin% to see?What are we %oin% to see?

*n+ury patterns*n+ury patterns

"ivilian trauma?"ivilian trauma?

"ombat trauma?"ombat trauma?

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%o& 'o "e 'evelo# ur%o& 'o "e 'evelo# ur

A##roach$A##roach$

"ivilian trauma"ivilian trauma Trimodal death distributionTrimodal death distribution

,irst pea),irst pea) Death results in the pre&hospital settin% from massive head in+ury andDeath results in the pre&hospital settin% from massive head in+ury and

massive vascular in+ury-massive vascular in+ury-Second pea)Second pea)

Death in the first few minute of arrival to the hospital and due toDeath in the first few minute of arrival to the hospital and due tomassive head. chest and abdominal in+urymassive head. chest and abdominal in+ury

Third pea)Third pea) 'ost resuscitation/operative complications'ost resuscitation/operative complications

Combat TraumaCombat Trauma We dont know the death distributionWe dont know the death distribution

It is believed that if the casualty can arrive alive and relatively stable toIt is believed that if the casualty can arrive alive and relatively stable tothe FST/CS!they will live"the FST/CS!they will live"

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%o& 'o "e 'evelo# ur%o& 'o "e 'evelo# ur

A##roach$A##roach$

ATLSATLS

ased on urban in+ury patternsased on urban in+ury patterns

'rimary Survey'rimary Survey

A&Airway/c&spine controlA&Airway/c&spine control

&reathin%&reathin%

"&"irculation"&"irculation

D&DisabilityD&Disability

#posure#posure

Detailed secondary surveyDetailed secondary survey

1ead&to&toe e0am1ead&to&toe e0am

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%o& 'o "e 'evelo# ur%o& 'o "e 'evelo# ur

A##roach$A##roach$

The "ombat "asualtyThe "ombat "asualty

Sli%htly different in+ury pattern&in this order2Sli%htly different in+ury pattern&in this order2

'enetratin% e0tremity trauma'enetratin% e0tremity trauma

Tension pneumothora0Tension pneumothora0

Loss of airwayLoss of airway

*nstead of A"s33thin) "As*nstead of A"s33thin) "As

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The Combat Casualty PrimaryThe Combat Casualty Primary

SurveySurvey

Assess for hemorrhae firstAssess for hemorrhae first *ntervene for life threatenin% bleed only2*ntervene for life threatenin% bleed only2

Then, assess for tensionThen, assess for tension#neumothorax#neumothorax 'erform needle decompression as needed'erform needle decompression as needed

Then, assess for an air&ayThen, assess for an air&ay 4tili5e a "ombitube or sur%ical airway4tili5e a "ombitube or sur%ical airway

(arely a need for c&spine control(arely a need for c&spine control

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The Combat Casualty PrimaryThe Combat Casualty Primary

SurveySurvey

'-disability- decision to evacuate'-disability- decision to evacuate 6"S scorin% is appropriate6"S scorin% is appropriate A$'4 also appropriateA$'4 also appropriate

-ex#osure-ex#osure

#0plore ideas on how to e0pose your casualty while#0plore ideas on how to e0pose your casualty whileprotectin% them from the environmentprotectin% them from the environment

%y#othermia is *A'%y#othermia is *A'

(emember. they may need that )evlar222(emember. they may need that )evlar222

+-foley+-foley Situational need for urinary catheterSituational need for urinary catheter

-astric tube-astric tube Situational need to decompress the stomachSituational need to decompress the stomach

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%y#othermia is *ad%y#othermia is *ad

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.e&armin in the trenches of "".e&armin in the trenches of ""

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%eat loss durin trans#ort%eat loss durin trans#ort

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%y#othermia%y#othermia

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%y#othermia%y#othermia

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The Combat Casualty SecondaryThe Combat Casualty Secondary

SurveySurvey

Occurs after you have performed yourOccurs after you have performed your

primary survey and appropriateprimary survey and appropriate

interventionsinterventions

%ead-to-toe exam alon AT0S%ead-to-toe exam alon AT0S

uidelines1uidelines1

*e very thorouh-*e very thorouh-many in+uries aremany in+uries aresubtle2subtle2

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Commonly used acronymsCommonly used acronyms

D"A'&TLS& deformities. contusions. abrasions.D"A'&TLS& deformities. contusions. abrasions.

penetrations. burns. tears. lacerations. swellin%-penetrations. burns. tears. lacerations. swellin%-

T*"& tenderness. instabilities. crepitus-T*"& tenderness. instabilities. crepitus-

T(D& tenderness. ri%idity. distensionT(D& tenderness. ri%idity. distension

'!S& pulse. motor. sensory'!S& pulse. motor. sensory

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%ead exam%ead exam

D"A'&TLSD"A'&TLS

'upils'upils

Otorrhea/(hinorrhea/1emotympanumOtorrhea/(hinorrhea/1emotympanum

(accoon/attle si%ns(accoon/attle si%ns

!id&face instability!id&face instability

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2ec3 exam2ec3 exam

Step&offStep&off

Tracheal deviationTracheal deviation

7u%ular vein distention7u%ular vein distention

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Chest examChest exam

D"A'&TLSD"A'&TLS

T*"T*"

AuscultationAuscultation

'ercussion'ercussion

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xtremity examxtremity exam

D"A'&TLSD"A'&TLS

T*"T*"

'!S'!S

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Posterior ThoraxPosterior Thorax

Lo% roll casualtyLo% roll casualty

SpineSpine

D"A'&TLSD"A'&TLS

Tenderness/step&offTenderness/step&off

D(#D(#

6ross blood only6ross blood only

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4uestions$4uestions$