Casualty Assessment

Perform a Casualty Assessment

INTRODUCTION

On the battlefield, rapid systematic assessment of a casualty increases the likelihood that life threatening injuries are identified and prioritized. If life threatening injuries are identified during the assessment, life saving treatment and interventions can be initiated immediately. As a review the A-B-C’s are the first step in an initial assessment. This handout outlines assessment techniques and reassessment interventions and how to perform a casualty assessment in a combat environment.

Determine threats in the area near the casualty

The medic situational assessment differs from the civilian scene size-up in that it centers around an awareness of the tactical situation and current hostilities in order to safely and effectively render care

Examining the battlefield and determining zones of fire during engagement

(1) Determine routes of access to the casualty and egress with the casualty to ensure safety

(2) Casualties will occur over time, thus, changing the demands on your services and resources

Consider care under fire

(1) Anticipate the care you will offer at the casualty’s side and what effect the care being given will have on drawing fire such as movement, noise or light

(2) Determine what care is best offered at the casualty’s side and what is best given after movement to safety

(3) Do not offer extensive assessment and care until you can move the casualty to cover or at least concealment

As you enter a fire zone, recognize hazards, seek cover and concealment, and carefully scan the area for potential danger

(1) Survey the area for small arms fire

(2) Detect area for fire or explosive devices

(3) Determine threat for chemical or biological agents

(4) Survey building(s) structure for stability

Remove casualty to safe area if necessary prior to assessment or treatment

(1) Getting the casualty to cover (or concealment) may entail moving the casualty. Tell the casualty to move as quickly as possible to cover while maintaining a low profile. If the casualty is unable to move, the medic may need to assist the casualty using manual evacuation. The risk in moving the casualty is further injuries, but the benefit of protection outweighs the risk

(a) In most cases the medic should never hesitate to move a casualty who is exposed to fire, however, each situation is different. You must evaluate the pros and cons of movement. If the casualty is not currently receiving fire and a C-spine injury is likely, you may elect to delay movement until it can be done safely.

(b) Ideally, choose a technique that is least likely to aggravate the casualty’s injuries

(2) Request assistance. You should request assistance in movement and treatment prior to attempting to move casualty.

(a) Direct Combat Life Savers (CLS) to provide treatment. CLS' will be utilized and directed by medical personnel once hostilities have ceased.

(b) Assign individuals to perform self aid or buddy aid as needed

(3) Request covering fire to reduce the risk to you and the casualty during movement to and from the casualty’s location

(4) Be sure that the location you are moving to will provide optimum cover and concealment. Plan you evacuation route prior to exposing yourself to hostile fire.

(5) Consider a NBC environment

Determine mechanism of injury

(1) Determine how the injury occurred

(a) Burns

(b) Ballistic, etc.

(d) NBC

(2) Determine number of casualties: Request addition help, if available (this information can be obtained from situational reports and evacuation requests)

(a) The number of casualties determines how and where you will treat

(i) Consider care of casualties under fire

(ii) Consider a mass casualty situation

(b) Manage time, equipment and supplies for casualty treatment

Perform Initial Casualty Assessment given a medic aid bag or CMVS

Form general impressions: Consider c-spine immobilization

(1) Observe position of casualty

(a) Body position

(b) Position in relation to surroundings

(2) Note activity in area surrounding casualty

(a) Survey the area for small arms fire

(b) Detect area for fire or explosive devices

(d) Survey building(s) structure for stability

(3) Appearance of casualty

(a) Skin color

(b) Severe bleeding

(d) Anxiety

(e) Obvious distress - breathing, etc.

Assess airway

(1) Assess the airway and level of consciousness (LOC)

(2) Use common sense when opening the airway. Provide c-spine immobilization when necessary.

(3) If the casualty can talk to you the airway is open and he/she is breathing

(4) Open the airway

(a) Head-tilt/Chin-lift

(b) Jaw thrust

(5) Sweep - use index finger to attempt to manually clear airway of obstructing object

Assess breathing

(1) LOOK--LISTEN--FEEL.

(a) Can you see the chest rise and fall?

(b) Can you hear the casualty breathing?

(d) Regular & full = Normal

(e) Labored, shallow, rapid, or irregular or absent = Abnormal

(2) Assist ventilations if abnormal breathing

Assess circulation

(1) Does the casualty have a pulse?

(a) Palpate and compare the carotid and radial pulse in the adult and child casualty, and auscultate the apical pulse in the infant casualty

(b) Full & regular = normal

(d) Capillary Blanch Test

(2) Both pulses absent, start CPR. In a combat situation with multiple casualties, there may be limited opportunities to initiate CPR.

(3) Do not start CPR on a solider who has been shot and is in cardiopulmonary arrest except on a very limited basis

Assess disability/neurological status

(1) Level of mental status: Level of mental status has partially been assessed in the medic's general impression and airway assessment using AVPU:

(a) Alert (awake and oriented)

(b) Verbal - responds to verbal stimuli (awake but confused/unconscious but responds in some way)

(d) Unresponsive (no gag or cough reflex)

(2) Pupils

(a) Are they equal, round and reactive?

(b) Pinpoint

Expose wounds

(1) Remove equipment and clothing (Except in a NBC environment or field of fire) from area around wound

(2) Identify additional life-threatening injuries

Obtaining an AMPLE history

Allergies

(1) Primarily to medications, also environmental allergies

(2) Check ID tag to see if red allergy tag is affixed

Medication

(1) Prescribed medication

(2) Over-the-counter medication

Pertinent medical history: Associated injuries/complications

Last oral intake

Events preceding incident. "What were you doing at the time of injury?“

Identify immediate life-threatening injury(ies)

Control life-threatening hemorrhage

(1) Direct pressure

(2) Pressure dressing/pressure points

(3) Tourniquet

Treat for shock

(1) Provide supplemental oxygen

(2) Consider intravenous fluids

(a) Utilize to reverse, or stabilize, effects of hypovolemia

(b) Should not delay direct transport or oxygen interventions

Provide airway/breathing support

(1) Manual maneuvers

(2) Airway adjuncts

(3) Proper positioning

(4) Provide supplemental oxygen: Assist ventilations

Identify chest injury

(1) Look for:

(a) Flail chest –multiple rib fractures that cause paradoxical chest movement

(b) Open wounds

(d) Hemothorax

(e) Impaled objects

(f) Lacerations

(g) Punctures

(h) Ecchymosis - bluish discoloration of an area of skin or mucous membrane cased by the etravasation of blood into the subcutaneous tissues as a result of trauma

(2) Provide immediate care

(a) Seal sucking chest wounds

(b) Stabilize flail chest

(d) Stabilize impaled objects

Assess the back

Assess the extremities

Perform additional casualty assessment given a medic aid bag

When performing a detailed trauma assessment

(1) Deformities

(2) Contusions

(3) Abrasions

(4) Punctures/penetrations

(5) Burns

(6) Tenderness

(7) Lacerations

(8) Swelling

Head

(1) Inspect for

(a) Obvious hemorrhage

(b) Ecchymosis, erythema, or contusions

(2) Palpate (touching or feeling) for

(a) Lumps

(b) Tenderness

(d) Crepitation

(e) Depressions

Eyes

(1) Inspect for

(a) PEARLA (Pupils, Equal, Round, Reactive, Light, Accommodation)

(b) Laceration to lid or globe

(d) Unequal pupils (anisocoria)

(e) Eye movements

(f) Pupillary reaction

(g) Raccoon Eyes - which may indicate skull fracture

(2) Palpate for

(a) Swelling in orbital or periorbital area

(b) Failure to sense touch in supra-orbital and infraorbital areas if casualty is communicative

Ear - inspect for

(1) Discharge from external auditory canal

(2) Ecchymosis over mastoid (Battle's sign)

(3) Lacerations

(4) Bleeding

(5) Avulsions

Nose - inspect for

(1) Rhinorrhea

(2) Patent nostrils

(3) Bleeding

(4) Flaring of anterior nares on inspiration

(5) Septal hematoma

Mouth

(1) Inspect for

(a) Potential airway obstruction

(b) Edema or hemotoma to in tongue

(d) Teeth or dentures lodged in pharynx

(e) Misalignment of teeth

(f) Pain when biting teeth together

(2) Palpate for fractures

(a) Zygomatic bones

(b) mandible

Neck

(1) Inspect for C-spine tend lacerations

(a) Retraction at suprasternal notch on inspiration

(b) Deviation of trachea from midline

(2) Auscultate for air sounds in trachea

Skin: Inspect for

(1) Jaundice

(2) Cyanosis

(3) Diaphoresis

(4) Temperature

(5) Moistness

(6) Pallor

Thorax

(1) Inspect for

(a) Respiration

(i) Rate-tachypnea

(ii) Depth

(b) Retraction of intercostal spaces

(d) Chest elevation symmetry-flail chest

(e) Lacerations, puncture, or ecchymosis

(2) Palpate

(a) Vertebrae and ribs for symmetry and tenderness

(b) Anterior to posterior compression of thorax

(d) Clavicle

(e) Costochondral junction

(3) Auscultate for lung and heart sounds

(a) Lung sounds

(i) Absent or unequal breath

(ii) Characteristics

* Crackles – a common abnormal respiratory sound heard on auscultation of the chest during inspiration. Sounds like shuffling of paper.

* Rhonchi – abnormal sounds heard on auscultation of an airway obstructed by thick secretions, muscular spasm, neoplasm, or external pressure.

* Wheezes – A form of rhonchus, characterized by a high-pitched or low-pitched musical quality.

* Stridor – abnormal high pitch musical sound caused by an obstruction in the trachea or larynx (Best heard in neck region).

(b) Heart sounds – a normal noise produced within the heart during the cardiac cycle that can be heard over the pericardium. It may reveal abnormalities in cardiac structure or function. Cardiac auscultation is performed systematically from apex to base of the heart, using a stethoscope to listen. Listen for the following:

(i) Rate

(ii) Rhythm

(iii) S1 – The first heart sound in the cardiac cycle, occurring at the outset of ventricular systole. A dull and prolonged „lub“.

(iv) S2 – The second heart sound in the cardiac cycle. It is associated with closure of the aortic and pulmonic valves at the outset of ventricular diastole.

(v) Abnormal or skipped beats

(4) Percussion

(a) Fluid in thorax

(b) Pneumothorax or collapsed lung – collection of air or gas in the pleura spaces causing the lung to collapse. May be the result of:

(i) An open chest wound that permits the entrance of air

(ii) The rupture of an emphysematous Bleb on the surface of the lung

(iii) Severe bout of coughing

(iv) May occur spontaneously without apparent cause

Back - Inspect for

(1) Deformities

(2) Contusions

(3) Abrasions

(4) Punctures/penetrations/exit wounds

(5) Burns

(6) Tenderness

(7) Lacerations

(8) Swelling

Abdomen

(1) Inspect for

(a) Lacerations, ecchymosis, burns, etc.

(b) Hematoma

(d) Wound

(2) Auscultate bowel sounds

(3) Palpate firmly for

(a) Distended abdomen

(b) Guarding

(d) Rebound pain

(e) Rigidity

Pelvis

(1) Inspect for

(a) Stable or not stable

(b) Fracture

(i) Could be a source of major hemorrhage

Extremities

(1) Inspect for

(a) Deformities or abnormal angulation or bone ends protruding

(b) Contusion

(d) Punctures, needle marks or bites

(e) Bruising

(f) Tenderness

(g) Lacerations or ecchymosis

(h) Swelling

(2) Assess

(a) Inability to move joint

(b) Presence of extremity pulse

(i) Dorsalis pedis

(ii) Radial

(d) Impaired sensation

(e) Pain

Central nervous system

(1) Inspect for

(a) Absent reflexes, paralysis

(b) Loss of bowel or bladder

SUMMARY

It is essential to assess casualties in a systematic way that allows for quickly finding and treating immediate threats to life. This search is called the initial assessment. By forming a general assessment, determining mental status, evaluating airway, breathing, and circulation and determining the casualty's priority, you can find and correct the problems that could otherwise end a casualty's life in just a few minutes.