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Pre-hospital Primary Survey

Anthony Boulton trauma-list@trauma.org
Mon, 14 Apr 2003 18:06:13 +1000


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Very well outlined Mark, it is important for us all to be aware of the
primary assessment, so that all personal can appreciate the time scales and
implications of processors that combine to eventually transport the pt.
 
In presenting MVA rescue techniques, I add a fair amount of trauma data, so
that new to middle level crews can appreciate the level of the task and the
concerns of the medics clawing at their backs, while rescue crews are
removing a door or pushing a dash etc..
 
It can be a fairly hectic scene when you see liters of bloody running from
the floor pan, but cannot access lower limbs to control hemorrhage. And then
some rescue bloke says '" Yeh, hang on mate, we'll get them out soon ".
 
Having said that, I must admit that during the last few years, with inter
service cross training, scene management has dramatically improved.
 
That brings me to my main point, with the introduction of mobile 3G service
and video conference mobile phones. 
What, if any, would be the benefit to the ED to receive real time image of
the scene, be it MVA or industrial / domestic etc.. including vitals ?
And what limitations would be placed on this by privacy laws ?
 
I will stop here to remain brief, but would be interested in comments, as we
have an opportunity to trial such a scheme.
 
Regards
Anthony Boulton
 
 
 
 
 
 
 

-----Original Message-----
From: MARK FORREST [mailto:atacc.doc@virgin.net]
Sent: Monday, April 14, 2003 7:51 AM
To: trauma-list@trauma.org
Subject: Re: Pre-hospital Primary Survey


Dear Paul, 
Interesting question! We can all quote the textbook answers, but what about
real world......3am, pouring rain, car on roof, cutting gear running!
 
On arrival on scene our team follow two basic courses.
If there is obvious massive external bleeding we apply 'MARCH'
 
M- massive haemorrhage control eg direct pressure, arterial pressure
(?tourniquet - discuss!). This is all about preservation of circulatory
volume...his own blood volume!
This should not take more than a few seconds and should not delay movement
onto airway. Even ATLS recommends immediate pressure dressings to obvious
bleeding wounds.
The rest is basically A,B.C
A - airway
R -respiration
C- circulation
H - head injury
 
MARCH - focuses the medics onto the primary problem, but does not distract
them from other essential issues.
 
If there is no obvious massive bleeding, then we follow a standard A,B,C....
approach.
On approach attempting verbal contact - indicates conscious level and airway
quality (if talking and orientated, no immediate head problem, not seriously
shocked, not hypoxic/hypercarbic).
Pulse oximeter immediately applied - indicates oxygen saturation, peripheral
perfusion/degree of 'shut-down' or hypothermia and heart rate.
If sats Ok - move onto 'C' 
If sats are poor, then fully assess chest from trachea down (largely looking
and feeling, percussion usually possible, auscultation rarely possible
without stopping the extrication and if it is not barn-door then it can
probably wait until extrication complete!) 
C  - conscious level continually assessed
    - radial pulse, if palpable give no fluid
    - no radial then feel for central pulse - no central pulse consider
other signs (blunt trauma with no output - are they dead already?)
    - capillary refill, forehead or finger
    - no radial pulse and prolonged cap refill then give fluid bolus of
100-250 ml (usually hypertonic saline with starch or dextran)
    - continually re-assess response whilst extrication continues
D - AVPU, until extricated then GCS
    - pupils
    - quick check of limbs for signs of serious injury
 
Aim to rapidly assess and to primarily detect seriously life-threatening
injuries whilst not delaying continuos extrication process. This process is
better facilitated as our team train docs, techs, fire-fighters and
paramedics together, with lots of skill overlap.
 
Hope that this helps Paul
 
 
Regards
Mark F
ATACC Medical Rescue Team, UK
 

----- Original Message ----- 
From: delta  <mailto:delta.uk@ntlworld.com> care uk 
To: trauma-list@trauma.org <mailto:trauma-list@trauma.org>  
Cc: NAEMT-L@naemt.org <mailto:NAEMT-L@naemt.org>  ; NAEMT-L@naemt.org EMED-L
<mailto:NAEMT-L@naemt.org EMED-L List> List ; NAEMT-R
<mailto:NAEMT-R@naemt.org>  ; EMS-L List  <mailto:ems-l@listserv.unc.edu>
Server ; Critical Care Medicine List <mailto:ccm-l@list.pitt.edu>  
Sent: Sunday, April 13, 2003 7:18 PM
Subject: Pre-hospital Primary Survey

Could list members help off list if need be. 

I am looking for the various sequences and methods of pre- hospital primary
survey. 
  
I am interested in everybody's viewpoint especially from those involved in
MVA/RTA incidents. I am consolidating information in what pre hospital
providers have found to be useless or what people have found to be priceless
when involved in entrapments, where access to the casualty may be limited
etc. 


All information will be relevant. 


Thanks in advance, 


Paul Cooper 
Fire fighter UK 


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<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff size=2>Very 
well outlined Mark, it is important for us all to be aware of the primary 
assessment, so that all personal can appreciate the time scales and implications 
of processors that combine to eventually transport the pt.</FONT></SPAN></DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff 
size=2></FONT></SPAN>&nbsp;</DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff size=2>In 
presenting MVA rescue techniques, I add a fair amount of trauma data, so that 
new to middle level crews can appreciate the&nbsp;level of the task and the 
concerns of the medics clawing at their backs, while&nbsp;rescue crews&nbsp;are 
removing a door or pushing a dash etc..</FONT></SPAN></DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff 
size=2></FONT></SPAN>&nbsp;</DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff size=2>It can 
be a fairly hectic scene when you see liters of bloody running from the floor 
pan, but cannot access lower limbs to control hemorrhage. And then some rescue 
bloke says '" Yeh, hang on mate, we'll get them out soon ".</FONT></SPAN></DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff 
size=2></FONT></SPAN>&nbsp;</DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff size=2>Having 
said that, I must admit that during the last few years, with inter service cross 
training, scene management has dramatically improved.</FONT></SPAN></DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff 
size=2></FONT></SPAN>&nbsp;</DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff size=2>That 
brings me to my main point, with the introduction of mobile 3G service and video 
conference mobile phones. </FONT></SPAN></DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff size=2>What, 
if any, would be the benefit to the ED&nbsp;to receive real time&nbsp;image of 
the scene,&nbsp;be it MVA or industrial / domestic etc.. including vitals 
?</FONT></SPAN></DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff size=2>And 
what limitations would be placed on this by privacy laws ?</FONT></SPAN></DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff 
size=2></FONT></SPAN>&nbsp;</DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff size=2>I will 
stop here to remain brief, but would be interested in comments, as we have an 
opportunity to trial such a scheme.</FONT></SPAN></DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff 
size=2></FONT></SPAN>&nbsp;</DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff 
size=2>Regards</FONT></SPAN></DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff 
size=2>Anthony Boulton</FONT></SPAN></DIV>
<DIV><SPAN class=601424007-14042003></SPAN>&nbsp;</DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff 
size=2></FONT></SPAN>&nbsp;</DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff 
size=2></FONT></SPAN>&nbsp;</DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff 
size=2></FONT></SPAN>&nbsp;</DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff 
size=2></FONT></SPAN>&nbsp;</DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff 
size=2></FONT></SPAN>&nbsp;</DIV>
<DIV><SPAN class=601424007-14042003><FONT face=Arial color=#0000ff 
size=2></FONT></SPAN>&nbsp;</DIV>
<BLOCKQUOTE dir=ltr style="MARGIN-RIGHT: 0px">
  <DIV class=OutlookMessageHeader dir=ltr align=left><FONT face=Tahoma 
  size=2>-----Original Message-----<BR><B>From:</B> MARK FORREST 
  [mailto:atacc.doc@virgin.net]<BR><B>Sent:</B> Monday, April 14, 2003 7:51 
  AM<BR><B>To:</B> trauma-list@trauma.org<BR><B>Subject:</B> Re: Pre-hospital 
  Primary Survey<BR><BR></FONT></DIV>
  <DIV><FONT face=Arial size=2>Dear Paul, </FONT></DIV>
  <DIV><FONT face=Arial size=2>Interesting question! We can all quote the 
  textbook answers, but what about real world......3am, pouring rain, car on 
  roof, cutting gear running!</FONT></DIV>
  <DIV><FONT face=Arial size=2></FONT>&nbsp;</DIV>
  <DIV><FONT face=Arial size=2>On arrival on scene our team follow two basic 
  courses.</FONT></DIV>
  <DIV><FONT face=Arial size=2>If there is obvious massive 
  external&nbsp;bleeding we apply <STRONG>'MARCH'</STRONG></FONT></DIV>
  <DIV><FONT face=Arial size=2></FONT>&nbsp;</DIV>
  <DIV><FONT face=Arial size=2><STRONG>M- massive haemorrhage control</STRONG> 
  eg direct pressure, arterial pressure (?tourniquet - discuss!). This is all 
  about preservation of circulatory volume...his own blood volume!</FONT></DIV>
  <DIV><FONT face=Arial size=2>This should not take more than a few seconds and 
  should not delay movement onto airway. Even ATLS recommends immediate pressure 
  dressings to obvious bleeding wounds.</FONT></DIV>
  <DIV><FONT face=Arial size=2>The rest is basically A,B.C</FONT></DIV>
  <DIV><FONT face=Arial size=2><STRONG>A - airway</STRONG></FONT></DIV>
  <DIV><FONT face=Arial size=2><STRONG>R -respiration</STRONG></FONT></DIV>
  <DIV><FONT face=Arial size=2><STRONG>C- circulation</STRONG></FONT></DIV>
  <DIV><FONT face=Arial size=2><STRONG>H - head injury</STRONG></FONT></DIV>
  <DIV><FONT face=Arial size=2></FONT>&nbsp;</DIV>
  <DIV><FONT face=Arial size=2>MARCH - focuses the medics onto the primary 
  problem, but does not distract them from other essential issues.</FONT></DIV>
  <DIV><FONT face=Arial size=2></FONT>&nbsp;</DIV>
  <DIV><FONT face=Arial size=2>If there is no obvious massive bleeding, then we 
  follow a standard A,B,C.... approach.</FONT></DIV>
  <DIV><FONT face=Arial size=2><STRONG>On approach attempting verbal 
  contact</STRONG> - indicates conscious level and airway quality&nbsp;(if 
  talking and orientated, no immediate head problem, not seriously shocked, not 
  hypoxic/hypercarbic).</FONT></DIV>
  <DIV><FONT face=Arial size=2><STRONG>Pulse oximeter immediately 
  applied</STRONG> - indicates oxygen saturation, peripheral perfusion/degree of 
  'shut-down' or hypothermia and&nbsp;heart rate.</FONT></DIV>
  <DIV><FONT face=Arial size=2><STRONG>If sats Ok - move onto 'C'</STRONG> 
  </FONT></DIV>
  <DIV><FONT face=Arial size=2><STRONG>If sats are poor, then fully assess chest 
  from trachea down</STRONG> (largely looking and feeling, percussion usually 
  possible, auscultation rarely possible without stopping the extrication and if 
  it is not barn-door then it can probably wait until extrication 
  complete!)&nbsp;</FONT></DIV>
  <DIV><FONT face=Arial size=2><STRONG>C&nbsp;&nbsp;- conscious level 
  continually assessed</STRONG></FONT></DIV>
  <DIV><FONT face=Arial size=2>&nbsp;&nbsp;&nbsp; - <STRONG>radial 
  pulse</STRONG>, if palpable give no fluid</FONT></DIV>
  <DIV><FONT face=Arial size=2>&nbsp;&nbsp;&nbsp; - no radial then feel for 
  central pulse - no central pulse consider other signs (blunt trauma with no 
  output - are they dead already?)</FONT></DIV>
  <DIV><FONT face=Arial size=2>&nbsp;&nbsp;&nbsp; - <STRONG>capillary 
  refill</STRONG>, forehead or finger</FONT></DIV>
  <DIV><FONT face=Arial size=2>&nbsp;&nbsp;&nbsp; - no radial pulse and 
  prolonged cap refill then give fluid bolus of 100-250 ml (usually hypertonic 
  saline with starch or dextran)</FONT></DIV>
  <DIV><FONT face=Arial size=2>&nbsp;&nbsp;&nbsp; - <STRONG>continually 
  re-assess</STRONG> response whilst extrication continues</FONT></DIV>
  <DIV><FONT face=Arial size=2><STRONG>D - AVPU, until extricated then 
  GCS</STRONG></FONT></DIV>
  <DIV><FONT face=Arial size=2>&nbsp;&nbsp;&nbsp; -<STRONG> 
  pupils</STRONG></FONT></DIV>
  <DIV><FONT face=Arial size=2>&nbsp;&nbsp;&nbsp; <STRONG>- quick check of limbs 
  for signs of serious injury</STRONG></FONT></DIV>
  <DIV><STRONG><FONT face=Arial size=2></FONT></STRONG>&nbsp;</DIV>
  <DIV><FONT face=Arial size=2>Aim to rapidly assess and 
  to&nbsp;primarily</FONT><FONT face=Arial size=2>&nbsp;detect seriously 
  life-threatening injuries whilst not delaying continuos extrication process. 
  This process is better facilitated as our team train docs, techs, 
  fire-fighters and paramedics together, with lots of skill 
overlap.</FONT></DIV>
  <DIV><FONT face=Arial size=2></FONT>&nbsp;</DIV>
  <DIV><FONT face=Arial size=2>Hope that this helps Paul</FONT></DIV>
  <DIV><FONT face=Arial size=2></FONT>&nbsp;</DIV>
  <DIV><FONT face=Arial size=2></FONT>&nbsp;</DIV>
  <DIV><FONT face=Arial size=2>Regards</FONT></DIV>
  <DIV><FONT face=Arial size=2>Mark F</FONT></DIV>
  <DIV><FONT face=Arial size=2>ATACC Medical Rescue Team, UK</FONT></DIV>
  <DIV><FONT face=Arial size=2></FONT>&nbsp;</DIV>
  <BLOCKQUOTE dir=ltr 
  style="PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px">
    <DIV style="FONT: 10pt arial">----- Original Message ----- </DIV>
    <DIV 
    style="BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: black"><B>From:</B> 
    <A title=delta.uk@ntlworld.com href="mailto:delta.uk@ntlworld.com">delta 
    care uk</A> </DIV>
    <DIV style="FONT: 10pt arial"><B>To:</B> <A title=trauma-list@trauma.org 
    href="mailto:trauma-list@trauma.org">trauma-list@trauma.org</A> </DIV>
    <DIV style="FONT: 10pt arial"><B>Cc:</B> <A title=NAEMT-L@naemt.org 
    href="mailto:NAEMT-L@naemt.org">NAEMT-L@naemt.org</A> ; <A 
    title=EMED-L@ITSSRV1.UCSF.EDU 
    href="mailto:NAEMT-L@naemt.org EMED-L List">NAEMT-L@naemt.org EMED-L 
    List</A> ; <A title=NAEMT-R@naemt.org 
    href="mailto:NAEMT-R@naemt.org">NAEMT-R</A> ; <A 
    title=ems-l@listserv.unc.edu href="mailto:ems-l@listserv.unc.edu">EMS-L List 
    Server</A> ; <A title=ccm-l@list.pitt.edu 
    href="mailto:ccm-l@list.pitt.edu">Critical Care Medicine List</A> </DIV>
    <DIV style="FONT: 10pt arial"><B>Sent:</B> Sunday, April 13, 2003 7:18 
    PM</DIV>
    <DIV style="FONT: 10pt arial"><B>Subject:</B> Pre-hospital Primary 
    Survey</DIV>
    <DIV><BR></DIV>Could list members help off list if need be. 
    <P>I am looking for the various sequences and methods of <B>pre- 
    hospital</B> primary survey. <BR>&nbsp; <BR>I am interested in everybody's 
    viewpoint especially from those involved in MVA/RTA incidents. I am 
    consolidating information in what pre hospital providers have found to be 
    useless or what people have found to be priceless when involved in 
    entrapments, where access to the casualty may be limited etc. 
    <P>All information will be relevant. 
    <P>Thanks in advance, 
    <P>Paul Cooper <BR>Fire fighter UK </P></BLOCKQUOTE></BLOCKQUOTE></BODY></HTML>

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