UNITED STATES MARINE CORPS
Field Medical Training Battalion
Camp Lejeune
FMST
1420
Perform Casualty Assessment
TERMINAL
LEARNING OBJECTIVE
1.
Given a
casualty in a combat environment and the standard field medical equipment and
supplies, perform casualty assessment to prioritize injuries for treatment, per
the references. (FMST-HSS-1420)
ENABLING LEARNING
OBJECTIVES
1.
Without the aid of references, given a description
or list, identify the purpose of casualty assessment, per the student handout.
(FMST-HSS-1420a)
2.
Without the aid of references, given a description
or list, identify the three phases of combat casualty care, per the student
handout. (FMST-HSS-1420b)
3.
Without the aid of reference, given a list,
identify the sequence of steps for casualty assessment, per the student handout.
(FMST-HSS-1420c)
4.
Without
the aid of references, given a casualty in a simulated combat environment,
standard field medical equipment and supplies, and individual combat equipment,
perform casualty assessment, per the student handout. (FMST-HSS-1420d)
1.
OVERVIEW
Casualty Assessment is a
systematic process for assessment of the trauma casualty and is essential for
recognizing life-threatening conditions, identifying injuries, and determining
priorities of care based on assessment findings. Using this systematic approach
you will be able to assess, prioritize, and treat each trauma casualty and
ensure injuries are not missed.
This lesson will focus on
the assessment of the trauma casualty within the first two phases of the
Tactical Combat Casualty Care management plan. The third phase, Casualty
Evacuation (CASEVAC) Care, is performed during transportation of the patient to
the next level of care and is covered in a separate lesson.
2.
PHASE 1 - CARE UNDER FIRE
During this phase, the Corpsman and
casualty are still under hostile fire. The first step in saving a casualty is
usually to control the tactical situation. Very limited medical care should be
attempted while the casualty and the unit are under hostile fire. Suppression
of hostile fire and moving the casualty to a safe position are major
considerations at this point. Remember: “The best medicine on the battlefield
is fire superiority.” Casualties who have sustained injuries that are not life
threatening and have the ability to help should continue to assist in
suppressing the hostile fire. It may also be critical for you to help suppress
hostile fire before attempting to provide care.
Casualties whose wounds do not
prevent them from moving to cover should do so to avoid exposing other care
givers to unnecessary hazard. If the casualty is unable to move and is
unresponsive, the casualty is likely beyond help. Risking the lives of rescuers
is not advised. If a casualty is responsive and unable to move, a rescue plan
should be developed as follows:
a.
Determine the potential risk to the rescuers. Did
the casualty trip a booby trap or mine? Where is fire coming from? Is it
direct or indirect? Are there electrical, fire, chemical, water, mechanical, or
other environmental hazards?
b.
Consider
assets. What can rescuers provide in the way of covering fire, screening,
shielding, and rescue equipment?
c.
Make sure all understand their role in the rescue
and which movement techniques are to be used (i.e., drag, carry, rope,
stretcher). The fastest method for moving a casualty in the Care Under Fire
phase is the two person drag. This drag can be used in
buildings, shallow water, snow, and down stairs.
d.
Management
of an impaired airway is temporarily deferred until the casualty is safe,
thereby minimizing the risk to the rescuer and avoiding the difficulty of
managing the airway while dragging the casualty. Early control of severe
hemorrhage is vital. However, the tactical situation dictates that you must
maintain firepower supremacy so only life-threatening bleeding warrants any
intervention during Care Under Fire. Refer back to the lesson on Hemorrhage
Control for a review of the importance of this topic.
3. PHASE 2 - TACTICAL FIELD CARE
During this phase, the
Corpsman and casualty are no longer under hostile fire. This also applies to
situations in which an injury has occurred on a mission, but hostile fire has
not been encountered. However, medical equipment is still limited. Medical
care during this phase is directed towards more in-depth evaluation and
treatment of the casualty, focusing on those conditions not addressed during the
Care Under Fire phase of treatment. While the casualty and rescuer are now in a
somewhat less hazardous situation, evaluation and treatment is still dictated by
the tactical situation.
Casualties who show signs of an altered mental
status should be disarmed immediately.
a.
Airway Assessment
Casualties that are conscious and can talk, scream, or yell can
be presumed to have a patent airway. For unconscious casualties, initial
attempts to open the airway should be done using the modified jaw thrust (for
casualties whom you suspect C-spine injury) or Head Tilt-Chin Lift.
Once the airway is open, visually inspect for anything that may
potentially cause obstruction. Examples include broken teeth, blood, vomit or
tissue swelling. Remember the most common cause of airway obstruction in an
unconscious casualty is the tongue.
Clear any obstructions with a finger sweep and insert a
nasopharyngeal airway (NPA) to keep the airway open. Reassess your
interventions to ensure the casualty has an open airway. The standard method of
“Look, Listen and Feel” can be used to ensure the patient is breathing. If the
previously mentioned methods fail to establish an airway, surgical
cricothyroidotomy is indicated.
Remember to reassess any intervention performed to determine the
effectiveness of the procedure performed. Regardless of the method used to
establish an airway, you must also judge the quality and adequacy of the
ventilations.
b. Breathing
The goal of this step is to rule out chest wounds that either
have become, or could potentially develop into, a tension pneumothorax. Needle
thoracentesis is indicated if the casualty has difficulty breathing and
penetrating trauma to the chest area.
The only way for you to identify penetrating trauma is to EXPOSE
the area. This includes removing tactical gear such as flak jackets and uniform
tops. Once exposed you may also discover larger wounds, such as sucking chest
wounds, that will need to be treated with a three sided occlusive dressing
before moving on to the next step in the casualty assessment process.
Inspecting the area includes looking at the posterior. Based upon the MOI this
may need to be done by log rolling the casualty.
Remember to reassess any treatment performed. Needle
decompression should provide immediate relief. An occlusive dressing should not
make a sucking sound upon inspiration.
c.
Bleeding
Check for the presence and quality of pulses. Determining the
presence and quality (weak / strong) of a radial pulse will affect decisions
made later during casualty assessment.
Perform a blood sweep of the casualties entire body by gently
sliding your hands underneath the casualty and pulling them back, feeling for
any bleeding that was not controlled during “Care Under Fire”. Control it at
this time.
Assess for the possibility of tourniquet conversion. Tourniquets
that were placed due to the time constraints of “Care Under Fire” should be
converted to a pressure dressing or HemCon as appropriate. (See Hemorrhage
Control lesson if you need to review.)
d.
Consider Fluid Resuscitation
Casualties that do not exhibit signs of shock do not require and
should not be given IV or IO fluid. They should be encouraged to drink fluids
by mouth.
All casualties who exhibit
signs of tactically relevant shock (weak pulse and/or altered level of
consciousness) should have IV access started using an 18-gauge catheter.
Consider the IO route for casualties who require fluid resuscitation but IV
access can not be obtained. Administer enough fluid to restore a radial pulse.
If giving Hextend, give 500 cc’s, wait 30 minutes, and then give another 500
cc’s if needed. Do NOT give more than 1000 cc’s of Hextend to any patient.
Prevent Hypothermia
At
this point all life threatening issues should have been identified and treated.
You should begin to take precautions against hypothermia. Preventing
hypothermia is for more than just patient comfort, it is an important life
saving step. Hypothermia interferes with the body’s blood clotting mechanism
and increases mortality.
As soon as all life-threatening injuries are addressed, the
patient should have all of their wet clothing removed and replaced with dry
clothes or a Blizzard Rescue Blanket. Unless prohibited by wounds, cover the
head, as it is a prime source of heat loss. Good hemorrhage control and fluid
resuscitation will also help restore the casualty’s ability to generate heat.
e. Monitor Vital Signs
f. Head to Toe Assessment (DCAP-BTLS)
The acronym DCAP-BTLS should be used to guide the head to toe
exam. DCAP-BTLS stands for:
|
DCAP
D eformities
Contusions
Abrasions
Punctures
|
BTLS
Burns
Tenderness
Lacerations
Swelling |
Again, all life threatening injuries should have been identified
and treated by this time. The goal at this stage is to identify and address any
additional wounds. You may also identify signs or symptoms that will affect the
long term evacuation or treatment of the patient as well. It is important that
you carefully inspect the entire casualty. Using the head to toe method
described below ensures you do not miss anything.
Head
Check the skull, eyes, ears, nose and mouth for any potential
findings. At this time you should also reassess any treatments that have been
performed.
Neck
Check the neck to include the C-spine for any irregularities.
Jugular vein distension and tracheal deviation are very late signs of tension
pneumothorax (a condition you should have treated earlier). If, however, these
are encountered at this stage, perform a needle decompression immediately.
Chest
In addition to checking for DCAP-BTLS, you should also attempt to
auscultate the chest if the tactical situation permits. Simple rib fractures
and flail chest segments should be treated at this time. Reassess any previous
treatments, including needle decompression or occlusive dressings, which may
have already been performed.
Abdomen
In addition to inspecting for DCAP-BTLS you should also palpate
for Tenderness, Rigidity or Distension. Abdominal eviscerations should be
treated appropriately. Signs of internal hemorrhage, while not treatable on the
battlefield, may effect your decision during casualty evacuation (Triage and
Casualty Evacuation are covered in Block 3)
Pelvis
If the patient’s pelvic area is obviously deformed, DO NOT
PALPATE IT, as you will likely cause further instability and damage.
Extremities
Since you are already at the pelvis, palpate the lower
extremities first then the upper extremities using the same process (DCAP-BTLS)
Note and treat any minor injuries not already addressed.
Reassess any major interventions already performed, especially tourniquets or
pressure dressing.
Posterior (If not already done)
If the patient is unconscious or you suspect C-Spine injury
(based on MOI) you should log roll the patient. Examining the posterior is not
simply the back; remember that rectal bleeding is a sign of internal
hemorrhage. This should be checked as well. Reassess ALL interventions
following a log roll!
Pain Management
Conscious casualties who remain operationally engaged should be
given Mobic (15mg PO qd) and Tylenol Bi-layer Caplet (650 mg 2 PO q8h).
Casualties who can not continue to remain operationally engaged
but have no need for an IV should be given Oral Transmucosal Fentanyl Citrate (OTFC)
provided as a “lozenge on a stick” taped to their finger. Reassess the patient
every 15 minutes for respiratory depression.
Those who are out of the fight and require an IV should be
administered morphine 5mg (IV or IO). This can be given every 10 minutes as
necessary. The patient should be monitored for signs of respiratory depression.
You should have Naloxone (Narcan) on hand before administering either OTFC or
morphine.
Promethazine (Phenergan) 25 mg IV/IO/IM may be administered to
counteract the nausea associated with Morphine or OTFC.
Immobilization
Splint any extremities that need it.
Antibiotics
If the patient can tolerate oral medications, administer
Moxifloxacin 400mg, PO qd. If not, administer either cefotetan (2g IM/IV/IO) or
ertapenum (1g IM/IV/IO). (For more information on giving medications, see the
medication appendix at the end of this block.)
Patient Turnover
Document the patients initial wounds, treatments performed, and
response to any treatments. Ensure this, along with the most recent set of
vital signs, is transferred with the patient.
REFERENCE
Pre-Hospital Trauma Life Support, Medical Edition, 6th
Ed, Chapter 21
Rev: July 2008
Casualty Assessment
Review
1. List and briefly describe the three phases of Tactical Combat
Casualty Care (TCCC).
2.
Management of airway would be taken care of during
what phase of TCCC?
3.
Briefly describe why prevention of hypothermia is
so important for the casualty.
4. Describe why patients who can stay in the fight should not be
given morphine.
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