Full Examination of Casualty
In first aid you are taught the ABC, a Health Care Professional will expand this sequence to ABCDEFGHI whilst doing a full assessment of a casualty. And use advanced interventions to preserve life, prevent deterioration and promote the recovery of the casualty.
Firstly we will briefly examine the nine steps to casualty survey then expand on each
Topic individually.
Primary Assessment
A - Airway:
Secure the airway while taking precautions to stabilise the cervical spine, if indicated.
B - Breathing:
If the patient is not breathing, begin ventilation.
C - Circulation:
If circulation not present begin full CPR or Defibrillation
Determine pulse rate and blood pressure.
Cannulate
If bleeding Obvious or Suspected or Patient Shocked. Inset One or two large bore cannulars. For medical or minor injuries where hospitalisation may be required insert one medium bore cannular in non-dominant hand.
D – Deficits (Neurological):
Assess the patient's level of consciousness (LOC), pupil reflex (PEARL), response to verbal and pain stimuli (AVPU), as well as movement and sensation in the extremities.
Secondary Assessment
E – Exposure / Search
Remove all clothing and look for additional entry or exit wounds and any other unseen injuries. Check for medical alert bracelets, pendants or cards. Are they carrying any medication, a basic knowledge of common prescription medication will give you a good idea of a persons medical history. (Providing of course the medication is theirs)
F – Fahrenheit
After exposing the casualty to check for further injury, care must be taken to preserve body heat whilst performing any procedures required. If you have already started giving IV Fluids this will chill the body unless they have been pre-warmed.
G – Get Set of Base Vital Signs
H - History & Head-to-Toe Examination
If there was any witnesses to the incident or accident obtain as much information as possible from them. If they know the casualty asks about past incidents, medical history & any current medication or drug alleges. Then perform a Head to Toe
Examination
I – Invert ("its not over until they are over")
Turn the casualty over to examine using a log roll to examine his back.
Detailed Intervention
A - Airway:
Secure the airway while taking precautions to stabilise the cervical spine (see Spinal Immobilisation), if indicated.
If the casualty were conscious, they would have assumed a position where they can comfortable breath. Any further interventions must not impair their capacity to breath.
If the casualty is unconscious, log roll (see Spinal Immobilisation) the casualty on too their back examine their airway. 'Look', 'Listen' and 'Feel' for movement of air.
By placing your ear near the casualties' mouth you will feel the presence of the breath and will hear any sounds that the breathing produces. If air movement is partially obstructed then the amount of air you feel will be decreased and breathing noisy. Noise on breathing in (Inspiration) is indicative of a blockage in the upper respiratory system, whereas noise on breathing out (Expiration) indicates a lower blockage. The tongue partially blocking the windpipe may cause a 'snoring' sound or a 'gurgling' sound would suggest liquid or semi-solid matter such as vomit in the windpipe.
With you head in this position look down the body and place your hand on the casualties' chest. If the windpipe is completely blocked but the casualty is still making a respiratory effort then you may still feel and see chest movements, so the presence of breath must be verified. If the blockage is in one of the branches of the windpipe then chest movement may be uneven.
The simplest method of opening the airway is by tilting the head and lifting the chin. This is achieved by pushing the forehead backwards whilst supporting the back of the neck. At the same time place two fingers under the tip of the jaw and lift the chin.
Check mouth for obstructions either from the tongue or the presence of blood, vomit, oedema, loose teeth, dentures or other foreign matter. Sweep your fingers in the casualty's mouth to remove any debris.
If suction equipment is available use this too remove blood and debris from the mouth and throat. Being careful not too trigger the gag reflex which might cause fluid to move down to the lungs (aspiration).
Depending on your level of competence at airway management a number of aids is available.
Guedal airways are the easiest to insert and require little training or practice, they are slightly curved and flattened plastic tubes that when inserted lay on top of the tongue preventing it falling back and blocking the airway. They are available in a number of sizes and are suitable for infants, children and adults. To determine which size is suitable place them along the line of the jaw the correct size will be the distance between the corner of the mouth and the angle of the jaw.
The next type is a nasopharyngeal airway, which is a semi-rigid plastic tube that is inserted through the nose into the back of the throat. These should be used if there is damage to the jaw or swelling in the mouth which would make insertion of the Guedal difficult. When inserting the airway, check that the casualties' right nostril is not damaged, then place a safety pin through the end of the airway to prevent it being inhaled. Insert using a twisting motion. If however the casualty has a fractured nose or you suspect they may have a fracture of the base of the skull, these shouldn't be used as inserting them could cause additional damage. Additional this method is not suitable for children under 6 years of age.
The next method should only be used if you have received training in its use. Endotracheal intubation is where an airway is passed through the mouth and into the windpipe (trachea). This is achieved using an instrument called a Laryngoscope, which is placed in the mouth and used to lift the jaw and supplies an illuminated pathway though which to pass the endotracheal airway or E.T Tube between the vocal cords.
Advantages of this type of airway are that a bag and mask resuscitator may be attached directly to the top of the airway, which allows for easy ventilation of the casualty. If oxygen or a mechanical/electrical ventilator is available this can be also attached. This is the preferred method in hospitals if the casualty has stopped breathing and can also be used for the direct administration of drugs. Although injecting directly into the blood stream (IV) is preferred.
The last method is only rarely use where extensive swelling (odema) or damage
Blocks (Occludes) the windpipe. It is a surgical method called cricothyroidotomy
Where and instrument which consists of a hollow tube (catheter) over a needle is used to puncture the cricothyroid membrane in the throat and introduce an airway directly into the windpipe. This is a last ditch method as any cut (incision) in the skin bring with it the risks of bleeding (haemorrhage), Infection and damage to other internal structures.
After any airway has been inserted check if it works by repeating the 'Look', 'Listen', 'Feel' procedure to detect breath sounds and movement.
While examining Airway check for any smells on breath
Alcohol, Cannabis, Pear drops, Solvents etc
B - Breathing:
Ventilation -using bag & mask while preparing to intubate. Hyperventilate patients with head wounds. If the patient has adequate spontaneous respiration administer 100% O2 from a non-rebreather (see?). Be sure to check for adequate and bilateral chest expansion and breath sounds. (See Airway Management for further details)
C - Circulation:
Determine pulse rate and blood pressure. While there is some controversy about the proper treatment for traumatic injuries resulting in hypo-tension, aggressive fluid resuscitation with normal saline or lactated Ringer's solution through two large bore IVs (14 -16 gauge) is still the standard of care. Control haemorrhage with direct pressure or application of PASG, if not contraindicated.
D – Deficits (Neurological):
E – Exposure / Search
(Types of ID, Medication)
F – Fahrenheit
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