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ITLS Military 2e Ch01 Scene Sizeup

Scene Size-Up
International Trauma Life Support
Military, 2nd Edition
Scene Size-up
(Courtesy of Leo Garcia)
Course Objectives
• Save preventable deaths without mission
• Prevent secondary injuries
• How the combat situation affects the
provision of medical care
• Steps of scene size-up
• Time to patient survival relationships
• Basic mechanisms of injury
• Factors involved in patient assessment with
blast injuries
• Combat environment poses unique challenges
and requires special adaptations
• Military vs. civilian trauma care:
Requirement for mission completion
Gunfire and explosives
Often different MOI
Limited (or no) equipment/supplies
Need for darkness
Variable length of casualty care time
Different medic backgrounds, training, experience
• The 3 field interventions you can provide that
may save another fatality:
– Stop severe bleeding (hemorrhage)
– Relieve tension pneumothorax
– Restore the airway
Combat Lifesaver
• Principles of Combat Lifesaver program from
U.S. military:
– Your primary mission is still your combat duties
– Functioning as a Combat Lifesaver is your
secondary mission
– You should render care only when such care does
not endanger your primary mission
Source: Combat Lifesaver Course, U.S. Army Medical
Department Center and School, Fort Sam Houston, Texas
Combat Casualty Care
• 3 phases:
– Care Under Fire
– Field Medical Care
– Casualty Evacuation
(Courtesy of Leo Garcia)
Care Under Fire
• Initial phase of care at the point of injury
• Team is still receiving enemy fire
• Typically continue to fight rather than stop
returning fire to care for wounded
• Self-aid or buddy-aid for wounded; limited to
application of tourniquet
• Very limited or no medical equipment available
Field Medical Care
• Care given in the combat environment but
after effective enemy fire ceases
• Still potentially dangerous situation but can
concentrate on care for the wounded
• Medical equipment and resources still limited
Casualty Evacuation Care
• Phase begins with addition of evacuation
• Ideally brings additional medical personnel
and equipment
Care Under Fire
(Courtesy of Leo Garcia)
Care Under Fire
• If the casualty has severe bleeding from a limb
or has an amputation, apply a tourniquet
• Move the casualty to cover before ANY other
Combat Application
Tourniquet (CAT)
(© 2010 North American Rescue, LLC.)
Care Under Fire
• Reassure the casualty
• If unresponsive, move the casualty and his
mission-essential equipment to cover as the
tactical situation permits
Tactical Field Care
(Courtesy of Leo Garcia)
Tactical Field Care
• Perform tactical field care when you and the
casualty are not under direct enemy fire
• Recheck bleeding control measures if they
were applied while under fire
Tactical Field Care
• Any casualty with no pulse or respiration is
– CPR is NEVER performed
• All other casualties MUST be immediately
disarmed of all weapons and explosives unless
they are fully alert
Determine Level of
AVPU system
A The casualty is alert, knows who he is, the
date, where he is, etc.
V The casualty is not alert, but does respond to
verbal commands
P The casualty responds to pain, but not verbal
U The casualty is unresponsive (unconscious)
Recheck every 15 minutes
Tactical Field Care
• Initial assessment is the ABCs
– Airway
– Breathing
– Circulation
Tactical Field Care: Airway
• Open the airway with either a chin-lift or jawthrust maneuver
• Insert a nasopharyngeal airway if unconscious
and spontaneously breathing
• Place the casualty in the recovery position
Tactical Field Care: Breathing
• Sucking chest wounds must be closed with
some form of an occlusive dressing
• Place the casualty in the sitting position if
Occlusive Dressings
Photo courtesy of Teleflex Medical Incorporated, all rights reserved. No
other use shall be made of the image without the prior written consent of
Teleflex Medical Incorporated.)
(Courtesy of Jeffery D. Gilliard, NRP/CCEMTP/FPM, BS)
Tactical Field Care: Breathing
• Progressive respiratory distress with
decreased breath sound should be considered
tension pneumothorax
– A leading cause of preventable death on the
• Needle chest decompression is life-saving
Needle Chest Decompression
(Courtesy of Louis B. Mallory, MBA, REMT-P)
(Courtesy of Pearson Education)
(Courtesy of Louis B. Mallory, MBA, REMT-P)
Tactical Field Care:
• Apply a tourniquet to a major amputation of
the extremity
• Apply an emergency trauma bandage and direct
pressure to a severely bleeding wound
• If a tourniquet was previously applied, consider
changing to a pressure dressing and/or using
hemostatic dressings (HemConTM) or
hemostatic powder (QuikClotTM)
to control any additional hemorrhage
Hemostatic Dressing
• Apply directly to bleeding site and hold in
place 2 minutes
• If dressing is not effective in stopping
bleeding after 4 minutes, remove original
and apply a new dressing
Hemostatic Dressing
• Additional dressings cannot be applied over
ineffective dressing
• Apply a battle dressing/bandage to secure
hemostatic dressing in place
• Hemostatic dressings should only be removed
by responsible persons after evacuation to the
next level of care
Tactical Field Care: Shock
• Hypovolemic shock results when there is a
sudden decrease in the amount of fluid in the
casualty’s circulatory system
• Heat stroke, diarrhea, and dysentery can also
cause hypovolemic shock
• The casualty may also have internal bleeding,
such as bleeding into the abdominal or chest
Tactical Field Care: IV Fluids
• Before replacing, STOP THE BLEEDING
• Single large IV or IO is best method
• Do not place distal to a fracture or large
Tactical Field Care:
Additional Injuries
• Administer the Soldier’s Combat Pill Pack
– Tylenol, 1000 mg
– Non-steroidal anti-inflammatory
– Some sort of antibiotic
• Assess abdomen
• Check back
• Splint fractures
Tactical Field Care
• Communicate: Let your unit leader know the
casualty’s condition: Will casualty return to
duty? Does the casualty require medical evac
to save life or limb? Non-medical evac?
• Initiate a Field Medical Card
• Monitor the casualty: Airway, breathing,
bleeding, and IV infusion
Combat Casualty Evacuation Care
(Courtesy of Leo Garcia)
• If the casualty requires evacuation,
prepare the casualty
• Use a blanket to keep the casualty
• If the casualty is to be evacuated
by medical transport, you may
need to prepare and transmit
a MEDEVAC request
(Courtesy of James McCombs, DO)
• Use a SKED litter or improvised litter if the
casualty must be moved to a casualty
collection point
• If transported by a non-medical vehicle
(CASEVAC), you may need to arrange the
vehicle to accommodate the casualty
• If an unconscious casualty is transported on a
non-medical vehicle, you may need to
accompany the casualty and render additional
care as needed
• Restock your aid bag when possible
Battlefield Summary
• Some soldiers will die from injuries
• You can save those with salvageable injuries
with proper care
Battlefield Summary
“If during the next war you could do only
two things, (1) place a tourniquet and (2)
treat a tension pneumothorax, then you
can probably save between 70 and 90
percent of all the preventable deaths on
the battlefield.”
-COL (Ret.) Ron Bellamy, MD, US Army
Scene Size-up
(Courtesy of Leo Garcia)
Trauma Care
• Teamwork is important!
• You must know:
– How not to become a casualty
– What you should handle and what you shouldn't
– When to stay and when to leave
– Fastest, safest route there and away
– What to do, what not to do within the time
constraints of the combat situation
Scene Size-up
A critical part of trauma assessment
Anticipate real and potential scene dangers
Know equipment and resource availability
Can the casualty be safely approached
Be prepared to modify your plan
Failure to size up can jeopardize lives –
including yours
Scene Size-up
Standard precautions
Scene safety (consider threats)
Initial triage (total number of patients)
Need for more help or equipment
Mechanism(s) of injury
Identify a casualty collection point
Anticipate what can go wrong and be
prepared to modify your care
Standard Precautions
• Exposure to blood or OPIM very likely at a
trauma scene, especially with non-military
• Appropriate PPE must be worn depending on
situation and availability
Scene Safety
• Situational awareness
– Threats to you
– Threats to/from patient
– Threats to/from bystanders
Initial Triage
• Total number of patients
– Is more help needed (or
– Are MASCAL protocols
– Are all casualties
– Plan for evaluation
(Courtesy of Brian Hall, MD)
Mechanism of Injury
• Energy follows physics laws
– Injuries present in predictable patterns
• High-energy at risk of severe injury
– Consider injured until proven otherwise
• Type of MOI
– Generalized
– Focused
– Combat wounds can have both
(Courtesy of Charles Ussery, DO)
Basic Motion Mechanisms
• Penetrating injuries
– Projectiles
– Knives
– Falls upon object
– Blast injury
• Blunt injuries
– Rapid forward
– Rapid vertical
– Blunt instrument
energy transfer
– Blast injury
Penetrating Injuries
• Firearms
– Type of weapon
• Low-velocity
• High-velocity
– Caliber
• Missile size
• Bullet construction
• Tumbling/yaw
– Distance traveled
(Courtesy of Roy Alson, MD)
Wound Ballistics
• Internal wound
– Tissue contact damage
– High-velocity transfer of energy
• Shock waves
• Temporary cavity
• Pulsation of temporary cavity
(Courtesy of Pearson Education)
• Damage proportional to tissue density
– Highly dense tissue sustains more damage
Wound Ballistics
• Factors
– Missile velocity
– Missile size
– Missile deformity
– Missile design
– Tumbling and yaw
(Courtesy of Roy Alson, MD)
Penetrating Wounds
• Entry wound
– May be darkened, burned
• Exit wound
– One, none, or many
– May be ragged
(Courtesy of Edward T. Dickinson, MD)
Penetrating Injuries
• Knife-wound severity
– Anatomic area penetrated
• Fourth intercostal space may be
chest and abdomen
– Length of blade
– Angle of penetration
• Stabilize impaled object
– Minimize external movement
(Courtesy of Pearson Education )
Blast Injuries
• Primary
– Initial air blast
• Secondary
– Material propelled
• Tertiary
– Impact on object
(Courtesy of Pearson Education)
Blast Injuries
• Quaternary
– Thermal burns from the
explosion or respiratory injuries
from inhalation of toxic dust
or fumes
(Courtesy of Pearson Education)
• Quinary
– Contamination of the patient (and you) by
chemical, biological or radiological material
dispersed by the explosion (dirty bomb)
Motor-Vehicle Collisions
Each collision is three collisions:
(Courtesy of Pearson Education )
Other Collisions
• Secondary collisions
– Objects are missiles
– Additional impacts
– Vehicle collides with another object
– Other vehicles collide with original vehicle
Clues to Injury
• Deformity of vehicle
– What forces were involved in collision
• Deformity of interior structures
– What did patient hit
• Deformity or injury patterns on patient
– What anatomic areas were hit
Common Collisions
• Common types
– Frontal-impact
– Lateral-impact
– Rear-impact
– Rollover
– Rotational
(Courtesy of Mark C. Ide)
Frontal-Impact Collision
• Windshield injuries
– Brain, soft-tissue injury,
cervical spine
• Steering wheel injuries
– Traumatic tattooing of skin
• Dashboard injuries
– Face, brain, cervical spine,
pelvis, hip, knee
(Courtesy of Maria Dryfhout / Shutterstock )
Lateral-Impact Collision
• Similar to frontal-impact
with lateral energy
– Not easily predicted
– Consider organ damage
• Check impact side
– Head, neck, upper arm,
shoulder, thorax, abdomen,
pelvis, legs
(Courtesy of Anthony Cellitti, NREMT-P)
Rear-Impact Collision
• Posterior displacement
– Rapid forward deceleration
also possible
• Seatback position
– Hyperextension injuries
• Damage back and front
– Deceleration injuries
(Courtesy of Bonnie Meneely, EMT-P)
Rollover Collision
• Multiple impacts
– Multiple directions
– Multiple injuries
• Axial-loading injuries
– Spine injury
• Ejection
– Chance of death increases
25 times
(Courtesy of Bonnie Meneely, EMT-P)
Rotational Collision
• Head-on, lateral-impact
– Converts forward motion
to spinning motion
• Windshield, dashboard,
steering wheel, side
– Same possible injuries
of both mechanisms
(Courtesy Dedyukhin Dmitry / Shutterstock.com)
Small-Vehicle Crashes
• Small vehicles
– Motorcycles
– All-terrain vehicles
– Personal watercraft
– Snowmobiles
• Factors
– Protective gear
– Additional impacts
(Courtesy of Orientaly / Shutterstock.com)
Pedestrian Injuries
• Mechanism
– Primary collision
– Additional impacts
• Common injuries
– Internal injuries and fractures
• Adult: bilateral leg, knee
• Children: pelvis, torso
(Courtesy of Bonnie Meneely, EMT-P)
• Vertical deceleration
– Distance of fall
– Anatomy impact
– Surface struck
(Courtesy of James Miller)
• Time is critical; teamwork is essential
• Scene size-up can be lifesaving
• Mechanism of injury:
– An aid to predict injury
– Part of overall management of trauma patient
• Record scene and mechanism findings