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  • William W. Forgey, MD

Assessment and Stabilization part 1 of 3 - Initial and Focused Assessment

Updated: Nov 12, 2020

Excerpt from The Prepper's Medical Handbook. Page reference numbers point to more in-depth treatment and self-reliant care available within the book.


The technique of providing aid to an injured person is similar to giving appropriate treatment to someone who complains of sickness or sudden pain from a noninjury cause. Proper care can result only if several basic steps are performed correctly. The basics are straightforward, and you should not be intimidated by this process. The problem with medicine in general is that there are so many possible diagnoses and treatments that the whole thing can seem overwhelming. It is not, however, if you follow certain logical steps. These logical steps form the basis of starting the decision tree that will lead almost automatically to a correct course of action. They simplify the process into a much less scary proposition. The initial phase is assessment, the second phase is stabilization, and the third phase is treatment. While the first aid approach only includes assessment, this book is concerned with developing approaches to definitive treatment that could be reasonably performed in remote areas by relatively untrained (and undoubtedly very concerned) friends of the suddenly impaired.

Trauma assessment is divided into two phases called the initial assessment and focused assessment. What good is an assessment if you don't know what to do with the information? During rescue operations, what you do with the information is record it. This recorded information, which includes periodic reassessment data, can be valuable to physicians at treatment centers, as it indicates either a stable or a deteriorating patient and helps direct the future course of action. For those of us stuck with caring for the patient in a remote area, this data can be used to begin a decision tree that will help determine our best course of action. Sometimes this will be definitive treatment; other times it will amount to minimizing the damage and striving to keep the victim as functional as possible, or sometimes just alive.

INITIAL ASSESSMENT

Survey the Scene Before assessing the patient, assess the scene! Accidents tend to multiply. Make sure the scene is safe for the rescuers and the victim. Ensure that the situation does not become worse. This step can include such diverse aspects as avoiding further avalanches or rock falls and ensuring adequate clothing and food supplies for rescuers. Initially, however, scene assessment should consist of looking for immediate hazards that might result in more casualties among the group attempting to help the victim. Check the Airway and Breathing Check the airway. If the victim can talk, his airway is functioning. In an unconscious patient, place your ear next to his nose/mouth and your hand on his chest and look, listen, and feel for air movement. No air movement: Check to see whether the tongue is blocking the airway by pushing down on the forehead while lifting the chin. In case of possible neck injury, the airway can be opened by lifting the jaw without moving the neck. Open the victim's mouth and visually inspect, removing any objects you can see. Still no air movement: Pinch his nose, seal your mouth over his, and try to breathe air into his lungs. If the first attempt to breathe air into the victim fails, you should reposition the victim's head and try again. Still no air movement: Perform chest thrusts, similar to the compressions of cardiopulmonary resuscitation (CPR); see page 17.Perform 30 compressions followed by attempts to breathe in air as directed above. Once you are able to establish air movement, continue compressions until the victim's heart is beating and no longer requires compressions and he is breathing on his own. See one-person and two-person CPR on pages 17-20


Check Circulation Check circulation by placing several of your fingertips lightly into the hollow below the angle of the patient's jaw. See figure 2-1. No pulse: Start CPR; see page 17.

Check for Severe Bleeding Check quickly for severe blood loss. Check visually and with your hands. Slide your hand under the victim to ensure that blood is not leaking into the ground or snow, and check inside bulky garments for hidden blood loss. Severe bleeding: Use direct pressure and/or a tourniquet; see page 118.

Check the Cervical Spine During the primary assessment, keep the head and neck as still as possible if there is any suspicion of a cervical spine injury. This may certainly be the case if the patient is unconscious or suffering from an accident such as a steep fall, a sudden stop, or significant blows to the head. See treatment of spine injuries, page 168. In their excellent book Medicine for the Backcountry (Globe Pequot Press, 1999), Buck Tilton and Frank Hubbell state, “Do not let fear of spinal cord injury blind you to more immediate threats to life. If the scene is not safe, the patient may need to be carefully moved. If the airway is not open, grasp the sides of your patient's head firmly, and pull with steady, gentle traction, and attempt to align the head and neck with the rest of the body. Gentle traction should be maintained until mechanical stabilization can be improvised.” See spinal cord management, page 167.

FOCUSED ASSESSMENT

The Physical Exam

While the purpose of the initial assessment (formerly called the primary or hasty survey) is to rapidly find and correct life-threatening conditions, the focused assessment (formerly identified as the secondary survey) is an attempt to identify all of the medical problems that the patient might have. This requires a thorough examination because sometimes an obvious injury can be distracting: A broken bone may cause both you and the victim not to notice a less painful but potentially more serious injury elsewhere. The only way to perform a focused assessment is to do it thoroughly, using both your vision and sense of touch, asking simple questions, and being methodical in the approach. Sense of touch is important. Sliding your hand under the victim might find areas of tenderness or even considerable blood loss that would otherwise be unnoticed. It is surprising how much blood can be absorbed into snow or sand under a wounded victim and not even be noticed until your hand encounters it. The mission of the focused assessment is not only to discover various medical problems but also to record and keep track of them during periodic reassessments. The reassessment information is even more important than the first set of information taken during the initial focused assessment. How often the focused assessment needs to be repeated and how extensive it needs to be depend primarily on the history of the event. Very serious appearing events could initially require total body reassessment every 15 minutes. There can be no hard and fast rule concerning how often to repeat reassessments and how extensive they must be. There is no escaping the use of common sense. Eventually reassessment every few hours, even discontinuing this process, will become proper. This is particularly appropriate when the examination is unchanged and stable, the patient is alert, and you obviously have effectively dealt with the injuries. The scheme for recording this information is in the form of a SOAP note, which stands for Subjective, Objective, Assessment, Plan. The most significant difference between off-grid and standard urban first aid is that the focused assessment when you are off the grid must also lead to treatment protocols. This methodical examination should generally start at the head and work its way to the feet. The exception could be children, where you might want to alleviate their apprehension by starting with their legs before examining their heads. Generally starting at the head is best. Some ethnic groups demand this. For example, Romani find it insulting to be touched above the waist directly after being touched below the waist. This is good to know if you are coexisting with Romani. General Principles of the Focused Physical Assessment:

1. Start at the top and work your way down. 2. Move the patient as little as possible and try not to aggravate known injuries while looking for others. 3. Constantly communicate with the patient during the examination, even if she seems unconscious. 4. Look for damage, even cutting away clothing if necessary to visualize suspected injuries. 5. Ask about pain, discomfort, and abnormal sensations constantly during the exam. 6. Gently feel all relevant body parts for abnormalities. VITAL SIGNS

While even accurate measurements of the body's functions may not indicate what is wrong with a patient, the second and subsequent measurements indicate how well the patient is doing. You will need to use common sense to determine how often the signs are taken, but certainly close monitoring of the patient should be continued until she is “out of the woods," either literally or figuratively.

Vital signs consist of several elements: level of responsiveness, pulse, respirations, skin signs, blood pressure, and temperature. Level of Responsiveness

Is the patient alert, or does she respond only to verbal or painful stimulus? Or is she unresponsive? She should know who she is, where she is, what happened to her, and about what time of the day it is. Responsiveness ranges from alert to verbal (responsive to spoken contact) to pain (not responsive to verbal contact but responsive to being pinched or rubbed on the shin) to unresponsive. Pulse

Check and record rate, rhythm, and quality (weak, normal, or strong) of the pulse. If an injury has been sustained by a limb, check pulses on both injured and uninjured limbs, and compare.

Shock, see page 13.

Deformed fracture causing a decreased pulse, see page 178.

Respirations

Note the rate, rhythm, and quality of respirations (labored, with pain, flaring of nostrils, or noise such as snores, squeaks, gurgles, or gasps). An adult normally breathes 12 to 18 times per minute, while children breathe faster.

Respiratory difficulties, see page 16.

Skin Signs

Check skin color, particularly in the nonpigmented areas of the body, and note whether skin is hot/cold and moist/dry.

Hot, feaver, see page 11.

Heat stress, see page 255.

Cold, shock, see page 13.

Hypothermia, see page 246.

Yellow skin, jaundice, see page 225.

Anemia, see page 31.

Blood Pressure Blood pressure can be measured with a stethoscope and blood pressure cuff or by estimating. If you can feel a pulse in the radial artery at the wrist, the top (systolic) pressure is probably at least 80 mm Hg. If you can feel the femoral pulse only in the groin, the pressure is no lower than 70 mm Hg. When only the carotid pulse in the neck is palpable, the systolic is probably at least 60 mm. Normal systolic blood pressures range from 100 to 140. Low upper blood pressures with normal pulses (70 to 85 beats per minute) are safe. But an increased pulse rate with a low pressure is an indication of shock. Temperature Oral thermometers will give the most accurate field temperatures unless the ambient temperature is close to the room temperature of a Ritz-Carlton resort, in which case forehead infrared or ear temperature thermometers are convenient, until their batteries wear out. Plastic direct contact thermometers also require a similar ambient temperature range for accuracy. An estimation of fever can be made if the person's normal resting pulse rate is known. Each degree Fahrenheit will generally result in a 10-beats-per-minute pulse increase. There are exceptions, such as typhoid fever, when there is a relatively slow heart rate for a high fever (see page 242).

Oxygen Saturation I have not included a pulse oximeter in the Off-Grid Medical Kit. If you have anyone in your group with a lung problem, you need to consider an oxygen concentrator and a renewable power supply. This is very reasonable equipment to manage, both acquisition cost and weight. A pulse oximeter is only $30 and available over the counter at most pharmacies. Portable oxygen concentrators do not require prescriptions and power units—and power units are a mainstay of any prepper project, so no need for me to belabor the topic here.


MEDICAL HISTORY AND PHYSICAL EXAMINATION Taking a medical history allows you to factor in your patient's previous or current illnesses as they may relate to the situation at hand. Before or during your actual physical examination, if the patient is not in an acute stage, ask about any allergies, medications that your patient is taking, health history, last food or drink, and about the events that led up to the accident. If he is in pain, ask what provokes it, what action (if any) decreases its intensity, whether it radiates, how severe it is, what type it is (burning, sharp, dull), and when it started. Head Look for damage, discoloration, and blood or fluid draining from ears, nose, and mouth. Ask about loss of consciousness, pain, or any abnormal sensations. Feel for lumps or other deformities.

Losses of consciousness, see page 165.

Headache, see page 36.

Ear trauma, see page 54.

Eye trauma, see page 37.

Nose trauma, see page 53.

Mouth trauma, see page 131.

Neck Look for obvious damage or deviation of the windpipe (trachea). Ask about pain and discomfort. Feel along the cervical spine for a pain response.

Cervical spin trauma, see page 167. Chest Compress the ribs from both sides, as if squeezing a birdcage, keeping your hands wide to prevent the possibility of too much direct pressure on fractures. Look for damage or deformities. Ask about pain. Feel for instability.

Chest trauma, see page 191.

Difficulty breathing, see page 16

Abdomen With hands spread wide, press gently on the abdomen. Look for damage. Ask about pain and discomfort. Feel for rigidity, distention, or muscle spasms.

Abdominal pain, see page 65.

Back Slide your hands under the patient, palpating as much of the spine as possible.

Spine trauma, see page 168.

Pelvis/Hip Place your hands on the top front of the pelvis on both sides (the iliac crests), pressing gently down and pulling toward the midline of the body. Ask about pain. Feel for instability.

Hip or pelvis pain, see page 185 Legs One at a time, with your hands surrounding the leg, run your hands from the groin down to the toes, squeezing as you go. Note espe cially if there is a lack of circulation, sensation, or motion in the toes. Repeat for the other leg.

Bon injury, see page 154. Shoulders and Arms One at a time, with hands wide, squeeze the shoulder, and run your hands down the arms to the fingers. Check for circulation, sensation, and motion in the fingers. Repeat for the other shoulder.

Shoulder trauma, see page 172.

Joint trauma, see page 158

Broken bone, see page 161.



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