An account by an experienced first responder, guiding through the trained first aid and resuscitation procedures when faced with a multiple trauma.
Initial Case Description
"Male thrown from Quad bike, on rural property in Northern NSW. Nearest Ambulance resource is 25 minutes from scene, and based on description of the case, a Helicopter is awaiting a report to be activated."
Case Study: The FIrst Responder's Account
As the first responder, I am on the first Ambulance heading to the case, partnered up with a Junior officer who has just completed first responder training and is keen, but nervous. We discuss the case on the way in, read as much information about the case as we can on the screen in the ambulance and mentally prepare ourselves for the challenge of dealing with the trauma. As we drive further and further away from the township to the property, we realise we are going to be on our own for some time.
At the entrance to the property, we meet the family member who had called 000. He informs us anxiously that the patient was thrown from his quad bike whilst riding at high speed and was flung about seven metres, striking his head on rocky ground. He tells us the patient has not moved since the accident but is breathing.
Immediate Visual Assessment
We are taken to where the patient is lying on the ground, with two other people in attendance. They are holding pressure onto a large wound on his left lower leg which appears to be bleeding profusely, despite their best efforts. The patient appears to be unconscious but is breathing loudly. He was thrown onto a tree, from which a large branch has broken off and is dangling precariously above the scene. They have not moved him, as they were concerned that “he may have a broken neck”.
We need to ask ourselves - what are the priorities in this multiple trauma case? Where do we start?
Even after many years of first responder and trauma training, experience and study, I always revert first to the basic mnemonic DRS, where DRS stands for:
Danger - assess whether there are any immediate threats to you or anyone at the scene.
Response - see if the person is conscious and responding.
Send for Help - call for more assistance if needed.
First of all, mitigate the danger. The risk of the falling branch striking us, the patient and the bystanders, must be addressed immediately. Our actions to protect the patient's neck and spine would be rendered useless if the huge branch fell on all of us. Also, since the Australian Resuscitation Council (ARC) clearly outlines in their first responder training that the risk of neurological deterioration when moving a suspected spinal patient is very low, the need to protect him and ourselves from further injury takes precedence.
Consequently, we move the patient, taking as much precaution with his head and neck as possible. Then, checking his responsiveness, we find that he does not respond to Voice or Pain. It is obvious that he is breathing, but his wound is still bleeding, despite the best efforts of the bystanders.
At the “S” mark of DRS, I assess that we need assistance and ask my partner to give an initial report, signifying the need for the Helicopter to transport this patient to the nearest Trauma Hospital. It is extremely important to initiate this as soon as possible, preventing any possible delays in receiving further assistance from people with higher clinical capability.
Primary Assessment of Trauma Patient
It is highlighted very clearly in the ARC guidelines that, at this point, managing bleeding takes priority, even over Airway or Breathing. On assessing the wound, I find that it is spurting, indicating an arterial bleed. Now, before anything else, my priority must be immediate control of this haemorrhage. I apply an arterial tourniquet, a Sof T style, which appears to control the bleeding.
I quickly assess the patient's airway and recognise that it is patent. His breathing appears to be clear, with a simple airway manoeuvre. I decide to not worry about applying a cervical collar at this stage, as he is unconscious and not moving. Even if there is a spinal injury, muscle spasm tends to provide a natural splint. Besides, there are other priorities at the moment; my partner and I now need to apply a pelvic splint to reduce the area within the retro-peritoneal cavity into which a fractured pelvis may bleed, causing rapid deterioration and death. We apply the pelvic splint as quickly as possible and then continue with our primary survey.
First Responder ABCDE Approach to Assessment and Treatment
The patient’s Airway is patent, his Breathing rate is 28, equal and clear entry, with good tidal volume. Assessing his Circulation, the patient appears pale and diaphoretic, with a rapid HR of 124. Whilst the pulse appears rapid, it seems to be of good volume, strong and palpable in the distal pulses. I decide to cannulate at this stage, asking my partner to begin to set up for IV access, so we can make sure we manage the patient safely should his situation deteriorate.
Then we move on to the D section of the primary survey: his pupils are equal and reactive and we have assessed his level of consciousness to be “U”, for unconscious. A further scoring of his GCS is found to be:
Eyes – 1 (nil)
Voice – 2 (incomprehensible sounds)
Motor – 4 (withdraws to pain)
This total score of 7 is a concerning find, signifying that the trauma patient has a considerable head injury and needs urgent hospital treatment. He requires his airway to be protected via Rapid Sequence Intubation. This is a skill that the Doctor on the helicopter can provide so we need them ASAP for both this procedure and for urgent transportation to the hospital.
Moving onto E, we render the patient “trauma naked” in order to properly expose him for examination. This means that we cut his clothes off, leaving only his underwear. Then another full set of observations are needed and we attach monitoring leads. We record his heart rate, blood pressure, oxygen saturation, blood glucose level and also his temperature since it’s important to keep the patient warm.
A secondary survey involves a thorough “nose to toes” assessment. We find that there is a large boggy mass at the back of the head, the chest appears clear and the abdomen is soft with nil guarding. The wound on the left leg has stopped bleeding since the application of the tourniquet and there does not appear to be any further injury to the lower limbs. Both upper limbs have minor abrasions all over them, but with no active bleeding.
First Responders Handover to the Medical Team
A report has informed us that the helicopter is only a few minutes away. In our initial report we had indicated that we required the Police to assist with the helicopter landing. The Police have arrived and are ready and waiting, highlighting the need for keeping communication open and giving early, accurate reports. The Police are able to assist with landing the helicopter and bringing the medical team to join us, which they do promptly and efficiently.
I give the medical team a thorough handover using the IMIST-AMBO tool, highlighting our ABCDE assessment and treatment approach. The Doctor then takes over, using ultrasound to examine the abdomen for bleeding and the chest for pneumothorax. Not finding any, she then proceeds to perform a Rapid Sequence Intubation to protect the patient’s airway. The team get blood running and we package the patient up for transport via helicopter to the nearest trauma centre.
The patient departed shortly after, reaching the trauma hospital in the quickest possible time, achieving the best possible outcome to be expected considering the dire circumstances of this incident.
To learn the proper sequence of events for trauma assessment and treatment, contact Risk Response and Rescue today to enrol on our First Responder Training Course.