Carry out structured assessment and treatment

If a casualty is unresponsive, medical alert tags, bracelets or cards may provide information about pre-existing medical conditions. Prescribed medical equipment may also be an indicator of a pre-existing medical condition.

A structured assessment of the casualty should be carried out by a competent person, with the necessary equipment and using the following approach:

• <C> Control of catastrophic external compressible bleeding
  • The use of tourniquets, by trained personnel, forms part of the Faculty of Pre-Hospital Care (FPHC) position statement.
  • If there is a concern that a major bleed may occur on the casualty’s release, tourniquet(s) may be applied loose, prior to extrication. These can then be quickly tightened if required – this action should only be undertaken by trained personnel.
• Airway
  • A simple ‘airway ladder’ approach to airway care should be promoted
  • Assessment and monitoring of the airway should be continuous
  • Suction should be available to clear the airway

• Cervical spine (c-spine)
  • If possible, self-extrication of the casualty is encouraged, following the guidelines promoted in the Faculty of Pre-Hospital Care (FPHC) Spinal immobilisation consensus statement
  • Manual in-line stabilisation is an acceptable method of stabilising the c-spine
  • A long board is used for extrication only and the casualty is placed onto a spinal stabilising device. Ideally a vacuum mattress or split device (for example a scoop stretcher) should be used to transport the casualty to definitive care
  • If extrication cannot be effected quickly, a request for advanced medical support to deliver advanced medical care (doctor or immediate care practitioner) should be considered at the earliest opportunity
• Breathing
  • Assessment of breathing / ventilation and the chest should be structured
  • Suggest RV-FLAPS WET:
    • Rate and Volume of breathing
    • Feel the chest
    • Look at the chest
    • Armpits clear of injury
    • Press the chest wall
    • Search the back and side/shoulders
    • Wounds on the neck
    • Emphysema felt in the neck
    • Trachea central in the sternal notch
  • Assessment and monitoring of breathing should be continuous
    • Minimum (rate and volume)
    • The means to support a casualty who has stopped breathing should be available – pocket mask and/or bag valve mask (BVM)
  • Self-ventilating patients will receive high-flow oxygen via a non-rebreather mask
  • Sucking chest wounds should be covered with either a gloved hand or appropriate chest seal dressing with one-way air release valve

Figure: Diagram showing the bleeding ladder approach

• Circulation
  • All bleeding should be stopped or controlled
  • Stopping bleeding is a priority and should be achieved using the ‘bleeding ladder’ approach:
  • Pelvic fractures should be treated in line with the Faculty of Pre-Hospital Care (FPHC) consensus statement; pre-hospital providers must ensure that their employees do not apply pelvic binders unless they are appropriately trained with clinical governance structures in place
  • Assessment of circulation through methods such as checking capillary refill
  • Shock is a life-threatening condition that occurs when the body is not getting enough flow of blood; if there is no evidence of external blood loss, there is likely to be internal bleeding
• Disability
  • The casualty’s level of consciousness is measured using AVPU:
    • Alert
    • Voice
    • Pain
    • Unresponsive
  • AVPU assessment should be recorded every 3 to 5 minutes
  • Casualties should have a pain score recorded
  • The irritable or uncooperative casualty will require early specialist medical assessment and treatment
  • If the casualty is presenting with a psychiatric illness or personality disorder the police should be involved early
• Exposure, Extrication and Evacuation
  • Casualties should be protected from the elements
  • Active rewarming is encouraged
  • Casualties may require stripping to skin to enable assessment
  • The dignity of the casualty should be maintained
  • If trapped, extrication should be, where possible, swift but controlled
  • Casualty handling principles should be adopted as per Faculty of Pre-Hospital Care (FPHC) consensus statement