The author, Vanguard Survival, LLC, its agents, or assigns are not responsible for any misuse, injury, disability, or death that may result by the improper use of the information contained in this series of articles. The information presented in this series of articles should only be used by those with training in advanced first aid techniques. If you are not trained in first aid DO NOT ATTEMPT ANY OF THESE TECHNIQUES!
In a survival/SHTF situation YOU will become your own, or your groups,”doctor”. It will be up to you to diagnose and treat various injuries and illnesses correctly to make sure that you or a member of your group “make it”. In this series of articles we are going to cover Advanced Techniques used by Special Operations medics to do just that.
But first I am going to toss some $50 college words at you because you need to know a few medical terms and what they mean.
Here are a few anatomical terms that reference positions on the body. Knowing these terms will help you better relate the location of an injury to emergency personnel should the need arise. To do so you have to divide the body with a series of imaginary lines called planes.
Planes of the Body
A plane is a surface in which if any two points are taken, a straight line that is drawn to join these two points lies wholly within that plane or surface. The planes of the body are:
- Medial Plane- A vertical plane running from front to back
(Anterior-Posterior) dividing the body into right and left parts. The plane divides the body into equal right and left parts by running through the middle of the breast bone (sternum).
- Medial Plane of an Extremity- A plane running lengthwise through an extremity from front to back. This plane must pass through the third finger of the hand or second toe of the foot. It is used as a reference plane to movements that involve spreading the toes or fingers (except thumb) apart or together. moving them together.
- Transverse Plane- A plane that divides the body or limbs into upper and lower parts in relation to gravity and anatomical position.
- Frontal Plane- A plane dividing the body into Anterior (front) and posterior (back) portions.
Anatomical Position Terms
- Anterior-Refers to the front of the body
- Posterior- Refers to the back of the body
- Medial Line-Refers to an imaginary line that runs right through the center of the body from the head to the feet
- Lateral-Refers to a point or area that is more distant from the medial plane. The outer side of the elbow is lateral when compared with for example, the inner side.
- Superior-Towards the head
- Inferior-Towards the feet
- Proximal-Nearest; closer to any point of reference. An example is the elbow is proximal to the wrist on the upper extremity
- Distal- Remote; farther from any point of reference. An example is the elbow is distal to the shoulder joint.
Below is a diagram of the relative anatomical positions.
The human skeleton is lighter than stainless steel, as tough as reinforced concrete, and able to repair itself. The skeletal system is the scaffolding that allows you to walk upright, the various bones, ligaments, and tendons protect your internal organs and allow you to move. Without the skeleton we’d all just be a big pile of mushy flesh.
It helps to know what bones are where in order to better understand why something doesn’t function like it is supposed to in the event of an injury. There are 102 bones in the human body and each has a specific function in protecting organs and allowing you to move. Below is a diagram listing the various bones and their locations in the body.
The circulatory system consists of the heart, blood, veins and arteries and is a “closed system” (or at least it is supposed to be). The heart pumps the blood throughout the body using the system of arteries and veins transporting oxygenated blood and nutrients throughout the body.
By having a basic understanding of the circulatory system you will be able to more easily treat any disruption to that system to stop bleeding that can lead to life threatening complications. Below is a simple diagram of the human circulatory system.
Now that you have a little more understanding of the human body and its various “systems” before you can treat any injury or illness you first have to find it. By doing a patient assessment you can do just that, find the problem and correct it.
The standard “ABC” approach as outlined in PHTLS (Pre-Hospital Trauma Life Support), ATLS (Advanced Trauma Life Support), and AHA (American Heart Association) CPR guidelines provides an excellent method for addressing life-threatening injuries in a systematic fashion.
The “ABC” pneumonic prioritizes the search for injuries in accordance with their potential to kill the patient; it is simple to remember and it provides an anchor point from which patients can re-assessed if they deteriorate.
This system may require some modification in a survival or SHTF setting.
For example, in a survival or SHTF situation where you have mass casualties, you may need to address the “ABCs” of several patients at once. Simply asking them where they are injured can do this. Those casualties who answer the question appropriately have an intact airway, are breathing and are conscious.
You should then focus his attention on those casualties who are unconscious or in obvious distress. Meanwhile, you can direct the lightly injured casualties or non-medical members of your group to aid in controlling the bleeding of those patients with active hemorrhage, thus addressing the circulation step.
During a SHTF situation where you are taking fire, moving the patient to a safe location takes priority over the Primary and Secondary Survey unless a rapid maneuver can be performed for an obvious life-threatening injury, i.e., the application of a tourniquet. Rapid control of hemorrhage is a mainstay of this type of casualty care.
A conscious spontaneously breathing patient requires no immediate airway intervention. If the patient is able to talk normally his airway is intact. If the patient is semi-conscious or unconscious, the flaccid tongue is the most common source of airway obstruction. The chin lift or jaw thrust maneuver should be attempted and should readily relieve any obstruction created by the tongue.
Once the airway is opened or if further difficulty is encountered, a nasopharyngeal or oropharyngeal airway should be inserted. The nasopharyngeal airway is better tolerated in the semi-conscious patient and the patient with an intact gag reflex.
If the above measures fail to provide an adequate airway or if the patient is unconscious, unresponsive and apneic, orotracheal intubation should be considered. Orotracheal intubation done on a trauma patient with an intact gag reflex without the use of pharmacological sedation and paralysis will be difficult and may cause additional complications such as vomiting, airway trauma and increased intracranial pressure, and thus should be avoided except as a last resort.
If the patient is breathing and definitive airway control if needed, blind nasotracheal intubation (BNTI) may be attempted. Severe facial fractures and basilar skull fractures are relative contraindications to BNTI.
Other adjuncts to airway management can and should be used if available and if your are skilled in their use. Other possible adjuncts to airway management include the Laryngeal Mask Airway (LMA) the Intubating LMA, the Combitube, and the Lighted Stylet.
If the patient has obvious face, mouth, or jaw trauma with signs of airway compromise or if orotracheal intubation fails, then a surgical cricothyroidotomy may be a necessary and lifesaving maneuver, which we will cover a little later.
The most common mistake when performing a surgical airway is delaying too long before starting the procedure. Civilian models of trauma care include cervical spine control and immobilization with airway management.
Few if any casualties with penetrating trauma will have associated injury to the cervical spine (based on surveys done in Iraq and Afghanistan of combat casualties) unless they have combined blunt injuries from vehicle or aircraft crashes, falls or crush injuries, or penetrating injury to the spinal cord.
Meticulous attention to presumed cervical spine injury in a survival or SHTF situation is not warranted if penetrating trauma is the obvious mechanism. Furthermore, you or the casualty may sustain additional injury if treatment of other injuries such as bleeding is delayed while the cervical spine is immobilized.
In the conscious patient, who is alert and breathing normally, no interventions are required. If the patient has signs of respiratory distress such as tachypnea (very rapid breathing), dyspnea (difficulty breathing), or cyanosis (bluish coloration of the lips or skin), which may be associated with agitation or decreasing mental status, an aggressive search for why is required.
Injuries that may result in significant respiratory compromise include tension pneumothorax, open pneumothorax (sucking chest wound), flail chest, and massive hemothorax. The patient’s chest and back should be quickly exposed and inspected for obvious signs of trauma, asymmetrical or paradoxical movement of the chest wall, accessory muscle use and jugular venous distention (obvious swelling in the jugular vein(s)).
If possible, auscultation (listening) should be performed listening for abnormal or decreased breath sounds. The chest wall should be palpated to identify areas of tenderness, crepitus, subcutaneous emphysema or deformity.
Open pneumothorax should be treated with a three-sided occlusive dressing and a tension pneumothorax with needle decompression, which we will cover a little later.
The field management of a flail chest centers on controlling the patient’s pain and augmentation of the patient’s respiratory efforts with bag valve mask ventilation.
Chest wall splinting with tape, sandbags and the like has been advocated in the past but should no longer be performed as it decreases the movement of the chest wall and will further compromise the patient’s ability to ventilate. These casualties may have significant injury to the underlying lung and may deteriorate rapidly requiring endotracheal intubation and positive pressure ventilation.
Management of a massive hemothorax in the field should be directed at maintaining adequate ventilation with a BVM. If rescue is delayed and the patient continues to deteriorate, consideration may be given for the placement of a chest tube, which will be covered later. If more than 1000cc of blood is immediately drained by the chest tube or if the output is more than 200cc per hour for 4 hours, the patient likely has injury to the great vessels, hilum, heart or vessels in the chest wall that will require surgical repair. Flail chest and massive hemothorax are difficult injuries to treat in the field and should be evacuated are rapidly as possible.
Next to environmental causes (hypothermia and hyperthermia) uncontrolled bleeding is the leading cause of preventable deaths in a survival or SHTF situations. Rapid identification and effective management of bleeding is perhaps the single most important aspect of the primary survey while caring for a casualty in a survival or SHTF situation.
Obvious external sources of bleeding should be controlled with direct pressure initially followed by a field dressing or pressure dressing. If bleeding is not controlled by the previous measures or if gross arterial bleeding is present, an effective tourniquet should immediately be applied.
Clamping of injured vessels is not indicated unless the bleeding vessel can be directly visualized. Blind clamping of vessels may result in additional injury to neurovascular structures and should not be done.
NOTE: The current ATLS manual discourages the use of tourniquets in the pre-hospital setting because of distal tissue ischemia, tissue crush injury at the tourniquet site, which may necessitate subsequent amputation.
This admonition is based on a model of trauma care where most penetrating injuries are low velocity in nature and rapid evacuation to a trauma center is available. Withholding the use of tourniquets in a survival or SHTF situation for patients with severe extremity bleeding may result in death or injury that might have otherwise been prevented.
Sources of internal bleeding should be identified. A significant amount of blood can be lost into the chest and abdominal cavities, the retroperitoneal space and the soft tissues surrounding fractures of the pelvis and lower extremities.
Significant bleeding into the thoracic and abdominal cavities following trauma will require surgical exploration. In the absence of a head injury, hypotensive (low blood pressure) resuscitation will help prevent more bleeding.
Bleeding from injuries to the pelvis and groin or from fractures of the lower extremities not otherwise amenable to treatment with a tourniquet and not associated with thoracic injuries may be controlled with the application of Pneumatic Anti-Shock Garment (PASG), AKA Military Anti-Shock Trousers (MAST), which you can find for sale on eBay from time to time.
After sources of hemorrhage are identified and controlled, the need for intravenous access, which we will cover later, should be considered. If the patient has an isolated extremity wound, the bleeding has been controlled and there are no signs of shock, there is no need for immediate intravenous fluid resuscitation.
Intravenous access with a saline lock should be considered for all casualties with significant injuries. If there is a truncal injury and if signs of shock are present, or if blood pressure continues to drop, intravenous access should be obtained with a 12 to 16-gauge catheter followed by a 1-2 liter bolus of normal saline or lactated Ringers, or 500 milliliters of Hespan.
If the patient has improvement of the clinical signs of shock following the initial bolus, subsequent intravenous fluids should be given to achieve only a good peripheral pulse and an improvement in sensorium rather than to normalize blood pressure.
If there is no clinical improvement following the initial IV fluid bolus, the possibility of severe uncontrolled intra-abdominal or intrathoracic bleeding should be considered.
Further fluid resuscitation in uncontrolled hemorrhage is not indicated, may be harmful, and may waste the limited fluids available in a survival or SHTF situation.
Cardiopulmonary arrest from hemorrhage has a very high mortality in the hospital setting. Attempting to resuscitate patients who are in cardiac arrest secondary to hemorrhage while in the field will almost certainly be futile.
A brief neurological assessment should be performed using the AVPU scale:
- V-Responds to verbal stimuli; you ask a question, the patient answers
- P- Responds to painful stimuli; the patient responds to a pinch on the arm or sternal rub
- U-Unresponsive; the patient does not respond to any form of stimuli
After you have determined the patients neurological status using AVPU you want to determine if they are oriented to time, person, and place. Asking questions like, “Who is the president?” “What day of the week is it?” “Where are you?” Do you know what happened?” What’s your name?” and my personal favorite while I was a medic, “Is Mickey Mouse a cat or a dog?”
By asking these questions you can determine very quickly the mental status of your patient. Suspect some type of head injury in anyone who can’t answer these basic questions.
Clothing and protective equipment such as and body armor should only be removed as required to evaluate and treat specific injuries. If the patient is conscious with a single extremity injury or wound, only the area surrounding the injury should be exposed.
Unconscious patients may require more extensive exposure in order to discover potentially serious injuries but must subsequently be protected from the elements and the environment. Hypothermia is to be avoided in trauma patients at all costs.
Vital signs should be assessed frequently, especially after specific therapeutic interventions (IV’s, Airway placement, etc), and before and after moving patients. You should be sensitive to subtle changes in vital signs in wounded or injured members of your group.
Be aware that someone in great physical shape may have a great reserve and ability to compensate for blood loss longer than someone who is not in as good of physical shape and therefore they may not manifest significant changes in vital signs until they are
in severe shock.
The vital signs include:
- Pulse: The rate and character of the pulse should be evaluated. A weak, rapid, barely palpable (felt) radial pulse indicates the presence of hemorrhagic shock.
- Respiration: Respiratory rate can be an extremely sensitive indicator of physiologic stress. Resting tachypnea (rapid breathing) should be considered abnormal and should prompt investigation if there is no obvious cause.
- Blood Pressure: You aren’t going to be expected to carry a Blood Pressure Cuff in your medical bag or survival kit. But palpation of distal and central pulses provides a rough guide to systolic blood pressure.
- Radial– at least 70 mmHg
- Femoral– at least 60 mmHg
- Carotid– at least 50 mmHg
Temperature: Only if hypo or hyperthermia are suspected. Hypothermia is an often unrecognized and yet significant contributor to traumatic death.
After you have found and treated the immediate, life threatening injuries or conditions you found in the Primary Survey it is time to conduct a Secondary Survey.
The Secondary Survey, is a more methodical search for non-life threatening injuries. These injuries should be treated as they are encountered. Like the Primary Survey above, the Secondary Survey may need to be modified and adapted according to the tactical situation and the number and type of casualties encountered.
The vast majority (75%) of casualties in a survival or SHTF situation will have isolated penetrating trauma to the extremities. These patients do not require a detailed head to toe exam in the Secondary Survey.
They will need to have a bandage and/or splint applied with evaluation of their neurovascular status distal to the injury before and after treatment. They then need to be frequently reassessed for signs of deterioration as the situation permits.
Patients who are severely injured or unconscious will require a more detailed Secondary Survey as outlined below. Evacuation from a hostile area or situation should not be delayed to perform a Secondary Survey or for the treatment of non-life threatening injuries.
The Secondary Survey should be conducted in a systematic head to toe, front to back fashion using visual Inspection, Auscultation, and Palpation (IAP) where applicable. In children the Secondary Survey should be conducted in a Toe to Head fashion to alleviate fear and put the child at ease.
HEENT (Head, Ears, Eyes, Nose, Throat)
The head and face should be inspected for obvious laceration, burns, contusion, asymmetry or hemorrhage.
The bones of the face and head should then be palpated to identify crepitus, bony step-off, depressions or abnormal mobility of the mandible and mid-face.
The eyes should be opened and examined for signs of trauma, globe rupture, or hyphema. The orbits and zygomatic arches should be palpated for signs of fractures. Pupils should be checked for reactivity and symmetry. If the patient is awake, extra-ocular movements can be assessed along with gross visual acuity.
The ears should be inspected for obvious trauma and the ear canals for blood or cerebrospinal fluid (CSF). Battle’s sign indicating possible basilar skull fracture may be observed over the mastoid processes. The nares should be inspected for blood or CSF.
The mouth and oropharynx should be inspected for trauma or bleeding. Loose teeth, dental appliances or other potential airway obstructions should be removed. Any previous airway interventions should be reassessed.
The neck should be visually inspected searching for obvious trauma or deformity, tracheal deviation, jugular venous distention (JVD), or signs of respiratory accessory muscle use. The cervical spine should be palpated for step-off, tenderness or deformity.
The chest wall should be observed for penetrating injury or blunt injury, asymmetrical breathing movements (only one side of the chest moves when the patient breathes or one side rises and the other falls) or retractions (pulling inward of the muscles surrounding the rib cage).
Auscultation over the anterior lung fields, posterior lung bases and heart should follow. The entire rib cage, sternum and chest wall should be palpated for tenderness, flail segments, subcutaneous
emphysema (Air under and in the skin) or crepitus (bonne grating on bone). Percussion may be performed looking for hyperresonance or dullness.
The abdomen should be observed for signs of blunt or penetrating injury. The presence or absence of bowel sounds should evaluated. Palpation searching for tenderness, guarding or rigidity should
follow. Percussion may elicit subtle rebound tenderness.
The pelvis should be inspected for signs of penetrating trauma or deformity. Pelvic instability and fracture should be suspected with movement of the anterior iliac crests when lateral and anterior pressure is applied.
The perineum and genitals are inspected next for signs of injury. Scrotal, vulvar and perineal hematomas or blood at the urethral meatus may indicate pelvic fracture.
The extremities are inspected and palpated proximally to distally. Each bone and joint distal to the pelvis and clavicle should be assessed for crepitus, tenderness, deformity and abnormal joint motion.
Distal pulses and capillary refill are then examined. Asking the patient if he can feel the examiner lightly touching his hands and feet tests gross sensation.
Gross motor strength is tested by having the patient squeeze the examiner’s fingers and by moving his toes up and down against the resistance of the examiner’s hands.
A field neurological exam should consist of observation of the pupils for reactivity and asymmetry (done during HEENT exam), the level of consciousness, gross sensory and motor function (assessed during examination of the extremities) and calculation of the Glasgow Coma Scale (GCS).
Glasgow Coma Scale
No Response 1
Best Verbal Response
Inappropriate Words 2
Best Motor Response
Obeys Commands 6
Localizes Pain 5
Withdraws from Pain 4
Any patient with a GCS of 8 or less is considered to have a severe head injury. Those in the 9 to 12 range are considered moderate, but may require airway control. Any GCS of 13 to 15 is considered indicative of mild or no head injury, but even these patients can deteriorate and should be observed.
The GCS is a useful tool that can be used to monitor the clinical status of seriously injured patients. A declining GCS score over time indicates further neurological deterioration. A GCS less than 9 indicates severe neurological injury. A GCS of less than 8, intubate if you are able to, if not you have to ensure and maintain an airway since these patient more than likely can’t maintain one themselves.
Now that you have a better understanding of human anatomy and the initial steps you need to take to treat injuries sustained in a survival or SHTF situation. In our next article we will cover Airway Management and what you can do to secure your patients airway.
I look forward to seeing your comments and as always, Train to Survive!
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