Patient assessment–a structured approach to emergencies in the outdoors

Overview

When you come across a victim in need of help, they often are part of an accident scene, and so you must “size up” the scene and establish priorities. A structured approach will help bring order to chaos, give you an anchor from which to build calm, and will maximize the chances for a successful outcome. Fig. 1 depicts a structured approach to injury and illness in the outdoors. Your priorities in any significant medical situation are to maintain emotional self-control; ensure the safety of yourself, your team, and the victim(s); and try to determine a reasonable overview of the situation to allow yourself to be rational and effective.

• 1.

  Don’t rush in until you have had an opportunity to look over everything—the physical setting, any obvious hazards, and the victim(s).

• 2.

  Eliminate any physical dangers to the victims and rescuers. This is often referred to as “securing the scene.” Try to control the situation or have someone else do it. For instance, if you’re assisting an injured hunter, be certain that no one is in the firing line of a loaded weapon, or if you are near the edge of a cliff, move to a safe location. Move out of an obvious avalanche path and away from falling rocks, and distance yourself from hazardous animals. Take shelter from lightning. Retreat from a venomous snake, swarm of stinging insects, or edge of a swiftly flowing river.

• 3.

  Don’t assume that you appreciate how sick or injured the victims are until you have had a chance to examine them or take a report from a reliable examiner.

• 4.

  Protect yourself and other rescuers as best possible from exposure to contaminated blood and bodily fluids (see page 504).

• 5.

  Examine the victim(s). This first examination is called a “primary survey” and is intended to first identify any life threats using an ABCDE approach. ABCDE stands for airway (see page 18); breathing (see page 25); circulation (see page 28); disability and neurologic status (including neck injury—see page 33); and exposure / environment.

• 6.

  Treat any immediately life-threatening illnesses or injuries. This is known as resuscitation. If possible, explain to the victim what you’re doing.

• 7.

  Make an initial call for help as soon as you are able and include specific information about your location (use your map, cell phone, or GPS device to give exact coordinates or very specific landmarks and distances from known trails or junctions. Practice identifying your coordinates in your neighborhood or backyard before you venture into the backcountry. Your ability to give an exact location is essential for a rescue team to find you, especially in wilderness areas where it is very difficult to identify parties even with the aid of a helicopter). Report the conditions of the victims and what you need (supplies, food, etc.). If necessary, activate emergency medical services (e.g., call 911: EMS).

• 8.

  Perform a “secondary survey” (complete examination—see page 38) and then continue treatment. Communicate effectively with the patient. Whenever possible, explain what you’re doing while maintaining a calm, supportive demeanor. Persons who are seriously ill or injured need reassurance and psychological support to minimize stress injuries. Give the victim power to help make appropriate decisions in their care and participate in their own destiny.

• 9.

  Think about shelter and assign someone to that task, particularly in bad weather.

• 10.

  Create a treatment plan.

• 11.

  Create a plan for evacuation.

• 12.

  Prepare the victim for transportation. Protect them from environmental exposure.

• 13.

  Plan for things to go wrong, be flexible, and have back up plans. Maintain your priorities of safety. Be careful not to cause more victims during long or difficult evacuations. Brief your group and update group communication regularly. Think ahead. Assign clear roles.

Primary survey (a search for immediate life threats)

Issues of airway, breathing, circulation must be promptly identified and managed. These life threats are stop and fix problems. ABCs may be identified and managed out of “order” or concurrently. For instance, one rescuer might apply direct pressure to a serious bleed (a stop and fix circulation problem) while another is also checking for an open airway. In other words, you don’t need to ignore a spurting arterial wound because A, airway, comes before C, circulation, but you should not get distracted by or begin managing less threatening injuries until after each element of ABCDE has been investigated and all proper interventions started.

A note on ABC vs. CAB

When teaching cardiopulmonary resuscitation (CPR), the “ABC” (airway, breathing, circulation) method as the initial approach to determine whether or not to begin the chest compressions of CPR for cardiac arrest victims has been changed to a “CAB” approach, with initiation of chest compressions first, followed by airway and breathing (see pages 18–33). This approach prioritizes prompt initiation of chest compressions for victims that don’t have a pulse or appear dead (no coughing, breathing, moving). If you come across a victim that is unconscious, it makes sense to begin your assessment by checking for a pulse and for signs of life. If necessary, immediately initiate CPR starting with compressions followed by airway and breathing.

The vast majority of victims encountered will have signs of life and will not need CPR. For victims that are awake, moving, or breathing, an ABC approach is appropriate. Do not fret about ABC vs. CAB. Both of these systems are designed to empower rescuers to act swiftly and with a systematic plan. The guiding principle is to identify life threats and do your best to help without delay. As mentioned above, life threats can be managed concurrently, and the order of approach may depend on the situation. Similarly, the MARCH approach (massive hemorrhage, airway, respirations, circulation, head injury/hypothermia) was developed for tactical situations where patients often suffered high energy trauma. All of these approaches work. Use the system with which you are most familiar.

Everyone who is able should take a hands-on CPR training course to practice the skills of managing ABC problems and be comfortable with basic life support such as chest compression, airway positioning, and rescue breathing.

Airway

Check that the victim’s mouth and nose are open and empty. Adequacy of the airway and breathing must be attained rapidly in every victim. Airway obstruction is one of the leading causes of death in victims of head injury, and a frequent complication of vomiting in an unconscious person. In the absence of hypothermia, an interval of 4 minutes in which there is a failure to oxygenate the brain can lead to irreversible damage.

Fig. 2 depicts the anatomy of the respiratory system. Air enters the mouth and nose (where it is humidified), traverses the pharynx (throat), passes through the trachea (windpipe) and bronchi, and normally proceeds into the smallest air sacs of the lungs, known as the alveoli. Within these distal air spaces, inspired oxygen is exchanged for carbon dioxide, one of the end products of human metabolism. During swallowing, the epiglottis and tongue cover the entrance (via the vocal cords) to the trachea, so that food and liquid are directed to enter the esophagus and not the airway.

Obstruction of the airway at any level can interfere with the passage of air, delivery of oxygen via the lungs to the blood, and exhalation of carbon dioxide. The mouth and pharynx might fill with blood, vomitus, or secretions. With facial injury, deformation of the jaw or nose might hinder breathing. In a supine (face up) unconscious victim, the tongue might fall back into the pharynx and occlude the opening to the trachea. Facial swelling can be due to an allergic reaction. Inhalation of food can obstruct the opening between the vocal cords and cause rapid suffocation.

Symptoms of airway obstruction include sudden inability to speak, appearance of panic with bulging eyes, blue skin discoloration (cyanosis), choking gestures (handheld to the throat), harsh and raspy or “musical” and high-pitched noise (“stridor”) that comes from the throat during breathing, prolonged expiration, and difficulty with breathing as evidenced by struggling and profound agitation. Any person who collapses suddenly, particularly while eating, or who has been in an accident should be examined rapidly for airway obstruction. A person who can still breathe but is struggling because of airway obstruction, might be using “accessory” muscles of the chest wall, shoulders, neck, and abdomen while straining to breathe.

• 1.

  The neck should not be overly manipulated if there is a possibility of injury to the spine or spinal cord. If a victim is unconscious and has suffered a fall or multiple injuries, it’s safest to assume that their neck is broken and to stabilize the spine from excessive movement. In this situation, keep the airway open by gently but firmly lifting the jaw, either by grasping the lower teeth and jaw and pulling directly forward (away from the face) or by maintaining a forward pull on the angles of the jaw ( Fig. 3 ). Don’t bend the neck forward or backward. A modified jaw thrust ( Fig. 4 ) can be performed by a single rescuer while stabilizing the neck.

  
  

• 2.

  The neck may need to be carefully repositioned for safety or airway access. In the event the neck needs to be moved into a neutral, anatomical position, the movements should be done carefully and deliberately. Gently straighten the neck into a neutral position by moving one plane at a time. Stop if you meet resistance or pain. Gentle realignment in this manner is very unlikely to cause further injury and is considered safe. Once a spine is in a neutral position, it should be stabilized and protected in a neutral position (see page 33).

• 3.

  If there is no chance of a broken neck, maintain the airway with the jaw lifts previously described or by tilting the head backward while gently lifting under the neck ( Fig. 5 ). The alignment is different for an infant, small child, or older child or adult in terms of where one would position a pad or pillow ( Fig. 6 ). A head tilt with chin lift can be used ( Fig. 7 ). Extremely extending (backward) or flexing (forward) the head on the neck is not desirable. A neutral “sniffing” position should be attempted.

  
  
  

• 4.

  Keep the airway clear of blood, vomitus, loose dentures, and debris. This can be accomplished by sweeping the mouth with two fingers or by continuous suction with a field suction apparatus powerful enough to extract chunks. Take care not to force objects deeper into the throat. If the tongue appears to be the problem (you might hear a snoring noise when the victim inhales), wrap the end of the tongue in a cloth or gauze bandage, grasp firmly, and pull it out of the mouth ( Fig. 8 ). If it cannot be held in this manner, a seemingly brutal, but potentially lifesaving, maneuver can be used. A safety pin or sharp-pointed wire can be passed through the tongue and used to improve the grip (see Fig. 8 ), taking care to avoid the large, visible blood vessels at the base of the tongue. To keep the tongue out of the mouth, a string can be tied to the safety pin and then secured to the victim’s shirt button or jacket zipper. Fortunately, in most cases the jaw lift will carry the base of the tongue out of the airway. Another aggressive technique is to use two safety pins to attach the tongue to the face just below the lower lip ( Fig. 9 ) or with an extending string to the victim’s shirt button or jacket zipper.

  
  

• 5.

  If the victim is unconscious, don’t leave them lying flat on their back. Turn them on their side (“recovery position”) so that if vomiting or bleeding occurs, the fluid can drain from their mouth and the victim won’t choke or drown ( Fig. 10 ). Use a pillow or other padding as needed for comfort, but don’t occlude gravitational drainage from the mouth.

  

• 6.

  If the victim is conscious and having airway difficulty, allow them to assume whatever position keeps them most comfortable. This usually protects the airway and allows the victim to handle their secretions (e.g., saliva or bleeding from the mouth and nose).

Choking

Choking is a life-threatening airway problem in which the upper airway (above the vocal cords) is obstructed by a foreign object (tongue, broken teeth, dentures, food). The choking person is profoundly agitated (until they become unconscious from lack of oxygen), might appear to be panicked with bulging eyes, might grasp at their throat in a choking gesture, cannot breathe, and is unable to speak. You must respond rapidly:

• 1.

  Sweep the mouth with one or two fingers to remove any visible foreign material. Take care not to force material farther into the throat. Quickly extract loose dentures.

• 2.

  Using an open hand, give the victim two to four rapid, sharp blows on the back between the shoulder blades. This might be more effective if the victim is lying on their side or is bent forward at the waist. If a small child is choking, perform this maneuver while holding them face down or upside down. If the victim is an infant, place them face down on one of your forearms, with their head lower than their body. Support their head. Give five quick back blows, then turn the infant over and give five quick chest thrusts (similar to those given during CPR—see page 31).

• 3.

  Perform the Heimlich maneuver ( Fig. 11 ). Position yourself behind the victim and encircle them with your arms, clasping your hands in a fist in the upper abdomen just below their ribs. Squeeze the victim suddenly and firmly (“bear hug”) two or three times, in an attempt to produce a brisk exhalation (cough) and ejection of the foreign (choking) material. If you are the victim and no one is present to help during a choking episode, you can throw yourself against a log or table edge in an attempt to perform a self-Heimlich maneuver.

  

• 4.

  If the victim is lying on their back (supine), perform the Heimlich maneuver by sitting astride their thighs, facing their head ( Fig. 12 ). Place the heel of one hand on their upper abdomen and cover it with your other hand. Press into the abdomen suddenly and firmly in a direction toward the chest. Do this a few times, and then perform the chin lift (see step 1 on page 19) and sweep a finger deeply through the mouth to extract any visible foreign material forced up by your efforts. Take care not to push anything back into the throat.

  

• 5.

  If the victim is unconscious or becomes unconscious then apply the force in center of chest (the same technique as chest compressions for CPR. See page 28).

• 6.

  For a child older than 1 year of age, kneel behind the child or keep them supine (because the child is too large to hold face down or upside down) and place the heel of your hand well below their breastbone but above their navel.

• 7.

  If the victim is obese or pregnant, apply the force (with the victim sitting or lying down) to the center of the chest (breastbone) in the same motion as chest compressions for CPR, rather than the abdomen.

• 8.

  If necessary, begin mouth-to-mouth breathing (see page 26). If unable to get in a breath (look for chest rise), then reposition the airway and try again. If unable to get a breath a second time, then begin chest compressions and CPR. The chest compressions create pressure to dislodge an airway obstruction. Visualize the Airway and remove visible obstructions at the airway step of each cycle of CPR.

Sometimes a person will feel like they are choking if they have great difficulty swallowing. This is particularly true if they have something, usually food, stuck in the esophagus. In this situation, the object can be completely obstructive, so that nothing can pass by. The person might complain of chest pain and be anxious, drooling (can’t swallow saliva), and begin to retch in an involuntary attempt to dislodge the object. If they can remain calm, they will realize that their breathing is OK (because the airway is not obstructed). If a foreign body has become impacted in the esophagus, bring the victim promptly to medical care, so that someone can use an endoscope to look directly into the esophagus and remove the food or whatever else (sometimes part of a toy in a child) is causing the difficulty. If anyone is suspected to have swallowed a battery (usually a “button” battery), bring them promptly to medical attention, even if swallowing is normal.

Helmet removal

If the victim is wearing a helmet, it might be necessary to rapidly remove it to get to the airway. If the helmet is not interfering with the primary survey, it can be removed later. It is very important to do this in a way that protects the neck from excessive twisting or bending forward or backward. It usually takes two persons to safely remove a helmet:

• 1.

  The first rescuer, positioned above the head of the victim, holds the helmeted head steady by grasping it on each side. If necessary to support the airway, the first rescuer can reach down and hold the mandible (lower jaw).

• 2.

  The second rescuer, positioned below the head of the victim, prepares the helmet for removal by loosening and removing straps, goggles, and other attachments, so long as this process does not allow for unintended head movement.

• 3.

  The second rescuer takes over head stabilization, while the first rescuer continues to hold the helmeted head by sliding two hands along the sides of the victim’s head position; this should be done by either placing one hand behind the base of the head at its junction with the neck and the other hand under the chin or by sliding two hands along the sides of the head and up inside the helmet.

• 4.

  The first rescuer completes removal of retaining straps, then slides the helmet off the head using axial (straight up away from the feet, without any twisting) traction.

• 5.

  Head positioning is maintained while a cervical collar or other method (see page 33) is used to stabilize the position of the head and neck.

The issue of whether or not to remove a helmet in order to transport a patient (e.g., an injured skier) is somewhat controversial, but the general consensus is that if the helmet holds the head and neck in good alignment for breathing, and its removal will cause the patient to have a more difficult airway, it should be left in place. You might need to pad around it to keep the head and neck from moving during transport.