Ahh, the lack of questions either means I am being really clear, nobody gives a rat’s rear, or I am talking to myself. Oh well, I’ll keep going anyway I guess.
We’ve already talked about making sure the scene is safe and have started working through the Primary Survey. So far, that includes:
C - Catastrophic Bleeding
A - Airway Maintenance and C-spine Stabilization (situation dependent)
B – Breathing
So yeah, next up is the second ‘C’ as in circulation. At the First Aid level, this is kinda a yes/no thing but we’ll get into it a little more than that.
As I mentioned in one of my early posts, air goes in and out, blood goes round and round, any deviation from above is bad. We’ve really covered the air part but just touched on the blood side of things. That is where circulation comes in.
When we talk about circulation, we will talk about some anatomy we have already touched on in the Catastrophic Bleeding portion. There we were talking about the plumbing part of the Circulatory System; here we are mostly concerned with the pump. So obviously the heart is the major organ of the Circulatory System.
In the C-Circulation part of the Primary Survey, we are looking for signs of adequate circulation. Is the heart pumping blood well enough to sustain life? Now, AHA had us quit teaching people to check pulses a few years back because, well let’s be honest here, people suck at it. They did a big study and rescuers (professionals and lay-persons alike) were missing pulses on live folks and finding them on dead ones. Instead of trying to locate an artery close enough to the skin for you to feel and counting the beats (which is what we do when we take a pulse), look for things that tell you the Pt is circulating blood. What things you ask? Things like good skin color, movement, coughing, breathing, talking. This isn’t an exact science but if the guy is cold and grey, it’s a pretty safe bet their heart isn’t doing its job. (BTW, the heart’s job is to get oxygenated blood to the brain, everything else is secondary).
If you determine the ol’ ticker isn’t ticking, that’s bad news but it makes things easy for you. Dead people are stable; in fact a person can’t really get any more stable. Now if you don’t lik’m, there’s not much to do here. But, I am assuming because you’re reading this, you probably don’t want to let them die. So…insert CPR class here. As I said before, go take a CPR class. The instructor will spend lots of time showing you, and more importantly let you practice, the skills you need to treat the absence of ‘C’.
Now it gets tricky when they aren’t dead. In all cases, you need to keep them warm; hypothermia is a killer that can sneak in and zap your Pt if you aren’t careful (Goggle ‘Deadly Trauma Triad’). That whole Trendelenburg position (elevated feet) thing has been proven ineffective in most cases so don’t spend much time worrying about it.
We talked a lot about controlling bleeding in the Catastrophic Bleeding part so I’m not going to get into that. If they are still bleeding, get it under control.
TCCC pushes oral fluids in the trauma Pt if they have no altered mental status; they are the only program I know that does. The logic is sound even if the anesthesiologist will be pissed when they arrive at the hospital (water in the belly can become water in the lungs.) Right now, open the TCCC PowerPoint ‘Tactical Field Care’. Okay slow kid, I’ll wait while you go to this website http://www.naemt.org/education/PHTLS/TCCC.aspx
and download it….. You really should have done that a few posts ago…. Open the presentation and read slides 122-132 closely. If you happen to have IV fluids AND the training to use them, you can do a bit to help BP but it’s temporary, burns through resources, has a bunch of risks on its own, and if you get carried away (especially in a bleeder) can make the situation worse. If you have fluids in your FAk, read slides 133-139 VERY CLOSELY. Now go unpack the fluids from your go bag. That crystalloid isn’t worth it unless you couple it with high flow exhaust to get them to a hospital, is it? Your call…
One thing that is pointed out in those slides that I think should be emphasized is that the radial (at the wrist, if you can’t figure it out, try youtube. P.S. Don’t check a pulse with your thumb, it contains a pulse) represents a systolic (top number created when the heart contracts) BP of 80mm Hg. That is a great number to bring the half-dead to, especially if they are bleeding. I know you just read it in slide 132 but it’s important so I’ll say it again: “Too much fluid volume may make internal hemorrhage worse by ‘Popping the clot’.” Do not try to get them to a ‘normal’ blood pressure. I know this is a little disjointed, everyone still with me? Onwards then…
We’ve been out at the local range with our trusty sidekick when Tonto takes a round in the upper arm. Wow, THAT is Catastrophic Bleeding! And the way he’s jumping all around and dancing, he’s getting good coverage too! Well, good thing you’re a ZSer and have a Blowout kit right….where the hell is it? Oh crap, back at the truck. Hold on Tonto, I’ll BRB. Well, you get back and Tonto isn’t running and screaming anymore, in fact he’s slowed down a lot. You know, he’s not really moving much...
You spring into action (after throwing on a pair of gloves) and slam the CAT in place and control the Catastrophic Bleeding. Tonto has slowed down but he’s able to answer questions and talk if you really get in his grill. That tells you that, at the moment, he has an Airway and is Breathing. You grab his wrist (not the one on the arm with the extra hole) and feel his pulse (yeah, I told you before we don’t really teach it because people screw it up, especially when they are amped up and think they might be touching a dead guy. Guess you better practice if you want to be able to tell if Tonto has a BP of 80 or greater huh?). It weak but it’s there. This is a good thing. You get Tonto laying flat (not to redistribute blood in his body, because if he falls over and cracks his egg you’ll look like a tool), cover him with his jacket, and get help on the way.
We good? What are your questions? Anyone there?