Primary/Secondary Survey of the

Combat Casualty

CPT Allen Proulx, MPAS, PA-C

Tactical Combat Medical Care
(TCMC)

Objectives
Discuss the importance of the
primary/secondary survey
Outline how ATLS applies to the combat
casualty

Time of death

Primary/Secondary Survey
Why is it important?
What and where are the wounds?
What resuscitation is required?
Mode of CASEVAC?

What is the Approach?

ATLS

Created by surgeons for the non-surgeon

Designed in the urban environment
Performed in the hospital setting
Requires a lot of high tech resources

This is our classical training platform

Will this approach work in combat?

How Do We Develop Our

Approach?
What are we going to see?
Injury patterns
Civilian trauma?

Combat trauma?

How Do We Develop Our

Approach?
Civilian trauma
Trimodal death distribution
First peak
Death results in the pre-hospital setting from massive head injury and
massive vascular injury.

Second peak
Death in the first few minute of arrival to the hospital and due to
massive head, chest and abdominal injury

Third peak
Post resuscitation/operative complications

Combat Trauma
We dont know the death distribution
It is believed that if the casualty can arrive alive and relatively stable to

the FST/CSHthey will live.

How Do We Develop Our

Approach?
ATLS
Based on urban injury patterns
Primary Survey

A-Airway/c-spine control
B-Breathing
C-Circulation
D-Disability
E-Exposure

Detailed secondary survey

Head-to-toe exam

How Do We Develop Our

Approach?
The Combat Casualty
Slightly different injury pattern-in this order!
Penetrating extremity trauma
Tension pneumothorax
Loss of airway

Instead of ABCsthink CBAs

The Combat Casualty Primary

Survey
Assess for hemorrhage first
Intervene for life threatening bleed only!

Then, assess for tension

pneumothorax
Perform needle decompression as needed

Then, assess for an airway

Utilize a Combitube or surgical airway
Rarely a need for c-spine control

The Combat Casualty Primary

Survey
D-disability- decision to evacuate
GCS scoring is appropriate AVPU also appropriate

E-exposure
Explore ideas on how to expose your casualty while
protecting them from the environment
Hypothermia is BAD

Remember, they may need that kevlar!!!

F-foley
Situational need for urinary catheter

G-gastric tube
Situational need to decompress the stomach

Hypothermia is Bad!

Rewarming in the trenches of WWI

Heat loss during transport

Hypothermia

Hypothermia

The Combat Casualty Secondary

Survey
Occurs after you have performed your
primary survey and appropriate
interventions

Head-to-toe exam along ATLS

guidelines.
Be very thorough-many injuries are
subtle!

Commonly used acronyms

DCAP-BTLS- deformities, contusions, abrasions,
penetrations, burns, tears, lacerations, swelling.
TIC- tenderness, instabilities, crepitus.
TRD- tenderness, rigidity, distension
PMS- pulse, motor, sensory

Head exam
DCAP-BTLS
Pupils
Otorrhea/Rhinorrhea/Hemotympanum
Raccoon/Battle signs
Mid-face instability

Neck exam
Step-off
Tracheal deviation
Jugular vein distention

Chest exam
DCAP-BTLS
TIC
Auscultation
Percussion

Abdominal/Pelvic exam
DCAP-BTLS
TRD-P
Pelvic instability
Priapism
Scrotal/labial hematoma/blood at the
meatus

Extremity exam
DCAP-BTLS
TIC
PMS

Posterior Thorax
Log roll casualty
Spine
DCAP-BTLS
Tenderness/step-off

DRE
Gross blood only

Questions?