KEY POINTS
- Be systematic
- Think out loud
- Reassess when there is a change
- Note down your findings if you can
EXPLANATION
As you are walking towards the injured practitioner, look at the scene and think through what happened during the accident. This is called the ‘mechanism of injury’ and thinking about it will help direct your attentions during the casualty assessment. For example, did they land on their head, their legs or their back? This also allows you to check for danger to you or the rescuers. Could what just happened to them happen to you or the group?
Being systematic in your assessment is most important thing, so we use the mnemonic DRcABC to keep us on track. The key question you are asking when assessing each component is ‘is it normal?’:
D – Danger: are you, the rescuers or the casualty in danger of further injury? If so, either do not approach the casualty or move them to a safer place.
R – Response: when you arrive at the pilot, gently squeeze their shoulder, call their name and ask ‘can I help?’. This also ensures you have consent for your assessment and treatment.
c – Catastrophic Haemorrhage: in severe extreme sports trauma, the biggest risk to the casualty is bleeding. It is even more of a pressing problem than a closed airway. If you see a source of major blood loss, quickly attempt to staunch it before continuing your assessment.
A – Airway: open and assess the airway.
B – Look at their breathing rate (normally 12-18 breaths per minute in an adult), breathing pattern and symmetry and for any injuries to the chest wall. Ask yourself each time ‘does it look normal?’
C – Look for obvious bleeding, bruising or injury, feel the pulse in their neck for the rate (should be between per minute), feel their skin (cold, sweaty and clammy are signs of possible blood loss).
When looking for these key parameters, be thorough and systematic. Try not to zone in on the one area that is obviously injured and potentially miss other crucial findings. Look under clothes if possible but remember to keep the casualty warm and to protect their dignity.
If you can, think about gathering the following ‘AMPLE’ information for the rescue services:
A – Allergies
M – Medications
P – Past illnesses and injuries
L – (time of) Last meal
E – Events leading up to the accident
Assessment is a dynamic process. Keep reassessing and talking to the casualty. Think out loud so people can hear your assessment but try not to ‘talk over’ the casualty. Always be compassionate and reassuring. Be particularly sensitive when describing severe injuries but don’t try to conceal anything from the casualty: they will already know that they have been hurt, so will respond better to calm, kind but direct communication.
BREATHING AND CIRCULATION
Once the airway is open, place your ear close to the casualty’s mouth and nose while looking down the chest. Look, listen and feel for normal breathing for no more than ten seconds. You are checking rate, depth, regularity and symmetry. Noisy breathing is obstructed breathing until proven otherwise: snoring suggests the tongue, gurgling suggests fluid in the airway, and wheezing suggests narrowing of the lower airways. If the casualty is not breathing normally, start CPR or rescue breaths according to your training and the setting. In a remote or mountainous incident, remember that a tension pneumothorax can mimic breathing difficulty and deteriorate very quickly.
Move on to circulation only when breathing is adequate or being managed. Feel for a radial pulse and note its rate, rhythm and strength. At the same time, look at the casualty’s skin colour, temperature and moisture. Press a fingernail or the sternum for five seconds and release; normal capillary refill is under two seconds. Pale, cool, clammy skin with a fast, weak pulse is a strong sign of shock, even if the casualty is talking. Keep the casualty flat, protect them from heat loss and treat any obvious source of bleeding. In severe trauma, do not wait for blood pressure to fall before acting.
DISABILITY AND EXPOSURE
A rapid neurological check tells you whether the brain is being adequately perfused and whether there is a spinal or head injury. Use the AVPU scale: is the casualty Alert, responding to Voice, responding to Pain, or Unresponsive? Ask them their name, where they are and what happened. Check both pupils with a torch if you have one and note whether they are equal and reactive. Ask the casualty to squeeze your fingers and wiggle their toes, and compare strength left to right. Any change in consciousness is a major warning sign and should trigger immediate reassessment and evacuation.
Exposure means looking at the actual body, not just asking where it hurts. Protect the casualty’s dignity and keep them warm while you cut or remove clothing as needed. Check the head, neck, chest, abdomen, pelvis, arms and legs for deformity, bruising, swelling, bleeding or tenderness. If a spinal injury is possible, keep the head and neck in line and log roll the casualty with enough helpers to inspect the back. In cold environments, exposure can itself cause harm, so cover the casualty again as soon as each area has been checked and use blankets, foil or a group shelter.
ONGOING REASSESSMENT
A casualty assessment is not a one-off task. You must reassess after any intervention, after moving the casualty, when their condition changes, and at regular intervals while waiting for help. Return to the start of DRcABC and run through it again, because new problems can appear as shock develops or as pain distracts the casualty from a second injury. Compare each new finding with the previous one rather than looking at it in isolation. A falling level of response, a rising pulse or increasing pain are trends that matter more than a single abnormal number.
How often you reassess depends on how stable the casualty is. As a rule of thumb, repeat the primary survey every five minutes for an unstable casualty and every fifteen minutes for a stable one. Say your findings out loud so another group member can note them down, and do not rely on memory. If you are alone, repeat the key values to yourself and write them on a glove, a map or a phone as soon as you can. Reassessment also includes checking that your own treatment is still working: a pressure dressing may slip, an airway may become blocked again, and a conscious casualty may suddenly deteriorate.
RECORDING AND HANDOVER
Accurate notes are part of the assessment, not an optional extra. As soon as it is safe, write down the time of the incident, the mechanism of injury, the casualty’s name and age if known, your findings from each part of DRcABC, any treatment given and the response to that treatment. Include times for each entry, and do not alter or erase earlier notes. If another rescuer takes over the note-keeping, make sure they understand what you are telling them and that they read back the key numbers, especially pulse, breathing rate and level of response.
When you hand over to paramedics, mountain rescue or another trained person, give a clear, structured summary. A simple format is useful:
- Situation: who the casualty is and what has happened.
- Background: relevant medical history, medications, allergies and events before the injury.
- Assessment: key findings from your primary and secondary surveys, including vital signs and changes.
- Recommendation: what you have done, what you think is wrong and any concerns for transport.
Stay with the casualty until the receiving team has taken over formally, and offer your written notes if they are wanted. A good handover prevents information being lost and can make the difference between a smooth evacuation and a dangerous delay.