Chapter 2. Approach to the patient
The approach to the patient follows scene safety and scene assessment. In trauma cases you will already have information about the patient’s likely injuries after ‘reading the wreckage’ or understanding the nature of the accident. In medical cases, important clues will be gained on approach such as looking at the patient’s medications on the bedside table. While examining a patient, any Medic-Alert bracelet or card should be identified.
• Wherever possible, relevant medical history, current medication and allergies should be established. Use the mnemonic SAMPLE:
• S – Signs and symptoms
• A – Allergies
• M – Medication
• P – Past history
• L – Last meal
• E – Event (i.e. current problem).
Life-threatening associations
• Patient falling from a height greater than 5 metres
• Road traffic collision with an extrication time greater than 20 minutes
• Patient ejected from a vehicle
• Loss of life in the same vehicle
• Child (less than 12 years old), pedestrian or cyclist struck by a vehicle
• Pedestrian struck by a vehicle and thrown
• Vehicle intrusion greater than 30 cm.
Primary and secondary surveys
The patients seen by ambulance personnel may be divided broadly into two groups:
1. Medical patients
2. Trauma patients.
The initial approach to these two groups is similar. The components of the systematic approach are:
• Primary survey
• Resuscitation
• Secondary survey
• Definitive care.
The role of the primary survey is to identify any life-threatening problems or injuries. Whenever possible, treatment of any life-threatening problem is carried out as soon as that problem is identified and before moving on to the next stage of the assessment.
• Primary survey and resuscitation take place simultaneously
• The primary survey identifies life-threatening problems
• The secondary survey identifies non-life-threatening problems.
The primary survey
The primary survey follows the simple system of <C>ABCDE.
Although this system was originally designed for use in trauma, it is equally relevant to the management of life-threatening medical conditions.
<C< – Identify and manage catastrophic external haemorrhage
• Rapid bleeding from a main vessel requires immediate management with direct pressure and elevation
• Rarely it may be necessary to apply pressure over a pressure point or to use a designated tourniquet (never use improvised tourniquets)
• Remember that blood may be hidden under the patient or within thick clothing
• Can be skipped if external haemorrhage is clearly not an issue.
A – Airway with cervical spine control
• Assess the airway
• Anticipate the development of problems. In burns patients, for example, it is important to check for evidence of soot in the nose and on the lips or evidence of oedema of the upper airway
• Establish and maintain a patent airway
• In-line cervical immobilisation should be maintained during all airway manoeuvres in trauma patients.
Of unconscious trauma patients, 5% have a cervical spine injury.
• Patients with injury above the clavicle should be assumed to have a cervical spine injury until proved otherwise
• Medical patients with rheumatoid arthritis are at higher risk of having cervical spine injury.
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