A good understanding of anatomy, physiology and pathology is your best friend here, seriously, combined with experience.
Quite simply a quick gross assessment of vital signs is the first thing we do which means whether your patient is conscious and orentaited, if they are breathing and oxygenated, what sort of blood pressure and perfusion do they have and what (if any) are thier immediate life threats.
If I walk up to a job and say "hello I am Brown, I'm one of the helicopter doctors, this is Oz he is my sidekick and we are here to take you to see the Wizard in our flying contraption" to which the patient responds "bugger off, I want Dorothy as my flight attendant and not a bunch of convicts in orange prision jumpsuits" then I know I am dealing with somebody who is orentaited to place and person, has a patent airway and at least an acceptable pulse and blood pressure.
At this stage am I interested in what the pulse rate, respiratory rate and blood pressure are? No, I simply want to observe if my patient is dead or dying or traumatically injured.
Marco level exclsuions of things which are going to kill your patient very quickly is my goal here. Are they bleeding severely? Do they have massive cardiogenic shock? Have they been stabbed and now a large piece of knife is sticking out of thier intestines?
No, ok great, so what exactly happened? Ask your patient, MPDS strikes again so ask "exactly what happened?" and this gives you a good idea of where to look next. Did they get hit by a car? Have they been having crushing chest pain for two hours? Have they fallen over and traumatically injured themselves?
If you are assessing somebody who has been run over by a car you are looking for head and brain injury, fractures, abdominopelvic injuries, haemopneumothoracies, spinal injury and things of that nature. Nana who has had chest pain for two hours needs to be asked about onest, previous history, severity, radiation, medications, find out a cardiac rhythm etc
Trauma is quite simply really, its fairly obvious what has happened however medical problems can be multi factorial in etiology or pathology and often present rather vaugely. Somebody who has a guts ache might have appendicits, a perforated bowel, a kidney stone or ate too many of Brown's chocolate cookies. This is where your pathological knowledge is a bloody godsend.
You may want to take a few observations at this point, its probably a good idea. I mean after all it might help to exclude those patients who do not need a flying wanker called Brown knocking them out and sticking a tube in thier throat, right?
I cannot stress enough how important careful and accurate observations (especially a Glascow coma score) are. They can provide subtle clues which can help you differentiate between a patient who is OK and somebody who is beginning to get quite crook and might need Brown and Oz to swan dowm in thier red and yellow flying machine dressed in orange jumpsuits and stick a tube down thier throat.
If you wish to try and get simplistically sequential I suppose it would go something like this
Here's one I prepared earlier
Primary Survey
• Airway: examine for and establish an adequate airway.
Consider the possibility of cervical spine injury, but the airway takes priority.
• Breathing: examine for and establish adequate breathing. Look at and feel chest movement.
• Circulation: examine for and establish adequate circulation. Feel
pulse rate and strength, look at and feel peripheral perfusion/ capillary refill.
Check for (and compress) external bleeding.
• Disability: check the level of consciousness using AVPU or motor
score of GCS. Consider immobilising the cervical spine if appropriate.
• Exposure, examination and environmental control: appropriately
expose and examine the patient. Keep them warm
Secondary Survey
The secondary survey follows the primary survey.
Do not conduct a detailed secondary survey if there are major abnormalities in the primary survey.
Central Nervous System
• Record a GCS. Individually examine and record each component.
• Check the patient can talk normally, move their face and move and feel all four limbs. Look for unilateral weakness.
Head and Face
• Look and feel for deformity, tenderness and bleeding.
• Look for pupil asymmetry and reaction to light.
Neck
• Look and feel for deformity and tenderness.
• Immobilise cervical spine if required and not already done.
Chest
• Look, feel and listen for symmetry of air entry, breath sounds, tenderness and crepitus.
Abdomen and Pelvis
• Look and feel for tenderness or distension.
Extremities
• Look and feel for wounds, fractures, colour, capillary refill, gross
sensation and movement.
Back
• Look and feel for tenderness and deformity.
FURTHER RECORDINGS
Following the secondary survey, recheck and document the patient’s
vital signs:
• Respiration rate including regularity and depth.
• Pulse rate including regularity and strength, peripheral perfusion and capillary refill time.
• Blood pressure.
• GCS.
The completeness and frequency of vital sign recordings requires clinical judgement and must take into account patient condition,
priorities, treatments and transport times. In general it is
inappropriate to stop the ambulance to perform vital sign
recordings and these should be performed enroute. Depending on
the patient’s problem it is appropriate to record and document
other parameters such as blood glucose, cardiac rhythm, 12 lead
ECG, SpO2 etc. These should be re-recorded at clinically appropriate
intervals and documented accordingly.
Take and document an appropriate history. This should include
mechanism of injury (if trauma), symptoms, prior events, medical
history, medications and allergies. All treatments and interventions
must be documented. Rhythm strips and 12 lead ECGs should be
attached to the hospital and audit copy of the PRF.
