Last updated 11/11/23

Primary Survey - Circulation with Haemorrhage Control

Once all immediately life-threatening Breathing conditions have been identified and where possible treated, the assessment of the casualty can move on to C - circulation with external haemorrhage control. 

Haemorrhage is the predominant cause of preventable deaths after injury. The elements of good clinical observation that yield important information within seconds are level of consciousness, skin colour and pulse.  

Anaphylaxis is a cause of cardiovascular collapse that is usually picked up at the A or B stage of the Primary Survey. If this is not the case e.g. because of slower onset of symptoms, consider it now and treat (with adrenaline) – see the anaphylaxis section for more details.

Look for Obvious Bleeding

1). Look for and control obvious external bleeding with pressure, pack a cavity with a haemostatic dressing e.g Celox and apply pressure for 3-10min over the packed wound (time depends on the product used), and apply a trauma bandage.

2). Note the casualty’s skin colour and temperature. Pale, cold and sweaty indicates possible blood loss and shock.

Check the Pulse

Assess the pulse for rate only at this stage. If you happen to notice it’s irregular, abnormal, strong, weak or thready, it’s useful to make a note of that, but don’t intentionally spend time on working this out now because this level of detail is not essential for dealing with life threats.  Do that during the Secondary Survey.

The normal resting pulse rate of individuals can vary significantly depending upon their age, level of fitness and if they are taking medication.  Children and small infants, in particular, can have a normal rate which would be considered abnormal in adults.  The following table lists typical resting heart rates for the normal population. Some athletes may have rates below that listed.

Remember – other factors such as anxiety, uncertainty (about their diagnosis, our plans for management and how they will be evacuated), fear, distress and pain can elevate the heart rate. As a result, even in the absence of major injury and illness, most casualties will initially have a slightly raised pulse rate when we first arrive on scene. Your presence, a professional approach, elucidating a clear treatment and evacuation plan and multi-modal pain management will reassure them and help to normalise their heart rate.

Practical tip – Finding and counting a pulse can actually be quite difficult. It is something that non-medical people often struggle with (and even on occasions, have failed the Cas Care exam, which is why it is now a required skill). Practice on normal people (yourself, family, friends) as often as possible. That way, when you need to do it for real, you will do it properly.

Pulse Location

The pulse at various locations can be used as very rough guide to the blood pressure. If the radial pulse can be felt, the BP may be about 80 mm Hg. If only the carotid is palpable, the BP will be nearer 60 mm Hg. But remember – this is only a rough guide, and the actual BP may be lower.

The location where a pulse can be found does provide a relative guide to how ill the casualty is. A casualty with a palpable radial pulse is likely to be in a better condition than one in which you can only feel a carotid pulse.

If there is no radial pulse and the casualty is breathing continuously (not agonal gasps, which stop), check for a carotid pulse. If you still can’t find a pulse, assume very low blood pressure (BP).

Check Capillary Refill Time (CRT)

Check the central capillary refill time by pressing on the casualty’s forehead or sternum for five seconds and timing how long it takes for the skin colour to return to normal. This should be 2 seconds or less.  A slower response is indicative of low blood pressure. For speed, in the Primary Survey, you don’t need to formally measure the blood pressure. This can be done during the secondary survey.

Don’t measure CRT at the fingers. It is affected by the temperature of the fingers. If the casualty is cold, the CRT will be slow simply because blood flows more slowly through cold tissues.

Check for Injuries with the Potential for Significant Blood Loss

In the Primary Survey, a concern is major bleeding with the potential to cause shock.  We use the phrase “one on the floor & four more” to remember the places where significant amounts of blood can be lost.

One on the floor – look at the ground around the casualty for signs of blood and check for non-obvious external bleeding by running your hands under the casualty and inside their waterproof jacket, if possible. Remember that clothes may be soaked with blood before spillage is apparent on the ground.

Practical tip – the types of ground we operate on, particularly scree, can absorb significant amounts of blood without leaving obvious signs on the surface.  Just because only a small amount can be seen, doesn’t mean a large volume hasn’t been lost into the ground.

Four more – look for the possibility of major internal haemorrhage (bleeding) in the four areas that have the potential for large scale bleeding:

1. The chest (haemothorax) – consider in chest injuries, especially rib fractures (see chest injuries for further details).

2. The abdomen – which can be identified by gently pressing (palpating) the four quadrants of the abdomen to feel for tenderness & firmness. Also look for abdominal distension, which can indicate massive bleeding.

Practical tip - if there is internal damage in the chest or abdomen, the casualty will complain of  discomfort on taking a deep breath.

3. The pelvis (pelvic fracture) – ideally determined from mechanism of injury and feeling for deformity. Do not flex the pelvis (see fractures for further details).

4. The thigh (femoral fracture) – look and feel for shortening of the leg and outward rotation of the foot (see fractures for further details). In extreme cases, you might see bone sticking out of the thigh.

Beware – open fractures tend to bleed more heavily and have a higher mortality rate. Casualties taking drugs that affect blood clotting, such as warfarin, will also suffer increased blood loss.

Check for and Treat Shock

Shock occurs when the body’s vital organs are not receiving sufficient blood (see shock for further details). Whilst there are a number of types of shock, at this stage our main concern is haemorrhagic shock (insufficient blood volume due to blood loss) from significant internal or external bleeding.

To detect haemorrhagic shock, look for:

• Low blood pressure (as indicated by pulse location or central CRT)

• Pulse greater than 120 beats per minute

• Raised respiratory rate (greater than 30)

• Pale, sweaty, cold, clammy skin

• Fainting on sitting up

• Altered levels of consciousness or confusion

Treat by:

• Lying the casualty down

• High flow oxygen (15L/min).

• Raise the legs (if no risk of spine, pelvic or leg injury) – remember that if you subsequently put the legs down again, the BP will fall back.

• IV fluids (if an appropriately qualified person is present).

• Applying a pelvic splint if appropriate (treat before moving on)

• Reduce and splint a femoral fracture(s) if present (treat before moving on with the Primary Survey)

If the casualty has, or may have, injuries with the potential to cause shock, but no signs or symptoms are present, consider the possibility of shock developing over time. Monitor closely and watch for trends.  Young, fit individuals in particular have the ability to compensate for a time before their circulation collapses rapidly.

There is one other trap in this group of casualties. The presence of a high spinal injury (thoracic or cervical spine) will prevent the body from making its normal compensatory adjustments to cope with blood loss. Therefore, the pulse may be slow (rather than fast), the BP low, and the peripheries warm rather than cold.

Don’t forget! There are other types of shock

• Anaphylaxis

• Neurogenic (spinal cord injury)

• Cardiogenic (following heart attack)

• Other causes of low blood volume (hypovolaemia) e.g. due to dehydration

Splint Pelvic and Femoral Fractures

Treat actual or suspected pelvic and femoral injuries with splinting before moving on.

Specialist orthopaedic advice is that, because an unstable pelvic fracture can bleed profusely, the pelvis must be splinted with the SAM pelvic binder as soon as possible.

How to apply a SAM Pelvic Sling (also called SAM Pelvic Binder)

Kendrick femoral traction splint

Splint mid-shaft femur fractures with a traction splint.  We currently carry 2 ‘Kendrick’ traction splints. One in the Fracture Sac and one in the front pouch of the Vacuum Mattress Sac (Major Fracture Sac). We carry 2 Kendrick splints in case both femurs are fractured.

Pelvic and femoral fractures both present
If both pelvic and femoral fractures are present, the pelvic fracture takes precedence as it is potentially much more serious and can bleed much more. Apply a SAM Pelvic Binder immediately. You can then address the femoral fracture.

Although the thigh strap of a Kendrick pushes up against the groin (and therefore indirectly against the pelvis), expert opinion (the Faculty of Prehospital Care) suggests it may be acceptable to use the Kendrick when a pelvic fracture is also present. This is because the Kendrick does not push directly against the pelvis in the midline. Use this technique if the femoral fracture is really bad:

• Bad angulation of the femur (i.e. a bend in the middle of the thigh)

• Impaired blood supply, as shown by skin colour (pale) or absence of foot pulses, due to the femoral fracture

• Impaired nerve supply to the lower leg, as shown by diminished sensation in the lower leg or inability to wiggle toes

• Significant leg shortening (several inches) that appears to be due to the femoral fracture (caused by one part of the femur over-riding the other), rather than the pelvic fracture

• Open fracture (bone sticking out through the skin)

• Large collection of blood in the thigh, as shown by a big swelling around the fracture site due to bleeding into the thigh muscle

If there is a fractured femur but you are not sure about a pelvic fracture, apply a SAM sling and use the Kendrick.

IMPORTANT PRACTICAL POINTS

• Always check the blood supply and sensation at the foot BEFORE and AFTER applying the splint and record the findings on the Cas Card.

• If something changes after the splint has been applied, which would be very unusual but not impossible, release the tension on the splint.

• If the limb recovers e.g. impaired sensation recovers, then either try again but with less traction pressure or leave the splint off

• In all cases, record what you did and why

 How to apply a Kendrick splint

Circulatory problems warrant immediate evacuation

Once Circulatory Problems Have Been Managed Move On To Assess Disability