Home
S-CABCDE · Civilian Protocol · Lesson 5 of 7

S-CABCDE Assessment

MedReady Clinical Team  •  Combat Medic (12 yr) · Emergency Nurse (8 yr, PHTLS) · Risk Management (10 yr)  •   •  Follows CoTCCC guidelines

The systematic civilian trauma assessment framework — used by EMS, first responders, and civilian first aid practitioners worldwide. Bridges the gap between TCCC's military focus and civilian emergency medicine.

S-CABCDE is the civilian counterpart to MARCH. Where MARCH was developed for the austere, high-threat military environment, S-CABCDE is structured for civilian emergency medical services and first-responder contexts where scene safety, immediate threat-of-life bleeding control, and systematic head-to-toe assessment are the priorities. The two frameworks share significant overlap — catastrophic hemorrhage control, airway management, and breathing assessment appear in both — but S-CABCDE opens with scene evaluation and closes with a detailed exposure step reflecting the different threats and access conditions a civilian responder faces. Understanding both frameworks makes you effective in any setting.

ℹ️
MARCH vs S-CABCDE — Know Both
MARCH prioritises haemorrhage above airway because in a tactical environment you may be treating multiple casualties under fire with limited time. S-CABCDE opens with scene safety first because civilian first responders must not become casualties themselves. The clinical interventions are largely the same — only the opening sequence differs based on environment.

Scene Size-Up

Before touching a patient, assess the scene. Ask: Is it safe to approach? What is the mechanism of injury? How many patients? What resources do I need? A scene that injures one person can injure another. Traffic, unstable structures, electrical hazards, fire, chemical spills, and active violence are all reasons to hold back until the scene is controlled.

Standard Precautions

Don personal protective equipment (PPE) — at minimum, gloves — before contact with any patient. Eye protection if there is risk of fluid splash. PPE protects both you and the patient.

Send for Help — Early

Call emergency services at the earliest opportunity. In most civilian settings, definitive care is minutes away — your job is to keep the patient alive until they arrive. Give your exact location, the number of casualties, the mechanism of injury, and any hazards on scene. Do not wait until you have assessed the patient fully before calling — call while you are approaching or have a bystander call immediately.

🚨
Scene Safety Is Not Optional
Rushing into an unsafe scene — traffic, active aggressor, unstable structure — turns one patient into two. Emergency services cannot help you if they arrive to find two casualties instead of one. Pause, assess, then approach.

Identify and Control Immediately

Catastrophic hemorrhage — massive, life-threatening external bleeding — takes priority over airway, breathing, and circulation assessment. A patient with a severed femoral artery has minutes of survivable time. Identify the bleed, control it, then continue the assessment.

Control Methods — In Order of Severity

  1. Tourniquet for extremity (limb) bleeds. Apply 5–7 cm above the wound, tighten until bleeding stops. Note the time.
  2. Wound packing with direct pressure for junctional bleeds (groin, axilla, neck) where tourniquet is not possible. Pack tightly with hemostatic gauze and hold firm pressure for at least 3 minutes.
  3. Direct pressure with a gloved hand or pressure dressing for moderate surface bleeds.
💡
Civilian Tourniquets Work
Commercial tourniquets (CAT, SOFT-T Wide) are as effective in civilian settings as in military ones. In the absence of a commercial tourniquet, an improvised tourniquet — a belt, strip of fabric, or similar — can buy time. It is always better than uncontrolled hemorrhage.

Assess Airway Patency

Ask "Can you hear me?" — if the patient speaks clearly, the airway is open. Look for: noisy breathing (gurgling, stridor, snoring), visible obstruction, blood or vomit in the airway, swelling, facial or neck trauma.

Interventions — Least to Most Invasive

  1. Head-tilt chin-lift — standard first manoeuvre for an unconscious patient with no suspected cervical spine injury. Tilts the head back, lifts the chin, opens the airway.
  2. Jaw thrust — use when cervical spine injury is suspected. Displaces the jaw forward without extending the neck.
  3. Recovery position — unconscious, breathing patient with no suspected spinal injury. Place on their side to protect the airway from vomit.
  4. Suction / finger sweep — if visible solid obstruction (food, blood clot, vomit) is present.
  5. Nasopharyngeal airway (NPA) — if trained and available. Maintains airway in unconscious patients. Contraindicated in suspected basal skull fracture.
  6. Supraglottic airway (SGA / LMA) — advanced provider. Definitive airway maintenance without intubation.
⚠️
Spinal Precautions
In civilian trauma with a mechanism suggesting spinal injury (high-speed vehicle collision, fall from height, diving accident), minimise cervical spine movement. Use jaw thrust rather than head-tilt for airway opening. Manual in-line stabilisation if available.

Look, Listen, Feel

Expose the chest. Look for symmetrical chest rise, use of accessory muscles, paradoxical movement (flail chest), penetrating wounds, or bruising. Listen for breath sounds — absent on one side suggests pneumothorax or haemothorax. Feel for crepitus, surgical emphysema (crackling under skin), or tracheal deviation.

Key Breathing Emergencies

  • Open chest wound (sucking chest wound): Seal with a vented chest seal. A vented seal allows air to escape (preventing tension pneumothorax) while stopping air entry.
  • Tension pneumothorax: Absent breath sounds on one side, trachea deviating away, worsening respiratory distress, hypotension. Needle decompression is the treatment — second intercostal space, mid-clavicular line (or 4th/5th ICS, anterior axillary line). Advanced provider skill.
  • Flail chest: Multiple rib fractures causing paradoxical chest movement. Splint with gentle hand pressure or positioning on the injured side. Positive pressure ventilation if available.

Supplemental Oxygen

Administer high-flow oxygen via non-rebreather mask if available — target SpO₂ ≥94% (≥90% in COPD patients). In trauma, oxygen is rarely contraindicated.

Assess Shock

Check radial pulse — rate, rhythm, and quality. A weak or absent radial pulse suggests systolic BP ≤80 mmHg. Check skin — pale, cool, clammy skin indicates poor perfusion. Assess capillary refill: press the fingernail for 2 seconds; refill should occur in under 2 seconds. Check level of consciousness using AVPU (Alert, Voice, Pain, Unresponsive) — confusion and agitation are early signs of shock.

Control Secondary Bleeding

Any additional external bleeding not addressed at the C(atastrophic) step should be controlled now — pressure dressings, wound packing, or tourniquet as appropriate to location and severity.

IV Access and Fluids

Establish IV or IO access if trained to do so. In civilian trauma, fluid resuscitation follows similar principles to TCCC: avoid aggressive over-resuscitation in penetrating trauma. In blunt trauma, the threshold for fluid administration is slightly higher. Follow local protocols for fluid choice and volume. TXA should be given within 3 hours of injury if available and the patient is in haemorrhagic shock.

ℹ️
CPR in Trauma
Cardiac arrest in trauma has different causes than medical cardiac arrest. Tension pneumothorax, massive haemorrhage, and airway obstruction are reversible causes — treat these first. Standard CPR without addressing underlying trauma cause has low success rates. Prioritise reversible causes (the H's and T's of traumatic arrest).

Glasgow Coma Scale (GCS)

Assess GCS: Eye (1–4), Verbal (1–5), Motor (1–6). Maximum score 15 (fully alert), minimum 3. A GCS ≤8 is generally the threshold for advanced airway management. More importantly, assess trend — is the GCS improving, stable, or declining? A declining GCS is a high-priority evacuation indicator regardless of absolute score.

AVPU Scale

A rapid alternative to GCS: Alert, responds to Voice, responds to Pain, Unresponsive. AVPU maps roughly: A = GCS 15, V = GCS 13–14, P = GCS 8–12, U = GCS <8.

Pupils

Check both pupils: equal, round, and reactive to light (PERRL) is normal. Unequal pupils (anisocoria) or a fixed dilated pupil suggests raised intracranial pressure or direct eye injury. Bilateral fixed dilated pupils in trauma is an ominous sign.

Blood Glucose

If altered consciousness is present without obvious traumatic cause, check blood glucose. Hypoglycaemia is a correctable cause of altered mental status that is easily missed in a trauma assessment.

Spinal Assessment

Ask the conscious patient about neck and back pain, numbness, or tingling. If spinal injury is suspected — mechanism of injury, midline spinal tenderness, or neurological deficit — maintain spinal precautions throughout. Do not remove a properly applied cervical collar in the field.

Expose Fully

Remove or cut away clothing to expose the full body surface. Life-threatening injuries — penetrating wounds, pelvic fractures, abdominal injuries — are missed in patients who are not fully exposed. Use trauma shears and expose systematically from head to toe, front and back.

Examine Everything

Conduct a systematic head-to-toe survey: scalp and skull, face, neck (JVD, trachea position), chest (already assessed), abdomen (rigidity, guarding, distension — suggests internal bleeding), pelvis (apply gentle compression — if unstable, do not repeat: suspect pelvic fracture and apply a pelvic binder), extremities (deformity, open fractures, neurovascular status), and back (log roll if safe to do so).

Environment — Prevent Hypothermia

Hypothermia is the enemy of trauma survival. Once a patient is exposed and assessed, cover them. Remove wet clothing. Use a thermal blanket (space blanket or HPMK). Insulate from the ground. Warm IV fluids if available. Even mild hypothermia (core temp below 36°C) impairs clotting and cardiac function — in a shocked trauma patient, this compounds the lethal triad.

💡
Expose, then Cover
The mnemonic within E is "expose, examine, environment." Expose fully to find injuries, examine methodically, then immediately address the environment — cover and warm the patient. Time spent uncovered should be minimised.
🏥
S-CABCDE Quick Reference
S — Scene Safety · Send for help
C — Catastrophic haemorrhage (tourniquet / wound packing)
A — Airway (open, clear, maintain)
B — Breathing (assess, seal, decompress)
C — Circulation (pulse, shock, fluids)
D — Disability (GCS, pupils, spinal)
E — Exposure (expose, examine, environment / hypothermia prevention)