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Medicine In Remote Areas

COURSE MANUAL

WELCOME Welcome to Horizon and to the Medicine In Remote Areas course. This course is designed for professionals that work in remote and hostile environments. The course has been attended in the past by doctors, nurses, paramedics, search and rescue teams, members of the media, expedition team members and large amounts of personnel from the security industry. We hope that this course will give you the confidence to work in a somewhat unique environment, with the minimum amount of equipment and help available.

At Horizon, we are aware of the risks that you undertake every day. All members of the training team are experienced at working in remote environments all over the world, from the Arctic, Temperate, Desert, Jungle, Bush and Savannah. We have also had experience with high altitude, diving injuries and long-term care whilst carrying out long evacuations by air and road.

We also have a policy of continued development. All of our training team and Remote Area Medical Providers have to complete regular updates and attend courses and clinical attachments to maintain skills at the very highest level. This continued professional development is passed on to you the student when you attend a course such as this one.

This course and this manual have been written together to ensure that they complement each other. The content that is displayed as a part of the lectures and skill stations is also contained in this manual for future reference. The course content is approved by the Faculty of Pre- Hospital Care, Royal College of Surgeons (Edinburgh).

This course will give you the knowledge to perform the skills, however it is your responsibility to stay current and up to date with the latest thinking and ideas. This course does not give you a license to practice. In order to carry out the skills described in this manual and on the course you must have permission from the medical director of your company or organisation.

We hope that you enjoy the course.

Horizon

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CONTENTS CHAPTER 1 INITIAL ASSESSMENT AND MANAGEMENT

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CHAPTER 2 MECHANISM OF INJURY

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CHAPTER 3 AIRWAY

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CHAPTER 4 BREATHING AND CHEST INJURIES

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CHAPTER 5 CIRCULATION AND HAEMORRHAGE CONTROL

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CHAPTER 6 BURNS

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CHAPTER 7 ABDOMINAL AND PELVIC TRAUMA

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CHAPTER 8 HEAD INJURIES

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CHAPTER 9 SPINAL INJURIES

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CHAPTER 10 EXTREMITY TRAUMA

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CHAPTER 11 ENVIRONMENTAL INJURIES AND BITES AND STINGS

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CHAPTER 12 CASUALTY CENTRED RESCUE

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CHAPTER 13 PROLONGED FIELD CARE

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CHAPTER 14 MAJOR INCIDENT MEDICAL MANAGEMENT

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CHAPTER 15 DRUG CLASSIFICATION AND AND DRUG ADMINISTRATION

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CHAPTER 16 ANALGESIA AND PAIN MANAGEMENT

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CHAPTER 17 ANTIBIOTICS AND INFECTION

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CHAPTER 18 ANATOMICAL TERMINOLOGY

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SUGGESTED MEDICAL EQUIPMENT LIST

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CHAPTER 1: Initial Assessment and Management Patient care is stressful even in a good working environment. In a remote or hostile environment, conditions are far from ideal. It may be dark and uncomfortable, noisy, wet and cold; it will certainly be dangerous and you may be tired and hungry.

When dealing with casualties you must consider the phases of management: • Approach – Ensure scene safety and call for back-up • Primary survey - Identify life-threatening problems • Resuscitation - Deal with these problems • Secondary survey - Top-to-toe examination • Prolonged field care – After the casualty is stable and before evacuation • Definitive care - Specific management

Approach As the potential first responder on the scene, it is essential that you take a systematic approach to the incident. The approach to the incident should always ensure the safety of the rescuer first, “dead heros can’t save lives”, “only fools rush in” etc, etc.

6 Dimensions of safety Up & Down, Left & Right, Front & Back, Time.

Up & Down What is above or below the casualty? Is there any debris that could fall upon ourselves that could cause further injury.

What is below the casualty? Is the ground surface going to cause difficulty in extrication?

Left & Right We need to be aware of what is in our surrounding area, especially pertinent if dealing with a casualty on a road. Is the traffic still lowing?

Front & back We are very good at looking for potential dangers in front of us but we also need to be aware of any dangers that may be approaching from the rear which could easily be overlooked.

Time Time is important for two main reasons, taking a note of the time at point of contact with a casualty allows the timeline to begin and is vital information regarding ongoing care. The other reason is that it is important to ensure we do not spend a prolonged period of time at the scene of an incident which can easily occur when treating casualties in a stressful situation.

Communications By supplying an ETHANE report we can ensure the vital information is relayed to the correct persons and allow the most suitable responses to come and assist.

E – Exact location T - Type of incident H – Hazards A – Access and Egress N – Number of casualties E – Equipment required

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Primary Survey a. The aim of the Primary Survey is to rapidly identify any life threatening conditions using a systematic approach to patient assessment. b. On reaching the patients side the assessment process can be remembered through the acronym RCABC.

Respone Catastrophic haemorrhage Airway and cervical spine control Breathing and ventilation Circulation and haemorrhage control Disability or neurological status Exposure, Environment & Evacuation

Responses Initially on approaching the patient a verbal response should be sought by calling out to the patient and asking them to respond. Obtaining a verbal response at this point can be reassuring. To respond to you the patient must have a patent airway, a reasonable tidal volume to allow phonation and adequate cerebral perfusion to enable a coherent response.

Control catastrophic bleeding If the patient presents with a life threatening bleed then this should be controlled immediately with a tourniquet (if the bleed is on a limb) or by direct pressure/haemostatics/packing etc (if the bleed is in a junctional area or on the torso)

Airway with cervical spine control The mechanism of injury, if applicable, must be considered for the likelihood of causing the patient a neck injury. If the patient is suspected to have a cervical spine injury then manual immobilisation must be initiated. The patient’s airway must then be cleared, opened and maintained. A useful mneumonic to prompt airway management is COLMA: a. C-spine control? b. Open the mouth c. Look inside the mouth and Listen for snoring/gurgling d. Manually open the airway using head tilt or jaw thrust as necessary e. Adjunct – use an NPA, OPA, iGel to maintain an open airway After clearing, opening and maintaining the airway the patient may require oxygen. Trauma patients may require oxygen. Begin at 15L/min through a reservoir mask but this rate may be decreased to prolong the cylinders life so long as the oxygen reservoir on the face mask remains fully inflated. Medical patients require additional oxygen to maintain their oxygen saturations at 94% or higher. A pulse oximeter can be used to guide the oxygen low rate.

Breathing and ventilation A thorough examination of the patient’s respiratory system is essential. This should begin with a check of the respiratory rate, effort and depth.

R - Is the respiratory rate within the goal posts of life: 10-30 breaths per minute?

E - Is the patient breathing easily or is their effort of breathing increased.

D - Is the patient breathing at a normal depth, too shallow or too deep?

Feel the chest wall Look at the chest wall Auscultate the chest. Check the Armpits Percuss the chest Search the back Tracheal deviation Wounds to neck Emphysema to face/neck Laryngeal crepitus Veins in the neck Evaluate your findings

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Circulation and haemorrhage control A pulse rate should be obtained at the radius if possible, otherwise at the carotid artery. A central capillary refill time should also be sought either on the forehead or over the sternum.

If life threatening haemorrhage was controlled at the beginning of the primary survey this should be reassessed now.

Any areas of haemorrhage should now be search for and controlled as quickly and efficiently as possible. Blood may be lost externally and internally: Blood on the floor and four more. External, chest, abdomen, pelvis, long bones (2x femur, 2x humerus).

External haemorrhage should be controlled using the most appropriate method ie. Pressure dressings, haemostatic agents, tourniquets. Pelvic fractures should have a pelvic splint applied. Long bone fractures should be splinted in position or have a traction splint applied.

Intravenous or intraosseous access should be obtained as necessary and intravenous fluid therapy started if the patient has an absent radial pulse.

If external haemorrhage continues or if there is internal bleeding suspected then Tranexamic Acid should be administered. (see medications section).

Disability A brief evaluation of the patients level of consciousness should take place using the AVPU scale.

Alert (patient will call out to you without prompting) Voice (patient will only respond when you call out to them) Pain (patient will only respond when you provide a painful stimulus) Unresponsive (patient will not respond at all) The pupils then need to be assessed for their equality and response to light.

A blood glucose level should then be obtained to rule out hypoglycaemia (low blood sugar) as the cause of the patients decreased level of consciousness.

A final check should be done for wounds and deformities around the head/scalp and a check carried out for battle sign, racoon eyes or blood/CSF from the ears or nose.

Events & Environment Consideration must be given to protecting the patient from the surrounding environment. Whether that is ear protection, eye protection or protection from the environmental conditions. In particular, the patient MUST be protected from developing hypothermia. Hypothermia will significantly affect the patient’s ability to survive their injuries.

The patient must now be packaged in preparation for evacuation. Ideally, as part of your pre-expedition or deployment planning a casualty evacuation plan will have been developed which can now be initiated.

Secondary Survey The secondary survey is designed to identify non-life threatening injuries and is carried out when the casualty is stable. Casualties have backs, sides, fronts, bottoms, tops and lots of holes, both natural and as a result of injury. You must be systematic, going through a top-to-toe process as follows: • Scalp and vault of skull • Face and base of skull • Neck and cervical spine • Neurological examination • Remainder of spine and limbs • Chest • Abdomen • Pelvis • Limbs

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Obtaining a relevant history from the patient can also be carried out during this phase of the assessment. The acronym AMPLE can be used to guide this process: Allergies Medications Past medical history Last meal (time of) Events leading up to the patient presenting to the medic Prolonged Field Care In the remote environment, casualty evacuation times can vary dramatically. If we can’t remove the casualty to definitive care, we must take over that care until we have the means or resources to move the casualty to an appropriate facility. This can often be one of the most challenging aspects of remote medicine, as we then have to care for a sick or injured person with very few or no resources. This phase of care requires the use of antibiotics and long term pain relief, we must now feed the casualty, replace lost fluids, change dressings and ensure that correct body temperature is maintained, as well as taking care of ourselves. A system that we can use to enable us to ensure that we are completing the process is ‘FIELD CARE’ (See Chapter 13).

Definitive Care Deliver the doctor a live patient. If we can do this, the casualty has a very good chance of not only surviving, but also full recuperation. Definitive care has the resources and facilities to look after the sick or injured person. As a remote medic you may have the skills to maintain someone for a few hours or even days, but definitive care is an essential part of our evacuation plan and must be considered before venturing out into a remote environment. A through handover to the receiving clinician is vital to ensure good patient care and accurate patient records. An acronym to assist us with this process is MIST. Mechanism of injury Injuries (sustained/suspected), Illness Signs and symptoms Treatment A consistent, systematic approach to the primary survey is vital to the casualty’s survival.

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CHAPTER 2: Mechanism of Injury ‘The difference between a good clinician and an indifferent one is the time spent on history taking’ Sir Faraqar Buzzard - 1933 Assessment of a patient can begin even before reaching the patients side. Understanding and interrogating the mechanism of injury is a vital step in this process. If the medic can interpret the incident and develop an appreciation of the forces that were exerted on the patient during the insult then it is possible to predict the injuries that the patient may have suffered.

Laws of Motion To understand the MOI, it is necessary to have a basic understanding of some of the laws of motion. The first is that a body in motion remains in motion, at the same velocity, until acted upon by an outside force. This is known as Newton’s first law of motion. A person in a vehicle travelling forward at 60mph, for example, will continue to travel at this velocity when the vehicle stops suddenly until he strikes an object, such as the steering wheel or seat belt,that stops his forward momentum.

The speed (velocity) of the vehicle or projectile is a major contributing factor to the forces involved in the impact. A pedestrian struck by a vehicle travelling at 20mph has a 5 per cent chance of sustaining fatal injuries. In comparison, someone struck by a vehicle travelling at 50mph has an 85 per cent chance of being killed.

Consider the driver of the vehicle travelling at 50mph that hits a wall or other stationary object. He will be subjected to four separate impacts or transfers of forces: • The vehicle collides with an object, possibly another vehicle. It decelerates, and the air bags or crumple zone are activated to dissipate the energy of the driver’s velocity.

• The driver hits the internal structures of the vehicle, decelerates further, and is subject to compression forces, or will • The driver’s internal organs continue moving forward despite his body stopping, and they may undergo shearing forces.

• The driver recoils, with a velocity that is possibly enhanced by the position of the seatbelt, and experiences rebound injuries.

The above example shows that the energy of movement – kinetic energy – is subsequently transferred into other forms of energy such as compression, cavitation or shearing forces.

Acceleration and Deceleration (A/D) Forces The injuries that occur due to A/D forces fall into one of two groups: shearing injuries and compression injuries.

Shearing injuries, such as damage to the arch of the aorta, occur almost exclusively as a result of the A/D forces themselves. By contrast, compression injuries, such as those to the head from hitting the dashboard or windscreen, occur due to the impact causing deceleration forces.

Shearing forces can cause the liver, heart and other heavy organs to pull away or fold round the ligaments or muscles securing them, and so result in dramatic internal haemorrhage.

Compression injuries that occur due to an impact secondary to the A/D forces can include knee or femur injures, including dislocations in an RTA, or Pneumothorax if the chest walls or lungs are forcibly compressed at impact.

Rebound injuries, which occur due to recoil following deceleration, include spinal fractures and contra-coup injuries to the brain.

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Cavitation & Blunt Trauma Permanent cavitation occurs when a tract or hole is made through tissue and it remains even after the energy has been removed or dissipated. Temporary cavitation is not so easily recognised because the structures involved may have returned to their original location once the energy has been dissipated. Cavitation in blunt trauma is often only temporary because elastic body tissues return to their original position.

Cavitation can be obvious, but is not always so. For example, if a bat strikes the skull, it is fairly likely that there will be a depressed fracture that is easily detectable. But if the abdomen is struck, cavitation is less obvious because of the underlying structure’s ability to recoil. The results however, which may include organ damage or life threatening haemorrhage, can be just as serious. Remote medics must therefore be aware of the degree of cavitation that is likely to occur following blunt injury and the consequent damage to related organs and other structures.

When considering penetrating trauma the medic needs to identify whether the damaging object was travelling at either a low or high velocity (speed). a. A stab wound is a good example of a low velocity penetrating injury. In these injuries the energy transfer from the object to the tissues is much less than in high velocity injuries and therefore the degree of cavitation and tissue damage is reduced. However, in both low and high velocity injuries there will be a degree of both permanent and temporary cavitation. b. In low velocity penetrating injuries damage to the tissues is limited to the wound track and therefore damage to tissues and organs can be predicted by tracing the path of the object. In general male attackers tend to thrust in an upward motion and female attackers strike in a downwards fashion. However, predicting internal injury may be quite complicated. For example, a small external wound may mask significant internal injury if the knife was moved around inside the victim. Additionally, unless the object is able to be inspected it may be very difficult to determine how far the object has penetrated and in what direction. This means that a stab wound to the upper abdomen may also injure organs in the lower chest cavity or a stab wound to the lower chest may damage upper abdominal organs. c. High velocity penetrating injuries, such as those from a bullet or bomb shrapnel have additional complications. In particular, due to the high energy transfer involved, the degree of cavitation caused by a high velocity penetrating injury can be devastating.

The yaw and tumble of projectiles, particularly bullets, also increases the degree of cavitation to the point that a high velocity bullet can cause a temporary cavity twenty five times larger than the calibre of the bullet. Due to this cavitation, high velocity projectiles damage not only the tissue directly in the path of the missile but also the tissue involved in the temporary cavity on each side of the missile’s path. In general, high velocity objects cause more damage to solid organs, such as the liver and kidneys, than if they pass through air filled organs such as the intestines or stomach.

Blast An explosive is a substance that can be made to undergo a rapid chemical reaction that will transform a liquid or a solid into a gas, liberating a large amount of energy. The products of detonation (or explosion) of a conventional explosive are: A region of highly compressed gas (the blast), that rapidly expands to occupy a volume at least 10 times greater than that of the original explosive. Various solid residues from the explosive or casing.

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Beyond the fireball, the blast wave appears as a sharp line, which is caused by refraction of light by the higher density gas at the shock front

Classification of Blast Injuries Primary Blast Injuries: The rapid expansion of gas after an explosion takes place almost instantaneously and compresses the surrounding air into a shock or blast wave that moves supersonically in all directions from the explosion.

Secondary Blast Injuries: Secondary blast injury occurs when lying debris, buildings and other material energised by the explosion and picked up be the blast winds strike the body. A high incidence of casualties with secondary injuries from broken glass can be expected when a blast occurs in urban areas.

Tertiary Blast Injuries: Tertiary blast injury occurs when a casualty’s body is thrown against the ground, equipment, structures, trees or other stationary objects by the pressure differentials or blast winds. Mutilating blast injuries (traumatic amputations) occur as a combination of secondary and tertiary blast effects.

Quaternary blast injuries: Quaternary blast injuries may be seen after the initial blast has passed. Injuries may include burns from subsequent ires, trauma from collapsing buildings, infection from open wounds or possibly contamination from radiation or chemicals

Primary Blast Injuries This is caused by the direct effects of the shock wave/pressure front on the body with the greatest effect on gas containing organs, and may occur with out any external signs of injury. Organs Affected in Primary Blast Injuries include the middle ear, the lungs, intestines, the heart and the central nervous system as these are all gas containing organs whether as a gas or as a solute.

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Effects of Pressure Wave on Air Containing Organs Air spaces within the body are under the influence of atmospheric pressure (A) under normal conditions. When a pressure wave such as a high-pressure blast wave passes through these spaces (B) the increase of pressure results in a reduction in volume (Boyle’s Law), this can result in damage occurring such as implosion of the tympanic membrane. Immediately behind the pressure wave is a negative pressure vacuum that results in an increase in volume of air spaces (C), thus resulting in damage (D), whether temporary or permanent.

Injuries resulting from the blast wave include: Blast Ear: Common with other forms of injury, small over pressures can injure the ear with tympanic memebrane rupture being very common. Ossicle dislocation and cochlear injury can also occur. Symptoms include tinnitus or hearing loss Blast Lung: blast lung can take time to manifest clinically and can include: • Disruption of alveolar capillary interface • Disruption of bronchi and attachments • Disruption of pulmonary vessels • Accumulation of blood and fluid • Blood low Shunting • ARDS – Acute Respiratory Distress Syndrome Blast Gut: Air spaces within the gut being affected by the blast wave can result in damage to both the small and large intestines. There are several types of injuries related to blasts, it is important to remember primary blast injuries may go unrecognised for some time and communication with the casualty/casualties may be difficult. Most immediate deaths as a result of pure primary blast injury are related to air embolism to the heart or brain.

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Secondary Blast Injuries The blast winds cause the secondary classification of injuries, due the winds picking up debris or material from the explosive device (i.e. – grenades, claymore mines, vehicle bourne IED) causing both blunt and penetrating injuries from shrapnel/missile injuries and objects striking the body. In large explosions blast winds can cause traumatic amputations to limbs at joints, this is usually associated with pressure injuries and multiple traumatic injuries due to the proximity to the blast.

Displaced structures that become displaced causing falling masonry and structural collapse can result in crush/bury injuries and account for greatest number of victims statistically.

Tertiary Blast Injuries This is a secondary result of the blast winds where the victim may become a thrown against objects primarily resulting in blunt, deceleration injuries.

Quarternary Blast Injuries Miscellaneous injuries as a result of exposure to blast mechanism include burns and fractures which in themselves can be life threatening.

Conclusion Understanding the direction and extent of the forces that patients have been subjected to, and a working knowledge of the structures that might have been injured as a result, allows remote area medics to make targeted assessments to identify any life or limb threatening injuries. Alternatively, the information can be used to initiate appropriate diagnostic or treatment interventions to ease patient suffering and minimise the time required for recuperation.

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CHAPTER 3: Airway Introduction Once life threatening haemorrhage has been controlled it is necessary to gain airway control at the earliest available opportunity. Without a patent airway, any casualty will die in a very short space of time. Methods of gaining a patent airway vary from the positioning of the casualty and simple manoeuvres to the insertion of specialist devices.

The ability to provide an artificial airway or to assume control of respirations may be quite limited within the remote environment; optimally the victim can be an active participant in the remote-site rescue effort. The drive to breathe is one of the most powerful brainstem reflexes. Although they may be depressed, the autonomic reflexes to cough, gag, swallow, gasp, flare nostrils, open the vocal cords during inspiration, hyperventilate in response to hypoxia or head injury, and recruit accessory muscles of respiration are generally preserved until the victim is near death. The remote area medic should avoid any medications or interventions that might impair these reflexes.

Only a small minority of airway emergencies occur instantaneously, such as sudden complete airway obstruction by an aspirated foreign body or a crushed larynx from impact with a steering wheel. Certain other rapidly evolving lifethreatening emergency situations have major immediate airway considerations, but if the underlying condition can be stabilized or relieved, the need to manage the airway becomes less pressing. Examples in this second category include suffocation, near drowning, intoxication, or any circumstance in which absence of breathing (apnoea) can be converted to spontaneous respiratory effort or an obstructed airway can be converted to a patent one.

Causes of Airway Obstruction

Intervention

Aspiration of foreign body

5 x back blows 5 x abdominal thrusts

Unconsciousness/Tongue

Manual manoever. Airway adjunct

Facial or neck trauma

Remove debris in mouth/Account for teeth Assess potential for swelling Positioning Secretion assistance - Suction

Anaphylactic reactions

Adrenaline if available Consider inhaled b-agonists - Salbutamol Consider airway adjuncts / Surgical Cricothyroidotomy

Seizures

If possible, turn on side to facilitate gravity drainage of saliva or vomit.

Insert NPA if possible, do not place anything into the mouth

Airway compromises that are anticipated to worsen with time fall into a third important category. Without intervention, an otherwise viable victim might die from a potentially preventable airway death. Examples in this third category include inhalation burns, soft tissue trauma, infections involving the pharyngeal or hypopharyngeal soft tissues and allergic reactions.

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Assessment and management of the airway As with all aspects of patient assessment, the airway should be assessed and managed in a stepwise and logical fashion. The acronym COLMA can be used to guide the medic through this process: a. C – is a c-spine injury suspected due to the patient’s mechanism of injury? If so then the head should be moved into an in-line position and manually stabilised from here onwards. b. O – open the mouth c. L – Look in mouth, remove foreign bodies, listen for abnormal breathing sounds, may indicate obstruction or swelling. d. M – manually open the airway using either the head/tilt chin lift or jaw thrust manoeuvre as determined by their mechanism of injury e. A – an airway adjunct should then be inserted appropriate to the patients condition

Recognition of Airway Obstruction Cyanosis can be present as a result of hypothermia, hypovolaemia, insufficient cardiac output or inadequate tissue perfusion so is not always indicative of airway compromise. Also airway compromise can be present without cyanosis; an allergic reaction with airway oedema and vasodilatation is one example of an airway emergency in the absence of cyanosis; unconsciousness (with associated upper airway obstruction) resulting from carbon monoxide poisoning is another.

Laboured respirations are typified by a rate that is forcefully rapid, irregular, or gasping. Unusual sounds or noisy respirations could be present and accessory muscles of the chest wall, shoulders, neck, and abdomen strain with the effort.

Retractions result from mismatch between chest wall effort (when the rib cage expands) and ease of pulmonary air inflow. Pulmonary air inflow can be impeded by upper airway obstruction or by stiff lungs that do not readily expand.

The “restrictive” respiratory pattern for stiff lungs typically involves intercostal retractions, tachypnoea, and the respiratory noises of rales (alveolar fine crackles) and “grunting” (the brief holding of breath at the end of inspiration then letting it go with an expulsive and audible quick exhalation).

In contrast, the “obstructive” respiratory pattern for upper airway obstruction exhibits greater use of neck and abdominal accessory muscles; greater supraclavicular, subcostal and sternal retractions, stridor, snoring, gurgles, or other abnormal respiratory noises.

Description of Airway Sounds SOUND

DESCRIPTION

Stridor

A sharp, high-pitched squeaky sound with vocal quality that emanates from the larynx (upper airway) and is usually more prominent on inspiration than expiration

Wheezing

A sustained whistling sound made by air passing through narrowed airways usually distal to the larynx (lower airway), and generally more prominent on expiration than inspiration.

Rhonchi

Gurgling, congested, low-pitched rattling sounds in the chest caused by secretions in the large and medium-sized airways

Grunting

A staccato noise heard at the end of expiration only, with a lower pitch than that of stridor; can be found in tension pneumothorax or in association with restrictive lung disease or with thoracic or abdominal pain

Snoring

A characteristic low-pitched, very low-frequency inspiratory noise caused by periodically interrupted airflow through the soft tissues of the pharynx. Caused by tongue obstructing

Gurgling

Due to a fluid in the upper airway eg. vomit, saliva or blood

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Head Positioning The most common causes of upper airway obstruction are a floppy tongue and lax pharyngeal muscles, or soft tissue enlargement from infection or oedema. Because teeth play such an important role in preserving the size and patency of the mouth, lack of teeth (the young, elderly, poorly dentition, and recently traumatised) increases vulnerability to upper airway obstruction. Upper airway obstruction is almost always improved by optimal head positioning, mouth opening, clearing of nasal passages, and/or tongue manipulation.

Keeping the mouth of an unconscious person open is very important. With the interior of the mouth in view, it is possible to gauge the position of the tongue and the presence of vomit, foreign debris or pooling of secretions and can hear the quality and regularity of respiratory noises, even at a distance.

Head tilt, chin lift. Note airway obstruction by the base of the tongue against the posterior pharyngeal wall with closure of the epiglottis over the trachea

Jaw thrust

No matter what the person’s age, the most desirable posture is maintaining “neutral” head position with the chin “proudly” jutted forward, nose in the “sniffing” position, mouth open, tongue resting on the floor of the mouth. The least desirable head position in any age group is with the neck flexed and chin pointed towards the chest. Flexion also increases unfavourable stresses on a potentially unstable cervical spine. Extreme hyperextension of the head in any age group angulates the airway, and should be avoided.

If there is a suggestion of a possible cervical spine injury, efforts to stabilise the neck and head should be undertaken.

Neck flexion, hyperextension, or lateral rotation must be minimised as much as possible. Fortunately, the best head position for the airway is also good for the cervical spine.

Non-Invasive Airway Manoeuvres If the upper airway is obstructed, there are three basic non invasive airway-opening manoeuvres. The most simple is the head tilt, chin lift. The intended result is the sniffing position. Problems arise if the mouth is closed or soft tissues are infolded because of the chin lift. One hand should be placed on the patients forehead and the fingertips of the other hand placed underneath the patients chin. The head should now be tilted backwards and the patients chin lifted upwards.

A second manoeuvre is the jaw thrust. Pressure is applied to the angle of the mandible to dislocate it upwards while forcefully opening the mouth. This is painful, and the conscious or semi conscious victim may object by clamping.

The tips of the index and middle fingers of each hand should be placed onto the angles of the jaw, just below the ear lobes. Upwards pressure should then be applied and if necessary, additional pressure can be achieved by applying downwards pressure with the thumbs over the cheekbones.

A third manoeuvre is the internal jaw lift. The rescuer’s thumb is inserted into the victim’s mouth under the tongue, and the chin is lifted, thus stretching out the soft tissues and opening the airway. This is the best manoeuvre for the unconscious victim with a shattered mandible. The internal jaw lift is dangerous to the rescuer if the victim is semi conscious and can bite.

All non-invasive airway manoeuvres except the internal jaw lift can be used in conjunction with rescue breathing or bag-valve-mask assisted ventilation.

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Suctioning In the remote area, secretions must be removed without the benefit of electrically powered suction devices. A number of products are on the market that the remote area medic might want to consider for the medical kit.

The patient can also be positioned so that gravity facilitates drainage of blood, vomit, saliva, and mucous; something absorbent or basin like can be placed at the side of the mouth to catch drained secretions. Several positions are suitable for providing postural drainage depending on the severity of the fluid accumulation and the patients injuries. The recovery position is suitable for patients in whom a c-spine injury is not suspected. If the patient is suspected to have a spinal injury then the log roll should be utilised. Finally, if the bleeding is severe or the vomiting persistent then, if the patients injuries allow, they should be placed in the prone position. This is achieved by lying the patient face down to allow maximum drainage from the oral cavity. A rolled up blanket or pillow may be placed under the hips and shoulders to allow improved respiratory effort.

Suction devices can be included in an expedition first aid kit not just for secretion management purposes but also for gentle wound irrigation and burn dressing or wet compress moisturising. The rubber self-inflating bulbs marketed for infant nasal suctioning can also be used to suction out debris from the mouths and noses of adults. Large syringes with a piece of oxygen tubing attached can also be used for suction and wound irrigation.

Secretion removal by gravity or suctioning is key to the management of epistaxis and for maintaining the airway of a victim with mandibular fractures.

Airway Equipment Masks and One-Way Valves The purpose of the one-way non-re-breathing lap-valve is to permit air to be pushed into the victim through one aperture while exhaled air (and secretions) are exhausted through a separate route, thus helping minimise exposure to infectious substances. These one-way valves are small, lightweight, and inexpensive and would be easy to tuck into a small container along with gloves and a face barrier.

Facemasks differ in shape, type of seal, transparency, and materials used for construction. The universal connector at the peak of the mask dome provides a 22-mm female adaptor that connects the mask to a one-way valve to go to the rescuer’s mouth, the elbow of a Bag- Valve-mask system or the breathing circuit of a ventilator.

Non-cushioned masks are more difficult to use and demand a greater array of sizes. The cushioned masks are a far better choice for responding to out-of-hospital emergencies.

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Dedicated suction devices such as this Suction EasyŠ can be inexpensive and compact, and can provide good portable suction.

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Nasopharyngeal Airway Compared with the OPA, the nasopharyngeal airway (NPA) is better tolerated in the semi conscious person. Since it does not have to withstand the forces of biting teeth, the NPA can be more lexible and compliant. A flange outside the nostril prevents the NPA from slipping or being swallowed or aspirated. The flange can be improvised with a safety pin through the tube itself. The gentle curvature of the NPA follows the superior surface of the hard palate, descends through the hidden nasopharynx and down the visible posterior oropharynx, and ends up behind the base of the tongue.

The key to successful and atraumatic insertion involves lubrication (saliva works well); an understanding of nasal anatomy; and steady, gentle pressure. If the NPA has a bevel, the lat edge of the bevel is oriented toward the nasal septum.

The direction of insertion is straight back. As the NPA passes through the turbinates, there will be mild resistance, but once the tip has entered the nasopharynx, there will be sensation of a “give.” The tube should be visible in the oropharynx as it passes behind the tonsils, and the tip should come to rest behind the base of the tongue.

The NPA is an ideal airway for the semi-conscious patient who is responding to pain and also a person with trismus.

This is a condition where the jaw clamps shut meaning access to the oral cavity is impossible. This may occur in a patient suffering from a seizure or who is semi-conscious due to hypoxia.

Complications of NPAs include failure to pass through the nose (usually resulting from a deviated septum), epistaxis, mucosal tears and creation of pressure sores. If the NPA or any nasal tube is left in place for more than several days, impedance to normal drainage may predispose the victim to sinusitis or otitis media. NPAs are permitted for use in patients with a base of skull fracture so long as the correct insertion technique is used and excessive force is not used.

Sizing and Insertion Sizing – As with the OPA, the NPA comes in a variety of sizes. Sizing is very easily accomplished with the NPA, average females – size 6.0 and average males – size 7.0. The larger the casualty is, the larger the tube will have to be and vice-versa with a small casualty.

Insertion – Lubricate the tube (either saliva or KY jelly work well). Carefully insert the tube into the right nostril, parallel to the palate. Push the tube straight down towards the floor and NOT up the nose. If resistance is felt, withdraw the tube and try the left nostril.

After insertion, the patency of the airway must be checked.

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Oropharyngeal Airway An Oropharyngeal airway (OPA) holds the base of the tongue away from the posterior pharyngeal wall and keeps the mouth open and the lips apart. It may stimulate gagging or induce vomiting and is not well tolerated in the responsive or semiconscious victim. Improper or forceful insertion can cause soft tissue, palatal, or dental injury, as can subjecting the structures of the mouth to prolonged or intense pressures from biting down or holding the OPA in place with tethers.

An overly large oral airway can occlude the upper airway or will press down on and cause the epiglottis to fold over and occlude the glottis. Additionally, glottic stimulation can result in laryngospasm and a complete loss of airway. Too small an oral airway will miss the curvature of the tongue and will press down in the middle of it, worsening occlusion at the base of the tongue or causing the epiglottis to close over the glottis.

Sizing and Insertion Sizing - The OPA comes in a variety of sizes; from 00 for babies to 4 for large adults. As already discussed the correct size is vital if the airway is going to work correctly. The OP airway is sized from the centre of the teeth to the angle of the jaw. Typical adult sizes are size 2 for females and size 3 for average males. This does of course vary from casualty to casualty.

Insertion – The airway is inserted ‘upside’ down at first and then twisted through 180 as the end passes under the palate and into the oropharynx.

After insertion, the patency of the airway must be checked.

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i-gelTM Supraglottic Airway The i-gel airway is a novel and innovative supraglottic airway management device, made of a medical grade thermoplastic elastomer, which is soft, gel-like and transparent. The i-gel is designed to create a non-inlatable anatomical seal of the pharyngeal, laryngeal and perilaryngeal structures whilst avoiding the compression trauma that can occur with inflatable supraglottic airway devices.

The i-gel is a truly anatomical device, achieving a mirrored impression of the pharyngeal, laryngeal and perilaryngeal structures, without causing compression or displacement trauma to the tissues and structures in the vicinity. The i-gel has evolved as a device that accurately positions itself over the laryngeal framework providing a reliable perilaryngeal seal and therefore no cuff inflation is necessary.

The i-gel is used to secure and maintain the airway of an unconscious patient. It has the advantage of allowing delivery of high concentrations of oxygen, enabling effective ventilations via a bag/mask device, reducing gastric inflation and therefore the risk of vomiting, being easy to insert in awkward positions and during CPR it allows for continuous chest compressions to take place. i-gel size

Patient size

Patient weight guidance (kgs)

1

Neonate

2–5

1.5

Infant

5 - 12

2

Small paediatric

10 - 25

2.5

Large paediatric

25 - 35

3

Small adult

30 - 60

4

Medium adult

50 - 90

5

Large adult +

90 +

Sizing

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Pre-insertion preparation - Adult i-gel. Sizes 3, 4 and 5.

1. Always wear gloves 2. Open the i-gel package, and on a lat surface take out the protective cradle containing the device.

3. In the final minute of pre-oxygenation, remove the i-gel and transfer it to the palm of the same hand that is holding the protective cradle, supporting the device between the thumb and index finger. Place a small bolus of a waterbased lubricant, such as K-Y Jelly, onto the middle of the smooth surface of the cradle in preparation for lubrication.

Do not use silicone based lubricants.

4. Grasp the i-gel with the opposite (free) hand along the integral bite block and lubricate the back, sides and front of the cuff with a thin layer of lubricant. This process may be repeated if lubrication is not adequate, but after lubrication has been completed, check that no BOLUS of lubricant remains in the bowl of the cuff or elsewhere on the device. Avoid touching the cuff of the device with your hands.

5. Place the i-gel back into the cradle in preparation for insertion.

NB. The i-gel must always be separated from the cradle prior to insertion. The cradle is not an introducer and must never be inserted into the patient’s mouth.

Insertion A proficient user can achieve insertion of the i-gel in less than 5 seconds.

1. Grasp the lubricated i-gel firmly along the integral bite block. Position the device so that the i-gel cuff outlet is facing towards the chin of the patient.

2. The patient should be in the ‘sniffing the morning air’ position with head extended and neck flexed. The chin should be gently pressed down before proceeding to insert the i-gel.

3. Introduce the leading soft tip into the mouth of the patient in a direction towards the hard palate.

4. Glide the device downwards and backwards along the hard palate with a continuous but gentle push until a definitive resistance is felt.

WARNING: Do not apply excessive force on the device during insertion. It is not necessary to insert fingers or thumbs into the patient’s mouth during the process of inserting the device. If there is early resistance during insertion a ‘jaw thrust’, ‘Insertion with deep rotation’ or triple manoeuvre is recommended.

5. At this point the tip of the airway should be located into the upper oesophageal opening and the cuff should be located against the laryngeal framework. The incisors should be resting on the integral bite-block.

WARNING: In order to avoid the possibility of the device moving up out of position prior to being secured in place, it is essential that as soon as insertion has been successfully completed, the i-gel is held in the correct position until and whilst the device is secured in place.

Opening of cuff at laryngeal opening

Tip of cuff at oesophageal opening

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Black line on bite block level with teeth

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Cricothyrotomy If the upper airway is completely obstructed and obstruction cannot be relieved or bypassed, the only way to avoid death is to create an air passage directly into the trachea. The most accessible and least complicated access site is through the cricothyroid membrane.

The essential indication for a surgical airway is the need for an airway where all else has failed.

A Surgical Airway should be performed if all other methods have failed and there is no other way to secure the airway.

There are some exceptions to this rule. Situations in which a Surgical Airway should be considered as the primary method include Major Maxillo-Facial Injury (eg compound mandibular fractures, Le Forte III Midface Fracture), Oral Burns, Fractured Larynx and anaphylaxis.

Complications include bleeding, puncture of the posterior trachea and oesophagus, creation of a false passage, inability to ventilate, aspiration, subcutaneous and mediastinal emphysema, vocal cord injury, and subsequent tracheal stenosis.

Identifying the cricothyroid membrane The thyroid cartilage in the neck should initially be found. One finger should then be slide downwards from the thyroid notch (Adams Apple) until a hollow area is palpated. This is the cricothyroid membrane. Just below this notch is the cricoid cartilage which is felt as a thin band. Confirmation of the correct location may be approximated at one fingers width below the thyroid notch, or alternatively, place the little finger of one hand in the sternal notch and the index finger of that hand should land in the cricothyroid membrane.

Surgical airway technique a. The immediate area over and around the cricothyroid membrane should be cleaned thoroughly b. The thyroid cartilage should be stabilised using the thumb and middle finger of the non-dominant hand, leaving the index finger free to relocate the cricothyroid membrane as necessary.

The equipment required – Tube, syringe, forceps, scalpel, sutures, ribbon gauze

c. Carefully make a 2cm long vertical incision down the midline above the cricothyroid membrane with a scalpel held in the dominant hand

Thyroid cartilage

d. Re-identify the cricothyroid membrane

Incision

e. Incise the membrane horizontally using a stab technique

Cricoid cartilage

f. Place the forceps through the incision and into the trachea, using them to enlarge the incision particularly in the superior/inferior direction g. Now introduce the tracheostomy tube and insert it into the trachea until the wings sit lush with the neck h. Now inflate the cuff of the tube and remove the stylet from within the tracheostomy tube i. Confirm tube position and patency by feeling airflow or easily administering ventilations through a resuscitation bag with no resistance or appearance of subcutaneous emphysema j. Secure the tube around the patients neck If a specialist tracheostomy tube is not available then a size 6 endotracheal tube may be utilised as an alternative.

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When an evacuation by air or over radically different altitudes, is anticipated, the cuff should be filled with water.

Why? Different altitudes cause air to expand or contract. This could then mean that the cuff may delate or expand.

As water does not expand or contract with differing air pressure, it will ensure that the cuff is kept a constant size and therefore reduce the risk of the tube from becoming dislodged.

Other Airway Adjuncts Other commercial airway adjuncts used in pre-hospital circumstances include the endotracheal tube and the esophageal-tracheal Combitube. Successful insertion of these devices requires formal instruction and practice. Their use in the wilderness setting is limited to appropriately trained and experienced providers.

Summary The conscious or semi conscious person with an airway emergency instinctively seeks an optimal posture for air exchange. The unconscious person, unless deeply anesthetized, paralyzed, or profoundly hypoxic, continues effort to breathe until death is very near. If a victim shouts or cries out, the airway is intact and the lungs are filling. If a victim is breathing but obstructed, determination should be made as to why. If a victim is making no respiratory effort at all, a choice must be made about whether or not to initiate CPR. The fundamental goals of airway management in the field are to promote conditions supporting airway patency with: • Optimal positioning • Facilitated removal of secretions or debris • Close observation for emesis, bleeding, seizures, or other events leading to obstruction or aspiration • Avoid doing or administering anything that could further depress respirations, obstruct airway, or depress respiratory reflexes • Assess the potential for worsening • Plan the evacuation accordingly • Communicate the situation and concerns to others • Prepare for escalated intervention

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CHAPTER 4: Breathing & Chest Injuries Introduction Thoracic injuries account for 20-25% of deaths due to trauma and contribute to 25-50% of the remaining deaths.

Approximately 16,000 deaths per year in the United States alone are attributable to chest trauma. The increased prevalence of penetrating chest injury and improved pre-hospital and peri-operative care has resulted in an increasing number of critically injured but potentially salvageable patients presenting to trauma centres.

Blunt injury to the chest can affect any one or all components of the chest wall and thoracic cavity. These include the ribs, clavicles, scapulae, sternum, lungs and pleurae, tracheobronchial tree, oesophagus, heart, and great vessels of the chest. In the subsequent sections, each particular injury and injury pattern resulting from blunt mechanisms is discussed. The patho-physiology of these injuries is explained and diagnostic and treatment measures are outlined.

Penetrating trauma to the thoracic vessels was not extensively reported until the 20th century because of the absence of survivors. In 1934, Alfred Blalock was the first American surgeon to successfully repair an aortic injury.

Guidelines for treating thoracic trauma were not established until World War II. Additional experience in the treatment of penetrating trauma to the thorax was gained in later military experiences, including the conflicts in Korea and Vietnam, and to a lesser degree, in US actions in Grenada, Panama, the Balkans, Somalia and the Persian Gulf. Other large international experiences have derived from the Falkland Island conflict, various Middle Eastern engagements, and multiple conflicts in the African states.

The thoracic cavity, or chest The thoracic cavity, or chest, consists of 12 pairs of ribs which are connected in the posterior aspect to the spinal vertebrae. The first seven pairs of ribs are attached anteriorly to the sternum and the next three pairs of ribs are attached to cartilage. The final two pairs of ribs are termed “floating ribs� and are not attached to the sternum or cartilage.

The trachea The trachea extends from the larynx in the neck, down to the lungs and is about 11cm long. It is surrounded by several rings of cartilage which support the trachea and prevent it from collapsing. At the level of the fifth thoracic vertebrae the trachea branches into the left and right main bronchi which enter the lungs.

The Alveoli Each lung has about 300 million alveoli. They are very small and cannot be seen easily with the naked eye. Each alveolus is surrounded by a capillary blood vessel. Gases, e.g. oxygen and carbon dioxide, move across the alveolar membrane into the blood vessels and vice versa. A continuous exchange of gases takes place between the alveoli and the capillary blood vessels that surround them.

The Covering of the Lungs The Pleura There is a double-layered covering of the lungs called the pleura. The visceral pleura adheres to the surface of the lungs whilst the parietal pleura adheres to the inside of the chest wall. There is a small amount of lubricating fluid in between the two layers of the pleura.

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Divisions of the lungs The lungs are divided into lobes. The right lung has three lobes (upper, middle, lower) and the left lung has two lobes (upper and lower).

Anatomy & Physiology The Mechanism of Breathing To inhale, the intercostal muscles contract causing the chest wall to rise and expand, whilst the diaphragm flattens.

This then produces a negative pressure inside the chest, which draws air in through the upper airway and then down into the lower respiratory tract. Breathing out is a reversal of the process, the diaphragm relaxes, the chest wall falls and air is forced out.

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The Function of the Lungs - Exchange of Oxygen and Carbon Dioxide The main function of the lungs is to keep the correct amount of oxygen and carbon dioxide in the blood. In order to do this we breathe air into the airways which then moves all the way down to the sac-like endings of the airways called the alveoli. In the alveoli, the oxygen from the air moves into the blood stream that surrounds each tiny alveolus.

The blood then carries the oxygen around the body to the tissues where it is required. Carbon dioxide is carried from the cells of the body to the lungs, where the carbon dioxide moves across the alveoli into the airways and is then exhaled.

The exchange of gases can be increased or decreased by breathing at a faster or slower rate, or by breathing more deeply consequently, the body can increase the amount of oxygen and decrease the amount of carbon dioxide in the blood stream by breathing at a faster rate or more deeply.

The body needs more oxygen e.g. during exercise, running or straining. There may be some obstruction to the low of air in the airways or there may be an obstruction to the low of gases across the alveoli into the blood stream. This may be due to diseases like asthma, bronchitis or pneumonia. Whatever the cause, the body will try to increase the amount of oxygen in the blood stream by breathing at a faster rate or more deeply. Most of the time the lungs are able to provide enough oxygen for the body’s needs. If there is a severe shortage of oxygen in the blood, this is termed hypoxia and may result in a blueish tinge around the lips or face called cyanosis.

Carbon dioxide is an acidic waste product of body metabolism, levels of carbon dioxide in the blood may rise because there may be an over production of carbon dioxide, e.g. from running or exercising. In some medical conditions, e.g. diabetes, there may be an over production of acid (ketones) which will also result in deeper breathing. By breathing faster or deeper the body will usually be able to correct the level of carbon dioxide. The faster we breathe, the more carbon dioxide is moved from the blood into the airways and then exhaled.

The normal respiratory rate is 12 - 20 breaths per minute in adults. The goalposts of life are described as being between 10 and 30. If we are breathing at rate lower than 10 breaths per minute, then we are simply not moving enough oxygen into the body or removing enough carbon dioxide away from the body. If the respiratory rate is above 30 per minute, the air is moving into and out of the body at such a rapid pace that respiration cannot take place suffficiently. A faster breathing rate is called tachypnoea (tachy = fast, pnoea = breathing). A fast breathing rate (tachypnoea) is an important sign of respiratory dysfunction. A slow breathing rate is called bradypnoea.

A fast breathing rate can cause dehydration. There is always some moisture (water) in the air that is breathed out.

Therefore a fast breathing rate will result in water being lost from the body. If the breathing rate is increased for long periods of time it can result in dehydration.

The heart rate increases when the breathing rate increases. A faster breathing rate increases the amount of gases exchanged. The heart rate will increase the low of blood through the lungs. When there is a normal breathing rate (12 - 20 breaths per minute), the amount of oxygen and carbon dioxide in the blood stream is at the correct level for the body’s needs. Most respiratory conditions cause the breathing rate to increase.

Chest & Neck Examination A thorough assessment of the patients respiratory status is vital, not only allow us to identify life threatening breathing problems but also to give us a baseline to judge our interventions against to determine whether they have been beneficial. The respiratory status is assessed using the acronym RED FLAPS TWELVE. Initially we need to assess the adequacy of the patients breathing using the format RED: a. R – Rate b. E – Effort c. D – Depth Rate - Look, listen and feel for breathing over 15 seconds then multiply the number of breaths by four to determine the rate in one minute.

Effort - Is the patient struggling to breathe?

Depth – How deeply is the patient breathing? Look at the height of their chest rise

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The chest is examined using the acronym – FLAPS. • F – Feel • L – Look • A – Auscultate & Armpits • P – Percussion • S – Search the back Feel When we feel the chest, we are initially feeling for the rigidity of the chest and the symmetrical rise and fall of the chest. The hands must then feel every inch of the chest including the armpits and breasts.

Some deformities may be felt but not seen easily, especially at night, so a thorough feel of the chest is essential.

Look What can we see? Can we see any holes or deformities? Is the chest moving a normal amount? Can we see a section of the chest that is not moving in the same direction as the rest of the chest?

Auscultate & Armpits What can we hear? Using a stethoscope, we must check for breath sounds over both lungs. Air entry must be equal on both sides. Air entry is assessed at the top and sides of the lungs. Comparison is the easiest method of ascertaining normality. Armpits are often overlooked and can hide injuries that can easily be missed.

Percussion

Auscultate the chest

This process is used in conjunction with auscultation to determine if there is blood or air inside the chest. A finger is placed along a rib and then tapped. Comparison is used again as the best method to clarify if there actually is an abnormality. The noise that is produced may be hyper-resonant or snare drum like, indicating air in the chest, hypo-resonant or a dull thud, indicates blood in the chest.

Search the Back The back is just as important as the front and can be easily disregarded, especially if there is a large (or distraction) injury on the front of the chest. If possible (injuries allowing), the casualty should be turned, so that a full examination can be carried out. When this is not possible or if you happen to be on your own, hands must be used to feel for any abnormalities. The hands are placed underneath the casualty until the fingertips touch and are then removed. We then look at our (gloved) hands to see if there is any blood present. This process is then repeated until the entire back has been felt and any wounds have been located and dressed appropriately. The neck is examined using the TWELVE acronym. This is a vital step as findings here can indicate the type and severity of injury.

• T – Tracheal deviation • W - Wounds • E – Emphysema • L – Laryngeal crepitus • V – Veins, distended or lat • E - Evaluate

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Percussion of the chest

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Tracheal deviation The trachea is examined to establish if it is sitting in the correct position. If the trachea is deviated to one side, this could be an indicator of increased pressure inside the chest, usually due to tensioned air. Tracheal deviation is usually a late or pre-terminal sign of tension pneumothorax.

The method for ascertaining the correct position is best examined as low down the trachea as possible. Find the sternal notch (where the two clavicles meet the sternum) and then placing two fingers into the notch, feel the trachea.

If the trachea is deviated, it will have moved away from the injured side.

Tracheal tugging may also be seen or felt. This can be a sign that there is a blockage in the airway.

Wounds Any wound on the neck could have penetrated the chest cavity.

Evaluation of the mechanism of injury will help to confirm or deny any chest injury. Wounds that have transected the trachea become an airway problem, which may need an intervention such as a surgical Cricothyroidotomy. Any wound that has affected the great vessels in the neck becomes a circulation problem that must be managed aggressively.

Emphysema Surgical emphysema is a result of air escaping into the tissues.

Emphysema is indicative of some sort of pneumothorax. It can usually be felt at the base of the neck. The feeling has been described as being similar to Rice Crispies or bubble wrap.

Laryngeal Crepitus When the larynx becomes disrupted due to a direct insult, it is possible for the fractured parts of the larynx to collapse in on themselves. Swelling will also occur. This is essentially an airway problem that can be solved with surgical intervention in the field. We can feel for crepitus by placing three fingers onto the larynx and slowly moving the structure, feeling for any grating sensation.

Veins, Distended or Flat The large veins that run along the sides of the neck can be examined to see how full or empty they are. When the veins on the neck are distended, this means that they are not able to empty into the heart as they normally do. This is due to an increase in pressure inside the chest as found in a tension pneumothorax.

Flat neck veins can indicate that significant blood loss has occurred, possibly due to some sort of haemothorax. This is not always the case and cannot be used as a definite indicator of a chest problem alone. A casualty with blood loss in another part of the body could also present with lat neck veins.

Evaluate Evaluate your findings during the breathing assessment. How is the patients respiratory status? Do they have a life threatening injury? Have they responded to any treatment?

Life Threatening Chest Injury There are several life threatening chest injuries that need to be identified and treated quickly.

These are: • Tension Pneumothorax • Open Pneumothorax • Massive Haemothorax • Cardiac Tamponade • Flail Chest These conditions are described on the next page. The specific treatments are listed at the end of the section.

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Tension Pneumothorax This is an increasing accumulation of air in one, or both, pleural spaces. The increasing intrathoracic pressure causes lung collapse, mediastinal distortion and compression of the lung on the opposite side.

Signs and symptoms of a tension pneumothorax may include: a. R – Tachypnoea b. E – Significant difficulty breathing. Patient may be grunting c. D – Variable d. F – Variable e. L – Unequal chest rise f. A – Absent or decreased breath sounds on the injured side g. P – Hyper-resonance on the injured side h. S – Variable i. T – Deviated towards the uninjured side j. W – Variable k. E – Variable l. L – Variable m. V – Distended n. E – Patient requires urgent intervention of tension is suspected

Air is sucked in through the penetrating wound in the chest. Eventually the lung will collapse due to the excess amount of pressure.

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Signs such as distended neck veins or cyanosis depend on a normal circulating blood volume; these signs are likely to be absent in a hypovolaemic casualty. The main signs - respiratory distress and shock - demand immediate action.

Immediate treatment for a tension pneumothorax is to perform a needle thoracocentesis (needle chest decompression) using a large bore cannula such as a 12 or 14 gauge medicut/cannula, with a syringe, inserted into the pleural space via the second intercostal space in the mid-clavicular line on the affected side.

At some stage the move towards a definitive chest drain must be considered, dependant on whether someone skilled in the technique is available of if there is: • Delayed evacuation to definitive care due to terrain, assets, geography • High altitude evacuation route to definitive care in non-pressurised airframe • Failure of the needle thoracocentesis after prolonged management • Lack of further medical support/definitive care referral

Open Pneumothorax (Sucking Chest Wound) The critical size of a defect in the chest wall allowing air to low in and out of the chest cavity (as opposed to the normal route through the trachea) is two-thirds the diameter of the trachea. Smaller defects in the chest wall are not usually associated with sucking; they are more likely to result in a tension or simple pneumothorax.

The adult trachea is approximately 2.5cm wide and therefore any open wound on the chest which is less than 2cm wide has the potential to create a “sucking chest wound” and therefore an open pneumothorax.

However, any open wounds found on the chest wall should have a commercial chest seal applied over them.

When more than one open chest wound is present on a hemithorax, then the uppermost hole is sealed using a commercially available chest seal and the others are sealed with an occlusive dressing. The chest seal aim to produce a one-way valve that will allow air out of the chest, but no air in.

If respiratory distress follows the application of an occlusive chest seal, first burp the dressing to allow any trapped air to escape. If this fails then, assume the development of a tension pneumothorax and perform needle thoracocentesis as described above.

Massive Haemothorax The chest cavity is one of the four classical sites of hidden blood loss. Each hemithorax can hold up to 2·5 litres of blood. The most common cause is a penetrating wound disrupting the systemic or pulmonary vessels. A massive haemothorax is defined as 1500 ml or more of blood in the chest cavity.

Signs and symptoms may include: a. R – Tachypnoea b. E – May be some difficulty breathing c. D – Variable d. F – Variable e. L – Variable f. A – Decreased or absent breath sounds on injured side g. P – Dull or hyporesonant h. S – Variable i. T – unaffected j. W – Variable k. E – unaffected l. L – Variable m. V – Flat n. E – Evaluate

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Treatment of a massive haemothorax will require management of both the breathing and circulatory issues that the patient is facing. Additional oxygen will be required to compensate for the poorly functioning lung on the injured side and if no radial pulse is present then IV fluids will be required. A needle thoracocentesis is not used in this case as the lost blood may actually be slowing the bleeding. If we release the lost blood through a needle then we make the blood loss more severe.

Cardiac Tamponade Cardiac tamponade occurs when blood becomes trapped between the heart and the non-elastic pericardial sac. This will result in pressure being applied to the heart causing reduced filling of the heart chambers and therefore reduced cardiac output. It is most commonly caused by penetrating injury but can be as a result of blunt trauma to the chest. It is immediately fatal except when the leak from the heart or great vessels into the pericardial sac is small.

You should consider the possibility of this condition in any casualty with a chest injury who does not respond quickly to management of airway and breathing problems coupled with adequate fluid resuscitation. Signs such as distended neck veins can be absent in hypovolaemia; muled heart sounds can be very difficult to detect in a noisy environment. If you suspect this condition, little can be done in the remote setting and evacuation to definitive care is paramount.

Flail Chest When two or more consecutive ribs are fractured in two or more places, a free-floating, unstable segment of chest wall is produced, this is called flail chest. Separation of the bony ribs from their cartilaginous attachments can also cause flail chest. Patients report pain and tenderness at the fracture sites and pain upon inspiration.

Physical examination can reveal paradoxical motion of the flail segment, however this is not always immediately apparent as muscular splinting of the flail segment can hide this until the casualty tires. The chest wall moves inward with inspiration and outward with expiration. In large lail segments with developed paradoxical movement the casualty can demonstrate “air hunger� where little or no movement of air is present at the mouth/nose. Dyspnoea, tachypnoea, and tachycardia may be present.

A significant amount of force is required to produce a flail segment. Therefore, associated injuries are common and should be aggressively sought. The medic should specifically be aware of the high incidence of associated thoracic injuries such as pulmonary contusions and closed head injuries.

Pain relief and the establishment of adequate ventilation are the therapeutic goals for this injury. Flail segments should not be immobilised due to the risk of restricting chest wall movements. Rarely, a fractured rib lacerates an inter-costal artery or other vessel, which requires surgical control to achieve haemostasis.

Sternal Fractures The majority of sternal fractures are caused by road traffic accidents. The upper and middle thirds of the bone are most commonly affected. Patients report pain around the injured area. Inspiratory pain or a sense of dyspnoea may be present. Physical examination reveals local tenderness and swelling. A palpable defect or fracture-related crepitus may be present.

Associated injuries occur in 55-70% of patients with sternal fractures. The most common associated injuries are rib fractures, long bone fractures, and closed head injuries. The association of blunt cardiac injuries with sternal fractures has been a source of great debate. Blunt cardiac injuries are diagnosed in fewer than 20% of patients with sternal fractures. Caution should be used before completely excluding myocardial injury.

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Treatments Needle Thoracocentesis This procedure is for the rapidly deteriorating casualty who has a life-threatening tension pneumothorax. If this technique is used with a casualty who does not have a tension pneumothorax, there is a small risk of producing a pneumothorax or causing damage to the lung, or both.

A large bore (12 or 14 gauge) cannula is inserted into the 2nd intercostal space, in larger or muscular patients a degree of failure has been reported, therefore consideration of the alternative lateral site should be considered.

The landmarks for needle thoracocentesis

Identify landmarks: Find the angle of Louis on the sternum. Attached to the sternum at this point is the second rib. Run a finger along the second rib until the mid-line of the clavicle. Underneath this rib is the intercostal space where the needle will be inserted. The needle should be inserted over the top of the 3rd rib and not below the 2nd. This is because there is a neurovascular bundle that sits below the rib.

An alternative lateral site for needle chest decompression is in the “triangle of safety”, in the fourth or fifth intercostal space on the patients’ side. a. An imaginary line is drawn from the nipple to the floor in a supine patient (one lying down) b. A second line is drawn following the lateral edge of the pectoralis muscle c. A further line is drawn anterior to the mid-axillary line The cannula is then inserted at a 90° angle to the skin with a syringe containing 5ml of water attached to the end of the cannula. The cannula should be advanced up until the hub of the cannula is adjacent to the skin. Bubbles of air may be seen rising through the water. Then the needle is fully removed. A hiss of air may be heard at this point. The breathing rate will decrease. The cannula must then be protected so that it cannot become kinked or blocked.

This procedure is not definitive. It will buy time whilst a chest drain is setup before insertion. If no formal chest drain is available, the process can be repeated and multiple needles put in place until the casualty can be evacuated to a facility that is equipped to deal with the problem. If additional needles are to be placed they should proceed in a lateral direction, towards the armpits.

After the needle has been inserted, a reassessment of the casualty must take place in order to see if the intervention has worked.

Potentially Life-threatening Injuries There are also six potentially life-threatening injuries, which may not have been obvious during the primary survey.

These are grouped into two contusions and four disruptions as follows: • Pulmonary contusion • Myocardial contusion • Diaphragmatic disruption • Tracheobronchial disruption • Oesophageal disruption • Aortic disruption

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Pulmonary Contusion This can result from penetrating injury or, more likely, from blunt injury either by direct compression of the chest wall or from the effects of blast. The most obvious feature is the resulting respiratory compromise that increases as time elapses. The earlier this respiratory compromise appears, the more likely it is to be lethal. This is especially true in blast injury, producing blast lung, in these cases severe respiratory distress associated with haemoptysis can present very quickly.

Casualties with blast lung may initially appear to have minimal injury.

They then sit up to breathe and try to use their accessory muscles of respiration; they are literally drowning in their own fluid. This severe blast lung will usually develop within two to three hours following injury. In such cases, the mortality approaches 100%. Delayed onset may mean the casualty can be saved, but he will certainly require the high levels of oxygenation only achieved by intubation and ventilation and not necessarily possible in a field setting.

Myocardial Contusion Where there is a history of a crush injury to the central chest, myocardial contusion should be suspected. Irregular heart rhythms may be present; these casualties run the risk of developing sudden ventricular fibrillation. Proof of myocardial contusion depends on finding ECG abnormalities and abnormal serum cardiac enzymes; therefore remote area treatment should be rest, administration of oxygen and early transfer to a unit with monitoring facilities.

Diaphragmatic Disruption This occurs most commonly to the left hemi-diaphragm and is associated with severe blunt compressive abdominal injury. It produces tears in the diaphragm allowing the abdominal contents to herniate into the chest. Clinically, there may be pain in the area of the left chest with an absence of breath sounds.

Tracheobronchial Disruption The site of disruption may be the larynx, the trachea or a bronchus. Laryngeal fractures are rare; they can present early with airway obstruction. Initial management requires a tracheostomy, not surgical cricothyroidotomy.

Suspect this condition when there is hoarseness with localized subcutaneous emphysema in the absence of airway obstruction.

Casualties with injuries to the bronchus have a high mortality rate and many die quickly. Those with lesser injuries may present with haemoptysis or a tension pneumothorax. A classical sign is a pneumothorax that continues to leak significant amounts of air after a chest tube has been inserted. A second tube may be required in order to prevent air accumulating in the chest cavity and producing a tension pneumothorax.

Oesophageal Disruption This is an uncommon injury, caused not only by direct penetration but also by blunt injury to the abdomen producing increased pressure at the oesophagogastric junction. Forceful retching can also cause it. The most common symptom is severe pain, usually out of proportion to the apparent injury. Early surgical intervention is required.

Aortic Disruption Of all casualties with this injury, 80% will die immediately. Of those who do not die immediately, only a third will survive more than five days. Survivors from traumatic aortic disruption have usually received blunt injuries. In the initial phase there are usually very few symptoms and signs because, in survivors, the haematoma is contained. Early diagnosis is made from X-ray findings as fractures of the first and second ribs or a widened mediastinum. Accurate diagnosis in a field setting is impossible.

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Non-Lethal Injuries These should be sought in the secondary survey. They are: • Simple pneumothorax • Simple haemothorax • Rib fractures Simple Pneumothorax In the context of trauma, a simple pneumothorax is best treated with needle thoracocentesis and/or chest drainage.

In the field, this is the case even with a small spontaneous pneumothorax since the casualty must be evacuated and cannot be monitored continually. Furthermore, evacuation by air – with a fall in atmospheric pressure – will allow the pneumothorax to expand.

Simple Haemothorax There must be at least 500 ml of blood in the chest cavity for it to show on chest X-ray. A haemothorax of this magnitude requires chest drainage even if there is no gross upset to the circulation. Most cases will settle spontaneously.

Rib Fractures Rib fractures are the most common blunt thoracic injuries. Ribs 4-10 are most frequently involved. Patients usually report inspiratory chest pain and discomfort over the fractured rib or ribs. Physical findings include local tenderness and crepitus over the site of the fracture. Fractures of ribs 8-12 could include associated abdominal injuries.

Summary Casualties presenting with immediate life-threatening injuries can be dealt with by simple measures if diagnosed at an early stage. It is vital that these crisis injuries are detected and managed during the primary survey and resuscitation phases. Potentially lethal injuries come to light during the secondary survey. These in particular can deteriorate with time, and proper management requires repeated assessment both in the ield and throughout the evacuation process.

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CHAPTER 5: Circulation & Haemorrhage Control Introduction The circulatory system is responsible for the delivery of oxygen and nutrients to the body cells and the removal of waste products from the tissues. Any breakdown in the system can lead to serious tissue damage or death within a short space of time. Therefore remote medics need to be able to identify and treat any circulatory problem as it is found. This chapter will describe the basic anatomy and physiology of the system, the most common and life threatening conditions and what methods are needed to deal with them most effectively.

Anatomy & Physiology During our lifetime, the heart will beat more than 3 billion times and move 300 million litres of blood around the body. The usual pulse rate is between 60 and 100bpm.

There are several factors that can influence the rate of the heart. A high level of fitness can lower the resting heart rate, whereas smoking can raise the normal heart rate of an individual. Blood loss through injury will raise the heart rate. An injury to the brain may actually lower the rate.

These factors will be discussed in more detail later in this and in other chapters.

The Heart The heart is a muscular organ, roughly the size of a clenched fist, located in the centre of the chest with two thirds of the myocardium on the left side of the midline of the sternum. The heart is covered by the pericardial sac, which is a tough, non-elastic, protective bag.

Blood lows through the superior and inferior vena cava into the right atrium, the heart contracts and then pumps the blood through the tricuspid valve into the right ventricle. The heart contracts again and the blood is pumped through the pulmonary artery to the lungs, where diffusion and gaseous exchange takes place. The blood then returns to the heart through the pulmonary vein into the left atrium. The heart contracts and blood is then pumped into the left ventricle through the bicuspid (mitral) valve. The heart contracts again and the blood is pumped out of the heart into the aorta and around the body.

There is an intrinsic electrical system inside the heart that emits an electrical pulse that stimulates different parts of the heart to contract at different times. Several chemicals can affect the heart, some of which will block or hamper the electrical system from working and others will stimulate the heart to work faster or with more contractile strength.

These chemicals are released in the body naturally or can be introduced to have the appropriate desired effect.

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The Pulse The usual pulse sites that are used are the radial and the carotid. The pulse can also be taken at several sites around the body. A healthy adult at rest will have a heart rate of approximately 60-100bpm. The goal posts of life for an adult are 40-120bpm.

Radial Pulse

Carotid Pulse

Pulse locations

The presence of a pulse at different locations can give an approximate measurement of the systolic blood pressure.

• Carotid Pulse = BP > 60mmHg • Femoral Pulse = BP > 70mmHg • Radial Pulse = BP > 80mmHg Blood Pressure This is the measurement of pressure of blood against the inner walls of the arteries. The top number or systolic blood pressure (SBP) relfects the pressure in the arteries when the heart is pumping. The bottom number or the diastolic blood pressure (DBP) represents the arterial pressure when the heart is resting (e.g. 120/80 mmHg).

The Blood Blood is the only fluid that can carry oxygen around the body. Blood is able to do this because erythrocytes (red blood cells) contain haemoglobin (Hb). Oxygen binds to Hb so that it can be carried around the body. The blood also contains leukocytes (white blood cells) for fighting infection.

Blood Vessels There are three types of blood vessels, arteries, veins and capillaries.

The arteries are thick, muscular tubes that carry oxygenated blood away from the heart. The veins are relatively thin walled in comparison to the arteries and contain non-return valves because the blood that is contained within is at a lower pressure. Veins return deoxygenated blood to the heart. Capillaries are very small vessels that enable the exchange of oxygen and nutrients into the tissues and the removal of carbon dioxide and waste products.

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Capillary Reill Time (CRT) CRT can give a quick evaluation of the circulatory status. Blood is squeezed out of the capillary’s and the time it takes to refill will show how well the skin is perfused, giving a good indication as to the general circulatory state. In a shocked casualty, this time will be prolonged. The disadvantage of using this technique is that if the casualty is cold, the capillary’s that are close to the surface of the skin will have a long refill time regardless of the casualty’s haemodynamic state.

The method involves pressing on either the forehead or the sternum for 5 seconds and then releasing. The skin will become white and then ‘pink’ back up again and this gives the result. Normal time is less than 2 seconds.

Types of Bleeding Bleeding can be described as being arterial, venous or capillary.

Arterial This particular type of bleeding is the most life threatening. The blood is being pumped out of the vascular system under a great deal of pressure and therefore quicker than with other types of bleed.

Arterial bleeding occurs when an artery has been disrupted, either laterally or longitudinally. A complete transection of the artery will detract back inside the body because the muscular wall of the artery will contract in order to protect itself. This muscular contractility is not available in a wound that disrupts the artery longitudinally because of the anatomy and physiology of the vessels.

Types of bleeding

Venous Large venous bleeds can also be life threatening. Varicose veins that become disrupted will bleed profusely until the correct management has been carried out. This dark red blood that lows from a wound can usually be controlled with simple measures that will be described below. There is no muscular wall to aid with the stopping of the bleed, however this bleed is under a much less pressure, making it easier to control.

Capillary The least serious type of bleed is the capillary bleed. Again the wall of the vessel becomes disrupted and blood oozes from the wound. There is very little pressure behind this bleed and due to the size of the vessels involved; stopping this type of bleed is very simple.

Haemorrhage Control As blood is the only oxygen carrying fluid in the body, the blood needs to remain inside the body! There are several techniques that the remote area medic can use to control compressible external haemorrhage. These methods include, direct pressure, elevation, compression dressings, wound packing, indirect pressure, splinting, haemostatic agents, pressure enhancement and tourniquet’s. Each of these methods can be effective, but when used in combination they produce the most desirable results.

Internal haemorrhage can be controlled by applying traction splints to fractured femurs, applying pelvic splints to fractured pelvis’ and administering Tranexamic Acid to suitable patients. These interventions will be discussed in later chapters.

Direct Pressure Direct pressure is probably the most simple and effective method of haemorrhage control. Press on the wound with a pad, preferably a sterile wound dressing, but even a tea towel or a scarf will achieve a similar effect. By applying pressure directly over the top of the wound, this will compress the bleeding edges of the wound.

Elevation We can use gravity to our advantage. Whilst applying direct pressure, elevate the limb above the level of the heart to slow down the blood low into limb.

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Compression Dressing In order to provide both direct pressure and a sterile compression field a good quality trauma dressing should be used that will apply pressure directly over the wound. A dedicated dressing i.e. First Care Bandage or with a pad from a field dressing and a crepe bandage will provide this. Whilst using either dressing, the pad should completely cover the wound and then the crepe bandage is wrapped around the limb. After application the peripheral pulse should be checked to ensure that the bandage hasn’t been applied too tightly.

Wound Packing A large bleeding wound does not just bleed at the surface. A good compression dressing will deal with surface bleeding, however any large wound will need to be packed to ensure that the entire wound has been dressed, using either sterile gauze or material such as curlex. The gauze is pushed into the wound until they are standing proud of the surface of the skin. A compression dressing is then applied over the top. This then has the effect of dressing the inside and outside of the wound, providing better haemorrhage control.

Indirect Pressure Using a pressure point will stop the entire low of blood into a limb or area of the body. A pressure point is a point where an artery crosses over a bone close to the surface of the skin. We can apply pressure to these points to occlude the blood low through the artery. Several pressure points are easy to ind and occlude.

• Superficial Temporal Artery – Slightly anterior to the tragus of the ear and can be compressed against the temporal bone to occlude the blood low to scalp lacerations on that side of the head.

• Axillary Artery – This artery lies along the lateral line of the armpit. With the arm raised, a thumb can be used to compress the artery.

• Brachial Artery – This artery lies between the bicep and tricep muscles. We press in and up in between these two muscles.

• Radial and Ulna Arteries – The radial pulse site can be used to occlude the artery that supplies part of the palmer arch. Because of the anatomy, this will not stop an arterial bleed on the hand alone. The Ulna artery must also be compressed at the same time. This can be found by placing two fingers on the little finger side of the wrist. The artery can then be palpated in a similar manner to the radial artery. Brachial Artery – This artery lies between the bicep and tricep muscles. We press in and up in between these two muscles.

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• Femoral Artery – This is the compressible artery that is at the greatest pressure. Even though there is a great deal of pressure involved, it does not require a great deal of pressure to occlude the artery. Some of the older first aid manuals described having to use a great deal of force to achieve the desired effect. Methods included using the heel or knee to press over the general area. This amount of force is inappropriate and can be damaging to the underlying tissues. Practical methods of locating and compressing the Femoral artery using two thumbs are very effective.

• Popliteal Artery – The Popliteal artery supplies the lower leg and can be located in the centre of the posterior aspect of the knee. Pressure is then applied with the fingers until the bleed stops.

• Dorsalis Pedis – The main artery that supplies the foot. The pulse may be felt in the centre of the anterior aspect of the ankle, level with the malleolus. As with the others pressure is applied until the bleed stops.

Splinting The full immobilisation of bleeding limbs in the pre-hospital environment will aid in the stopping of large bleeds. And will also avoid further soft tissue damage, has an analgesic effect and therefore reduce the heart rate. Methods of applying splintage will be discussed in the chapter on extremity trauma.

Pressure Enhancement The use of an improvised windlass tourniquet directly over the site of a wound will apply not only direct pressure over the top of the wound, but also circumferential pressure around the limb. Both of which will reduce bleeding. The method of application is very simple. A broad fold triangular bandage (the width should be approximately 7-10cm’s) is wrapped around the limb and a knot is tied over the top of the wound. Then place a pen, a small stick, an unused OP airway, a pair of scissors or something similar on top of the knot. Tie another knot on top of the pen. Then twist the pen, so that a large knot starts to form directly over the top of the wound. This presses down on top of the wound and gives good circumferential pressure around the limb.

Tie a knot over the top of the wound

Place a solid object on top of the knot and then tie another

Start to twist the object until the knot starts to form over the top of the wound

Tie the ends away securely

Tourniquet These are the primary method of arresting haemorrhage from a life threatening bleed on an extremity eg. Arm or leg.

They should be applied as soon as a life threatening bleed has been identified and prior to assessing the airway. The site of application of the tourniquet depends on where the life threatening bleed is located. There are two discreet methods according to the Faculty of Prehospital Care who state: a. Wound above knee/elbow: The first tourniquet should be place mid-point over the single bone and if bleeding is not controlled then a second tourniquet is placed just below the first. b. Wound below knee/elbow: The first tourniquet should be placed on the single bone above the wound and as close to the joint as possible. If bleeding is not controlled then a second tourniquet should be applied about two inches above the edge of the wound.

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Some things to note: a. If the initial bleeding has been controlled by a single tourniquet then as the muscles relax or blood pressure increases due to fluid resuscitation, bleed from the wound may restart. Tightening the initial tourniquet or application of a second tourniquet may be necessary to regain control of bleeding. b. When applying a tourniquet above the knee joint it is important not to be too close to the knee as the femoral condyles can prevent adequate compression of the artery here. c. In blast injury to lower limbs, application of a second tourniquet within two inches of the wound edge may be impossible due to the associated tissue damage. In these cases, the second tourniquet should be applied as close to the wound as is possible.

The CAT The CAT uses a windlass type mechanism to apply the relevant amount of pressure in order to stop the bleed. The method of application is below.

Wrap the CAT around the afected limb, feeding the tail through the belt buckle

The bar is then twisted. This tightens the CAT. Once the bleed has stopped, enough pressure has been applied

The bar is then locked of and another piece of Velcro is used to ensure the bar does not come loose. The time of application MUST be noted

There are other types of tourniquet available but, as with all medical equipment, familiarity is essential. Before using any piece of equipment, the full functions of it must be examined and tested.

Haemostatic agents There are an increasing number of products available in the commercial setting that are aimed at providing increased ability for the blood to form into a clot around large, potentially uncontrollable haemorrhage. Examples of these include QuikClot, Hemcon and Celox.

Most of these products are inert and have no chemical action and work due to their ability to absorb water molecules (plasma) from the blood enabling rapid localised coagulation and the formation of a stable blood clot in a variety of wounds. Celox has the additional benefit of additionally containing clotting agents.

These agents do not absorb into the body and are safe to leave in wound as long as necessary.

Most haemostatic agents are now produced bound to gauze and are relatively simple to use. The wound is packed with the gauze so that the wound space is filled with the gauze. Pressure is then applied over the gauze for three minutes (depending on the product) and finally a pressure dressing is applied above the wound prior to evacuation.

It is important to note that these products alone will not arrest haemorrhage, they must be used in conjunction with direct pressure.

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Hypovolaemic Shock Shock is defined as an inadequate supply of oxygen or nutrients to tissues because of inadequate tissue perfusion, misdistribution of cardiac output or abnormal microcirculation. Prolonged shock states can lead to multiple organ failure. Prompt recognition and treatment of shock can avoid costly, prolonged intensive care unit (ICU) stays and more importantly unnecessary deaths.

Hypovolaemic shock is the most common form of shock after trauma and potentially one of the easiest to treat.

There are many causes of hypovolaemic shock, including internal or external bleeding, losses from the gastrointestinal tract, such as diarrhoea or vomiting and “third space� losses after major surgery or trauma. The loss of intravascular volume causes decreased cardiac filling with decreases in intraventricular pressure and volume. The sympathetic nervous system allows some compensation by increasing peripheral impedance (resistance) to low and by increasing myocardial contractility. This causes blood low to be diverted from organs that can withstand temporary decreases in oxygen and nutrient supply, such as the intestines and kidney, while preserving blood low to the brain and heart.

Physiology Oxygen is carried in the blood in two forms. Most is carried combined with haemoglobin but a small amount is also dissolved in the plasma. Each gram of haemoglobin can carry 1.31ml of oxygen when it is fully saturated. Every litre of blood, therefore, (which has a haemoglobin concentration of 150g/l) can carry about 200ml of oxygen when fully saturated (occupied) with oxygen (partial pressure 100mmHg). At this partial pressure, only 3ml of oxygen will dissolve in every litre of plasma. When considering the adequacy of oxygen delivery to the tissues, the haemoglobin concentration, cardiac output, and oxygenation need to be taken into account.

Several factors contribute to decreased oxygen supply to the tissues following haemorrhage. When substantial amounts of blood loss occur, the fall in the oxygen carrying capacity of the blood and the reduction in blood volume cause a fall in oxygen delivery.

Hypovolaemic shock is divided into four categories depending on its severity as described below

Classification of Shock Class

I Up to 750ml <15% Lost

II Up to 750-1500ml 15-30% Lost

III 1500-2000ml 30-40% lost

IV >2000ml >40% Lost

Heart Rate

<100/min

>100-120/min

120-140/min

>140/min

Systolic Blood Pressure

Normal

Normal

Decreased

Decreased, unrecordable

Pulse Pressure

Normal

Weak

Weak

Very Weak, absent

Capillary Refill Time

<2 Seconds

2-3 Seconds

>3 seconds

>4 Seconds, absent

Respiratory Rate

14-20/min

20-30/min

>30/min

>35/min

Urine Output

>30ml/hr

20-30 ml/hr

5-20ml/hr

Negligible

Cerebral Function

Normal, slightly anxious

Anxious, frightened, hostile

Anxious, confused

Confused, unresponsive

Class I haemorrhage corresponds to a less than 15% blood volume loss and generally is well tolerated (blood donors fall into this category). Treatment is oral rehydration or judicious use of IV fluids. These patients do have a diminished intravascular volume, but generally compensate well enough to have no classic physical signs of shock.

Class II haemorrhage is a 15%-30% volume loss. These patients generally will have tachycardia, anxiety and a lowered urine output. These are the first signs of shock. In these cases, prompt control of haemorrhage is essential. Restoration to a completely normal blood pressure usually can wait until definitive control of bleeding has been achieved. If complete haemostasis cannot be achieved in the field, then controlled hypotension may be best for the patient.

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Class III haemorrhage is a 30%-40% blood loss. These patients will have a decreased blood pressure, tachycardia, minimal urine output and confusion. Such patients are unable to compensate for their volume loss. Class III and IV hemorrhagic shock are also known as “decompensated shock.” Control of bleeding and rapid resuscitation are essential to prevent later multiple organ dysfunction and death. This group of patients requires blood transfusion and may require surgical intervention to stop the source of bleeding.

Class IV haemorrhage is a greater than 40% blood loss and is rapidly fatal in all patient age groups. These patients will be profoundly hypotensive, have cool extremities, minimal or no urine output, and be minimally responsive to external stimuli.

The site of bleeding may be obvious in the case of penetrating trauma, but it is often less easily found. Internal bleeding in the extremities can be difficult to assess in the field because it may stay in the subfascial planes. For example, a fractured femur can cause a greater than one litre blood loss without obvious external haemorrhage.

Intrathoracic bleeding will cause dullness on percussion and auscultation. This is easily found with a chest x-ray when the patient is in-hospital, but is more difficult to detect in the field when only clinical signs can be measured. The peritoneal cavity is a frequent site of occult bleeding. Several litres of blood may accumulate in the abdomen before any clinically notable distension. The retroperitoneal space may also mask large volumes of blood; this is particularly common after pelvic fractures.

Because many bleeding sites may be difficult to assess in the initial field examination, physical signs of shock are of paramount importance. The mechanism of injury should be noted and then an examination of the area’s to dispel any injury. Sites of internal bleeding include ‘the chest, abdomen, pelvis and long bones. Cool, pale skin coupled with confusion or anxiety should alert the medic to the possibility of clinical shock. Urine output may be of help in assessing these patients, but this usually requires catheterisation of the bladder to measure urine output over time.

Tachycardia, defined as a heart rate of greater than 100 beats per minute, is a sensitive but not specific indicator of the shock state. Several emergency department studies have shown similar heart rates between hypotensive and normotensive injured patients. Up to one-third of patients in shock may not be tachycardic. The presence of tachycardia does not always indicate that the patient is in shock and, more importantly, the absence of achycardia does not indicate that shock is not present.

Hypotensive Resuscitation Hypotensive resuscitation, amongst other terms, is now commonly discussed during the treatment of hypovolaemic shock. These terms reflect a thought process to keep the blood pressure at a level that prevents any fresh clot from being dislodged, resulting in rebleeding. In large animal “uncontrolled haemorrhage” models, the clot is “popped” at approximately 80mmHg systolic. This extremely reproducible level of hypotension is identical to the observations made in patients with penetrating or blunt trauma.

Recall that the presence of a radial pulse indicates that the patient has a blood pressure of at least 80mmHg systolic.

As such, we can use the absence of a radial pulse to guide our IV fluid therapy. If the patient does not have a palpable radial pulse then 250ml of 0.9% NaCl should be administered through an IV cannula or IO needle and the radial pulse should be checked again. If it is still absent then further doses of 250ml 0.9% NaCl should be administered, with a pulse check in between, up to a maximum of 2L of fluid, until the radial pulse returns. Once the radial pulse returns then no further fluid should be given unless the radial pulse disappears again in the future.

If the patient has a weak radial pulse and is deemed to have lost significant amounts of blood then it is advantageous to plan ahead and place a cannula into one of the patient’s veins but until the radial pulse is absent, no fluid should be administered.

Fluid Replacement Techniques There are two methods for administering fluids to a shocked patient, either intravenously through a cannula in a peripheral vein or intraosseously through a needle into the sternum. Both routes allow for drug and fluid administration.

Intravenous Cannulation Cannulation is a skill that requires regular practice in order to be successful. A good knowledge of the anatomy and equipment required is essential as is an understanding of the potential complications and hazards.

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Sites The back of the hand and the antecubital fossa have veins that are ideal for cannulation, as they are easily accessible and close to the surface of the skin. Both of these sites also have alternative veins located within close proximity.

The dorsal metacarpal veins of the hand run adjacent to the 3rd, 4th and 5th metacarpals. Traditionally, the vein that runs between the 3rd & 4th is a preferred site. A benefit of using the back of the hand is that natural splintage is achieved, preventing the cannula from becoming kinked. This site is also very accessible.

The cephalic vein (or housemanâ&#x20AC;&#x2122;s vein) that runs along the length of the radius is a large vein that also has the advantage of natural splintage. As it is a relatively large vein the insertion of a cannula can usually be achieved very successfully at this site.

The antecubital fossa affords the relatively unpractised medic a good site for cannulation. The basilic and cephalic veins are large and close to the surface of the skin. Due to the joint that is in this area, a splint of some sort should be used in order to prevent kinking of the cannula. The long saphenous vein runs proximal to the ankle.

This vein is often used with the cutdown technique.

Equipment There are a variety of different manufacturers of cannulas and there are a number of sizes of cannula available. When deciding on the size of cannula required for the individual patient consideration needs to be given to what the cannula is to be used for (fluid or drug administration) alongside the size of the vein that has been identified for access. A 22G or 20G cannula is well suited to drug administration, is easy to place and is relatively painless for the patient. An 18G cannula is versatile for multiple uses and allows relatively rapid fluid administration along with drug delivery and only being slightly more uncomfortable than a 20G. Finally, the 16G and 14G cannulas are painful to insert due to their larger size but allow for rapid administration of fluid. These large cannulas would be inappropriate purely for drug administration due to the pain involved in insertion.

VenlonÂŽ This cannula is very widely used in the UK and is certainly the most popular. The cannula consists of a metal needle with a plastic catheter over the top. Small wings are attached to the sides of the cannula, allowing ease of securing in place. An injection port is on the top of the cannula and a standard Luer lock connection for the attachment of a giving set.

Insertion Technique 1. Gather and check equipment â&#x20AC;&#x201C; Suitable size cannula for vein and purpose, alcohol swab, tape or a specific cannula dressing for securing the cannula after insertion, venous tourniquet, sharps container and disposable gloves.

2. Put on gloves, swab the area to be cannulated (alcohol should evaporate before cannulation takes place), apply venous tourniquet, prepare lengths of tape to be used for securing.

3. Encourage the vein to dilate - this can be achieved by gently tapping on the skin above the vein. In a cold environment a heat pack may be required to encourage the vein to come to the surface. Swob the area to be cannulated with the alcohol wipe.

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4. Immobilise the vein by pulling the skin over the vein tight.

5. At an angle of approximately 20 degrees, advance the cannula through the skin and into the vein. A flashback of blood should be seen in the chamber at the back of the cannula. Once the flashback has been seen, decrease the angle of the cannula and needle to approximately 5-10 degrees then advance the needle only another 2-3mm and then stop.

6. Hold the needle still and slide the plastic cannula into the vein until the hub is adjacent to the skin.

7. Remove the venous tourniquet.

8. Occlude the end of the vein at the end of the cannula and fully remove the needle and dispose of in the sharps container. Attach the plastic cap to the end of the cannula.

9. Secure the cannula in place using either tape or a specific dressing.

10. Confirm correct placement by either injecting a saline lush or attaching a giving set. Observe the local area for swelling, which might indicate that the cannula is not placed correctly.

Immobilise the vein

Advance the cannula through the skin at approximately 20째

Flashback of blood in the rear chamber.

Flatten the angle of the cannula

Whilst holding the needle still, advance the plastic cannula

Occlude the end of the vein and remove the needle completely

Attach the plastic cap

Tape the cannula in place

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Hazards of Cannulation Several hazards and complications can arise from IV cannulation: Failure to Cannulate This is by far the most common complication. Whilst inserting the cannula, it can be very easy to pass completely through the vein or miss completely. Experience often conquers this problem. It therefore can be useful to start to distally on the limb and work proximally. If further attempts are required, fluids and drugs will not leak from the previously made puncture sites.

Misplacement If the cannula has not been placed correctly in the vein or has become dislodged, fluid or drugs may leak into the local tissues. A sign of this will be a â&#x20AC;&#x2DC;bubbleâ&#x20AC;&#x2122; of fluid underneath the surface of the skin. At this point a new cannula needs to be inserted at a different site.

Damage to Local Structures A consequence of poor technique is also damage to underlying structures. A good knowledge of the local anatomy helps to negate this problem.

Air Embolus When air enters the cannula and into the vein, a build up of air may take place in the heart. This can be fatal if it is not recognised.

Cannula Shear A small portion of the plastic cannula can be sheared if the needle is removed and then reinserted into the cannula.

Small fragments can then enter the circulatory system. If this is suspected, the entire cannula should be discarded and a fresh cannula used.

Needle Breakage This complication is very rare. Excessive or careless manipulation may cause the needle to break. This problem usually occurs with the smaller cannulae. Surgical intervention is then required to remove the needle fragment.

Thrombophlebitis This is an inflammation of the vein and is due to the length of time the cannula has been in place and the local irritation of caused by the substances lowing thorough it. The vein will show signs of infection as well as having a decreased low rate through it. The cannula must be removed and a new site found for a subsequent cannulation. This can be avoided if the skin is cleaned correctly before cannulation.

Intraosseous infusion In some patients IV access is either not practical or not possible. For this cohort of patients the alternative method of vascular access using the intraosseous route is highly beneicial. Intraosseous devices, such as the FAST system, insert a needle into the bone marrow of a bone which is highly vascular. The advantage to this route of vascular access is that, unlike veins which collapse under low pressure, the bone never collapses and allows easy access to the circulation even when massive blood loss has occurred.

One device used is the FAST system (Fast Access for Shock and Trauma). This provides an automated needle injection into the manubrium, designed to achieve the correct depth. Flow rates through this system provides the same rate as a green (18g) cannula, although the fluid through the IO route needs to be pressure infused (squeezed).

The F.A.S.T.1TM Device

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Intraosseous access should be attempted when there have been two failed attempts at cannulation OR no suitable vein is identified within one minute, in a patient where urgent administration of drugs or fluid is needed to prevent morbidity or mortality.

Insertion technique 1. Clean and shave (if required) the area with the steret supplied

2. Locate the sternal notch, place a finger as a guide and place the target patch centrally as shown, ensure that the circular hole is midline on the patient.

3. Remove sharps cap from introducer. Place cluster needles in target zone. Push with a firm and constant pressure at 90째 until cluster needles withdraw and central needle ires.

Withdraw system leaving behind the IO cannula.

4. Connect infusion tube on target patch to cannula. Use syringe to aspirate marrow to confirm placement.

5. Draw up 10ml NaCI into the syringe and then push the NaCI through the infusion tube to lush the line and create a space in the bone marrow.

Fluid Therapy Now that the casualty has been cannulated and the decision has been made to give fluids, which one is best suited to our requirements? Several different types of fluids are available on the market; crystalloids, colloids and blood.

Crystalloids Crystalloids are physiological solutions that remain only temporarily in the circulation (about 30 minutes) before passing into the intercellular space. They are useful for the immediate replacement of lost volume, especially when evacuation times are short and definitive medical care is nearby.

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Hazards of Cannulation The advantages of crystalloids are: • They are inexpensive, plentiful and have a long shelf life • They have no allergenic reactions • They do not cause coagulation problems • There is no risk of transmitted infection • Crystalloids can also be used effectively to correct dehydration The disadvantages are: • Three volumes are required for each volume of blood lost (the 3:1 rule) (remember hypotensive resuscitation – are we going to use this much fluid?).

• An overload may cause pulmonary and cerebral oedema There are many different types of crystalloid solution, the two main types are normal saline 0.9% (NaCl 0.9%) and Hartmann’s or Ringers lactate solution.

There are many diferent types of crystalloid luid

Colloids Colloids are either natural (derived from blood products) example plasma, or synthetic (derived from starches and gelatins) example, polygeline (Haemaccel) which is a gelatine suspended in physiological solution, or Gelofusine.

for for

The advantages of colloids are: • They replace lost volume on a one-to-one basis • They remain in the circulation for long periods •

There is no risk of transmitted infection

The disadvantages are: • Significantly more expensive than crystalloids • Occasionally (1:5000), they cause allergic reactions • When cold, they either become viscous or form a jelly

Haemaccel

Blood As blood is the only fluid that has the capability of carrying oxygen around the body, it would seem to be the best fluid to give to a shocked casualty that has lost a significant amount of their own circulating blood volume. In the correct setting blood is ideal and is often used, however blood is very difficult to transport, store and administer properly in a remote setting. Apart from the requirement for correctly cross matched blood, that can be overcome by giving the universal donor (O Rh negative) there is a significant risk of hypersensitivity, provoking an anaphylactic type reaction. Blood must also be stored in an appropriate refrigerator and then warmed before administration.

Although warming can be achieved in the field, storing or moving blood whilst it remains cool is very difficult.

Due to their ease of use, storage, availability and physiological effects, crystalloids are probably the most helpful fluid to carry.

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Setting up the Drip Fluids are administered through a cannula with a giving set attached.

The fluid bag for administration must be set up correctly. The checks that are required are; • Exterior bag intact • Correct luid • Correct patient • In date • Clear fluid with no sediment or floating items There are a couple of different giving sets that can be used. Some are designed specifically for blood. Some have two chambers, which are used for setting a specific drip rate. The ideal version for remote medic use has one chamber. As we give fluids in aliquots of 250ml, it is not necessary to have a chamber for the drip rate, also lack of personnel means we can’t spare one person to carry the drip during an evacuation, therefore a “closed system” is used. The chamber on our giving set is filled completely, with all excess air squeezed out of the bag. The tap is turned on and the fluid is run through, until there are no expanses of air in the tubing. The tap is then clamped of. The giving set is now ready for attaching to the cannula. This method prevents any air from entering the cannula and therefore the potential for air embolism.

There are many diferent types of crystalloid luid

Other Supplementary Treatments and Supportive Measures Protect casualties from the environment as hypothermia exacerbates shock. Administer oxygen at the highest possible percentage whenever it is available. Painful stimuli can exacerbate shock. Use analgesia in responsive casualties.

To promote and maintain haemostasis, the patient should be managed with the aim of reducing any unnecessary movements. Log rolls should be avoided where possible because there is evidence that dramatic changes in patient position may promote further bleeding. Log rolling a patient with multiple fractures is also a very painful process often despite analgesia. This pain can cause a release of hormones which can increase the heart rate and blood pressure which again increases the likelihood of promoting bleeding. Log rolling a patient is only indicated for protecting the airway or when essential assessment of the back is needed. When assessment of the back is essential, for example with a penetrating injury to the chest, then minimal tilt to each side should be used and not a roll to ninety degrees which has been used previously.

Conclusion The control of compressible haemorrhage is the most important point to remember. The past doctrine of pushing as much fluid as possible into a casualty needs to be eradicated from memory. The use of fluids should be conservative and only used in order to maintain a radial pulse.

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CHAPTER 6: Burns Introduction A burn is defined as any destruction of skin or body tissue resulting from heat, chemicals, radiation or electricity. The severity of a burn depends on several factors, a few of which include the amount of body surface area injured, the depth of destruction and the location of the burn.

With modern medicine, technology and proper pre-hospital care, burn injuries as large as 80% of total body surface area (TBSA) can survive and children with up to 95% TBSA burned have a 50% survival rate. The three most common causes of burns in descending order are thermal (flame/fire), scald and contact.

Skin Anatomy & Physiology In order to clearly understand the impact of the various sources of burns and/or to effectively assess and manage thermal injuries, a clear understanding of and appreciation for the anatomy of the skin is needed.

The layers of the skin The skin is the largest and most versatile organ of the body, and it is vital in maintaining homeostasis. It is this protective covering that prevents many harmful substances, as well as microorganisms from entering the body. Skin also retards water loss by diffusion from deeper tissues and helps regulate body temperature. It houses sensory receptors, contains immune system cells, synthesizes various chemicals and excretes small quantities of waste.

The skin includes two distinct tissue layers; the epidermis and the dermis. The outer layer called the epidermis is composed of stratified squamous epithelium and lacks blood vessels.

The deepest layer of the epidermis is called the basal layer and it sits adjacent to the dermis. This layer is nourished by dermal blood vessels. The epidermis is usually very thin averaging from 0.07-0.12mm and is thickest on the palms of the hands and soles of the feet, where it can be as thick as 0.8-1.4mm. The inner layer or dermis is thicker than the epidermis, and it is made up of connective tissue containing collagen, which gives skin its strength and holds everything together, along with:- elastic fibres, epithelial tissue, smooth muscle tissue, nervous issue, and blood.

Beneath the dermis is the subcutaneous tissue (or hypodermis), which is made up of masses of loose connective and adipose tissues and serves to bind the skin to underlying organs.

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Regulation of Body Temperature The body is constantly in a state of thermoregulation attempting to maintain a temperature of 36.9°C. The regulation of body temperature is vitally important because even slight shifts can disrupt the rates of metabolic reactions and skin plays a key role in the mechanism that regulates body temperature. As the body temperature rises, the blood vessels of the dermal layer dilate to allow heat to escape into the environment. Radiation, conduction, convection and evaporation all play a role in regulating body temperature through the skin. When the body (hypothalamus) senses a lower temperature than the normal set point of 36.9°C, dermal blood vessels contract, reducing blood flow to the skin limiting the effects of heat loss through the methods mentioned above. In addition to regulation of body temperature the skin also provides the following functions: • Combats infection (forms a barrier to invading micro-organisms).

• Protects against ultraviolet radiation.

• Protects against mechanical and chemical assaults.

• Contains sensory organs that assist with its regulatory function.

• Prevents excessive fluid and electrolyte loss.

• Is an important part of the body’s immune system

Pathophysiology of Burns Thermal Burns The extent of a burn injury relates to the amount of heat energy transferred to the patient’s skin. The amount of that heat energy in turn depends upon three components of the burning agent. To apply this to real world problems we’ll use water, which produces scald burns as an example: 1. Temperature (e.g. water > 60ºC (140ºF) will create a deep burn) 2. The concentration of heat energy it possesses (e.g. water has a high concentration of heat energy) 3. The length of its contact time with the patient’s skin. (e.g. Water at the temperature mentioned above will cause a deep burn in 4 seconds.

This table illustrates the relationship between temperature and time associated with burns Injury. The results are based on actual fact but are represented here as estimations.

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A burn is a progressive process, and the greater the Zone of hyperemia heat energy transmitted to the body, the deeper the Zone of coagulation wound. Initially, the burn damages the epidermis Zone of stasis by the increase in temperature. As contact with the substance continues, heat energy penetrates further and deeper into the body tissue. Thus, a burn may involve the epidermis, dermis and subcutaneous tissue as well as muscles, bones, and other internal tissue. The higher the temperature the less time required to produce a full thickness burn. For example, contact with a hot object of 60°C for approximately 10 seconds would result in a full thickness burn. We will revisit this principle later in the module during management of thermal burns.

With a burn, the skin nearest the heat source suffers the most profound changes. Cell membranes rupture and are destroyed, blood coagulates, and structural proteins begin to break down. This most damaged area is the zone of coagulation. Adjacent to this area is a less damaged, yet still inflamed region where blood flow decreases that is called the zone of stasis. More distant from the burn source is a broader area where inflammation and changes in blood flow are limited. This is the zone of hyperaemia; this zone accounts for the erythema associated with some burns.

The body’s response to burns occurs over time and can usefully be classified into four phases: 1. Emergency phase 2. Fluid Shift phase 3. Hypermetabolic phase 4. Resolution phase The first stage immediately following the burn is called the “Emergency Phase”. This is the body’s initial reaction to the burn. This phase includes a pain response as well as the outpouring of catecholamines in response to the pain, physical and emotional stress.

The Fluid Shift Phase follows the Emergency Phase and can last for up to 18-24 hours. The fluid shift phase begins shortly after the burn and reaches its peak in 6-8 hours. In this phase, damaged cells release agents that initiate an inflammatory response in the body. This increases blood flow to the capillaries surrounding the burn and increases the permeability of the capillaries to fluid. The response results in a large shift of fluid away from the intravascular space into the extravascular space resulting in massive oedema. It is important to note that the capillaries leak water, electrolytes and some dissolved protein, not blood.

The Hypermetabolic Phase follows the fluid shift phase, which may last for many days or weeks depending on the severity of the burns. This phase is characterised by a large increase in the body’s demand for nutrients as it begins the long process of repairing damaged tissue. This phase leads to the Resolution Phase, in which scar tissue is generated. The local and systemic complications associated with burns are extensive. As already mentioned, immediately after a burn injury, the body’s inflammatory response is triggered both at the injury site itself, and in areas of the body distant from the injury. The systemic response is not likely to be seen in the pre-hospital environment but a simple understanding will improve overall management.

Cardiovascular Response Immediately after the burn injury the changes that occur in the cardiovascular system are important and require immediate consideration. The cardiovascular changes include decreased blood flow to tissues and organs.

Hypovolaemia may develop following the increase in the capillary permeability and fluid and protein loss into the extravascular space with widespread oedema often noted. Within minutes of the burn injury, cardiac output falls (in proportion to the burn size) as a result of the significant decrease in blood volume.

Pulmonary Response Respiratory failure is one of the major causes of death after a burn injury. The damage to the lung tissue may be as a direct result of thermal injury and/or smoke inhalation. Respiratory complications from smoke inhalation vary based on amount of smoke, chemical involved, duration, available oxygen, health status etc.

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Renal Response Blood flow to the kidneys is reduced which is a result of the decreased cardiac output, systemic vasoconstriction and decreased blood volume (as a result of fluid shift). Elevated hormones that you would expect to see in “fight or flight” responses such as adrenaline, noradrenaline, angiotensin and vasopressin all contribute to renal complications. Renal complications are seen with extensive deep burns with large surface areas affected. Immune

Response The immune response in burn victims is reduced. The natural protective function of the skin is removed. The epidermis of the skin becomes damaged allowing invasion of bacteria and the coagulated skin and exudate that results from the burn are excellent environments for bacteria to grow. This may ultimately lead to septicaemia and septic shock.

Electrical Burns Electrical injuries occur when an electric current travels from the contact site into the body, arcing from one body point to the other.

As the current passes into the body, it is converted to heat. The heat, which causes extensive damage, most commonly follows the current flow, which is usually along blood vessels and nerves (the path of least resistance), and less commonly, may damage other structures, such as muscle and bone. Electrical current can cause the following three types of burns:

Electrical burn

• Contact Burn Injuries: this is a true electrical injury in which the current is most intense at the sites of entrance and exit and along the tissue it damages. At the entrance and exit sites, a “bull’s-eye lesion” may be present with a charred zone in the centre; a middle zone of grey dry tissue; and an outer red zone. The entrance and exit sites may not appear serious, but these wounds indicate there may be considerable damage along the path of the current.

Electrical currents may cause damage to other organs such as the heart and lens of the eye.

• Flash Burn (Electrical), this type of burn is an electro thermal injury and is caused by the arcing of the current.

• Flame Burn, which is the same as a thermal injury, except this type of burn occurs when electricity ignites a person’s clothing or surrounding material.

Chemical Burns Chemicals break down the biochemical makeup of cell membranes and destroy cells. A chemical burn must destroy the tissue before it can chemically burn any deeper. This fact generally limits the “burn” process unless very strong chemicals are involved. Agents that cause chemical burns are either strong acids or alkalis.

Both acids and alkalis burn by disrupting cell membranes and damaging tissue on contact. As they cause damage, acids usually form a thick, insoluble mass at the point of contact. This process is called coagulation necrosis and helps limit the depth of acid burns. Alkalis, however, do not form a protective mass. Instead the alkali continues to destroy cell membranes releasing the intercellular and interstitial fluid, destroying tissue in a process called liquefaction necrosis. This process allows the alkali to rapidly penetrate the underlying tissue, causing progressively deeper burns.

For this reason, alkali burns can be quite serious.

NB. You must never try to neutralise an acid with an alkali or vice-versa as a form of treatment for chemical burns

Inhalation Injury The burn environment frequently produces inhalation injury. This is especially true if the patient is in an enclosed space or unconscious. A patient who is unconscious or trapped in a smoke filled area eventually inhales gases, heated air, flames or steam. The inhalation results in airway and respiratory injury.

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Airway Thermal Burns Another, although less frequent injury, is the airway thermal burn. Very moist mucosa lines the airway and helps insulate it against heat damage.

Because of this mucosa, upper airway structures may absorb the heat and prevent lower airway burns. High levels of thermal energy are required to evaporate the fluid and injure the cells. Inspiration of hotgases or flame rarely produces enough heat to cause significant thermal burns to the lower airway (that is not to say that a high index of suspicion should not be maintained).

Depth Classification of Burns Superficial Superficial (or First degree burns in USA) involve only the outer layers of the epidermis. The skin is usually red or pink (due to increased blood flow to the area), dry and painful with no blister formation. Mild sunburn is an example. The skin maintains its ability to function as a vapour and bacterial barrier and usually heals in 3-10 days. Superficial burns usually require only palliative treatment such as pain relief measures and adequate fluid intake. These burns are rarely important, unless they cover a large area of the body. Extensive first degree burns to infants or elderly patients may require additional care.

Partial Thickness Burns Partial thickness (2nd degree in USA) burns by definition but can be further classified into superficial and deep. In superficial injuries all of the epidermis is destroyed as well as varying superficial portions of the dermis. The injury presents as moist, red, blistered and painful due to surviving nerve endings. The skin is sensitive to temperature changes, air exposure, and touch. The blisters prevent the loss of body water and superficial dermal cells. Blisters serve as good “bandages” and promote healing. These burns usually heal within 1-2 weeks.

Partial thickness deep burns on the other hand, involve the entire epidermis and dermis. Structures that originate in the subcutaneous layer, such as hair follicles and sweat glands remain intact. These burns can be very painful because the pain sensors remain intact. Tactile sensors may be absent or greatly diminished in the areas of deepest destruction. These burns appear as mottled pink, red or waxy white areas with blisters and oedema. The blisters resemble flat dry tissue paper rather than the bulbous blisters seen with Partial superficial burns.

Full Thickness Deep Burns Full thickness deep burns (3rd Degree in USA) extend into the subcutaneous tissue and may involve muscle and bone. Full thickness burns vary in colour from waxy white or yellow to tan, brown, deep red and black.

These burns are hard, dry and leathery. Oedema is extensive in the burn area and surrounding tissues. There is no pain because the nerve sensors have been destroyed. However, there is no such thing as a “pure” third degree burn. Third degree burns are almost always surrounded by second degree burns, with superficial burns at the out most edges of the burn site.%

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20-35% of patie n admitt ed to b ts urn centres an 60-70% d some patient of burn s have an who die associa te inhalat ion inju d ry

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Methods for Determining Body Surface Area Burned “Rule of Nines” The “rule of nines” identifies topographical body regions, each of which approximates a percentage of the patients’ body surface area (BSA).

Because infant and child anatomy differs significantly from that of adults, a modification of the rule of nines is made to maintain an accurate approximation of BSA. The rule of nines is at best an approximation of the area burned. It is, however, a useful tool to help measure the burn’s extent.

“Rule of Palms” The “rule of palms”, an alternative system for approximately the extent of a burn, uses the palmar surface as a point of comparison in gauging the size of the affected body area. The patient’s palm (the hand less the fingers) represents about 1% of the BSA, whether the palm is adult, a child, or an infant.

Assessment of Thermal Burns Skin evaluation tells more about the body’s condition than any other aspect of patient assessment. Not only is the skin the first body organ to experience the effects of burns, it is often the only organ to display them. Therefore, assessment of the skin and the associated burns must be deliberate, careful and complete.

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Initial Assessment Burn victims require special attention of their airway. Look for signs of thermal or inhalation injury by carefully searching for clues / clinical indications of inhalation injury such as: • Singed facial and nasal hairs • Facial burns • Carbonaceous sputum • History of altered Level of Consciousness and/or confinement in a burning environment • Any airway sounds, such as stridor, hoarseness, or coughing, that indicate irritation or inflammation of the mucosa The presence of any of these findings suggests acute inhalation injury. Such injury requires rapid transport followed by immediate and definitive care. Be prepared to insert a surgical airway.

Treatment/Stop the Burning Process All clothing should be removed to stop the burning process, keeping in mind that this step is often difficult and poses a risk whilst removing the articles. Synthetic fabrics ignite, burn rapidly at high temperatures, and melt into hot residue that continues to burn the patient. Thermal burns should be cooled for at least 10 minutes under running water.

Specific products are available (such as ReliBurn) and may be used in the absence of water. Such products come either as gels or as dressing smothered in the gel. Burn Gels absorb and dissipate heat and provide a protective barrier that prevents burns progressing to healthy tissue. They can be found in many work environments and first aid kits but are only a substitute for when cool, clean running water cannot be administered immediately.

NB - Do not apply any creams or lotions unless they are for the sole purpose of burns treatment.

Chemical Burns Any clothing with chemical involvement should be removed carefully. Chemicals in the form of a dry powder should be brushed off, in such as a way so as to not contaminate any other part of the casualty or the responder. Chemical burns should be irrigated for at least 20 minutes with copious amounts of water. This is to wash away any of the remaining chemical as well as cooling the skin. Remember to avoid excessive cooling.

NB – Some chemicals can react violently with water. It is always advised that you should check the chemical’s MSDS (Material Safety Data Sheet) which will guide treatment. For those working in the Oil and Gas industry, it is advisable that you make yourself familiar with the MSDS for all chemicals used or stored at your location.

An assessment of the area of the burn and its depth should be made. This approximation guides your care and helps definitive care facilities prepare effectively. Once you have determined the depth, extent and other factors that contribute to burn severity, categorise the patient as having minor, moderate or critical burns.

Burn Severity: Minor • Superficial: BSA < 50% • Partial Thickness: < 15% • Full Thickness: < 2% Burn Severity: Moderate • Superficial: BSA > 50% • Partial Thickness: BSA < 30% • Full Thickness: BSA < 10% Burn Severity: Critical • Partial Thickness: BSA > 30% • Full Thickness: BSA > 10% • Any partial or full thickness burns involving the feet, hands, joints, face or genitalia

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Ongoing Assessment Conduct ongoing assessment for all burn patients every 15 minutes for minor burns and every 5 minutes for moderate or critical burns. Although the burn injury mechanism has been halted, the nature of the burn will continue to affect the patient. In addition to monitoring vital signs, watch for early signs of hypovolaemia and airway problems. Also, monitor distal circulation and sensation with any circumferential burn.

Fluid Replacement Regimes Due to excessive capillary permeability, there is loss of protein-rich fluid from the burn surface, as well as significant interstitial oedema in the area. In full-thickness burns there is direct destruction of blood within burnt vessels.

Replacement of fluid loss as early as possible is one of the most important aspects of treatment to prevent the development of hypovolaemic shock.

If the patient has a total burn surface area of less than 15% then they do not require intravascular fluids through either the IV or IO route. If the patient has a total burn surface area of greater than 15% then they should be given 1litre 0.9% NaCl IV or IO.

Analgesia Consideration must be given to providing pain relief to the victims of even relatively minor burns. Note that simply cooling the burn provides a good degree of pain relief. See the chapter on Analgesia that discusses this in greater detail.

Antibiotics Burnt casualties essentially have a large wound that is open to infection. In the remote area, prophylactic antibiotic cover will be required. See the chapter on Antibiotics for antibiotic types and regimes.

Phosphorus Burns Phosphorus combusts spontaneously on contact with air and consequently contamination of clothing or skin with particles of phosphorus produces deep burns.

Immediate treatment is as follows: • Douse the lames and keep covered with water or some other solution such as saline.

• If possible remove with forceps any large fragments of visible phosphorus that are not adherent.

• Apply moist dressings and keep them wet.

• Continue with standard burn therapy.

• Avoid contaminating yourself with particles of phosphorus.

At a definitive care facility, phosphorus burns may be treated as follows, usually under general anaesthetic: • Irrigate the wound with 1% copper sulphate solution. This combines with the phosphorus to neutralise it and turns the fragments black allowing easy identification for removal.

• You must then lush the copper sulphate from the wound with saline.

Copper sulphate is highly toxic if absorbed and must never be left on a wound as a dressing.

Conclusion Burn care has made many advances over recent years and continues to improve. With advances in pre-hospital care, medics are able to manage the first few minutes of a burn victim effectively to promote improved prognosis, reduce complications and facilitate recovery. It is for this reason that frequent review in principles of burn care is essential.

When caring for a burn victim, prioritisation skills, recognition of the severity, and a thorough understanding for the potential for complications all work together to ensure the best outcome for the patient.

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CHAPTER 7: Abdominal & Pelvic Trauma Introduction Unrecognised abdominal injuryâ&#x20AC;&#x2122;s cause preventable deaths. A casualty that has sustained an abdominal injury will ultimately require a surgical opinion and possibly surgical intervention. After the mechanism of injury has been examined, a high index for suspicion must be maintained as abdominal injury can go unrecognised for a long period of time. Any haemorrhaging that takes place with in the abdominal cavity can remain undetected for a long period of time. The haemorrhaging is non-compressible, which makes management of essentially a circulation problem much more difficult.

Pelvic fractures are devastating injuries that are associated with a number of complications that often require extensive rehabilitation. Pelvic fractures represent about 0.3% to 6% of all fractures and occur in 20% of all polytrauma cases.

Anatomy and Physiology The abdomen is split into nine regions. Using these regions, we can accurately start to build up a picture of the particular organs that may have been affected.

There are several organs that make up the abdomen. The anatomy and physiology of the major organs will be discussed below.

Diaphragm The diaphragm is a smooth muscle that acts as the upper border of the abdomen. It is the primary muscle of inspiration creating negative pressure within the pleural cavity, thereby causing the lungs to expand and air to be drawn in. The size of the abdominal cavity therefore changes with the pattern of breathing. During inhalation the diaphragm falls and rises during expiration. This means that the upper level of the abdomen can at certain times, be almost as high as the nipple line.

The Liver It is one the major bodily organs in the body, and has many important functions, the most important of which include red blood cell breakdown, bile production and heat production. It has four main lobes; left, right, quadrate and caudate. This large dense vascular organ is held in place by a large ligament â&#x20AC;&#x201C; the ligamentum teres (the white vertical line that can be seen on the diagram to the right. It is located in the right hypochondrial region of the abdomen lying between ribs 7 - 11.

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The Gall Bladder This is associated with the liver at a point level with the ninth costal cartilage on the right hand side. Its function is to produce bile, a mixture of predominantly water and bile salts, together with the bile pigments. Its secretion is into the common bile duct via the cystic duct before entering the second part of the duodenum along with the pancreatic secretions.

The Spleen This is the largest lymphatic organ in the body and is located in the upper left quadrant of the abdomen. It has a characteristic notched anterior border, and is supplied by the splenic arteries. It bares considerable similarity in size to a clenched fist.

The Kidneys These are the organs concerned with nitrogenous excretion, filtering the blood of nearly all its contents and regulating the osmolarity of the blood. There are two of them and they are found on the posterior abdominal wall between the levels of T12 and L3, however the left lies slightly higher than the right because of the presence of the large size of the right-hand lobe of the liver.

Adrenal Glands These are paired organs that sit on the superior surface of the kidneys and secrete important hormones.

The Pancreas This single organ has both endocrine and exocrine function, secreting insulin, glucagon and bicarbonates, lipase and enterokinase respectively. Its head lies adjacent to the inner curvature of the duodenum, whilst its tail is related to the spleen.

The Gut The gut starts at the oropharynx and then at the level of C6 becomes the oesophagus. The oesophagus meets the stomach at the cardiac sphincter. Food, once it enters the stomach, remains there for a few hours where the gastric secretions of low pH hydrochloric acid and gastric peristaltic movements, achieve sufficient food breakdown such that the pyloric sphincter will relax and allow the chyme to pass through into the duodenum. The blood supply to the foregut comes from the caeliac trunk which is a major branch of the abdominal aorta at T12, immediately below the diaphragm.

The blood supply to the small intestine comes from the superior mesenteric artery. Which is a branch of the abdominal aorta at L1. The duodenum is a C-shaped tube approximately 30cm long found close to the midline of the abdomen between L1 and L3/L4 curving around the right hand lateral border of the pancreas. The Jejunum is thicker and more vascular, although slightly shorter at around 20cm and lies in the umbilical region. The suprapubic region houses the predominance of the ileum which twists and turns as it reaches its end at the ilieocaecal junction nearly 6.5m later, all of which is held by the mesentery which provides its vascular, nervous and lymphatic communication.

The majority of the assimilation of nutrients from the digested food occurs in the small intestine, whereas the large intestine is predominantly concerned with the absorption of water and ultimately faecal production.

The descending colon passes down the left side of the abdomen and eventually reaches the characteristic s- shaped flexion from which it receives its name, sigmoid colon. This is a section that varies considerably between individuals in length, whereas the rectum that follows is usually near 15cm in length and terminates in the anus. The rectum is the area that faeces are stored ready for eventual release.

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The Posterior Abdomen and the Major Vessels The posterior of the abdomen primarily consists of the major abdominal vessels, kidneys and adrenal glands which all lie against the posterior of the abdominal cavity.

The major blood vessels of the abdomen

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The Pelvis Three major bones compose the pelvis: ilium, ischium, and pubis. The ilium is situated superiorly. The uppermost portion forms the iliac crest. The right and left ilium forms the pelvic girdle. The ischium lies inferiorly and posteriorly. Eventually, the three bones fuse into one at the acetabulum, which forms a socket of the head of the femur. Anterior fusion of the right and left pubi form the symphysis pubis.

The pelvis houses several large vascular structures. The common iliac artery branches of the abdominal aorta.

The internal iliac artery branches of the common iliac and supplies most of the blood supply to the pelvic wall and viscera via several tributaries. The external iliac artery traverses the brim of the lesser pelvis then becomes the femoral artery as the vessel passes through the leg. The lumbar and sacral arteries, which divide of the aorta, also lie in the pelvic cavity. The veins in the pelvis, for the most part, correspond to the arteries.

Other vital structures within the pelvis include the reproductive organs, sigmoid colon and rectum, bladder, ureters, and urethra. Important nervous system structures that traverse the pelvis include the sacral plexus, which is composed of the 4th and 5th lumbar nerves and sacral nerves 1,2 and 3. Also, the femoral, sciatic, and obturator nerves pass through the pelvis.

Mechanism of Injury Blunt abdominal trauma can be classified into two main groups: â&#x20AC;˘ Compression forces â&#x20AC;˘ Deceleration forces Compression or concussive forces may result from direct blows or external compression against a fixed object (e.g., lap belt, spinal column). Most commonly, these crushing forces cause tears and haematomas to the solid viscera.

These forces also may deform hollow organs and transiently increase pressure inside the hollow organs, resulting in rupture. This transient pressure increase is a common mechanism of blunt trauma to the small bowel.

Deceleration forces cause stretching and linear shearing between relatively fixed and free objects. These longitudinal shearing forces tend to rupture supporting structures at the junction between free and fixed segments. Classic deceleration injuries include hepatic tear along the ligamentum teres and injuries to the renal arteries.

The liver and spleen seem the most frequently injured organs. Small and large intestines are the next most injured organs, respectively. Recent studies show an increased number of hepatic injuries.

Penetrating Trauma Penetrating injuries to the abdomen are caused by a wide variety of instruments. Each class of instrument is associated with a different injury pattern. The most commonly injured organs associated with penetrating injuries (PIâ&#x20AC;&#x2122;s) are the small intestine (29%), liver (28%), and colon (23%).

Tissue is lacerated by the passage of the wounding implement.

If the structure is a vein, surrounding tissue may tamponade bleeding. Partially transected arterial walls probably will continue to bleed as the elastic tissue of the media contracts and further widens the wound. Completely divided arteries may contract enough to arrest haemorrhage.

Eviscerated liver

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Intraperitoneal blood can induce severe local irritation and pain, which usually is accompanied tachycardia.

Intraperitoneal blood also can induce a seemingly paradoxical vagal response and an associated bradycardia by unclear mechanisms when the blood loss is small. A large volume haemorrhage may present with bradycardia as a pre-terminal event.

Lacerated hollow or solid organs result in haemorrhage and leakage of contained fluids into the peritoneal and/or retroperitoneal space. Irritated nerve endings at the skin and fascial levels result in local wound pain.

Peritoneal signs develop when the peritoneal and the posterior aspect of the anterior abdominal wall are both inflamed. Impaling objects may tamponade otherwise uncontrolled haemorrhage if the object resides within or crosses a major vessel or solid organ such as the portal vein or liver. Therefore, penetrative objects should not be removed in the field.

Gunshot wounds have a much broader injury pattern due to several mechanisms. First, any structure directly in the path of the missile suffers a loss of integrity. Approximately 85% of abdominal wall GSW’s penetrate the abdominal cavity, and 95% require a surgical procedure for correction. Remember that peritoneal injury can result from penetrating wounds to the low chest and back.

Fractured Pelvis High-velocity trauma accounts for most pelvic fractures, including motor vehicle accidents, motor vehicle-pedestrian accidents, crush injuries, and falls. Rapid assessment and diagnosis, along with rehabilitation that begins as soon as the individual stabilises, are vital to good outcomes.

Assessment A full abdominal assessment is carried out as part of the “blood on the floor and four more” check during the circulation phase of the primary survey. Usual diagnostic methods include CT scanning, ultrasound and diagnostic peritoneal lavage. These methods are not available to the medic in the field; therefore clinical examination must be thorough. Any medic that is assessing a casualty with a potential blunt abdominal injury must be aware that many victims present with a benign abdomen upon initial presentation. Many injuries initially are hidden and manifest over time. Frequent examinations are essential in any patient with significant mechanism of injury. Early signs of shock may be present, tachycardia, tachypnoea, delayed capillary refill time, weak pulse, cold clammy skin, etc. These signs should raise the index of suspicion for abdominal injury in the absence of other injuries.

Inspection Examine the abdomen to determine the presence of external signs of injury. External inspection for injuries with respect to anatomic landmarks aids identification of violated body cavities. Note patterns of abrasion and/or bruised areas. Note injury patterns that predict the potential for intra-abdominal trauma (e.g. lap belt abrasions, steering wheel-shaped contusions). In most studies, lap belt marks have been correlated with rupture of the small intestine and an increased incidence of other intra-abdominal injuries.

The Cullen sign (i.e. periumbilical bruising) may indicate retroperitoneal haemorrhage; however, this symptom usually takes several hours to develop and is seldom seen. Flank bruising and swelling may raise suspicion for a retroperitoneal injury. Inspect genitals and perineum for soft tissue injuries, bleeding, and haematoma.

Palpation Carefully palpate the entire abdomen while assessing the patient’s response. Note abnormal masses, tenderness, and rigidity.

Rigidity or hardness to the abdomen, may indicate intra-abdominal haemorrhage. Crepitus or instability of the lower thoracic cage indicates the potential for splenic or hepatic injuries associated with lower rib injuries.

Signs of peritonitis (e.g., involuntary guarding, rigidity) soon after an injury suggest leakage of intestinal content.

Peritonitis due to intra-abdominal haemorrhage may take several hours to develop.

Abdominal distension may result from gastric dilation secondary to assisted ventilation or swallowing of air. Distension secondary to haemorrhage is a very late sign and is never present without signs and symptoms of shock.

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Examination of the Pelvis The pelvis should be assessed for bruising, bleeding, deformity or swelling. The patient may also complain of severe pain at the back of their pelvis or report that they feel as though their pelvis is “lying open”. It is no longer recommended to spring the pelvis to assess for injury. There is concern that compressing the pelvis in this way may result in further haemorrhage. If no obvious injury is found to the pelvis BUT the mechanism of injury is suggestive of a pelvic fracture AND the patient has no radial pulse, then the patient should be managed as though they have a pelvic fracture.

Specific Injury Patterns Evisceration is a clear indication for operation. Eviscerated organs usually are covered with a saline-moistened gauze and another sterile dressing, which is secured with tape to prevent further evisceration en route to definitive care. On rare occasions, the omentum may be replaced in the abdomen to prevent desiccation, this clearly is an exception to standard practice.

Treatment Penetrating injuries • Do not remove object • Secure/splint object • Think - Tamponade effect • Transfer to surgical facility ASAP • Cannulate en-route • Think: protective hypotension Evisceration • Do not panic • Leave bowel in the position you ind it • Cover with • Clean (sterile) water proof dressing • Sterile saline soaked dressing [keep wet!]

• Bring patient’s knees up if possible • Transport ASAP. Ruptured diaphragm This is difficult to recognise, aspects leading to diagnosis include: • Reading the wreckage • Unexplained shortness of breath • Patient becomes worse on lying down/head down!

• Think of it!

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Fractured Pelvis Kills casualties due to loss of circulatory body fluid!

• Do not spring pelvis, this increases bleeding • Apply a figure of eight bandage around the feet and tie a bandage around the knees to stabilise the legs before application of the pelvic splint Apply a pelvic splint during Circulation phase of the primary survey. This is a treatment device and not a packaging device. Ensure that the splint is applied over the greater trochanters of the femur and not the iliac crests of the pelvis.

Ideally the pelvic splint will be applied directly to the skin but if this is not possible with only limited movement of the patient then it should still be applied over the clothes. Placing the splint next to the skin allows accurate placement and will prevent the splint being removed at hospital when clothing is removed to allow thorough examination.

• Administer vascular luids in 250ml boluses to maintain a radial pulse if necessary • DO NOT log roll the patient unless assessment of the back is absolutely necessary or the airway is in jeopardy • Administer TXA as per protocol in the medicines section at the back of this manual

Intraabdominal haemorrhage • Administer TXA as per protocol in the medicines section at the back of this manual • Administer vascular luids in 250ml boluses to maintain a radial pulse if necessary

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CHAPTER 8: Head Injuries Introduction The brain can be described as a blancmange inside a rigid box. Head injury is the largest killer in adult men under 35 years with intoxication with alcohol or drugs often involved. The mechanism of injury must be examined carefully as head injuries are also involved with other injury patterns. Cervical spine injuries are a commonly associated injury, especially in blunt trauma to the head.

Anatomy & Physiology The Brain Three main parts make up the brain.

• The left and right cerebral hemispheres, which contain different lobes, where the higher motor and sensory functions are controlled.

• The cerebellum is a control centre that is also responsible for balance and coordination.

• The brain stem has the midbrain, pons and medulla as its components. The medulla becomes a part of the spinal cord. The vital functions of cardiac and respiratory control are contained in the lower brain stem.

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The brain has a very good blood supply and nerve cells do not tolerate a lack of oxygen well. Once nerve cells begin to die, they do not regenerate like other cells within the body.

The Meninges These are the linings of the brain. Similar to the pleura around the lungs and the pericardium around the heart, three protective coverings surround the brain, the dura mater, arachnoid mater and the pia mater. The dura mater is a thick fibrous layer of tissue that lines the inside of the skull. Underneath this lies the arachnoid mater and covering the brain is a thin ilm known as the pia mater.

In between the pia mater and the arachnoid mater is a space that is filled with cerebrospinal fluid (CSF). This fluid is straw like in colour and acts as a shock absorber.

The Skull The rigid box. The skull is responsible for protection.

There are many bones that make up the skull (Figure 8-2).

Physiology The brain is sensitive to oxygen and glucose. It has no way of storing either of these. If the blood supply to the brain is interrupted, consciousness can be lost after 15-20 seconds and death starts to occur after 3-4 minutes.

Increased pressure inside the brain is also not well tolerated.

Mechanism of Injury Two types of injury can occur, a primary and a secondary injury. The primary injury involves the initial insult, whether blunt or penetrating and cannot be influenced by the medic in the field. However, the secondary injury can be prevented or reduced by good pre-hospital management.

Primary brain injury • Damage caused at time of impact • Can be focal or diffuse • Diffuse axonal injury is due to deceleration and shearing forces • Dependent on extent of initial injury Secondary brain injury Insult imposed after initial injury due to • Hypoxia • Hypercapnia • Systemic hypotension • Intracranial haematoma • Intracranial hypertension

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Damage may result from skull penetration or from rapid brain acceleration or deceleration, which injures tissue at the point of impact , at its opposite side of the skull, or diffusely within the frontal and temporal lobes. Nerve tissue, blood vessels, and meninges can be sheared, torn, or ruptured, resulting in neural disruption, intracerebral or extradural haemorrhage, and cerebral oedema.

Haemorrhage and oedema can cause focal neurological deficits or increased intracranial swelling and pressure, which can lead to fatal herniation of brain tissue through the foramen magnum.

Susceptibility to shearing forces plays a role primarily in injuries that involve rapid and forceful movements of the head, such as in motor vehicle accidents. In these situations rotational forces might occur, whiplash-type injuries are particularly important.

Collectively these injuries can result in swelling of the brain. If the pressure within the skull is not relieved through surgery, cooling or medication, the brain will gradually be pushed down through the opening at the base of the skull, the foramen magnum. The brain stem controlling breathing and cardiac function will eventually be compressed resulting in death.

Skull fractures may lacerate meningeal arteries or large venous sinuses, producing an extradural or subdural haematoma. Fractures, especially at the skull base, can also lacerate the meninges, causing CSF to leak through the nose or ear or bacteria or air to enter the cranial vault.

Assessment The assessment of the head injured patient must take a structured approach that is easily repeated at all levels of the evacuation chain. The purpose of this is to ensure that the casualty can constantly be monitored to the same standard therefore giving a more accurate result in regards to whether the casualty is deteriorating or improving over time. The speed and degree of any deterioration gives the neurological team vital clues as to the seriousness of the head injury and the best course of action to take.

History After the primary survey has been carried out and any life threatening conditions identified and managed, an assessment of the head injured patient can take place. The standard items of information that is required: • Mechanism of injury • Has the casualty lost consciousness at any point (when and how long for) • Has the casualty vomited (may indicate serious injury in adults) • Is there any headache, drowsiness, dizziness, double vision, nausea, weakness, pain elsewhere in the body, numbness or a sensation of pins and needles • Has the casualty taken any drugs or alcohol (can provide misleading results whilst carrying out an examination) • Underlying illnesses (could the underlying illness be the cause of the injury?)

• SAMPLE history The level of consciousness is the single most important assessment point for the head injured casualty. There are two common methods of measuring the levels of consciousness, AVPU and the Glasgow Coma Score (GCS). The AVPU score is quick and easy to use during the primary survey. The GCS is a more complex and sensitive assessment which can be used during the secondary survey and is described in the “Prolonged Field Care” chapter.

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AVPU This method is a very short and simple measuring tool when assessing the level of consciousness. It is appropriate for any type of casualty and not just the head injured. The acronym stands for: • A – Alert. The casualty that has his eye’s open and is talking coherently without prompt is a casualty of little concern. They must still be watched for deterioration.

• V – Voice [responds to]. A casualty that must be told to ‘open your eyes’ or ‘can you squeeze my fingers’ is of a slight concern. However, this response can be slightly misleading, as some casualties that are fully conscious and aware of their surroundings will want to close their eyes and lie still without talking.

• P – Painful stimuli [responds to]. A casualty that is responding only to painful stimuli is of concern. This is a good indicator that the brain has started to close down and that only the most basic of reflexes are remaining.

• U – Unresponsive. The casualty that will not respond to any external stimulus is of great concern. Due to the extent of their injuries the brain has shut down. This can only be a temporary loss or for an extended period time. In general terms, the longer the unconsciousness the more serious the casualty.

Other Examinations Assessment of the vital signs will give valuable information on the state of the casualty’s underlying medical condition. Early and repeated examinations will aid in giving the best clues as to the longer-term care that the casualty may require.

• Pulse – Asses rate, strength and rhythm. A rapid weak pulse will suggest that there is some sort of hypovolaemia. In the head injured patient the pulse is usually normal or slow. The pulse will also slow in a response to rising intracranial pressure. This is a response called Cushing’s syndrome.

• Respirations – Assess rate and quality. Head injuries produce several different types of abnormal respirations. Initially, with the rise of intracranial pressure, the breathing rate will slow. As the brain injury develops, the respiratory centre within the brain starts to become crushed, this will then produce tachypnoea.

• Blood Pressure – In general the blood pressure will rise as the intracranial pressure rises (particularly the systolic blood pressure).

If a low BP is found this is generally an indicator that there is hypovolaemia from another injury.

Mastoid bruising or Battles Sign

Physical Assessment The head must be fully examined to give vital clues as to the cause of the injury. The injuries that must be identified are; • Scalp lacerations • Signs of skull fracture - Depression of the skull - Battles Sign (bruising seen over the mastoid processes behind the ears) - Bilateral bruising around the eyes (Raccoon eyes) - Blood or clear straw like fluid (cerebrospinal fluid – CSF) leaking from the nose or ear • Instability of the facial bones

Bilateral bruising around the eyes or Raccoon Eyes

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• Pupils - P.E.A.R.L. Are the Pupils Equal And Reacting to Light? If there is a bleed inside the brain, a haematoma may develop. As the optic nerve is compressed the reaction of the pupil is affected. The pupil will become dilated and not constrict when a light is shone into the eye or the reaction may be slower than the other pupil.

This gives a good indicator of raised intracranial pressure (ICP). This can take some time to develop.

• Facial lacerations or bruising • Mouth – Bleeding inside the mouth or broken teeth

CSF leaking from the Ear

Injury Types Closed Head Injuries This broad term describes any injury to the brain or structures within the skull that are not caused by a penetrating injury (such as a gunshot wound or stab wound). They range from very minor to potentially fatal injuries.

Skull Fracture A skull fracture is a break in the bone surrounding the brain and other structures within the skull.

Linear Skull Fracture A common injury, especially in children. A linear skull fractures is a simple break in the skull that follows a relatively straight line. It can occur after seemingly minor head injuries (falls, blows such as being struck by a rock, stick, or other object; or from motor vehicle accidents). A linear skull fracture is not a serious injury unless there is an additional injury to the brain itself.

A linear skull fracture that has been repaired

Depressed Skull Fractures These are common after forceful impact by blunt objects— most commonly, hammers, rocks, or other heavy but fairly small objects. These injuries cause “dents” in the skull bone. If the depth of a depressed fracture is at least equal to the thickness of the surrounding skull bone (about 1/4-1/2 inch), surgery is often required to elevate the bony pieces and to inspect the brain for evidence of injury. Minimally depressed fractures are less than the thickness of the bone.

Base of Skull Fracture This is a fracture of the bones that form the base (floor) of the skull as a result of severe blunt head trauma of significant force. A basal skull fracture commonly connects to the sinus cavities. This connection may allow fluid or air entry into the inside of the skull and may cause infection. Surgery is usually not necessary unless other injuries are also involved.

A depressed skull fracture

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Subdural Haematoma Bleeding between the brain tissue and the dura mater is called a subdural haematoma. The stretching and tearing of “bridging veins” between the brain and dura mater causes this type of bleeding. A subdural haematoma may be acute, developing suddenly after the injury, or chronic, slowly accumulating after injury. They are potentially serious and often require surgery.

Extradural Haematoma Bleeding between the dura mater and the skull bone is an extradural haematoma. These occur when arteries are cut. Injury in the temple area is a common cause. Extradural haematoma is potentially serious and often requires surgery.

Subdural Haematoma

Intraparenchymal Haemorrhage/Cerebral Contusion These terms describe bleeding into the brain tissue itself. A contusion is like a bruise to the brain tissue and usually requires no special intervention, much like a concussion. Most doctors admit people with cerebral contusion into the hospital for observation for rare complications such as brain swelling. An intraparenchymal haemorrhage is a pool of blood within the brain tissue. Minor bleeding may stop without any treatment and cause no serious problems. More serious or large bleeds usually require surgery.

Extradural Haematoma

Intraparenchymal Haemorrhage/Cerebral Contusion These terms describe bleeding into the brain tissue itself. A contusion is like a bruise to the brain tissue and usually requires no special intervention, much like a concussion. Most doctors admit people with cerebral contusion into the hospital for observation for rare complications such as brain swelling.

An intraparenchymal haemorrhage is a pool of blood within the brain tissue. Minor bleeding may stop without any treatment and cause no serious problems. More serious or large bleeds usually require surgery.

Signs & Symptoms Loss of consciousness or coma and post traumatic amnesia, are the two most common symptoms used to identify the severity of head injury. A mild head injury is one in which the period of unconsciousness is less than twenty minutes and post traumatic amnesia lasts for less than one hour, while a head injury in which the person is unconscious for at least one day and experiences post traumatic amnesia for more than twenty four hours is considered severe.

Concussion describes an injury to the brain following trauma. The term concussion is used to describe an injury to the brain that results from an impact to the head. By definition, a concussion is not a life-threatening injury, but it can cause both short-term and long-term problems. In medical terms, a concussion might be described as a closed head injury or head trauma.

A severe concussion may involve prolonged loss of consciousness with a delayed return to normal. A concussion can be caused by any significant blunt force trauma to the head such as a fall, a car accident or being struck over the head with an object. The symptoms include: • Loss of consciousness • Confusion • Headache • Nausea or vomiting • Blurred vision • Loss of short-term memory (may not remember the actual injury and some time before and after the impact) • Perseverating (repeating the same thing over and over, despite being told the answer each time, for example, “Was I in an accident?”)

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Intracranial Haemorrhage Increased intracranial pressure is likely to be as a result of a bleed in the brain. This is a very serious condition that needs to be managed in hospital by a specialist team. The symptoms that can be seen are: • Loss of consciousness • Lucid interval – The casualty may wake up after the injury and then loose consciousness again • Pupil dilation on the side of the injury • Weakness on one or both sides of the body • Slurred speech • Vomiting • Rising blood pressure with a slowing pulse • Abnormal respirations

Management The main priorities for the remote area medic are always the ABC’s. This is especially true when managing the head injured casualty. There is very little that can be done about the primary injury, however the secondary injury can be influenced by good assessment and management of the ABC’s in the field.

High low oxygen (if available) is probably the most useful treatment. Any build up of carbon dioxide (CO2) must be eliminated as early as possible, as CO2 can worsen brain oedema. So assisting the patients ventilations with a bag valve mask if their breathing rate falls outside the goal posts of life or if their breathing depth is too shallow is vital. To deliver oxygen to the brain depends on: • The amount of oxygen in the blood (that can be improved by administering high low O2 with a non-rebreathing mask.

• The cerebral perfusion pressure (CPP). This is the Mean Arterial Pressure (MAP) minus the Intracranial Pressure (ICP).

CPP = MAP - ICP

It must be recognised that hypotension is not caused by an isolated closed head injury and so if a head injured casualty is found to be hypotensive, this is usually caused by another injury, usually hypovolaemia. External haemorrhage must be controlled. If there is a severe haemorrhage and hypotension, IV cannulation and fluid replacement should be done enroute to definitive care.

Do not allow the casualty to become overheated. Casualty’s that have a significant head injury tend to have some degree of hyperpyrexia, which may in turn worsen the injury.

All wounds on the head should be covered. If CSF is leaking from the nose or ear it should not be ‘bunged’ up. A gauze pad should be placed over the top.

Constant monitoring of the pulse, respiratory rate, pupil response (PEARL) and the level of consciousness (AVPU or GCS) to provide the ‘trend over time’ are of vital importance. Meticulous record keeping is a useful tool when handing the casualty to further medical care. Due to the mechanism of injury, cervical spine control must be considered. Illfitting collars may make the airway difficult to control and a collar that is itted too tightly may raise ICP.

Summary The casualty that has sustained a significant head injury is at risk of not only immediate death from the complications that are involved with unconsciousness, but also from longterm disability. The rapid identification and appropriate management of a head injury can prevent both of these. Re-assessment of the level of consciousness gives the definitive care team the greatest clue as to the state of the casualty.

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CHAPTER 9: Spinal Injuries Introduction In the UK there are approximately 500 new injuries every year of a spinal nature. There is an increase in the number of incidents in the under 30â&#x20AC;&#x2122;s this is probably due to the increasing number of adventurous sports people are undertaking.

As the world becomes a smaller place with the advent of globalisation more and more sports/adventure holidays are identified and the risk is increased. Although relatively rare,spinal injury is devastating to the patient his/her family and society as a whole. Spinal care is extremely expensive not only in financial cost but in carer time and effort. â&#x20AC;&#x153;However techniques for immobilization and extrication of the patient with a real or potential spine injury have been implemented for decades. These techniques use practical but not systematic approaches driven by a well-intentioned aversion to inflicting further serious injury. Furthermore, there is little evidence to support the effectiveness or necessity of these techniques. Prehospital care of the spine may represent one of the more illustrative examples of clinical medicine being driven more by medicolegal implications than sound clinical or scientific evidence. Although the high cost (in terms of both dollars and resources) of defensive medicine in this regard may or may not be justified in the civilized environment, in the austere (dangerous or compromised) environment any decision to immobilize a spine is directly associated with the potential for further injury to the patient as well as rescuers.â&#x20AC;? (Wilderness Medical Society, 2013) Recent evidence has shown that by immobilising patients on a long backboard/spine board the patient may suffer restricted ventilation, increased intracranial pressure, increased risk of aspiration of vomit and can result in pressure sores developing if the patient is immobilised for a prolonged period. As such, focus is shifting away from the use of spinal boards for transport with the gold standard now being a vacuum mattress but a scoop stretcher with head blocks is an acceptable alternative.

Anatomy The spinal column (or vertebral column) extends from the skull to the pelvis and is made up of 33 individual bones termed vertebrae. The vertebrae are stacked on top of each other group into four regions:

Term

No of Vertebrae Body Area

Cervical

7

Neck

Thoracic

12

Chest

Lumbar

5

Lower back

Sacrum

5 (fused)

Pelvis

Coccyx

4

Tailbone

The spine is made up of vertebrae, which articulate with each other. A typical vertebra has a body, two pedicles and two laminae joining over the spinal canal.

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Consider spinal injury with a mechanism of injury associated with: • Blunt trauma above the clavicles • RTC • Diving • Forced movement of the neck • Falls from heights • In any doubt

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C-Spine clearance in the Field An immobilised patient in a hostile environment is a liability to himself and his colleagues. The difficulty and dangers of prolonged spinal immobilisation, especially in a remote and hostile environment, should therefore not be underestimated.

Making the decision to immobilise a patient will represent a substantial drain on equipment and personnel and may significantly increase the complexity of evacuation compared to an ambulatory patient. The remote area medic therefore has a particular interest in avoiding unnecessary spinal immobilisation, but this needs to be done in a safe, structured and evidence based fashion.

Where possible seek topside support before attempting to clear the cervical spine. Be aware of individual patient factors that may influence the response to pain, e.g. medications, cultural and behavioural norms and the circumstances of the incident. Remember, if there is suspicion of spinal injury in any one part of the spine requiring immobilisation then the whole spine will need to be immobilised.

The Wilderness Medical Society released their “Practice guidelines for spine immobilisation in the austere environment” in July 2013 and, given their relevance to the expected working environment of many MIRA medics, are the guidelines suggested here. ALL patients should have manual immobilisation applied initially if the mechanism of injury is suggestive of spinal injury and whilst the initial primary survey is completed. Once the practice guideline on spinal immobilisation has been completed, most likely during the E phase of the primary survey, it is possible to remove the manual immobilisation if the guideline states “No Immobilisation”. Note that this is a guideline for assessing the c-spine in the neck. Patients may have injury to the lower spinal areas (thoracic or lumbar) either alongside c-spine injury or without c-spine injury. If you suspect lower spinal injury, even if the c-spine has been cleared, then full immobilisation should take place.

Manual immobilisation Manual immobilisation of the c-spine should be applied to ALL patients if the mechanism of injury is suggestive of spinal injury and whilst the initial primary survey is completed. Manual immobilisation can be removed once a c-collar and headblocks have been applied to the patient or if the spinal immobilisation algorithm results in a NO Immobilisation outcome. Manual immobilisation should be achieved by bring the head gently into neutral alignment, placing 2cm of padding underneath the head and then applying the head squeeze or trap squeeze technique. In the head squeeze technique the rescuers hands are placed either side of the head with the second and third fingers free to implement a jaw thrust if necessary. The trap squeeze has been shown to be more effective in immobilising the head than the head squeeze but has the limitation of the rescuer being unable to provide a jaw thrust simultaneously.

Here, the rescuer holds the trapezius muscles on either side of the head, with the thumbs above the muscle and the fingers below, whilst the forearms gently squeeze the head at approximately the level of the ears.

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Cervical collars After applying the WMS spinal immobilisation algorithm and the decision has been made to immobilise the spine, the first step during the E phase of the primary survey is to apply a carefully sized c-collar.

A collar should not be placed onto a casualty before this phase as it will result in delaying the primary survey.

The Laerdal C Spine select is used by Horizon, this allows anterior access to the trachea if a surgical airway is to be performed, not withstanding that airway management should always take precedence over C Spine management.

A cervical spine collar should never be used in isolation, it should be a case of all or nothing in regards to C Spine management.

Application • Preferably a two-person procedure • Check the method of sizing for the particular collar used • Pass the back of the collar under the neck with an assistant maintaining in-line stabilisation • Pass the anterior portion with the chin rest around the neck to velcro with the posterior part • Ensure that the neck/head is now held in a neutral position • Check that the patient is comfortable and that the collar is not pinching ears, etc

Caution These cervical collars do not completely prevent rotation of the neck, therefore the rest of the spinal column must also be immobilised. Incorrect placement may result in airway obstruction it can also reduce venous return from the head and therefore increase intracranial pressure with prolonged use.

If a commercial c-collar, such as the Laerdal C Spine Select, is not available then evidence shows that a well formed collar utilising a flexible SAM splint can be as effective as a commercial device.

Neurogenic Shock Due to the disruption of the sympathetic outflow from T1-L2 due to injury (penetrating or blunt), a triad of hypotension and bradycardia and sometimes hypothermia can be seen; this is referred to as neurogenic shock. The patient may present with acute hypotension without associated blood loss. A classic sign and symptom is Priapism (erection), tachycardia; swollen hands and feet are also signs and symptoms. The treatment must be in line with maintaining patients haemodynamic status. Caution must be taken when administering fluids. Atropine is the drug of choice administered intravenously over 5 mins up to a maximum of 3 mg.

Spinal Shock This is a transient state, which is caused by the reflex depression of the spinal cord below the level of injury with associated loss of sensor motor functions. An initial increase in BP is noted due to catecholamine release but this is followed by hypotension. Paralysis of the bladder and bowel sometimes occur with associated priapism. These symptoms tend to last several hours to days until the reflex arcs below the level of injury begin to function again. Due to the transient nature of this the remote area medic must manage a patient with this type of injury and symptoms as if he/she has sustained permanent spinal cord damage.

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Log roll As previously stated, the log roll should be avoided if at all possible. However, it does remain a useful technique in a small set of circumstances which include: a. Airway management for continuous bleeding/vomiting that is unable to be controlled by suction alone b. Assessing the back of a patient who is deemed to have a high likelihood of posterior damage to the back which will require management eg. Gun shot wound c. Rolling a patient initially found on their front, onto their back

Method This is preferably a five-person technique • Check the patient’s pockets for items that may cause pressure on the skin • The team leader will take control of the head and neck and maintain in-line stabilisation of the cervical spine during the roll • The second person takes the shoulders • The third person takes the pelvis • The fourth person takes the legs • The casualty is rolled on command of the team leader towards the turners ensuring that there is no twisting of the spine • The fifth person can then inspect the back or slide the spinal board underneath • The casualty is rolled back by the reverse of the above

Caution • Ensure there is no twisting of the spine during the turn • If there are not enough assistants then bystanders may have to help • If there are only three people then one person takes the shoulders/pelvis and the other the pelvis/legs

Straddle Lift: a. Use: Lifting an injured patient onto a stretcher or vacuum mattress. This technique is particularly useful for patients located on uneven terrain or in confined space. It also results in much less patient movement than a log roll and should be used instead of the log roll if at all possible. b. It is also the method for which to safely apply a pelvic splint over the greater trochanters of the femur. c. Method: This is ideally a five person technique i. Position one member at the patients head/neck to maintain inline immobilisation throughout the procedure. ii. Position a second member at the patients shoulders, a third at the patients hips and the fourth member at the feet/legs. iii. The fifth member of the team is in charge of the stretcher and places it at the patients head or feet or by their side depending on the available space. iv. The lifting team stand over the patient at their designated positions and, on the command of the member at the head of the patient, the team lifts the patient approximately 2-5cm of the ground. v. The fifth team member then slides the stretcher in place underneath the patient and they are then lowered onto it.

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Spinal board This is usually a non-metallic board that has handgrips and straps for securing a casualty. “The long spinal board is predominantly a RESCUE BOARD whose main role is in extrication. The patient should spend no longer than necessary on the device as this can lead to pressure area problems, particularly if a spinal injury is present. Ideally, the patient should be transferred using a scoop stretcher to a vacuum mattress, especially if the anticipated transfer time is greater than 30 minutes” (Faculty of Prehospital Care, 2013)

Kendrick Extrication Device - KED

Head Blocks Spider Straps

This device provides support and stabilisation to the upper spine

Use: Extrication from a vehicle for a stable patient with a suspected spinal injury in a scenario that does not pose an immediate threat.

Method • Use manual in-line cervical stabilisation • Apply a cervical collar • Position the ked between the casualty and the seat Adjust the KED so that the wings sit just under the armpits a. Loosely apply the yellow (middle) chest strap and the green (bottom) chest strap

The Kendrick Extrication Device

b. Loosely apply the leg straps either to the same side or using a criss-cross pattern c. Fill the gap between the KED and the back of the head with the padding provided d. Secure the patient’s head with the head straps e. Now apply the red (top) chest strap f. Work down all the straps checking and tightening them g. The patient can now be extricated using the lifting straps on the KED

Caution When the patient is to be placed supine, e.g. onto a spinal board or vacuum mattress, the leg straps will have to be loosened so that the legs can be straightened. Whilst useful to ensure spinal protection prior to moving it can be timeconsuming.

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Scoop stretcher Use: The best way to lift a patient from the floor onto a vacuum mattress but a scoop may also be used with head blocks and a c-collar to provide spinal immobilisation during transport. Ideally, a patient will be left on a scoop stretcher for a maximum of 45minutes.

Method • Adjust the length of the stretcher alongside the casualty • Split into two halves and spread one on either side of the casualty • Bring together taking care not to pinch under the shoulders or hips • Clip the ends together • Provide head support during the move May bend with heavy patients. Watch out for trapped fingers

Basket stretcher Use: A rigid plastic stretcher with a foam base, footplate and patient securing straps that can be used as a general lifting or transfer device. There are anchoring points for helicopter winching. Can also take vacuum mattress or scoop stretcher inside.

Paraguard stretcher Use:

A selection of extreme stretchers that have been trialled by Horizon on operations worldwid

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CHAPTER 10: Extremity Trauma Introduction Of all the problems that might be experienced in remote areas it is extremity trauma that is probably the most common. Limbs are injured in about 85% of victims of blunt trauma. It is important to realise however that patients do not die from fractures, dislocations and sprains; they die from hypoxia and hypovolaemia.

While patients may not die from extremity trauma there may be complications later on such as the potential for damage to soft tissue, extremity ischaemia, compartment syndrome, fat embolism, and serious morbidity exacerbated by inappropriate or poor management.

The most important step is to rule out or manage any life threatening injury that may be present. Suspected fractures of the pelvis, femur, spine and skull should focus the rescuer to have a high index of suspicion for those life-threatening problems associated with these injuries. Once these have been eliminated one can focus on a detailed examination of the injury, taking time to think and evacuate the patient without rushing and with a degree of safety without placing the lives of rescue services at risk.

Anatomy The muscular-skeletal system is simply a series of pulleys, levers and cables that work in balanced opposition to each other to generate motive power. It is made up of bone, muscles, cartilage, tendons and ligaments.

• Tendons connect muscles to bone.

• Ligaments connect bone to bone over across or over a joint.

• Cartilage provides a smooth surface for bone to slide on and acts as padding.

Musculo-Skeletal Problems Contusions: Bruise of soft tissue or bone.

Strains: Stretching injury to muscle or tendon.

Sprains: Stretch injury to ligaments.

Fractures: Broken bones or cartilage.

Dislocations: Bone joint disruption.

There are many other medical terms used to further describe fractures however these are not really helpful in remote areas due to the lack of X-Ray facilities. A much more useful guide is whether the injury is stable or unstable.

Unstable Injuries – Fractures & Severe Sprains A fracture is a break anywhere in the continuity of a bone. They simply classified into open or closed fractures. A closed fracture is more difficult to diagnose in the field but an open fracture means that there is a connecting wound to the outside environment. This opening can be produced internally by sharp broken bone ends or externally by the same object that caused the fracture, such as a bullet or piece of shrapnel. This can make the treatment of the injury difficult because there is now an entry portal into the body for harmful bacteria to gain entry. Outside of the tactical context these fractures are quite rare however many ballistic injury mechanisms are associated with fractures.

Other fractures that are classed as being unstable are fractures of the femur and pelvis. These fractures are associated with significant hypovolaemia and perhaps fluid replacement. They will also require stabilisation of the whole body as part of their management.

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In order for a fracture or severe sprain to occur there must have been sufficient force therefore when assessing fractures it is useful to consider the mechanism of injury to determine the answer to this question. Once a positive mechanism has been identified one can then consider the signs and symptoms of instability.

Signs & Symptoms of Unstable Injury: • Rapid onset of pain • Inability to move, use or weight-bear • Tenderness • Swelling • History of hearing a crack or snap • Limb deformity or angulation (may be severe) • Crepitus (sound of bone grating on bone) • Feeling instability when handling the limb • Bone protruding from a wound

Unstable Injuries – Dislocations Muscle forces act across a joint and each joint has a certain minimum function to allow for stability and a normal range of motion. A dislocation interrupts the normal relationship of a joint. The force required to disrupt a bone out of its normal alignment within a joint often disrupts tendons, ligaments, nerves, and blood vessels and may complicate treatment or where the distal circulation is affected prompt an immediate attempt at reduction to prevent ischaemia and before the onset of muscle spasm.

Simple dislocations are caused by indirect injury, whereby the force is applied from a distance and the dislocation is as a result of leverage or torque. The usual mechanism being forced rotation.

Complex dislocations are caused by direct injury mechanisms and are the result of high-speed impacts. These injuries are usually more serious because the force of the impact is applied directly to the joint area to force the bone ends apart and are almost always associated with other major trauma and a higher incidence of fractures.

Assessment Physical examination of the extremities is divided into assessment of: • Circulatory Function • Nerve Function • Skeletal Function • Joint Function More simply it is a Circulation – Sensation – Movement examination.

Circulatory Function Fractures can produce injury to blood vessels by direct laceration (rarely) or by stretching, which produces intimal laps. These laps can immediately occlude distal blood low leading to platelet aggregation and delayed occlusion.

Repeated assessment of distal blood low is a continuing and vital part of assessment. The colour and warmth of the skin of the distal extremity must be assessed. Distal pallor and a unilateral coldness or hypothermia could mean a vascular injury. A Capillary Refill test should be performed and the pulse assessed if possible, although blood loss and cold may make this difficult. An extremity can usually survive approx 2 hours of ischaemia with minimal damage. A suspected arterial injury that does not improve with manipulation and splinting mandates evacuation to definitive care as soon as possible.

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Nerve Function Nervous system tissue is the most sensitive to oxygen deprivation. The onset of ischaemia leads to the nervous tissue stopping functioning. Loss of sensation is the first sign of ischaemia. A normal limb will be able to feel the light touch or slight pain of a stimulus. In the early stages the patient could complain of tingling or pins and needles followed by numbness. The loss of the ability to wiggle toes develops later, Nerve function is often difficult to assess in the unconscious or uncooperative patient but when it is possible it is important to record and document the status of nerve function to the distal extremity after stabilisation. Applying a mildly painful stimulus distally can test sensory function. If possible assess muscle function by observing active function and grading the strength of the muscle against resistance.

Skeletal Function Long bones of the lower extremity are major supports for locomotion and those of the upper extremity stabilise the soft tissues and maintain the position of the hand in space. Angulated deformity indicates a fracture, the existence of crepitus confirms, and appropriate splinting should be should be performed after aligning the limb with axial traction.

Once the degree and orientation of a limb has been noted there is no reason to delay aligning and splinting fractures.

Joint Function Palpation of long bones should begin distally and continue across all joints. In the cooperative patient, the examiner should request that the joint be moved through a complete range of movement. When this is not possible evaluate by palpation and passive motion noting any areas of crepitus, swelling, deformity or a block in motion. Dislocations of the shoulder, patella and digits should be promptly reduced if possible within the first hour. These dislocations are the easiest to reduce in the field and can reduce pain and discomfort.

Life Threatening Complication

Example

Concealed, non compressible haemorrhage

Pelvic fracture

Obvious, compressible haemorrhage

Shrapnel wound to upper thigh with femoral artery involvement

Concealed, compressible haemorrhage

Closed femoral shaft fracture

Venous thrombo-embolism

Pelvic fracture

Fat embolism syndrome

Femoral shaft fracture

Sepsis (gangrene, streptococcal sepsis, tetanus)

Contaminated wounds, amputations

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Threats To Life Injuries to the limbs may be life threatening, not because of the damage to the structures but by virtue of the trauma itself.

Limb Threatening Injuries There are some injuries that threaten the viability of a limb, or a portion of that limb. These injuries will often compromise the blood supply to the limb, such as: • Direct vascular damage.

• Vascular occlusion in a distorted limb perhaps due to displaced fracture or dislocated joint.

• Microcirculatory compromise caused by swelling within fascia leading to compartment syndrome.

As well as limb threatening injuries, many of these insults will threaten limb function. Additionally lesser injuries may have major consequences, and threaten limb function in more subtle ways that bring about a major impairment to function. The effects of these injuries are compounded several-fold, with potentially devastating functional results, if the injuries are unrecognised or neglected for days after the initial insult. Such injuries include: • Digital nerve injuries.

• Dislocation of small joints.

• Tendon injuries • Peri-articular and ligament injuries.

Treatment – Unstable Injuries It is important to remember that a fracture, dislocation, strain or sprain is never in itself an emergency. It is the potential for further damage that is the real concern. Treatment is aimed at restoring circulation and sensation if required, immobilising the limb securely in the position of function, applying traction as appropriate and packaging the casualty correctly for evacuation. Once evacuation is underway the limb will require adequate monitoring to ensure that any traction is continually effective and that under splint swelling is not causing additional problems such as induced compartment syndrome or ischaemia.

General Principles Manual stabilisation (to reduce pain) The limb should be grasped and stabilised to prevent the broken bone ends from causing further tissue damage or grating together. This is particularly important when there is a displaced fracture. Some traction may be required.

Traction of long bones should be applied This should be done manually with both hands, using counter traction if appropriate. This should be maintained until the splint is in place and secured.

Splintage When applying a splint the device selected or improvised should be long enough to immobilise the joints above and below the injury. The fracture site should be bound to the splint above and below the actual injury.

Adequate splinting is an essential part of the management of limb injuries. Splinting helps to reduce bleeding, prevent further tissue damage, aids analgesia and reduces the incidence of fat embolism syndrome. While there is an abundance of commercial splints that may be available to rescuers in some circumstances, such as mountain rescue teams, adequate splinting will have to be improvised. A commercial product of value in the remote environment is the

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SAM Splint and this when used correctly can greatly enhance any improvised techniques and can be useful as a standalone splint for some injuries.

The Sam Splint The SAM Splint is made from aircraft grade aluminium that has been coated in hypo-allergenic foam.

The basic curve is simply to form the length of the splint in to a gutter shape. The more times the splint is folded along its length the greater the rigidity. The demo is more effective if the curve is demonstrated with at least one fold along the length and then the curve formed. It is explained that the now rigid splint can be used as a simple backboard for any long bone but is more effective if used like a â&#x20AC;&#x2DC;sugar tongâ&#x20AC;&#x2122;.

The Reverse C Curve is a stronger form than the standard C curve and is used in situations where strength is required, particularly when using the splint with no folds along its length such as for lower limb injuries.

From head to toe the SAM splint can be used for: 1. A cervical collar 2. Anterior shoulder dislocation support 3. Upper arm splint. Rigid backboard and sugar tong.

4. Radius and Ulnar sugar tong and back board.

5. Skiers thumb dislocation.

6. Finger splint formed from a cut of section of SAM splint about 2â&#x20AC;? wide.

7. Possible fractured rib employing spine to sternum strapping with the splint folded to provide rigidity.

8. Pelvic stabilisation using 2 x SAM splints enclosed in Tubigrip and passed under the body and aligned anteriorly over the pubis.

2 Splints are required and the ends are brought together and tightened using a windlass.

9. Femur stabilisation using SAM splints as back slabs.

10. Lower limb back slabs using 2 x splints. Both have half stirrups placed under the soles of the feet and then guttered up each side of the lower leg.

11. Fig 8 splint of the ankle with the wrap placed according to whether it is inversion or eversion injury.

Thumb dislocation

Water bowl/urinal or a water basin for rewarming extremities or stool collection

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Other Uses for the SAM Splint There are many uses for this splint and it is very versatile. It is an item of equipment that is perfect for the outdoors as it has multiple uses.

Amputations Traumatic amputation is the accidental severing of some or all of a body part. A complete amputation totally detaches a limb or appendage from the rest of the body. In a partial amputation, some soft tissue remains attached to the site. These injuries pose a threat to life due to uncontrolled haemorrhage. It is important to use all methods to control severe bleeding including tourniquet if necessary.

The amputated part should be cleaned in sterile solution if possible and placed in a sterile soaked cloth in a plastic bag and kept cool, but not in contact with ice. Limbs can be viable at room temperature for up to 6 hours without ice and up to 18 hours with ice. Possible complications of traumatic amputation include; excessive bleeding, infection, muscle shortening and pulmonary embolism.

Crush Syndrome Crush syndrome is a condition caused by skeletal muscle cell rupture and the release of muscle cell contents into the circulation. It is a problem of re-perfusion. When the limb is crushed for a prolonged period, sudden release of the pressure allows the toxins to rapidly enter the blood stream causing fluid and electrolyte shifts. Large amounts of potassium is particularly dangerous and life threatening.

The accumulation of these cell contents, particularly myoglobin and urates in the kidneys can cause obstructive renal failure. This is compounded by the relative hypovolaemia caused as the vessels begin to leak. Treatment includes assessing and treating the ABC’s and fluid administration to dilute the ‘debris’ in the circulation and prevent build up in the kidney tubules.

Symptoms The patient will be very distressed. The immediate concern will be the injury. They may have symptoms of hypovolaemia.

Signs This condition is characterised by profound shock. If a limb has been trapped, it will be pulseless on release. Later, it will become red, swollen and blistered. There may be loss of sensation and muscle power. Compartment syndrome occurs after crush because of the uptake of fluid into muscle cells contained within a tight compartment. Once compartment pressure exceeds capillary perfusion pressure at about 30 mmHg, the tissue inside the compartment becomes ischaemic, and Compartment Syndrome develops.

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This man sufered a sufered a severe crush injury of the right side of the body when crushed in a RTC. The severe oedema of his right leg can be seen, and this required extensive fasciotomy of both his thigh and calf.

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Management Non-Drug Get venous access as early as possible. In the adult, a saline infusion of 2 litres should be initiated during extrication.

Compartment Syndrome Thick layers of tissue called fascia separate groups of muscles in the arms and legs from each other. Inside each layer of fascia is a confined space, called a compartment which includes the muscle tissue, nerves, and blood vessels. They are surrounded by the fascia much like wires surrounded by insulation. Unlike a balloon, fascia do not expand, so any swelling in a compartment will lead to increasing pressure in that compartment, compressing the muscles, blood vessels, and nerves. If this pressure is high enough, blood low to the compartment will be blocked, which can lead to permanent injury to the muscle and nerves. If the pressure lasts long enough, the limb may die and need to be amputated.

Swelling leading to compartment syndrome is associated with high-energy trauma, such as from a car accident or crush injury, or surgery. Compartment syndrome may also occur due to tight bandages or casts; with significant swelling, pressure will build up and can cause compartment syndrome. Chronic compartment syndrome can be caused by repetitive activities like running that increase the pressure in a compartment only during that activity.

Compartment syndrome is most common in the lower leg and forearm, although it can also occur in the hand, foot, thigh and upper arm. The hallmark symptom of compartment syndrome is severe pain that does not respond to elevation or pain medication. In more advanced cases, there may be decreased sensation, weakness, and paleness of the skin.

Signs and Tests Typically, severe pain will occur when a muscle running through a compartment is passively moved. For example, if the toes are moved up and down, a patient with compartment syndrome in the foot or lower leg will experience severe pain. The skin overlying the compartment will be tensely swollen and shiny. There will also be pain when the compartment is squeezed. When the compartment pressure is greater than 45 mmHg or when the pressure is within 30 mmHg of the diastolic blood pressure (the lower number of the blood pressure), then the CS will occur.

Treatment Treatment for compartment syndrome is usually surgery. Long incisions are made in the fascia to release the pressure building inside. The wounds are generally left open (covered with a sterile dressing) and closed during a second surgery, usually 48-72 hours later. Skin grafts may be required to close the wound. If a cast or bandage is causing the problem, the dressing should be loosened or cut down to relieve the pressure.

Dislocation A dislocation is a separation of two bones where they meet at a joint.

(Joints are areas where two bones come together.) A dislocated bone is no longer in its normal position. A dislocation may also cause ligament or nerve damage. It may be hard to tell a dislocated bone from a broken bone.

Squaring of the injured shoulder is often seen

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Shoulder Dislocation The shoulder can dislocate either forward, backward, or downward. In 98% of dislocations, the shoulder displaces in an anterior direction, and in about 2% of cases it displaces in the posterior direction. Several structural changes are associated with traumatic instability of the shoulder joint.

To reduce anterior shoulder dislocation the patient lies on the back with a sheet around the chest and also around the assistant’s waist for counter traction. The rescuer stands on the side of the dislocated shoulder near the patient’s waist with the elbow of the dislocated shoulder bent to 90 degrees. A second sheet, tied loosely around the responders waist and looped over the patient’s forearm, provides traction while the responder leans back against the sheet while grasping the forearm. Steady traction along the axis of the arm usually causes reduction.

If three reduction attempts fail, carry the forearm across the chest and apply a sling and swathe. An alternate method involves having the patient lie face down on an elevated surface with the injured arm hanging over the side. Apply prolonged, firm, gentle traction at the wrist with gentle external rotation. A bag with a padded strap should be placed in the crook of the patient’s elbow. Gradually add sand or water to increase traction. Grasping the wrist and using the elbow as a pivot point, gently rotate the arm into the external position.

Once reduced an assessment of the distal nerves and circulation should be conducted and the limb bandaged in place to the upper body. Regular checks should be performed and the patient monitored throughout. The earlier the reduction is carried out the better, however this is not an easy technique and patience is required. Untrained persons should not attempt this procedure!

Dislocation Of The Jaw When the lower jaw is dislocated, the victim cannot speak or close the mouth. A blow to the mouth often causes this dislocation, also occasionally by yawning or laughing. This type of dislocation is not always easy to reduce, and there is considerable danger that the operator’s thumbs will be bitten in the process. For your own protection, wrap your thumbs with a handkerchief or bandage. While facing the victim, press your thumbs down just behind the last lower molars and, at the same time, lift the chin up with your fingers. The jaw should snap into place at once. You will have to remove your thumbs quickly to avoid being bitten. No further treatment is required, but you should warn the victim to keep the mouth closed as much as possible during the next few hours.

Dislocation Of The Finger The joints of the finger are particularly susceptible to injury, and even minor injuries may result in prolonged loss of function. Great care must be used in treating any injury of the finger. To reduce a dislocation of the finger, grasp the finger firmly and apply a steady pull in the same line as the deformity. If it does not slip into position, try it again, but if it does not go into position on the third attempt, DO NOT TRY AGAIN. Whether or not the dislocation is reduced, the finger should be strapped, slightly flexed, with an SAM splint or with a bandage over can be immobilized by strapping it to a lat, wooden stick, such as a tongue depressor.

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Sprains Sprains are injuries to the ligaments and soft tissues that support a joint. A sprain is caused by the violent wrenching or twisting of the joint beyond its normal limits of movement and usually involves a momentary dislocation, with the bone slipping back into place of its own accord. Although any joint may be sprained, sprains of the ankle, wrist, knee, and finger are most common.

Symptoms of a sprain include pain or pressure at the joint, pain upon movement, swelling and tenderness, possible loss of movement, and discoloration. Treat all sprains as fractures until ruled out by X-rays. Emergency care for a sprain includes application of cold packs for the first 24 to 48 hours to reduce swelling and to control internal haemorrhage; elevation and rest of the affected area; application of a snug, smooth, figure-eight bandage to control swelling and to provide immobilisation. (Basket weave adhesive bandages can be used on the ankle).

NOTE: Check bandaged areas regularly for swelling that might cause circulation impairment and loosen bandages if necessary. After the swelling stops (24 to 48 hours), moist heat can be applied for short periods (15 to 30 minutes) to promote healing and reduce swelling. Moist heat can be warm, wet compresses, warm whirlpool baths, etc.

Strains Injuries caused by the forcible over-stretching or tearing of muscles or tendons are known as strains. Lifting excessively heavy loads, sudden or violent movements, or any other action that pulls the muscles beyond their normal limits may cause strains. The chief symptoms of a strain are pain, stiffness (sometimes involving knotting of the muscles), moderate swelling at the site of injury, discoloration due to the escape of blood from injured blood vessels into the tissues, possible loss of power, and a distinct gap felt at the site.

Keep the affected area elevated and at rest. Apply cold packs for the first 24 to 48 hours to control haemorrhage and swelling.

After the swelling stops, apply mild heat to increase circulation and aid in healing. As in sprains, heat should not be applied until 24 hours after the last cold pack. Muscle relaxants, adhesive straps, and complete immobilisation of the area may be indicated. Evacuate the victim to a medical facility where X-rays can be taken to rule out the presence of a fracture.

Contusions Contusions, commonly called bruises, are responsible for the discoloration that almost always accompanies injuries to bones, joints, and muscles. Blows that damage bones, muscles, tendons, blood vessels, nerves, and other body tissues cause contusions. They do not necessarily break the skin. There is immediate pain when the blow is received. Swelling occurs because blood from the broken vessels leaks into the soft tissue under the skin.

At first the injured place is reddened due to local skin irritation from the blow. Later the characteristic â&#x20AC;&#x153;black and blueâ&#x20AC;? marks appear.

Perhaps several days later, the skin turns yellowish or greenish before normal coloration returns. The bruised area is usually very tender. As a rule, slight bruises do not require treatment. However, if the victim has severe bruises, treat for shock. Immobilise the injured part, keep it at rest, and protect it from further injury.

Sometimes the patient will be more comfortable if the bruised area is bandaged firmly with an elastic or gauze bandage. If possible, elevate the injured part. A sling may be used for a bruised arm or hand.

Pillows or folded blankets may be used to elevate a bruised leg.

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CHAPTER 11: Environmental Injuries, Bites and Stings Desert Medicine Heat Illness Regulation of heat is controlled via the brain, specifically the thalmus and the hypothalmus. This controls blood low to the skin and therefore the amount of cooling occurring at the body surface through peripheral vasodilation. The Kidneys are involved in fluid loss and retain of excrete fluid according the needs of the body.

Heat illness causes include: • Excessive sweating • Inadequate luid intake • High temperatures at work • Excessive periods of sun Prevention is the Best form of Defence. Prior preparation & planning prevents heat illness (management/leadership issue) with basic common sense and education.

Water Balance Fluid (water based) makes up approximately 55 - 60% of our body weight and is vital for the body to maintain life. It is not only water that is important but also electrolytes that are present within the body fluid, the main electrolytes are: • Sodium (Na +) • Potassium (K +) • Chloride (Cl -) • Calcium (Ca 2+) • Bicarbonate (HCO3 -) Fluid is stored in 3 main areas within the body: • Extracellular • Intravascular: Plasma • Interstitial: Within the tissues but outside the cells • Intracellular The amount of water contained in each area is approximately as follows: • 2/3 – Intracellular • 1/3 – Extracellular • 80% Interstitial • 20% Plasma Therefore a male weighing 90kg will have the following fluid distribution, each kg of weight is equal to 1 litre: • Total water weight = 54kg • Intracellular = 36kg or litres • Interstitial = 14.5 kg or litres • Intravascular = 3.6kg or litres Water is lost in the following ways; the amount varies dependant on clothing, ambient temperature and work levels: • Breathing 250cc -1500cc • Perspiration 500cc - 15000cc • Urine 500cc - 1500cc

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A potential maximum total = 18,000cc with a daily normal loss of approximately 2250 mls The body will constantly try to maintain its blood pressure by drawing in fluid from the interstitial spaces with in turn will draw fluid from the cells of the body.

Dehydration Effects From Water/Salt Loss Reduced mental performance 1ltr Reduced industrial performance 2ltrs Difficulty in walking and seeing 4ltrs Coma or Death 6ltrs

Planning Factors The key message is that environmental injuries are preventable and prevention is much better than reactive treatment.

Given the fact that heat stroke carries with it a high mortality rate, prevention becomes further emphasised. The following are controllable risk factors: a. Some pre-existing medical conditions can predispose individuals to developing heat stroke, in particular any condition which limits heat loss through the skin eg. extensive sunburn, hypohydrosis, extensive scars and diminished cardiopulmonary reserve. b. Overweight or obese individuals are more at risk from developing heat illness. c. Acclimatisation, by exposing individuals to 1-2hours of heat-exposed exertion per day over 10-14 days, increases the body’s ability to tolerate and disseminate heat. d. Individuals with a high level of aerobic fitness are better able to tolerate activity and acclimatise faster in hot condition than those individuals with moderate fitness e. The most easily controlled risk factor is hydration status. Hyperhydration has not been shown to have a significant efect on heat tolerance so individuals should aim to achieve normal levels of hydration. f. Maintaining adequate hydration should be ongoing throughout the day with a mixture of water, isotonic drinks and food to maintain champagne coloured urine of good quantity. g. Previous history of heat stroke is a risk factor for its recurrence h. Consider the weather and try to avoid exertion during the hottest parts of the day i. Take regular breaks in proportion to the levels of exertion and the ambient conditions to allow the body to cool j. Clothing should be worn appropriate to the activity and conditions but ideally, long sleeved, breathable material that is loose fitting should be employed.

Temperature measurements When taking the temperature of any environmental illness it should be taken from the core as oral or armpit measurements can give false and lower temperatures. There are two methods for achieving this: • Rectal – this requires exposure of the casualty and holding the thermometer in place for at least 2 minutes.

• Tympanic – Becoming the preferred option as in only take a few seconds without exposure of the casualty, cheaper tympanic thermometers are less accurate than both more expensive models and the digital rectal option.

Heat Disorders • Heat Cramps • Heat exhaustion • Heat stroke • Prickly heat rash

Heat Cramps These are muscular spasms that occur when the body loses too much salt during profuse sweating and not enough salt is taken in. With too much water and not enough salt, electrolyte imbalance takes place and the already stressed muscles are further affected. Hot weather is not necessary to heat cramps.

The casualty usually presents with tachycardia, pale/clammy skin, nausea and headache. Tingling extremities and cramping can be seen in both extremities and abdominal regions. The temperature of the casualty will be within normal values.

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Treatment should begin by putting the casualty at rest ideally in a shaded area; oral fluid replacement should be given with consideration to providing electrolyte replacement through drinks with care not to overload the casualty with electrolytes, a ratio of 2 units of water to 1 unit of water/electrolyte solution is suitable. Oral salt tablets should be avoided due to the effect of inducing vomiting. Enforced rest for 12 + hrs. If Heat cramps are left untreated it may develop into Heat Exhaustion.

Heat Exhaustion The body’s mechanism to compensate for overheating is to increase its heat loss by vasodilation of the peripheral circulation and increase sweating in order to lose heat by evaporation, convection and radiation to the environment.

If equilibrium is not achieved or an underlying disorder such as diarrhoea is present then profound dehydration can occur and the body’s temperature can begin to rise.

Signs and Symptoms • Temperature < 40°C • Profound sweating • Tachycardia • Tachypnoea • Associated muscular cramps • Fatigue, lethargy • Headache, dizziness • Nausea and vomiting • Eventually a change in mental state occurs an eventual decrease in levels of consciousness • Fitting • Intense thirst

Heat Stroke This can occur when the core body temperature is raised past 40°C; the danger is that sweating (the body’s cooling mechanism) stops!!

Symptoms & Signs • Hot, dry flushed skin • Slow bounding pulse • Slow noisy breathing • Abnormal behaviour • Unconscious • Confused/delirium and fainting • Seizures/fitting • Severe headache • Nausea

Management As previously emphasised, prevention of heat related illness is far more preferable to treating the resulting conditions particularly when optimal treatment in remote settings may be challenging or impossible. Regardless of the severity of the heat illness, the initial priority of treatment focusses on stabilisation of the airway, breathing and circulation before cooling therapies are initiated.

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Severity of heat-related illness

Diagnosis

Treatment

Mild

Heat cramps

Oral isotonic luid replacement

Heat oedema

Extremity elevation Compression stockings

Heat syncope

Remove from heat source Passive cooling Oral isotonic luid hydration

Heat exhaustion

Remove from heat source Evaporative and convective cooling Oral or intravenous isotonic luid hydration

Heat stroke

Remove from heat source Address ABCs Ice water immersion Evaporative and convective cooling Intravenous hydrationa Evacuationb

Moderate

Severe

a. Passive cooling – Move victim into shade, loosen tight fitting clothing, place patient at rest and lay them directly onto the ground with no insulation. b. Rehydration – Oral and intravenous hydration have been shown to be equally effective but a patient suffering from heat stroke may have a reduced level of consciousness so administering intravenous fluids will minimise the risk of aspiration. The most appropriate fluid is 0.9% Sodium Chloride. c. Ice water immersion – the OPTIMUM treatment if possible as it has been shown to reduce body temperature twice as fast as evaporative cooling. Using bodies of water such as streams, ponds, lakes or rivers is an acceptable method of achieving cold water immersion. Care should be taken to avoid currents in the water and the patient should never be left alone. In the absence of a cold water source then repeated dousing of the victim with cold water or snow is an acceptable alternative. d. Evaporative cooling – If immersion is unavailable then evaporative cooling should be used. Loosen or remove clothing, spray with water and fan the patient. The Wilderness Medical Society (2013) note that the downdraft of a helicopter can be utilised although is technically difficult to achieve! e. Ice packs – Minimal benefit has been shown by placing ice packs in the axillae, neck and groin. Best effects are seen when ice packs cover the entire body. f. The aim of all cooling modalities is to reduce the core body temperature to 39degrees. g. Patients with Heat Stroke should be transported to a medical facility with critical care facilities where staff will focus on continuing cooling efforts and supporting body organ function.

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Prickly Heat Rash This is caused by blocked sweat glands by dirt and salt crystals creating a pressure under the skin. This can be as a result of poor hygiene or excessive sweating in a dirty environment.

Signs & Symptoms Intense irritation over affected part of skin, this usually occurs in areas such as waistbands, shoulders under Bergen straps, backs during long treks with bergens/backpacks. Red spotty rash over affected area.

Treatment Usually relieved in the short term with cool water due to reduction in pressure from vasoconstriction DO NOT apply creams/powders as these further block the pores. Use antiseptic (ideally non-scented) soap with a rough flannel/ sponge to wash in order to remove the crystals from the pores.

Prevention is the best treatment in this illness – there are no magic treatments.

Polar Medicine Heat Loss And Gain When the body looses the battle of heat generation or gain to that of heat loss cold injuries occur. Heat is transferred by several methods: Conduction - Conductive heat loss is heat transfer by direct contact with an object specifically the ground when dealing with a casualty. This can be reduced by insulation.

Evaporation - Heat loss from evaporation (i.e. respiration and perspiration) is affected by the relative humidity and ambient temperature of the environment. The body loses heat faster if the skin is wet.

Evaporative loss is reduced by staying dry, using a vapor barrier and using mouth and nose moisture traps.

Convection - Convection heat loss is determined by air movement over the skin (i.e. windchill) and is reduced by a windproof layer.

Radiation - heat is lost or gained by means of heat waves which transmit the heat energy

Cold conditions Cold environments are found at altitude, Polar Regions, wet temperate climates and even equatorial regions. The human body can withstand considerable cold but is related to levels of insulation, good nutrition and shelter.

Casualties will need this providing for them, not just in remote environments but also in first world care structures, an area where hypothermia is occasionally overlooked.

Altitude causes a decrease of temperature by 1°C for every 100m of ascent as a general rule, thus resulting in mountainous areas of the world competing with the Polar Regions to be the coldest on earth; with the summit of Everest for example being routinely below -40°C. Wind-chill was first coined by the American explorer Paul Siple in describing the way that wind enhances the rate of heat loss by its removal of warmed air around the body and replacement of cold air. The table below shows the formula that both Paul Siple and Charles Passel developed in Antarctica. Today’s expeditions and travellers can experience temperatures in excess of those in the table on the next page.

The body’s thermometer and regulator of its temperature is contained in the hypothalmus in the brain. The hypothalmus regulates the body temperature mainly via the skin and the circulatory system. Heat loss in mammals is determined by the amount of warm blood lowing to the surface of the skin, with the trade of being that the greater the blood low the more potential heat will be lost.

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One mechanism for retaining heat is Vaso-constriction thus reducing heat loss, however when the external temperature drops below 10°C the circulatory vessels dilate, with any shivering increases production of heat within the muscles but at a cost, it is a very inefficient way of producing heat and can use up glycogen stored in the muscles quickly.

WIND CHILL CHART

Hypothermia The normal body temperature is normally around 36.9⁰c and the human body likes to maintain its core temperature within a narrow range around this temperature. Humans can achieve this despite wide variations in the external environment. Unfortunately, as humans evolved in the tropics the body is very good at loosing heat, through the four mechanisms previously discussed. However, heat can only be generated in two ways: muscular activity and metabolism of food.

Hypothermia develops when the rate of heat loss exceeds the ability of the body to generate adequate levels of heat.

Hypothermia begins when the body temperature drops below 35⁰c.

At this point the patient will report feeling cold and they will begin shivering. They will also develop the “UMBLES” where co-ordination, motor skills and mental function begin to deteriorate resulting in: Stumbling, Grumbling, Fumbling, Mumbling.

As core temperature continues to drop, mental and bodily function deteriorates further. Severe hypothermia is said to begin at 32⁰c.

Now the patient displays apathy towards staying warm where they may be seen to leave a jacket unzipped, not replace gloves after removing them or they leave skin unnecessarily exposed. There may also be slow or difficult decision making and their memory may deteriorate. The patient will stop shivering, a vital mechanism for generating heat and therefore heat loss continues unchecked.

The level of consciousness will drop, the pulse will become weak and irregular and the breathing slow and shallow. At the limits of hypothermia the patient may appear dead, or indeed be dead.

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Prevention When it comes to preventing hypothermia humans have only two options: 1. Increase heat generation: a. The only effective increase in heat generation is through muscular activity and voluntary use of the large leg muscles results in the largest heat generation b. Ensuring regular intake of sufficient calories throughout the day will enable sustained heat generation secondary to the metabolic breakdown of food 2. Decrease heat loss a. Adequate clothing to prevent against the four types of heat loss is the best way to decrease heat lost from the body: i. Using layering to trap immobile layers of warm air (Still air is a poor conductor and therefore a good insulator) ii. Use a base layer which retains insulating properties when damp iii. Reduce convective heat loss using wind proof layers iv. Avoid sweating (sweat reduces the insulating value of clothing and increases heat loss through evaporation) v. Wear a hat/buff (Reduce radiant heat loss from the head/neck area) vi. Keep outer clothing dry with waterproof shell

Management Management of hypothermia follows the same theories as prevention, alongside attempts to re-warm the patient.

Initially further heat loss should be prevented: a) Remove the patient from the environment, placing them into a warm area if possible with protection from the wind b) Remove wet clothing to reduce evaporative heat loss and add dry layers to increase insulation c) Keep the patient insulated from the ground to reduce conductive heat loss d) Put a hat on the patient to reduce radiation losses Once further losses have been minimised, methods for warming the patient can be implemented: a) Place hot water bottles in the groin, armpits and the sides of the torso b) Provide warm, sugary drinks to conscious patients. If you only have cold sugary drinks then administer these as it is the sugar which is vital. This provides the body with fuel to continue shivering. c) If available then place the patient in a warm shower or bath d) Mild exercise can be encouraged once the patient is dry, has had calorie replacement and has been stable for 30mins If the patient has severe hypothermia then efforts to reduce heat loss should be implemented but the rescuer needs to be more cautious over re-warming attempts. Due to their decreased level of consciousness, patients should not be given anything to drink and should not be put in a bath. These patients need to be handled very carefully as the heart can spontaneously go into cardiac arrest and therefore exercise, on recovery, should also not be encouraged. If the patient has no obvious signs of life, no palpable pulse and no spontaneous respirations then CPR should be initiated and continued until the patient has been warmed and resuscitated in a definitive care facility. CPR should not be continued if the patient: a) has obvious fatal injuries, e.g. decapitation b) is frozen, e.g. ice formation in the airway c) has a chest wall that is so stiff that compressions are impossible d) rescuers are exhausted or in danger

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Frostbite Taken from the Wilderness Medical Society Practice Guidelines 2011.

a. Frostbite has been divided into 4 tiers or â&#x20AC;&#x153;degreesâ&#x20AC;? of injury, historically following the classification scheme for thermal burn injury. These classifications are based on acute physical findings and advanced imaging after rewarming. These categories can be difficult to assess in the field and before rewarming, since the still-frozen tissue is hard, pale, and anesthetic. i. Frostnip is distinct from frostbite but may precede it. Frostnip is a superficial non-freezing cold injury associated with intense vasoconstriction on exposed skin, usually cheeks, ears, or nose. Ice crystals, appearing as frost, form on the surface of the skin. By definition, ice crystals do not form in the tissue nor does tissue loss occur in frostnip. The numbness and pallor resolve quickly after covering the skin with appropriate clothing, warming the skin with direct contact, breathing with cupped hands over the nose, or gaining shelter that protects from the elements. No long-term damage occurs. The appearance of frostnip signals conditions favourable for frostbite and appropriate action should be undertaken immediately to prevent injury. ii. First-degree frostbite presents with numbness and erythema. A white or yellow firm, slightly raised plaque develops in the area of injury. No gross tissue damage occurs but mild swelling is common. iii. Second-degree frostbite injury results in blisters filled with a clear or milky fluid, surrounded by erythema and swelling. iv. Third-degree frostbite creates haemorrhagic blisters, which have a dark maybe black appearance and indicate that deeper layers of tissue have been damaged. v. Fourth-degree frostbite injury extends completely through the dermis and involves the comparatively avascular subcutaneous tissues, with necrosis extending into muscle and to the level of bone.

As with heat related illness, frostbite is often completely preventable but there is the added problem that commonly frostbite is not improved with treatment. Frostbite injury occurs when tissue heat loss exceeds the ability of local tissue perfusion to prevent freezing of soft tissues. To prevent frostbite we must both ensure adequate perfusion and minimize heat loss. As such, the following strategies should be considered and implemented: a. Maintain peripheral perfusion: i. Maintain adequate core body temperature and body hydration, ii. Cover all exposed skin iii. Minimise restrictive clothing iv. Ensure good nutrition b. Exercise is an effective method to maintain core body temperature. c. Protection from the cold: i. Avoid environmental conditions with a risk of frostbite (below -15degrees) ii. Protect skin from moisture, wind and cold iii. Avoid perspiring or wet extremities iv. Increase insulation by layering clothes v. Use chemical/electric hand/foot warmers vi. Performing regular cold checks on buddy vii. Recognise frostnip early viii. Minimise the duration of cold exposure

If prevention measures have been unsuccessful and the patient develops frostbite then the frozen part should be protected from further damage and treatment instigated. A decision needs to be made early as to whether the frozen

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part has a risk of re-freezing or whether it can be kept warm after thawing. If the thawed tissue could refreeze it is safer to keep the part frozen until a thawed state can be maintained. It is VITAL to absolutely avoid refreezing if fieldthawing is achieved. a. Treat hypothermia – This often occurs concurrently with frostbite and causes peripheral vasoconstriction that will impair blood low to the extremities. Mild hypothermia is treated at the same time as frostbite but moderate/severe hypothermia should be treated first. b. Hydration – Fluids should be given to optimise circulating blood volume and maintain normal levels of hydration.

Oral fluids should be given to alert patients with no gastrointestinal problems and IV fluids to those patients with nausea, vomiting or altered mental status. c. Ibuprofen – This drug reduces inflammation which can reduce blood low to the peripheries. 12mg/kg/day should be given, divided into two doses. The maximum daily dose 2400mg. d. (If the frozen area cannot be kept warm after thawing then apply bulky, dry gauze or cotton dressings to the frozen part and between the fingers/toes. If at all possible the patient should not use the frozen part for walking/climbing or other activities until definitive care is reached) e. Rapid rewarming – Field rewarming with a warm water bath should be performed if definitive care is more than 2hours away. Water should be kept around 37-39degrees but if a thermometer is not available the care giver should place their hand in the water also to ensure the water will not cause a burn injury. Rewarming should be complete within approximately 30minutes but visually the caregiver is looking for the affected part to turn a red/purple colour and become soft and pliable to touch. f. Dry – The area can be patted dry or left to air dry to minimise further damage. g. Pain relief – Rewarming will be an intensely painful procedure and so, additional to ibuprofen, the medic may wish to give stronger analgesia if it is within their skill set. h. Dressings – Apply dry, bulky dressings to the frozen part for protection and wound care. Circumferential dressings should be applied loosely in the anticipation of significant swelling. i. Elevation – If possible the injured part should be elevated above the level of the heart which may decrease the development of swelling j. Protection – Ideally a newly thawed part will not be used for walking, climbing or other activities but a risk/benefit analysis must be carried out to balance the risk of further trauma against evacuation by ambulation (walking) Do Not: a. Give alcohol b. Rub the affected area c. Burst blisters d. Thaw affected part using a ire, heater or oven

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Immersion Foot Immersion foot was first described during World War one and coined as trench foot. Napoleons Surgeon has described it with other terminology during the campaign against Russia. It is defined as a non-freezing injury occurring when tissue is immersed in water for a prolonged period where the temperature is above freezing or feet are kept wet inside socks and ill fitting boots for prolonged periods.

Damage occurs to soft tissue cell, blood vessels and nerves and the longer the exposure to cold, the greater the chance of injury. Injury may be temporary or may result in permanent damage particularly to the nerves of the feet. Chilblains are used to describe permanent symptoms following one or more incidents of trench foot.

The symptoms of trench foot include burning and tingling of the feet. Loss of sensation is common. The effected potions of the foot and toes can appear cyanotic (grey) and blotchy (marbling). When warming the feet after cold exposure, burning can become severe. Maceration and fissures of the skin are common. Blisters, erythema (redness) and skin that peel are also common with repeated exposure to the cold. In warm environments such as the jungle immersion foot can lead onto severe fungal infections and open sores.

Treatment involves removing from the cause with gentle cleaning and drying. Expose the foot to room temperature and handle with extreme care to reduce tissue damage. Avoid rubbing which causes further tissue damage and provide adequate analgesia as the rewarming period can result in severe pain, anti-inflammatory analgesia is effective due to the associated swelling.

Antifungal treatment might be appropriate and can include potassium permanganate washes and antifungal creams such as daktarin.

In severe cases the part is painful to touch and an inability to walk, wear footwear is found, with the patient only able to withstand a loose covering over the feet to insulate.

Altitude Illness: Travel to elevations above 2500 m is associated with risk of developing one or more forms of acute altitude illness: acute mountain sickness (AMS), high altitude cerebral oedema (HACE), or high altitude pulmonary oedema (HAPE). Acute mountain sickness is the most common of the spectrum of altitude illness and generally begins 6 to 12 hours after arrival at altitude. Symptoms include headache, fatigue, loss of appetite, nausea and sleep disturbance.

High altitude pulmonary oedema typically occurs within 2 to 4 days after arrival at altitudes over 2500m. HAPE is not necessarily preceded by AMS. Symptoms include shortness of breath with exertion which progresses to shortness of breath at rest along with a dry cough which progresses to a productive cough which may be blood-stained.

On auscultation a wet sound may be heard at the base of BOTH lungs, similar to the sound of fresh snow being walked on. High altitude cerebral oedema represents the end stage of the altitude illness cascade and, if left untreated, will progress to death. Signs and symptoms include headache, lethargy, confusion and ataxia. As with many expedition medical complaints altitude illness is potentially preventable using simple techniques: a. Gradual ascent â&#x20AC;&#x201C; Controlling the rate of ascent is a simple but very effective means of preventing altitude illness.

When assessing the rate of ascent, the altitude at which the person sleeps is the most important factor. Above an altitude of 3000m individuals should not increase the elevation at which they sleep by more than 500m per day and a rest day should be included every 3-4 days. b. Medications â&#x20AC;&#x201C; Acetazolamide is the preferred drug for AMS prevention. It should be started the day before ascent, 125mg twice daily. Dexamethasone is an alternative drug and should be started on the day of the ascent, 4mg every 12 hours. Once descent has begun medications can be stopped.

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Treatment: a. The SINGLE BEST TREATMENT for all altitude illness is to descend. Individuals should descend until their symptoms resolve. This is usually within 1000m. i. Acute mountain sickness – Patients may remain at the current altitude and use non-opiate analgesics to control headaches along with antiemetics for gastrointestinal symptoms. This may be all that is required. ii. High altitude pulmonary oedema – Descend! Supplemental oxygen may be used and targeted to oxygen saturations of 90%. Portable hyperbaric chambers can be utilised but should not delay descent in situations where descent is feasible. Nifedipine can be used alongside descent and oxygen but ideally is not used as a sole treatment. 60mg per day of the sustained release version can be given in divided doses of 30mg twice a day. iii. High altitude cerebral oedema – Descend! Portable hyperbaric chambers can be utilised and are an effective treatment, but should not delay descent in situations where descent is feasible. Supplemental oxygen can be used but is reserved for severe cases and is targeted to oxygen saturations of 90%. Acetazolamide 250mg twice daily or dexamethasone 8mg followed by 4mg every 6 hours until symptoms resolve. iv. Note – HAPE: Prior to initiating treatment, care should be taken to rule out other causes of respiratory symptoms at high altitude, such as pneumonia, viral upper respiratory tract infection, bronchospasm, or myocardial infarction. HACE: Care should be taken to exclude disorders whose symptoms and signs may resemble those seen in AMS and HACE, such as dehydration, exhaustion, hypoglycemia, hypothermia, and hyponatremia.

Jungle Medicine Malaria Malaria is a serious mosquito-borne infectious disease. If not treated promptly it can be fatal. It can be caught from the bite of a single infected mosquito. Malaria is endemic in more than 100 countries in tropical and sub tropical areas of the world; see the map below, copied from the World Health Organisation, for Malaria endemic areas.

Depending on the malaria risk in the area to be visited, international travellers may need to take preventive medication (chemoprophylaxis) prior to, during, and upon return from their travel. Advice can be found on the National Travel Health Network and Centre website (www.nathnac.org) with regard to malaria and other endemic diseases but, in addition, guidance should be sought from a specialist travel clinic.

Prevention is better than cure • Prevention of mosquito bites between dusk and dawn is the first line of defence against malaria. Measures to prevent mosquito bites include sleeping under long-lasting insecticidal nets, and using protective clothing and insect repellents.

• Chemoprophylaxis is not 100% effective however taking preventative drugs and taking bite avoidance measures will give substantial protection against malaria.

Symptoms of malaria include fever, headache, and vomiting, and usually appear between 10 and 15 days after the mosquito bite. Any traveller who develops a fever of 38°C or more in a malaria endemic area should assume malaria until proven otherwise.

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Snake Bites Snake bites account for approximately 125,000 deaths annually worldwide. The venom from four families of snakes (Atractaspididae, Colubridae, Elapidae, and Viperidae) is toxic to humans. Any snake bite must be treated as a medical emergency. Field Management is aimed at slowing the envenomation process, by reducing the spread of venom. It is critical that a patient is transferred to a medical centre equipped to deal with snake bites.

Management Airway and breathing must be closely monitored. Tight fitting clothing and rings must be removed to prevent constriction with inevitable swelling. Studies have shown that fast immobilisation with a pressure bandage can result in significant delay in systemic envenomation.

• Place the patient at rest and do not allow movement unless in immediate danger • Reassure the patient • Pressure bandages need to be applied as soon as possible, do not take clothing of, movement may promote envenomation. See diagram below for correct pressure bandage immobilisation technique. (www.bmj.com).

Bandage applied as tight as for a sprained ankle • Start bandaging as distally as possible and extend the bandage as high as possible on the limb • Apply a splint to immobilise the limb • Give analgesia but avoid aspirin Continue to monitor ABCs as patients can deteriorate rapidly. There is continued debate as to washing wounds, this can theatrically reduce the bacterial load, however keeping the venom on the skin potentially allows for hospitals to identify the snake involved.

There are many old wives tails which can make snake bites worse; • DO NOT apply tourniquets • DO NOT apply ice • DO NOT apply heat • DO NOT apply and type of lotions or ointments.

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Bites and Stings While a snake bite is not usually serious, it is safer to assume that a snake is venomous. A venomous bite is normally painless. It is good practise for the first aider to make themselves aware of types of snakes that are in the area they are working.

Snakes are normally “dry” ( no venom is released by the snake) and do not result in envenomation. Most envenomous bites result when the snake is antagonised, kicked or by an accidental encounter in or around its territory.

Cobra

Mamba

Precautionary measures Leave the snake alone and stay away from it.

Stay out of tall grass when possible, if this is not possible wear thick boots Be carefully when picking things up such as rocks and firewood Be cautious with gaps in rocks when climbing If you encounter a snake, give it at least six feet between you and the snake.

Signs and symptoms Elapids (Cobra, Mamba, Coral) .

Pins and needles, spreading from bite site Paralysis, numb tongue, inability to swallow Cardiac problems, Respiratory problems Vipers (Rattlesnake, Puff adder, Saw scaled Viper, Russell’s viper) Pain +++ and bleeding around bite site Swelling and bleeding gums

Treatment • Medical support ASAP • Identify snake if possible • Reassure, stay calm. (remember most bite are non envenomous) • Sit casualty down, try to reduce casualties heart rate • Thoroughly wash wound as much as possible • Immobilise limb to reduce blood flow • Remove constricting jewellery • Apply constricting bandage if bite is on limb. (armpit to hand/groin to foot) • Give pain relief DO NOT GIVE ASPRIN • If spitting venom, bath and irrigate with water or milk.

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Spiders There are thousands of spider species worldwide. Most spider bites are minor and not life threatening. There are some which give life threatening bites.

Black Widow

Camel Spider

Brown Recluse Spider

Signs and symptoms (in most cases) • Redness around area of bite • Pain • In rare circumstances casualties may have an Anaphylactic reaction

Treatment • Pain relief such as Paracetamol • Cool with ice packs if available As with snakes, check to find out which spiders inhabit the area you may be working in

Scorpions The amount of venom injected by the scorpion will determine how severe the sting may be. Scorpion stings can be fatal but this is very rare in adults. Most stings are in the hands due to people trying to pick them up or interrupting the place they are occupying. Scorpions are rarely seen during daylight as they hunt mostly in the evening.

Black Widow

Camel Spider

Brown Recluse Spider

Signs and symptoms • Sharp pain • Swelling/discoloration that gradually spreads • Nausea and vomiting • Restlessness • Drooling and poor coordination • Incontinence • Seizures

Treatment • Apply ice to relieve pain • Ensure clear airway • If available, give antivenom • Transport to hospital ASAP

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CHAPTER 12: Casualty Centred Rescue Improvised Extrication for Remote Operations Heat Illness

The Casualty Centered Approach To be of use the team / Individual needs to have had appropriate training, reasonable experience of road traffic collision care and, ideally, should be known personally to the rescue crews calling for assistance. There are various qualifications in pre hospital care that within first world urban areas are appropriate e.g. ATLS, PHTLS, PHEC, Diploma, PALS etc. and individual doctors will have various levels of experience and expertise. Remote Practitioners may support medical / rescue teams in the following ways: This type of support can help in 3 ways: • To provide telephone / Radio advice for difficult situations / locations or to help make difficult decisions • To provide specialist skills/equipment i.e. Cricothyroidotomy, chest drain, certain specialised drugs and IV access techniques • To help manage the trapped patient in a general manner, bringing their experience to help avoid possible problems; i.e. acting as a roadside consultant to the local rescue agencies.

Every trapped patient should have the benefit of an experienced MIRA Practitioner if optimal care is to be given. It also allows rescue crews the opportunity of learning from the practitioner’s experience of similar problems in the past.

This will only be of value if the practitioner is properly trained and experienced.

In this way the concept of seamless care from accident to definitive treatment can be promoted using, if necessary, the practitioner’s presence at the scene to facilitate decisions regarding “the right patient to the right hospital in the right time” rather than the current practice in most services / locations of having to take the casualty to the nearest hospital, whether or not it has the facilities to cope with that particular casualty.

Reading the Scene Examination of the accident scene helps to predict the kind of injuries that the victim may have sustained and these injuries should be positively sought.

It is therefore essential to take an overall impression at the accident scene as we (the rescuers) approach. This requires great discipline, not to be distracted into doing what others expect of you or what your emotions want you to do.

In addition it is essential that we assess safety not only from the rescuer’s point of view but also considering overall scene safety and the safety of all the casualties involved in the incident.

From a background of knowledge and observation it should be possible to predict the injuries that the casualty may have sustained even although these injuries may not be apparent on one’s first examination.

Injury Prediction Let us look at certain situations in order to illustrate injury prediction, remembering at all times that there are potentially three collisions in any accident, all having the potential to produce damage to the body. These collisions are: • Firstly, that of the vehicle collides with another object.

• Secondly the occupant of the vehicle colliding with the inside of the vehicle which has now stopped.

• Thirdly the patient’s own body structures or organs move within the body cavities.

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When assessing a casualty remember that the possibility of unrecognised injury is increased when: • There has been a fatality in the same vehicle • The impact speeds are greater than 30 mph • There has been ejection from the vehicle of the casualty • The casualty has been involved in a rollover • The casualties vehicle has been hit from the side • There is significant deformity of the vehicle length or width • There has been a fall from height of over x2 or x3 the patient’s height • There has been a fall of greater than 6 meters

Road Traffic Collisions Cars In dealing with road traffic collisions, discover whether the accident involved a frontal, side or rear impact, and whether a rollover has occurred. Look for deformity of the vehicle and the potential intrusion into the passenger or driver compartments caused by forces from outside.

Objects within the vehicle may cause injury as they move at speed through the passenger compartment during a deceleration incident. Look for clues from inside the vehicle, which may suggest occupant injury: hand baggage in front seat area (originally in boot!)

Frontal Impacts Frontal impacts occur when the front or front corner of the vehicle collides with another vehicle or a stationary object.

Whether the occupants of the vehicle were restrained or unrestrained by seat belts alters the patterns of injury that may be seen. The forces imparted to the occupants are related to the solidity of the object hit and the speed.

The unrestrained front seat occupant will move forward, there will be extension of the lumbar spine, their knees will hit the parcel shelf or fascia and often there will be upward movement of the body so that the head hits the vehicle roof.

This will then be followed by flexion of the neck as the body continues to move forwards in an unrestrained way and the head will then hit and often break the windscreen. In the case of a driver, the chest then comes in contact with the steering wheel. The occupant will then tend to move backwards and there may well, at this point, be hyperextension of the neck.

Restrained front seat occupants still tend to move forward and depending upon the force there may be injuries from the seat belt, both the chest and the lap components of the modern system. The occupant will still tend to lex their cervical spine and the head can still come in contact with either the windscreen or the steering wheel.

Other injuries seen in this type of impact are those associated with the arms and legs moving forward and hitting the dashboard. Multiple limb fractures are often the result.

Airbags can reduce the forward movement but may be associated with different but less severe injuries, particularly to the arms and wrists or abrasions to the face and neck.

Injuries to rear seat occupants on the whole are less severe, but an unrestrained rear seat passenger will be thrown forward causing either injury to themselves or possibly further injury to the front seat occupants. The rear seat occupants may suffer neck and knee injuries or if they have been restrained by a lap belt may have injuries to the abdominal viscera.

During the impact it is possible that the doors may have burst open and any unrestrained passenger may have been ejected causing further injury. Unrestrained rear seat passengers, particularly children or babies’ may have been thrown through the windscreen

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Expected injuries from frontal impact: Lower Limb Injuries • Fracture Patella – Dashboard • Dislocated Knee – Dashboard • Femoral shaft fracture – Indirect • Dislocated hip – Indirect • Tibial fracture - Dashboard Abdominal compression (Seat Lap belt) • Rupture of hollow organs – stomach, bowel • Compression of solid organs- liver spleen kidneys Thorax Compression Skeletal (Steering Wheel) • Rib Fractures • Sternal Fractures • Flail chest Thorax Compression Viseral (Steering Wheel) • Heart – Tamponade contusion • Lungs – Heama-Pnuemothorax • Traumatic tear of arch of aorta Head Injuries Direct (Windscreen) • Frontal laceration • Skull Fracture Head Injuries Indirect (Sheer forces) • Whip Lash • Severed Spinal cord

Head-on Impact As the knee of the front seat occupant hits the inside of the car forces are transmitted along the leg, there may be dislocation of the knee, damage to the patella, fracture of the femur or posterior dislocation of the hip. Transmitted forces through the brake pedal particularly as the brake is being forcibly applied at the time of impact may result in mid foot, hind foot or ankle fracture dislocations. If the person was unrestrained, as the body moves forwards and upwards, and depending on whether the steering wheel hits primarily the chest or the abdomen, rupture of the organs within the body cavities may result.

There may be rupture of the liver or intestines but the injury to look for, is rupture of the diaphragm. As the forces compress the abdomen the diaphragm can rupture and the abdominal contents may enter the chest cavity. This injury should be remembered particularly when assessing ventilation or if invasive procedures such as chest drains are to be considered. There may also be tearing of the vessels on the posterior abdominal wall.

The only clue to these potential serious injuries may be pattern bruising which may extend across the abdomen or chest. If the chest itself has taken more of the force there may be rib injuries, producing a flail chest, pulmonary or myocardial contusion, or possibly thoracic aorta or coronary arteries damage. Finally, the lungs themselves may have been ruptured.

As the occupant became aware of the impending accident they may gasp, hold their breath and at the point of impact the respiratory system may, in essence, be a closed system. This may cause the lungs to rupture creating a pneumothorax or potentially a tension pneumothorax.

Damage to the head may result when it either strikes the roof, and/or the windscreen resulting in laceration or fracture of the skull. The brain underneath may receive the typical contra-coup type injury and there may be more widespread vessel damage with the development of an extradural or subdural haematoma or intracranial injury.

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The cervical spine may receive flexion or extension injuries resulting in either soft tissue or bony injury. In the prehospital situation, the potential for cervical spine injury should be recognised at all times. If there is any injury to the person above the clavicles then cervical spine injury should be assumed until that person has been assessed and X-rayed in an accident department.

Remember, ejection from a vehicle is associated with a six times greater mortality than a restrained and retained occupant.

Rear Impact Rear impact may cause hyperextension injuries to the cervical spine or spinal injuries at a lower level to the occupants of the vehicle. Much will depend on the use of correctly fitted seat belts and properly adjusted head restraints. In rear impact collisions it is again essential to understand how the accident occurred. If the vehicle was stationary and struck from behind the occupant will be accelerated forward and will often suffer a hyperextension injury to the cervical spine. However, if the accident was a result of the driver braking very suddenly and strikes the car in the front and at the same time is struck from the rear, the injury pattern will be a mixture of injuries seen in a head-on collision coupled with that of a rear collision. If a car skids or spins, it may be travelling backwards when the impact occurs. The movement of the body in this situation will produce a different pattern of injury.

Front Seat Passengers • Posterior chest/Spinal injuries (From Rear Passengers impact) • Whiplash Rear Passengers • Spinal trauma • Knee/Femoral injuries • Whiplash

Side Impact Side impact may produce injuries such as arm and leg fractures, chest or abdominal injury (these injuries may be time critical due to bleeding) which will obviously depend upon which side of the body was hit and how much intrusion has taken place into the passenger or driver compartment. This type of impact is often more serious because of the engineering difficulties in making vehicles resistant to side impact.

Left Sided • Rib Fractures Pulmonary contusion • Splenic Injury • Renal Contusion • Upper limb fractures • Femoral/pelvic Fractures • Head/Neck injuries & Brain injury Right Sided • Rib Fractures Pulmonary contusion • Hepatic Injury • Renal Contusion • Upper limb fractures • Femoral/pelvic Fractures • Head/Neck injuries & Brain injury With side impact there are two possible injury patterns and these will depend whether the car was hit squarely on the side or whether it was hit more towards one corner or the other. In the latter type of collision, the car hit on the side may rotate around the point of impact and this motion may create further injury. Side impact without any movement away from the impact or rotation often results in greater damage to the occupant causing injury to the arm, clavicle and chest wall on the side of the impact resulting in a fractured clavicle or a flail chest. There may be injury to the organs on that side (either the lungs or abdominal contents) There may be damage to the pelvis and femur on the side of impact.

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Head and scalp injuries may occur as the side of the car and the head collide producing either external lacerations or possibly internal cerebral haemorrhage. The cervical spine often suffers considerably in side impact because the forces produce not only lateral flexion but also rotation producing tears and strains in the ligaments as well as fractures of the spine itself.

If there has been impact more to the front corner of the car there may be additional injuries to the lower limbs depending upon the amount of intrusion that has occurred into the front well of the car.

Rollover or Somersault These events often cause multiple injuries with a mixture of the patterns of injury described above. In addition there may be vertebral column injuries due to compressive forces with collapse of the roof.

Deceleration Injuries In deceleration injuries not only will the body sustain injury as a result of contact with some point of the interior of the car or due to excessive bending or twisting of the body but deceleration produces significant injury to certain body structures which may not be obvious initially.

Organs or structures within the body moving forward or twisting around a fixed point bring about deceleration injuries. This will often result in injury to the thoracic aorta (particularly rupture), injury to the liver or damage to the coronary arteries. It is also possible to have damage to the cerebral blood vessels. Within the abdomen there may be mesenteric tears caused at the point of attachment of the mesentery with the small or large intestine or it is possible to have damage to the kidneys or renal system.

Head Direct Force • Frontal Laceration & Fractures with underlying cerebral contusion.

• Head Indirect Force (Shear) • Vascular shear subdural haematomas Spinal • Hyperextension and flexation resulting in brain stem tear.

Thoracic Direct • Rib and sternal fractures underlying contusions Thorax indirect • Traumatic aortic tear • Airbags being deployed

Airbags Airbags and seat belt pre-tensioners are found on more and more cars. Airbags are commonly fitted into the steering wheel on the driver’s side but some cars have passenger airbags, side impact or roof impact bags as well. The system is activated by a head-on accident or within 10° of a direct head-on accident. Within milliseconds of an accident the airbag is inflated and then rapidly delated. The driver moves forward and actually hits the airbag as it is delating.

The whole process works so quickly that people who have been involved in an accident, in which airbags have been deployed, have very little recollection of the airbag at all and often report that the airbag did not work.

Following deployment the inside of the car will be filled with a white talc-like powder, which is completely inert, and the patient also looks white. Airbag deployment has reduced the number of facial and chest injuries but there have been reports of increased hand and arm injuries.

The fear of emergency care workers revolves around the concern that an airbag may activate during a rescue.

Unfortunately even following disconnection of the battery themcapacitor in the airbag system may retain its charge for a considerable length of time but it is unlikely that an airbag will be activated. The ire service can give expert advice on safety. Vehicles having airbags fitted will usually display an airbag symbol on the windscreen.

Some seat belt pre-tensioners have explosive charges, which ire under particular load conditions and increase the tension in the seat belt so improving the effectiveness of the belt system. Again care is required because casual handling and cutting of seat belts may activate the firing mechanism.

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Motor Cycle Accidents Injuries to motorcyclists are often due to the motorcyclist being thrown of his bike during the accident. Injuries are due to the motorcyclist coming in contact with the motorcycle, another vehicle or surface on which the motorcyclist lands.

Always check the helmet for signs of damage and look for pattern bruising during the secondary survey and send the helmet to hospital with the patient.

As the motorcyclist moves forward and upwards often their thighs will strike the handlebars resulting in mid-shaft femoral fractures, which can often be bilateral.

Other forms of impact may cause the rider to be thrown of the bike and as a result may strike other parts of the motorcycle or other vehicles causing either lacerations or fractures to the part of the body struck. If the motorcyclist is not thrown clear then there may be resulting crushing of the lower limb as the motorcycle lands on the rider or dislocation of the ankle as the bike drags the rider. These injuries may often produce a lot of soft tissue mutilation.

Depending upon the way in which the motorcyclist lands and the surface upon which he is landing on further injury may be produced. It must also be remembered that there is the potential for a second accident with the motorcyclist being struck by another vehicle.

It should be remembered that motorcycle helmets, although providing considerable protection to the head and face provide no protection at all to the cervical spine.

Pedestrian Accidents The patterns of injury in pedestrian accidents vary depending whether an adult or child was involved because of their obvious difference in height. Modern cars have â&#x20AC;&#x153;softâ&#x20AC;? frontal structures and the aerodynamic styling tends to lift adults onto the bonnet. The fitting of bull bars to the front of cars removes this safety feature.

Adults are usually struck on the lower legs producing fractures of the tibia and fibula and then depending upon how the pedestrian was thrown, they will either be hit by the vehicle producing injury to the thorax, abdomen, pelvis, or possibly to the head. Injury may also be caused as the pedestrian comes into contact with the ground producing abrasions or, more significantly, depending upon the speed and attitude of the body, spinal injury. There also exists the potential for further damage as a second vehicle may hit the pedestrian.

Children being smaller are hit higher in the body and therefore often receive injuries to their femurs or pelvis as the first point of impact. As they are lighter than adults they tend not to be thrown clear but often may be caught up by the vehicle and dragged along, either being run over by a wheel or coming to rest underneath the vehicle with the potential for injury particularly from the hot exhaust system.

Adults The vehicle bumper resulting in open or closed lower limb fractures strikes lower limbs. The thorax is hit by the windscreen and the patient head hits the roadside.

Children (Waddles Triad) The vehicle bumper resulting in open or closed lower limb fractures strikes lower limbs. The abdomen is hit by the bonnet resulting in injury to the internal organs and the patient head hits the roadside.

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Phases of Rescue 1 Scene safety-Assessment of scenario- Perimeter Security / Fire risk / Vehicle stability / passive safety systems 2 Immediate contact with casualty, assess priority. CCA! Nominate casualty carer 3 Rapid entry, door/rear /hatch, Time Critical 4 Rescue- disentanglement procedure, space creation techniques. Relocating material (cut/pull) 5 Extrication of casualty from vehicle, Immobilise. Minimise twisting/potential for damage 6 Evacuation method-requires early consideration (comms)

Improvised Extrication • Perimeter Security –Con Ops/SOP Vehicle specific FIRE (DP extinguisher, Isolate battery, suppress leaks) PASSIVE SYSTEMS (deployment path, accidental triggering) HAZ SUBSTANCES cargo, other vehicles, weapon/ammunitions • Stability of wreckage.

• Assess type/No. Vehicles- generic design • Read wreckage- deformation will indicate injuries • Ensure control measures active.

• Improvised Extrication • Space Creation Techniques • Minor damage - Open Doors!!

• Windows-glass• Rear door/hatch • Major damage-Windows, glass • Rear hatch • Breach doors!

• Cut, pull away, push.

• Roof removal by cutting pillars. LIMITED !!!

• 3rd door creation. LIMITED !!!

Casualty Centred Approach • AIRWAY - basic, don’t focus on dramatic injuries elsewhere. C spine control.

• Breathing - assess rate/function.

• Circulation - overt haemorrhage.

• Disability - AVPU. Record GCS • Revisit vital signs - Time is Critical!

Improvised equipment Bottle jack Wheel brace Hacksaw Hooligan bar Jerrycans Rope Floor mats Sandbags Tape Glass hammers/seat belt cutter

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CHAPTER 13: Prolonged Field Care Once a patient has been stabilised and all life threatening injuries have been addressed it may be pertinent to consider the ongoing treatments and care plan for a patient for a prolonged length of time.

Obviously the amount of further care and treatments delivered will vary depending on the skill level of the medic and also the amount of time that the patient is going to be in your care.

Secondary survey: a. Once the primary survey is complete and any life threatening injuries have been identified and treated, the medic may now continue with a secondary survey as necessary. A patient with a life threatening injury should never be detained unnecessarily in the field if at all possible and transport towards definitive care should be initiated as soon as possible. However, if transport is delayed or the patient has only minor injuries then a secondary survey may be relevant. b. A secondary survey of the patient involves a thorough examination from head to toe with the aim of identifying all the patients’ injuries no matter how trivial. The secondary survey should be carried out in a warm, sheltered and well lit location, if at all possible, as the patient should be full exposed, whilst maintaining dignity. Whilst checking all areas of the body for injury, the hands and feet should be checked for MSC – Motor: test for movement and power, Sensation – apply light touch to test for sensation, Circulation – check pulse, capillary refill and skin temperature. c. After the physical assessment is complete a set of observations should be taken from the patient, initially following the ABCD pattern. The airway should be checked for patency and maintenance, the rate and work of breathing should be assessed along with the oxygen saturations. The pulse rate should be gained along with a capillary refill, blood pressure and ECG if possible or relevant. A more detailed assessment of the patient’s level of consciousness should then be undertaken using the GCS scale as below. This scale is used as it is more sensitive to changes in the patient’s condition than the AVPU score. The eye, verbal and motor scores are added up to give a score out of 15. The most significant risk associated with a deteriorating GCS is that the patient’s airway may become compromised. d.

Adult Glasgow Coma Score Eye Response

Verbal Response

Motor Response

Open spontaneously

4

Open to verbal command

3

Open in response to pain

2

No response

1

Talking/Orientated

5

Confused speech/Disorientated

4

Inappropriate words

3

Incomprehensible sounds

2

No response

1

Obeys commands

6

Localises pain

5

Withdraws from pain

4

Abnormal flexion

3

Extension

2

No response

1

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e. Observations relevant to the patients’ situation and condition can then be taken including blood sugar levels, temperature etc. f. An AMPLE history should then be obtained from the patient: i. Allergies – what the patient is allergic to (if anything) ii. Medications – what tablets the patient is taking iii. Past medical history – what injuries, illness has the patient had in the past iv. Last meal – when did the patient last eat or drink v. Events leading up to patient presenting to you g. All the obtained information should then be documented in an orderly fashion and the observations taken from the patient (pulse, blood pressure, respiratory rate etc) should be repeated regularly. Observing the condition of the patient is a continual process but formal recording of the patient’s vital signs should take place on a regular basis depending on their condition. A patient who is critically ill will require more frequent formal recording of their vital signs.. As a guide, a generally unwell patient in hospital will have vital signs recorded approximately every four hours whereas a critically ill patient can have them taken as often as every fifteen minutes. h. In some situations the medic may be responsible for a patient for a prolonged period of time, either due to geographical or logistical challenges. In these cases there are further issues which will need to be considered to ensure effective and holistic patient care. These issues can be remembered using the pneumonic: FIELD CARE: i. F - Fluids/Food: A patient being managed in the remote environment will require adequate food and fluid intake to ensure that they maintain nutrition and hydration. Oral fluids are the preferred route for administration.

Oral re-hydration solution (ORS) should be given if the person can tolerate it and it can easily be prepared in the field by mixing 8 teaspoons of sugar, ½ teaspoon of salt, and 1 L of water. ORS is especially effective because it contains both salt and sugar, which contribute to its rapid absorption by the gut. Unfortunately, this is sometimes difficult to accomplish in patients with significant vomiting, diarrhoea, or altered level of consciousness. Vomiting itself does not mean that oral re-hydration cannot be given. As long as more fluid enters the body then exits, re-hydration will be accomplished. It is safe to give adults as much fluid as they can tolerate, guided by their thirst sensation. If oral fluids cannot be given then IV fluids will need to be given to prevent against dehydration. An adult should be given 2litres of 0.9% NaCl per day which should be given over the period of 24hours at one drip per second. Fluid intake should be targeted to produce champagne coloured urine of good quantity and regularity. If the patient is able to eat then they should eat small amounts of carbohydrates on a regular basis. ii. I – Infection: Ensure all wounds are cleaned with clean water (any water than can be drunk is clean enough for wound care) or saline and dressed with clean, sterile dressings and closed with an appropriate material as per the medics training. Prophylactic antibiotics should be given up to the skill level of the medic and the wound should be observed over the coming hours/days for signs of developing infection. These include: redness, heat, swelling, pain or exudate (pus). iii. E – Environment: Ensure the patient is being managed in a situation that allows the medic to work efficiently as well as protecting the patient from adverse conditions. This not only ensures patient comfort but also positively affects the way that the body responds to injury. If the patient’s injuries allow then consideration should be given to moving the patient every four hours to prevent pressure sores developing. iv. L – Lines: Any lines or tubes that have been introduced into the patient, for example airways or cannulas, need to be regularly checked for patency and to ensure that there is no developing infection with the signs and symptoms listed above. v. D – Documentation: As previously discussed, all interventions, observations and patient history need to be carefully recorded. vi. C – Communication: As necessary, Doctor top cover should be consulted, evacuation plans initiated or expedition field base updated. vii. A – Analgesia and medications: Keeping the patients pain under control is important not only for their wellbeing but also because a patient who has their pain under control will be more compliant and are likely to have better outcomes. Use the World Health Organisations “Analgesia Ladder” along with your scope of practice to determine the strength of analgesic to administer (see below). Additional medications such as antiemetics, antihistamines etc also need to be considered as necessary.

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viii. R – Reassess: Constant re-assessment of a patient is vital to establish any improvement or deterioration in the patients’ condition which will further guide the care of your patient. Reassessment should include questioning the patient on their needs may result in information previously overlooked. ix. E – Excretions: An ill or injured patient still needs to urinate and defecate. This needs to be taken into consideration when planning patient care and evacuation. In addition to this, urine colour, amount and frequency should be recorded as this gives an indication to the patient’s level of hydration. An adult needs to urinate a minimum of 30ml/hr otherwise they are in danger of severe dehydration and kidney failure.

Analgesic Ladder (based on WHO guide):

Severe Pain Moderate Mild Pain

Paracetemol Ibuprofen Asprin

Co-codamol Codeine Tramadol Diclofenac

Fentanyl Morphine

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CHAPTER 14: Major Incident Medical Management Introduction The management of a single seriously injured casualty is frequently problematic in its own right. In a remote setting, problems are compounded by environment, difficult terrain and other constraints. The situation is made even more difficult when faced by a large number of casualties.

If a system for prioritisation of care of the injured is not in place, many salvageable casualties may die unnecessarily.

Triage (from the French verb: trier, to sieve or to sort), has evolved through military conflicts dating from the Napoleonic wars to recent civilian disasters.

Definition The process of Triage is complex. The preferred definition is: “Sorting casualties and the assignment of treatment and evacuation priorities to wounded at each role of medical care”

Aims The aims of triage, whenever it is done, are not only to deliver the right patient to the right place at the right time so that they receive optimal treatment but also to “do the most for the most”.It can be deducted from this that triage principles should be applied whenever the number of casualties exceeds the skilled help immediately available.

Timings Triage is a Dynamic rather than a Static progress. The state of the patient may change for better or worse either because of a progression of the injuries or due to interventions being made. Triage may be repeated many times during the care of a casualty. For example, a typical casualty might be triaged when he is first seen, again prior to movement from the immediate scene, in a casualty clearing station, prior to further evacuation, on reception to definitive care establishment, during resuscitation and treatment and prior to surgery. In addition to this, a reassessment may be carried out when the patient’s condition is noted to have changed.

Priorities There are four priority systems that are widely used. Two of these are derived from the military, although they are also incorporated into civilian triage labels: they are the “P” Priority system and the “T” treatment system.

For the purposes of this text the T system will be used. The four priorities are defined as shown below.

• T1, immediate priority – casualties who require immediate life saving procedures • T2, urgent priority – casualties who require surgical or medical intervention within 2- 4 hours • T3, delayed priority – less serious cases whose treatment can be safely delayed beyond 4 hours • T4, expectant priority – casualties whose condition is so severe that they cannot survive despite the best medical care and whose treatment would divert medical resources from salvageable patients who may then be compromised

Triage methods Having established the triage categories, it is necessary to provide a reliable method of triage so all users will come to the same triage decisions. There may be considerable numbers of casualties and a corresponding number of critical decisions have to be made very quickly (that carried out by the first rescuers on the scene) therefore needs to be as rapid, simple, safe and reproducible.

Once primary triage has been carried out, more time and resources may be available at a designated safe area for a more detailed “secondary triage” assessment. The simple methods to support these two levels of triage will be referred to as the “triage sieve” and the “triage sort” respectively.

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Triage methods Having established the triage categories, it is necessary to provide a reliable method of triage so all users will come to the same triage decisions. There may be considerable numbers of casualties and a corresponding number of critical decisions have to be made very quickly (that carried out by the first rescuers on the scene) therefore needs to be as rapid, simple, safe and reproducible.

Once primary triage has been carried out, more time and resources may be available at a designated safe area for a more detailed “secondary triage” assessment. The simple methods to support these two levels of triage will be referred to as the “triage sieve” and the “triage sort” respectively.

Triage Sieve This first look sorts quickly sorts the casualties into priorities. As it is quick it is not perfect, but any mistakes made at this stage can be corrected later on.

Mobility: Those patients who can still walk are categorised as T3, delayed. This is the mobility sieve. Those patients who are not walking are assessed according to airway, breathing and circulatory parameters. A “quick” look to see if the patient is not breathing. If this is the case the airway is opened with a simple manual manoeuvre, and the patient assessed to see if breathing has started. Those patients who cannot breathe despite opening the airway are dead.

For those patients who are breathing, respiratory rate is used as an objective assessment of adequacy. If the rate is unusually low, (less or equal to 10) or unusually high (greater or equal to 30) then there is a breathing problem, these patients have a breathing problem therefore they are T1, immediate. If the respiratory rate is normal (i.e. between 10 and 30) an assessment of their circulation is made. This can be difficult in the pre-hospital environment.

A capillary refill time is assessed in the nail bed. If it is over two seconds the patient has a circulatory problem, they are therefore categorised as T1, immediate. If capillary refill time is less than two seconds then the patient is assigned to the T2, urgent priority.

Capillary refill time is used for the circulatory assessment because it can be rapidly ascertained and reflects peripheral tissue perfusion. It is, however, affected by ambient temperatures and will be significantly reduced in normal subjects in cold conditions. It is reasonable to assume that the normal capillary refill time for a casualty is the same as that for a rescuer when in the same conditions. Thus in cold weather, rescuers should be aware of their own capillary refill time and adjust the triage sieve accordingly.

In extremely cold conditions or in the dark, the capillary refill time may become impossible to use and in such circumstances it is reasonable to use a pulse of 120 beats per minute as the circulatory sieve, but this will take longer to assess (a capillary refill time takes seven seconds – five seconds to press and two seconds to read: a pulse takes at least fifteen seconds to measure).

The Triage Sieve is illustrated on the next page:

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Best practice is to carry out TRIAGE SIEVE in pairs

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Triage Sort Once casualties arrive in a stabile area they can be re-triaged in a more leisurely manner, providing there are the additional available resources to allow this. This process is deemed the “triage sort”.

Many physiological scoring systems have been described and the best known of these is the Trauma score. In the prehospital setting the Triage Revised Trauma Score (TRTS) has been advocated as the best system currently available. This is based on three parameters: respiratory rate, systolic blood pressure and Glasgow coma scale. These parameters are shown below to give a score from 0 to 12.

Respiratory Rate

10 – 29

4

>29

3

6-9

2

1-5

1

0

0

>90

4

76-89

3

50-75

2

1-49 1

0

0

Glasgow coma score

13-15

4

9-12

3

6-8

2

4-5

1

3

0

Systolic Blood pressure

The TRTS can be then used to assign triage priorities as shown below: Score Priority 1 – 10

T1

11

T2

12

T3

0

Dead

If the forth (expectant) category is used, then a TRTS of 1-3 can be used to define it. Trials carried out for government agencies have shown that non-expert staff can reliable trauma score casualties after a very short period of training.

The use of this system has been proven in recent terrorist attacks in mainland Europe (when a mass incident plan was in place using the triage system). Furthermore, many modern casualty labels incorporate trauma scoring as part of the patient report.

The advantages of the physiological methods are that they are quick, reproducible and essentially a part of the triage sieve. However, they do not take into account the nature of the injury at all and therefore cannot be used to decide whether a casualty should be sent to a specialist or a general medical facility.

By mixing together the best parts of the anatomical and physiological methods as described before, something close to an ideal can be achieved. The rapidity and simplicity of a physiological method such as the TRTS are used to define the initial priority. This is supplemented by as much relevant anatomical information as can be obtained in the time and conditions. Thus patients with head injuries can be selected to go to a neurological unit and casualties with burns can go to the relevant burns centre.

If evacuation from the area is delayed, the anatomical information can be expanded up to the level of a full secondary survey if time allows.

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Glasgow Coma Score The GCS is scored between 3 and 15, 3 being the worst, and 15 the best. It is composed of three parameters: Best Eye Response, Best Verbal Response, Best Motor Response, as given below:

Best Eye Response. (4) No eye opening (1) Eye opening to pain (2) Eye opening to verbal command (3) Eyes open spontaneously (4)

Best Verbal Response. (5) No verbal response (1) Incomprehensible sounds (2) Inappropriate words (3) Confused (4) Orientated (5)

Best Motor Response. (6) No motor response (1) Extension to pain (2) Flexion to pain (3) Withdrawal from pain (4) Localising pain (5) Obeys Commands (6) Note that the phrase â&#x20AC;&#x2DC;GCS of 11â&#x20AC;&#x2122; is essentially meaningless, and it is important to break the figure down into its components, such as E3V3M5 = GCS 11.

A Coma Score of 13 or higher correlates with a mild brain injury of 9 to 12 is a moderate injury and 8 or less a severe brain injury.

Summary The first look triage assessment is carried out at the site of the injury by using the triage sieve: this is usually followed up by a mixed approach to triage sorting consisting of a physiological score (TRTS) supplemented by relevant anatomical information.

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CHAPTER 15: Drug Classification & Administration Medicines should be prescribed only when they are necessary, and in all cases the benefit of administering the medicine should be considered in relation to the risk involved British National Formulary

Specific names All drugs in general use have three names, the chemical name, the generic name and the brand name. As a general principle it is better to use the generic name especially when travelling abroad as brand names will differ from country to country.

For example: Chemical name

4-1,4,4a,5,5a,6,11,12,a-octahydro-3,6,-10,12,12a penthadroxy-6 methyl-1,11-dixo-2naphthacenecarboxamide

Generic name

Tetracycline

Propriety name/brand

Achromycin, Cyclopar, Mysteclin

Drug Administration The majority of drugs need to reach the blood stream in order to reach the area in which they are needed. The method in which a drug is administered can affect the speed with which it can become effective. Common methods of administration are orally, rectally, injection (intramuscular, intravenous, intradermal and sub cutaneous) or implants under the skin. Other methods that limit absorption into the bloodstream and act locally are topical applications to skin or mucous membranes.

Sometimes a drug is given through the skinâ&#x20AC;&#x201D;by needle (subcutaneous, intramuscular, or intravenous route), by patch (transdermal route), or by implantation

Subcutaneous route For the subcutaneous route, a needle is inserted into fatty tissue just beneath the skin. The drug is injected, then moves into small blood vessels (capillaries) and is carried away by the bloodstream or reaches the bloodstream through the lymphatic vessels. Protein drugs that are large in size, such as insulin usually reach the bloodstream through the lymphatic vessels because these drugs move slowly from the tissues into capillaries. The subcutaneous route is used for many protein drugs because such drugs would be digested in the digestive tract if they were taken orally.

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Intramuscular route The intramuscular route is preferred to the subcutaneous route when larger volumes of a drug product are needed.

Because the muscles lie below the skin and fatty tissues, a longer needle is used. Drugs are usually injected into muscle in the upper arm, thigh, or buttock. How quickly the drug is absorbed into the bloodstream depends, in part, on the blood supply to the muscle: The sparser the blood supply, the longer the drug takes to be absorbed. The blood supply is increased during physical activity.

Intravenous route For the intravenous route, a needle is inserted directly into a vein. A solution containing the drug may be given in a single dose or by continuous infusion. For infusion, the solution is moved by gravity (from a collapsible plastic bag) or by an infusion pump through thin flexible tubing to a tube (catheter) inserted in a vein, usually in the forearm. Intravenous administration is the best way to deliver a precise dose quickly and in a well-controlled manner throughout the body. It is also used for irritating solutions, which, if given by subcutaneous or intramuscular injection, would cause pain and tissue damage. An intravenous injection can be more difficult to administer than a subcutaneous or intramuscular injection, because inserting a needle or catheter into a vein may be difficult, especially if people are obese.

When given intravenously, a drug is immediately delivered to the bloodstream and tends to take effect more quickly than when given by any other route. Consequently, doctors closely monitor patients who receive an intravenous injection for signs that the drug is working or is causing undesired side effects. Also, the effect of a drug given by this route tends to last for a shorter time.

Sublingual Route A few drugs are placed under the tongue (taken sublingually) so that they can be absorbed directly into the small blood vessels that lie beneath the tongue. The sublingual route is especially good for nitro-glycerine, which is used to relieve angina (chest pain due to an inadequate blood supply to the heart muscle) because absorption is rapid and the drug immediately enters the bloodstream without first passing through the intestinal wall and liver. However, most drugs cannot be taken this way because they may be absorbed incompletely or erratically.

Rectal Route Many drugs that are administered orally can also be administered rectally as a suppository. In this form, a drug is mixed with a waxy substance that dissolves or liquefies after it is inserted into the rectum. Because the rectumâ&#x20AC;&#x2122;s wall is thin and its blood supply is rich, the drug is readily absorbed. A suppository is prescribed for people who cannot take a drug orally because they have nausea, cannot swallow, or have restrictions on eating, as is required after many surgical operations. Drugs that are irritating in suppository form may have to be given by injection.

Ocular Route Drugs used to treat eye disorders (such as glaucoma, conjunctivitis, herpes simplex infection, and injuries) can be mixed with inactive substances to make a liquid, gel, or ointment, so that they can be applied to the eye. Liquid eye drops are relatively easy to use but may run of the eye too quickly to be absorbed well. Gel and ointment formulations keep the drug in contact with the eye surface longer. Solid inserts, which release the drug continuously and in slow amounts, are also available, but they may be hard to put and keep in place. Ocular drugs are almost always used for their local effects. For example, artificial tears are used to relieve dry eyes.

Drug forms Most drugs are prepared in a form for convenience of administration and to ensure accuracy of dose, the more common forms are tablets, capsules, liquids (mixture, elixir, emulsion, syrup) creams, ointments, lotions, injection/ infusion solutions, suppositories, pessaries, drops(eye, ear, nasal) sprays and inhalers.

Over-the-counter (OTC) drugs OTC drugs enable people to relieve many annoying symptoms and to cure some diseases simply and without the cost of seeing a doctor. However, safe use of these drugs requires knowledge, common sense, and responsibility. Most OTC drugs unlike health foods, dietary supplements have been studied scientifically and extensively. Also, some OTC drugs were originally available only by prescription. Often, the OTC version has a substantially lower amount of active ingredient in each tablet, capsule, or caplet than does the prescription drug.

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Prescription Only Medication drugs. (POM) A prescription drug is a licensed medicine that is regulated by legislation to require a prescription before it can be obtained. The term is used to distinguish it from over-the-counter drugs, which can be obtained without a prescription. Different countries have different definitions of what constitutes a prescription drug. As a general rule, over the counter drugs are used to treat conditions not necessarily requiring a doctorâ&#x20AC;&#x2122;s care and will have been proven to meet higher safety standards for self-medication by patients. Often a lower dosage of a drug will be approved for OTC use, while higher dosages will remain the province of a doctorâ&#x20AC;&#x2122;s prescription; a notable case is ibuprofen, which has been widely available as an OTC pain killer since the mid-1980s but is still available in doses up to four times the OTC dose for use in cases of severe orthopaedic pain.

Controlled Drug (CD).

The Misuse of Drugs Regulations 2001 divide controlled drugs into five schedules corresponding to their therapeutic usefulness and misuse potential.

Schedule 1 (CD licence): Have no recognised medicinal use and include hallucinogenic drugs. Examples include coca leaf, LSD and mescaline. Production, possession and supply of these drugs are limited to research or other special purposes. Practitioners and pharmacists may not lawfully possess Schedule 1 drugs except under licence.

Schedule 2 (CD): Includes the opiates, amphetamine and cocaine are subject to safe custody requirements and so must be stored in a locked receptacle, usually in an appropriate CD cabinet or approved safe, which can only be opened by the person in lawful possession of the CD or a person authorised by that person. A licence is required to import or export drugs in Schedule 2. The drug may be administered to a patient by a doctor or dentist, or by any person acting in accordance with the directions of a doctor or dentist. A register must be kept for Schedule 2 CDs and this register must comply with the relevant regulations. The destruction of CDs in Schedule 2 must be appropriately authorised and the person witnessing the destruction must be authorised to do so.

Schedule 3 (CD No Register): Includes a small number of minor stimulant drugs and other drugs that are less likely to be misused than the drugs in Schedule 2. These are exempt from safe custody requirements and can be stored on the open dispensary shelf except for lunitrazepam, temazepam, buprenorphine and diethylpropion, which must be stored in a locked CD receptacle. These are subject to the same special handwriting requirements as Schedule 2 CDs, except for temazepam and phenobarbital. Phenobarbital and temazepam can be dispensed in response to a computergenerated prescription but the prescriberâ&#x20AC;&#x2122;s signature must be added by hand. There is no legal requirement to record transactions in a CD register. The requirements relating to destruction do not apply unless the CDs are manufactured by the individual. Invoices must be retained for a minimum of two years.

Schedule 4 (CD Benzodiazepines and CD Anabolic steroids): These are exempt from safe custody requirements, with destruction requirements only applying to importers, exporters and manufacturers. Specific CD prescriptionwriting requirements do not apply. CD registers do not need to be kept, although records should be kept if such CDs are produced, or if a licensed person imports or exports such drugs.

Part 1 (CD Benzodiazepines): Includes most of the benzodiazepines, plus eight other substances including fencamfamin and mesocarb. Possession of is an offence without an appropriate prescription. Possession by practitioners and pharmacists acting in their professional capacities is authorised. These are subject to full import and export control.

Part 2 (CD Anabolic steroids): Includes most of the anabolic and androgenic steroids such as testosterone, together with clenbuterol (adrenoreceptor stimulant) and growth hormones. There is no restriction on the possession when it is part of a medicinal product. A Home Office licence is required for the importation and exportation of substances unless the substance is in the form of a medicinal product and is for self-administration by a person.

Schedule 5 (CD Invoice): Includes preparations of certain CDs (e.g. codeine, pholcodine, morphine) which are exempt from full control when present in medicinal products of low strengths as their risk of misuse is reduced. No restriction on the import, export, possession, administration or destruction of these preparations and safe custody regulations do not apply. A practitioner, pharmacist or a person holding an appropriate licence may manufacture or compound any CD in Schedule 5. Invoices must be kept for a minimum of two years.

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CHAPTER 16: Analgesia & Medicines It has been accepted that intravenous morphine is the gold standard for pre-hospital analgesia for severe injury however there is significant anecdotal evidence that intramuscular administration of morphine provides inadequate analgesia and may have an adverse effect on respiration when shock is a feature of the clinical picture. This occurs typically when the patient is resuscitated and perfusion to peripheral tissues is improved then the drug is taken up as a bolus where it contributes to respiratory depression, perhaps leading to cessation.

Perception of Pain In 1946 Beecher HK noted that on the beeches of Anzio soldiers who had lost limbs might not express pain to the same degree as a civilian in a road accident with comparable or less injuries (Note: Up to 75% of combat patients did not demand analgesia for up to 12 hours). He attributed this to soldiers regarding their injuries as a means to end their exposure to the horrors of war, whereas civilians regarded injury as the start of their misery. Culture, beliefs and mood affect the meaning of pain for an individual. Generally speaking the perception of pain is affected by age (younger people generally require more analgesia), sex (females of childbearing age require less analgesia), and previous pain experiences. Anxiety is a powerful modulator of pain.

Many trauma patients are restless following injury it is vital that the cause of restlessness is established before administering analgesia. Possible causes of restlessness are: • Hypoxia – identify shock and manage haemorrhage.

• Head injury • Effects of drugs and alcohol • A full bladder

Causes of Acute Pain There may be many causes of pain and many reasons why a patient requires pain relief: • Fractures, dislocations, sprains etc • Acute medical conditions e.g. appendicitis, testicular torsion.

• Acute disease e.g. myocardial infarction, renal colic • In support of clinical conditions e.g. chest - drain insertion, fracture or dislocation reduction.

Pain Assessment and Adequacy Analgesia is often ineffective due to underestimation of the patients needs. There is convincing evidence to suggest that both pre-hospital rescuers and even emergency doctors fail to recognise and adequately treat pain. A variety of tools are available to assist in the rapid and objective assessment of pain.

Simple Descriptive Pain Intensity Scale

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Both psychological and educational barriers have been cited as contributing to inadequate and inconsistent analgesia.

Before treating pain it is necessary to conduct an assessment by taking a history and doing a physical examination to determine what the cause of pain might be. Treating the underlying cause is the best treatment, where this is not possible a simple stepwise approach using physical, psychological and pharmacology should be adopted. Questioning the patient will point the rescuer in the right direction. Use the Mnemonic.

SOCRATES a. S – Site. Where in the body is the pain? b. O – Onset. What time did the pain begin? What was the patient doing? Was it sudden or gradual? c. C – Character. What does the pain feel like? (Sharp, aching, tearing etc) d. R – Radiation. Does the pain go anywhere else? e. A – Associated symptoms. Are there any other relevant symptoms (vomiting, diarrhoea, fainting, blurred vision etc). f. T – Timing. Is the pain constant or intermittent? g. E – Exacerbates/Eases. Does anything make the pain any better or worse? Patient positioning, analgesics etc. h. S – Severity. Get the patient to rate the score out of 10 with ten being the worst pain the patient could ever imagine and zero being no pain.

The Pain Pathway The exact mechanism by which an unpleasant stimulus causes pain is still unclear. It is believed that there are a number of receptors that are able to convert the range of painful stimuli into electrical signals and these are then transmitted via the nerves to the spinal cord. The ‘signal’ then ascends the spinal cord to the brain. Once in the brain it is then interpreted as pain.

The Management of Pain – Non-Pharmacological Fear and anxiety worsen pain. It is important not to underestimate the power of reassurance and being honest about the degree of pain that a patient may experience for any given condition. In some cases pre-preparing the patient by asking for their co-operation prior to any potentially painful intervention such as the application of traction, may bring about a ‘grit your teeth’ attitude from the patient.

The best treatment for pain is to treat the cause. First aid techniques go a long way to providing relief. Pain from superficial burns can be reduced by cold water in the immediate post injury phase, and later by air occluding dressings such as cling film.

Traction and splinting is very effective when done correctly, in reducing pain from fractures and dislocations and may well be adequate enough when complete to provide enough analgesic effect for the patient to tolerate his injury.

The Management of Pain – Pharmacological An ideal analgesic for pre-hospital remote areas would have the following properties: • Rapid onset • Simplicity of use • Low significant side effect profile • Sustained action • Ability to reverse the effects in the event of an overdose • Non-invasive administration • Low cost • Long shelf life • Broad range of temperature stability • No ‘Dangerous Air Cargo’ limitations • No ‘Controlled Drug’ limitations for storage and disposal

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Most analgesic pain medications can be divided into two general groups: narcotics and Non Steroidal Anti Inflammatory (NSAID). Narcotics exert their effects on the central nervous system, relieving pain by suppressing the brains ability to perceive it. Pain impulses still travel up the pain pathway from the injury site, but the intensity is dulled.

Examples are morphine, codeine, nubain. A related effect of narcotics is to depress the mental function, respiration and intestinal motility. You feel less pain but you are also clumsy, drowsy and constipated. This is ok in the context of a first world care system, but perhaps not so desirable in the middle of the Hindu Kush!

Another choice and perhaps a more useful one in acute pain situations are the NSAID’s because they do not cause central nervous system depression. These drugs exert their effect in peripheral nerves by inhibiting the release of prostaglandins (pain receptor stimulators). These drugs also reduce inflammation and swelling. Because these analgesics work at the site of the injury they do not produce the typical narcotic high, drowsiness, or impaired mental function nor do they depress respiration or blood pressure. NSAID’s are however associated with gastro intestinal side effects and should be taken with food orantacids. All patients should be questioned for history of any allergies. As a general principle any pain medication should be used in the lowest effective dose for the shortest time necessary to minimise side effects.

Another way of relieving pain is through the use of local and regional anaesthesia. Techniques range from the subcutaneous infiltration of a small specified are to major regional blockade. The latter techniques should only be attempted by medical professionals with appropriate training and experience.

ROUTES OF ADMINISTRATION There are various routes of administration including: • Oral • Buccal • Rectal • Intravenous (IV) • Intraosseous (IO) • Intramuscular (IM) • Intranasal (IN) • Inhalational (INH) Oral Traditional route of self administration so well accepted. Disadvantages are that some people will not swallow. A liquid formulation may help. Absorption is reduced in a traumatised patient therefore is likely to be an inappropriate route if the patient is nauseated or vomiting.

ORAL ANALGESIC OPTIONS Mild Pain

Moderate Pain

Severe Pain

Paracetamol NSAID’s

Combination therapy: Paracetamol + NSAID

Morphine as solution i.e.

Oramorph

Buccal This route takes advantage of rapid absorption of a drug across mucus tissues. It is painless to administer and is socially acceptable. However if by accident it is swallowed it will be subject to first pass metabolism and will not be as effective. These products are often small and difficult to use and may be difficult to use with cold or gloved hands.

Examples are Buprenorphine and Fentanyl lollipops. Glyceryl trinitrate is effective for relieving pain in patients with angina.

Intramuscular While this is a traditional route of administration for many medications, in terms of analgesia, in the presence of shock, absorption can be delayed. In military forces the IM route is the traditional method by which soldiers and military medics administer opiates, often through a specially designed auto injector.

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Intraosseous The IO route enables access to the central venous circulation with a consequent immediate in the circulating blood volume. Some skill is required and the correct equipment but this is a good option for the delivery of both medications and fluid replacement.

Intramuscular While this is a traditional route of administration for many medications, in terms of analgesia, in the presence of shock, absorption can be delayed. In military forces the IM route is the traditional method by which soldiers and military medics administer opiates, often through a specially designed auto injector.

Intranasal This is a common route used for sedation and analgesia in children with fentanyl being the drug of choice for analgesia. Drugs are well absorbed and reach plasma concentrations equal to that delivered via the IV route. Work is underway to identify what drugs may be able to be administered by this route. It is not as attractive if the patient has a respiratory infection, has blood in the nose or is medicating on topical vasoconstrictors.

Inhalation Typical agents delivered via this route are methoxylurane and nitrous oxide. The latter is probably not a choice for analgesia due to the need to store the gas in a pressurised cylinder (making it Dangerous Air Cargo) and the availability of re-supply. The former however is seeing a re-emergence particularly in Australia and New Zealand in the prehospital arena. INH agents have a very short onset of action and rapid offset of action making this a good drug for patient self administration.

Formulary of Common Medicines Useful in Remote Areas It is important to stress that unless you are a registered health professional with an established scope of practice that legally allows you to administer medications, then administration of any medicines must be done under a doctor-led clinical governance system which authorises the medic to administer named medicines. It is the responsibility of the individual medic to ensure that they are practicing safely and legally with regard to not only medicines but all other invasive skills.

The following drugs are provided as a guide only and local policy and procedures should be followed and clinical governance should be sought from a medical professional/employer.

This is a list of SOME of the emergency drugs you may be supplied with in your MIRA bags. Please be aware that it should be the responsibility of your company Clinical Supervisor to authorise the use of these drugs and clarify their own policy governing each specific drug.

Horizon does not take responsibility or authorise the use of drugs to any of its students.

PARACETAMOL [iv/io] (POM) PROPRIETARY NAME

Acetaminophen, Tylenol

DRUG CLASS

Analgesic

INDICATIONS

Mild to moderate pain, fever

CONTRA-INDICATIONS

Allergic to paracetamol, other paracetamol taken within last 4 hours, maximum daily dose already given

INTERACTIONS

None

SIDE-EFFECTS

Very rare

DOSE

1 gram IV/IO every 4-6 hours.

MAXIMUM DOSE 4 grams in 24 hours

SPECIAL INSTRUCTIONS

Pain relief within 10 minutes but maximum effect after 1 hour

PRESENTATION

Bottle containing 1g in 100ml

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epinephrine PROPRIETARY NAME

Adrenaline

PRESENTATION

Pre-filled syringe or ampoule containing 1 milligram of adrenaline (epinephrine) in 1ml (1:1,000) ADM. Pre-filled syringe containing 1 milligram of adrenaline (epinephrine) in 10ml (1:10,000) ADX.

ACTIONS

Adrenaline is a sympathomimetic that stimulates both alpha- and beta-adrenergic receptors. As a result the myocardial and cerebral blood flow is enhanced during CPR and CPR becomes more effective due to increased peripheral resistance maintaining a central blood reserve.

Reverses allergic manifestations of acute anaphylaxis.

Relieves bronchospasm in acute severe asthma.

CAUTIONS

Severe hypertension may occur in patients on beta-blockers and half doses should be administered unless there is profound hypotension.

For patients taking tricyclic anti-depressants (e.g. amitriptyline, imipramine) half doses of adrenaline should be administered for anaphylaxis.

INDICATIONS

Cardiac arrest Anaphylaxis Life threatening asthma with failing ventilation and continued deterioration despite nebuliser therapy.

CONTRA-INDICATIONS Do not give repeated doses of adrenaline in hypothermic patients.

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DOSAGE AND ADMINISTRATION

1. Cardiac arrest Route: IV/ET rapid bolus Concentration – 1 milligram in 10ml (1:10,000) AGE Adult Adult 11 years 10 years 9 years 8 years 7 yearst 6 years 5 years 4 years 3 years 2 years 18 months 12 months 9 months 6 months 3 months 1 month Birth

DOSE 1 milligram (IV) 3 milligrams (ET) 350 micrograms 320 micrograms 290 micrograms 260 micrograms 230 micrograms 210 micrograms 190 micrograms 160 micrograms 140 micrograms 120 micrograms 110 micrograms 100 micrograms 90 micrograms 80 micrograms 60 micrograms 44 micrograms N/A

VOLUME 10.0ml 30.0ml 3.5ml 3.2ml 2.9ml 2.6ml 2.3ml 2.1ml 1.9ml 1.6ml 1.4ml 1.2ml 1.1ml 1.0ml 0.90ml 0.80ml 0.60ml 0.44ml N/A

REPEAT every 3-5 minutes of ongoing cardiac arrest.

2. Anaphylaxis Route: IM antero-lateral aspect of thigh or upper arm.

Concentration – 1000 micrograms in 1ml (1:1,000) AGE DOSE Adult 500 micrograms 6 years-<12 years 250 micrograms 6 months-<6 years 120 micrograms <6 months 50 micrograms REPEAT every 5 minutes as clinically indicated.

VOLUME 0.50ml 0.25ml 0.12ml 0.05ml

NOTE: 250 micrograms in pre-pubertal children even if >12 years of age.

3. Asthma Route: SC/IM – antero-lateral aspect of thigh or upper arm.

Concentration – 1000 micrograms in 1ml (1:1,000) AGE Adult Child

DOSE 500 micrograms Not indicated

VOLUME 0.5ml

REPEAT after 5 minutes if clinically indicated.

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Aspirin PRESENTATION

300 milligram aspirin (acetylsalicylic acid) in tablet form (dispersible).

ACTIONS

Has an anti-platelet action which reduces clot formation.

Analgesic, anti-pyretic and anti-inflammatory.

CAUTIONS

As the likely benefits of a single 300 milligram aspirin outweigh the potential risks, aspirin may be given to patients with: Asthma Pregnancy Kidney or liver failure Gastric or duodenal ulcer

SIDE EFFECTS

Gastric bleeding.

Wheezing in some asthmatics.

DOSAGE AND ADMINISTRATION

Adults Adults with apparent, suspected or possible myocardial infarction.

Route: Oral – chewed or dissolved in water Concentration – 300 milligrams.

AGE Adult

INDICATIONS

DOSE 300 milligrams

VOLUME 1 tablet

Adults with: Clinical or ECG evidence of myocardial infarction or ischaemia Central chest pain, possibly of cardiac origin.

Aspirin should be administered to any patient with chest pain unless the diagnosis is very clearly noncardiac or the drug is contraindicated.

CONTRAINDICATIONS

Known aspirin allergy or sensitivity.

Children under 16 years.

Current treatment with anti-coagulants.

Haemophilia or other clotting disorders.

ADDITIONAL INFORMATION

In suspected MI a 300 milligram aspirin tablet should be given regardless of any previous aspirin taken that day.

Aspirin is contra-indicated in children under the age of 16 years as it may rarely precipitate Reye’s Syndrome. This syndrome is very rare and occurs in young children, damaging the liver and brain. It has a mortality rate of 50%.

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Benzylpenicillin (Penicillin G) PRESENTATION

Ampoule containing 600 milligrams of benzylpenicillin as powder.

ACTIONS

Antibiotic active against a range of bacteria.

DOSAGE AND ADMINISTRATION

Administer en-route to hospital (unless already administered by GP etc).

Administer by slow IV injection.

If it is not possible to gain rapid vascular access, the drug should be given by the IM route, as detailed below, into the antero-lateral aspect of the thigh or upper arm – preferably in an area that is well perfused. Route: IV (or IO <7 years) Concentration – 600 milligrams dissolved in 9.6ml water for injections.

AGE <1 year 1-<9 years 9 years – adult

DOSE 300 milligrams 600 milligrams 1.2 grams (2 vials)

VOLUME 5.0ml 10.0ml 20.0ml

Route: IM Concentration – 600 milligrams dissolved in 1.6ml water for injections.

AGE <1 year 1-<9 years 9 years – adult INDICATIONS

DOSE 300 milligrams 600 milligrams 1.2 grams (2 vials)

VOLUME 1.0ml 2.0ml 4.0ml

The initial treatment of suspected meningococcal septicaemia. This is indicated by the presence of a non-blanching rash and signs/symptoms suggestive of meningococcal septicaemia (as below). Some signs/symptoms may be absent and the order in which they appear may vary. The signs and symptoms are: • respiratory rate and effort – raised • heart rate – raised (relative bradycardia is a very late sign) • capillary refill >2 seconds, skin cold to touch (especially in extremities). Skin may appear mottled (early in illness skin may be warm) • oxygen saturation may be poor or unrecordable (due to poor perfusion) • temperature – raised (peripheral shutdown or any anti-pyretics given may mask this) • rigors • vomiting/diarrhoea/abdominal pain • rash – develops into petechial, bruise-like purpuric rash or blood blisters. May be no rash • pain in joints, muscles and limbs • seizures • level of consciousness: • early in shock – alert/able to speak • as shock advances – babies become limp, floppy and drowsy; older children/adults may develop difficulty in walking/standing, drowsy, confused.

Meningococcal septicaemia is commonest in young children and young adults. It may progress rapidly and the sooner benzylpenicillin is administered the better the outcome.

CONTRAINDICATIONS

Genuine penicillin allergy.

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ADDITIONAL INFORMATION

Penicillin Allergy Antibiotic allergy – This will be a very difficult judgement for ambulance staff as many members of the public think that they have a penicillin allergy because of minor gastrointestinal upset or other minor symptoms.

DO NOT give penicillin if the history is suggestive of unconsciousness, collapse, swelling, difficulty in breathing or rash on previous administration of penicillin.

Penicillin MAY be given if the history is suggestive only of diarrhoea, vomiting or other gastrointestinal upset on previous administration as this is related to the side effects of penicillin rather than an allergy to it.

If in doubt do NOT give penicillin and ensure rapid transport to hospital with an appropriate alert message. Document your consideration of penicillin and your reasons for not administering it.

SIDE EFFECTS

In the context of meningococcal septicaemia the release of toxins into the blood stream may actually make the patient feel worse initially and can cause sudden hypotension. Where vascular access is available fluid therapy at 250ml for adults, up to 20ml/kg for children should be commenced en route unless the journey time is short.

Hypersensitivity reactions, including urticaria, fever, joint pain, angio-oedema, anaphylaxis and convulsions may occur.

Gastrointestinal upset (diarrhoea, vomiting etc) is a recognised side effect of high dose antibiotic therapy.

CHLORPHENAMINE

PROPRIETARY NAME

(Chlorpheniramine, Piriton)

PRESENTATION

Ampoule containing 10 milligrams chlorphenamine malleate in 1ml.

ACTIONS

An antihistamine that blocks the effect of histamine released during a hypersensitivity (allergic) reaction. Also has anticholinergic properties.

DOSAGE AND ADMINISTRATION

Route: IV Concentration – 10 milligrams in 1ml.

AGE Adult >12 years Child 6-<12 years Child 1 year-<6 years

DOSE 10 milligrams 5 – 10 milligrams 2.5 milligrams

VOLUME 1.0ml 0.5ml–1.0ml 0.25ml

Administer by SLOW intravenous (IV) injection over 1 minute CAUTIONS

Hypotension Epilepsy Glaucoma Hepatic disease

SIDE EFFECTS

Sedation Dry mouth Headache Blurred vision Psychomotor impairment Gastro-intestinal disturbance Transient hypotension Convulsions (rare) The elderly are more likely to suffer side effects.

Due to the sedative and psychomotor side effects, anyone receiving chlorphenamine should be advised against driving or undertaking any other complex psychomotor skills.

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DEXTROSE 40% GEL PRESENTATION

One box containing three single dose plastic tubes of 40% dextrose gel (23 grams each).

ACTIONS

Rapid absorption through the buccal mucosa resulting in a rapid increase in blood glucose levels.

ADDITIONAL INFORMATION

Glucose gel may be repeated as necessary in the hypoglycaemic patient although a failure to achieve effective results should prompt the use of glucagon or glucose 10% (refer to glucose 10% drug protocol) as an alternative.

INDICATIONS

Known or suspected hypoglycaemia in a patient with a sufficient level of consciousness for there to be no risk of choking or aspiration.

CAUTIONS

Reduced level of consciousness – patient may choke or aspirate. In such circumstances glucose gel can be administered by soaking a gauze swab and placing it between the patient’s lip and gum to aid absorption.

SIDE EFFECTS

None.

DOSAGE AND ADMINSTRATION

Route: Buccal Concentration – 40% dextrose gel AGE Adults Children

DOSE up to 69 grams <23 grams

VOLUME up to 3 tubes <1 tube

Blood glucose concentration should be measured after each dose.

CHILDREN – Assessment should be more frequent in children who should require a smaller dose for a response.

CHILDREN – For those less than 12 years of age, an appropriate amount, considering the patient’s age and ensuring protection of the airway should be given.

DIAZEPAM (AS DIAZEMULS AND STESOLID) PRESENTATION

Ampoule containing 10 milligrams diazepam in an oil-in-water emulsion making up 2ml of milky white fluid (Diazemuls).

Rectal tube containing 2.5 milligrams, 5 milligrams or 10 milligrams diazepam (Stesolid).

ACTIONS

Central nervous system depressant, acts as an anti-convulsant and sedative.

ADDITIONAL INFORMATION

The intravenous route is preferred for terminating fits and thus, where IV access can be gained rapidly, Diazemuls should be the first choice. Early consideration should be given to using Stesolid when IV access cannot be rapidly and safely obtained, which is particularly likely in the case of children. In small children Stesolid should be considered the first choice treatment and IV access sought subsequently.

The earlier the drug is given the more likely the patient is to respond, which is why the rectal route is preferred in children, while the IV route is sought.

Diazepam should only be used if the patient has been fitting for >5 minutes (and is still fitting), or if fits recur in rapid succession without time for full recovery in between. There is no value in giving this drug “preventatively” if the fit has ceased. In any clearly sick or ill child, there must be no delay at the scene while administering the drug, and if it is essential to give diazepam, this should be done en route to hospital.

Care must be taken when inserting the rectal tube and this should be inserted no more than 2.5cm in children and 4-5cm in adults. (All tubes have an insertion marker on nozzle).

INDICATIONS

Fits longer than 5 minutes and STILL FITTING. Repeated fits – not secondary to an uncorrected hypoxia or hypoglycaemic episode.

Status epilepticus.

Eclamptic fits (initiate treatment if fit lasts >2-3 minutes or if it is recurrent).

Symptomatic cocaine toxicity (severe hypertension, chest pain or fitting).

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CAUTIONS

Respiratory depression.

Should be used with caution if alcohol, anti-depressants or other CNS depressants have been taken as side effects are more likely.

Recent doses by carers/relatives should be taken into account when calculating the maximum cumulative dose.

SIDE EFFECTS

Respiratory depression may occur, especially in the presence of alcohol, which enhances the depressive side effect of diazepam. In addition, opioid drugs also enhance the cardiac and respiratory depressive effect of diazepam.

Hypotension may occur. This may be significant if the patient has to be moved from a horizontal position to allow for extrication from an address. Caution should therefore be exercised and consideration given to either removing the patient flat or, if fitting has stopped and it is considered safe, allowing a 10 minute recovery period prior to removal.

Drowsiness and light-headedness, confusion and unsteadiness.

Occasionally amnesia may occur.

DOSAGE AND ADMINISTRATION

Route: IV or IO < 7 years Concentration – 10 milligrams in 2ml AGE Adult 11 years 10 years 9 years 8 years 7 years 6 years 5 years 4 years 3 years 2 years 18 months 12 months 9 months 6 months 3 months 1 month Birth

DOSE 10 milligrams 10 milligrams 9.5 milligrams 8.5 milligrams 8 milligrams 7 milligrams 6.5 milligrams 5.5 milligrams 4.9 milligrams 4.3 milligrams 3.65milligrams 3.3 milligrams 2.95 milligrams 2.65 milligrams 2.3 milligrams 1.8 milligrams 1.3 milligrams 1.05 milligrams

VOLUME 2.0ml 2.0ml 1.9ml 1.7ml 1.6ml 1.4ml 1.3ml 1.1ml 0.98ml 0.86ml 0.73ml 0.66ml 0.59ml 0.53ml 0.46ml 0.36ml 0.26ml 0.21ml

ADULT – Administer SLOWLY– titrated to response. Repeat after 5 minutes 20 milligrams maximum dose.

CHILDREN – Administer SLOWLY– titrated to response ONCE only.

Route: Rectal AGE Adult Child 6-12 years Child 1-<6 years Child <1 year

DOSE 10 milligrams 10 milligrams 5 milligrams 2.5 milligrams

CONCENTRATION 10 milligrams in 2.5ml 10 milligrams in 2.5ml 5 milligrams in 2.5ml 2.5 milligrams in 1.25ml

RECTAL TUBES 1 x 10mg Tube 1 x 10mg Tube 1 x 5mg Tube 1 x 2.5mg Tube

ADULT – If required repeat after 10 minutes – maximum dose 20 milligrams.

CHILDREN – If required repeat ONCE after 10 minutes.

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Glyceryl Trinitrate (GTN, Suscard) PRESENTATION

Metered dose spray containing 400 micrograms glyceryl trinitrate per dose. Tablets containing glyceryl trinitrate 2, 3 or 5 milligrams for buccal administration (depends on local ordering).

ACTIONS

A potent vasodilator drug resulting in: • dilatation of coronary arteries/relief of coronary spasm.

• dilatation of systemic veins resulting in lower pre-load.

• reduced blood pressure.

DOSAGE AND ADMINISTRATION

Route: Buccal/Sub-lingual (spray under the patient’s tongue and close mouth).

AGE Adult Adult Adult Adult

DOSE 1-2 spray 2 milligrams 3 milligrams 5 milligrams

CONCENTRATION 400 micrograms per dose spray 2 milligrams per tablet 3 milligrams per tablet 5 milligrams per tablet

VOLUME N/A 1 tablet 1 tablet 1 tablet

The mucosa must be moist for GTN absorption, moisten if necessary.

Remove tablet if side effects occur e.g. hypotension.

The effect of the first dose should be assessed over 5 minutes. Further doses can be given every 5-10 minutes as indicated provided systolic blood pressure is >90mmHg. ADDITIONAL INFORMATION

Glyceryl trinitrate causes vasodilatation, with enlargement of the venous system bed. This causes pooling of blood in the veins with reduction in “preload” to the heart. This relieves the work of the left ventricle, and secondarily reduces lung vessel congestion, lessening breathlessness and is the primary treatment in acute left ventricular failure.

When using buccal nitrates the patient may spit out the remainder of the tablet when their chest pain is relieved. This may avoid the onset of headache.

SIDE EFFECTS

Throbbing headache.

Flushing.

Dizziness.

Postural hypotension.

Tachycardia.

These side effects are mainly related to a generalised vasodilation effect of this drug and are usually transient.

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Metoclopramide (Maxolon) PRESENTATION

Ampoule containing metoclopramide 10 milligrams in 2ml.

ACTIONS

An anti-emetic which acts centrally as well as on the gastro-intestinal tract.

CAUTIONS

If patient is likely to require thrombolysis then intramuscular administration of any drug should be avoided.

Avoid in cases of drug overdose.

ADDITIONAL INFORMATION

Metoclopramide should always be given in a separate syringe to morphine sulphate. The drugs must not be mixed.

INDICATIONS

The treatment of nausea or vomiting in adults over 20 years.

Prevention and treatment of nausea and vomiting following administration of morphine sulphate or nalbuphine.

CONTRAINDICATIONS

Age less than 20 years.

Avoid in first trimester of pregnancy.

Renal failure.

Phaeochromocytoma.

Gastro-intestinal obstruction.

SIDE EFFECTS

Severe extra-pyramidal effects are more common in children and young adults. Drowsiness and restlessness. Cardiac conduction abnormalities following IV administration.

DOSAGE AND ADMINISTRATION

Route: IV Concentration â&#x20AC;&#x201C; 10 milligrams in 2ml.

AGE Adult

DOSE 10 milligrams

VOLUME 2.0ml

ONCE only, given over 2 minutes, prior to opiate administration.

Monitor pulse, blood pressure, respiratory rate and cardiac rhythm before, during and after administration.

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Naloxone Hydrochloride (Narcan) PRESENTATION

Naloxone Hydrochloride 400 micrograms/1ml ampoule.

ACTIONS

Antagonism of the effects (including respiratory depression) of opioid drugs.

ADDITIONAL INFORMATION

Naloxone may be administered intramuscularly, undiluted, (into the outer aspect of the thigh or upper arm) when IV access is impossible, but absorption may be slow. Wherever possible, the IV route should be used.

Overdose with opioid drugs can be fatal as a result of respiratory and cardiovascular depression. The effects of naloxone are short lived and patients frequently relapse once the drug has worn off. All cases of opioid overdose should be transported to hospital, even if the initial response to naloxone has been good. If the patient refuses, consider, if the patient consents, a loading dose of 800 micrograms IM to minimise the risk described above.

Some prescription opioid drugs include: Buprenorphine

(Temgesic)

Codeine

(Used in combination in Codis, Diarrest, Migraleve, Paracodol, Phensedyl, Solpadeine, Solpadol, Syndol, Terpoin, Tylex, Veganin)

Dextromoramide

(Palfium)

Dipipanone

(Dicanol)

Dextropropoxyphene (Used in combination in Distalgesic/co-proxamal) Diamorphine

(‘Heroin’)

Dihydrocodeine

(Co-dydramol, DF 118)

Meptazinol

(Meptid)

Methadone

(Physeptone, Methadose)

Morphine

(Oramorph, Sevredol, MST Continus, SRMRhotard)

Oxycodone

(Oxycontin)

Pentazocine

(Fortral)

Pethidine

(Pamergan)

Phenazocine

(Narphen)

NOTE: This list is not comprehensive, other opioid drugs are available.

INDICATIONS

Respiratory depression, depression of cardiovascular system and central nervous system depression associated with opioid overdose.

Accidental overdose of opioid drugs, e.g. morphine, nalbuphine.

Overdose of some common analgesics, e.g. co-proxamol (Distalgesic) containing substances such as dextropropoxyphene and codeine (in combination with paracetamol) produce respiratory depression, which is reversed by naloxone.

Unconsciousness associated with respiratory depression of unknown cause, where opioid overdose is a possibility. (Refer to depressed level of consciousness guideline).

CONTRAINDICATIONS

1. Neonatal patients of opioid addicted mothers, as serious withdrawal effects may occur – emphasis should be on bag-valve-mask ventilation and oxygenation.

SIDE EFFECTS

In patients who are physically dependent on narcotic drugs, violent withdrawal symptoms, including cardiac arrhythmias, may be precipitated by naloxone. Ideally, in these cases titrate the dose of naloxone as described above, to effectively reverse the cardiac and respiratory depression, but still leave the patient in a groggy state.

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DOSAGE AND ADMINISTRATION

Respiratory arrest/extreme respiratory depression – When the URGENCY of the situation outweighs the need for a controlled effect.

Route: IV/IM bolus Concentration – 400 micrograms in 1ml.

AGE Adult Adult

DOSE 400 micrograms (IV) 800 micrograms (IM)

VOLUME 1ml 2ml

If there is no response administer further doses of 400 micrograms, every 2-3 minutes until an effect is noted.

Repeated doses may need to be given up to every 2-3 minutes en-route to hospital, as the half-life of naloxone is short.

The maximum dose of naloxone is 10 milligram (equivalent to 25 repeat doses of 400 micrograms).

Respiratory Depression – When a more CONTROLLED effect is required, e.g. in known or potentially aggressive patients who are suffering respiratory depression rather than arrest, dilute up to 800 micrograms (2ml) of naloxone into 8ml of water for injections or sodium chloride intravenous infusion 0.9% (to a total of 10ml). Administer IV by slow injection, titrated to response. Aim to relieve respiratory depression, but maintain patient in ‘groggy’ state.

Route: IV/IM Concentration – 400 micrograms in 1ml.

AGE 11 years 10 years 9 years 8 years 7 years 6 years 5 years 4 years 3 years 2 years 18 months 12 months 9 months 6 months 3 months 1 month Birth IM ONLY

FIRST DOSE 352 micrograms 320 micrograms 288 micrograms 260 micrograms 232 micrograms 208 micrograms 184 micrograms 164 micrograms 144 micrograms 124 micrograms 112 micrograms 100 micrograms 88 micrograms 78 micrograms 60 micrograms 44 micrograms 200 micrograms

VOLUME 0.88ml 0.80ml 0.72ml 0.65ml 0.58ml 0.52ml 0.46ml 0.41ml 0.36ml 0.31ml 0.28ml 0.25ml 0.22ml 0.19ml 0.15ml 0.11ml 0.50ml

SUBSEQUENT DOSE 3520 micrograms 3200 micrograms 2880 micrograms 2600 micrograms 2320 micrograms 2080 micrograms 1840 micrograms 1640 micrograms 1440 micrograms 1240 micrograms 1120 micrograms 1000 micrograms 880 micrograms 800 micrograms 600 micrograms 440 micrograms N/A

VOLUME 8.8ml 8.0ml 7.2ml 6.5ml 5.8ml 5.2ml 4.6ml 4.1ml 3.6ml 3.1ml 2.8ml 2.5ml 2.2ml 2.0ml 1.5ml 1.1ml N/A

If NO response (or a partial but inadequate response), a subsequent dose of 100 micrograms/kg (NOTE: this is 10 times the initial dose)

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Oxygen PRESENTATION

Oxygen (O2) is a gas provided in compressed form in a cylinder. It is also available in liquid form, in a system adapted for ambulance use. It is fed via a regulator and flow meter to the patient by means of plastic tubing and an oxygen mask or nasal cannula.

ACTIONS

Essential for cell metabolism. Adequate tissue oxygenation is essential for normal physiological function. It assists in reversing hypoxia, by raising the concentration of inspired oxygen. Hypoxia will, however, only improve if respiratory effort or ventilation and tissue perfusion are adequate. If ventilation is inadequate or absent, assisting or completely taking over the patientâ&#x20AC;&#x2122;s ventilation is essential to reverse hypoxia.

CAUTIONS

Oxygen increases the fire hazard at the scene of an accident.

INDICATIONS

All cases with cardiac symptoms, decreased level of consciousness, sickle cell disease, carbon monoxide poisoning, major trauma, and long bone fracture.

Chronic obstructive pulmonary disease (COPD) with oxygen saturation (SpO2) <90-92%.

Hypoxia with SpO2 <95%.

CONTRAINDICATIONS

Paraquat poisoning.

Defibrillation.

Explosive environments.

NOTE: COPD is NOT a contra-indication in the critically ill or injured hypoxic patient but the COPD guidelines should be followed.

DOSAGE AND ADMINISTRATION

Oxygen therapy is essential in virtually ALL cases of serious or potentially serious illness or injury.

Administer high concentration oxygen (O2) via a nonre-breathing mask, using the stoma in laryngectomee and other neck breathing patients, to ensure an SpO2 of >95%, except in patients with COPD (see below).

High concentration O2 should be administered routinely, whatever the oxygen saturation in all patients sustaining major trauma, long bone fracture, chest pain, acute coronary syndrome, sickle cell crisis, and patients with decreased level of consciousness (Glasgow Coma Score (GCS) <15).

Patients with COPD should receive metered oxygen therapy to achieve an O2 saturation in the range of 90-92%. In cases of serious respiratory distress, cardiac chest pain, or major trauma in COPD patients, high concentration oxygen may be required.

Oxygen therapy is administered via a mask and tubing. Masks are either the standard (nonreservoir bag) or with reservoir bag. Oxygen may also be administered via an automatic ventilator or self inflating bag-valve-mask and reservoir.

High concentration Oxygen can be provided through a non-rebreathing mask with a reservoir bag and with an oxygen flow rate sufficient to keep the reservoir bag fully inflated (usually 10-15 litres/min).

Low flow 24â&#x20AC;&#x201C;28% oxygen can be provided at flow rates of 2 litres per minute through a medium concentration, non reservoir bag mask.

Layngectomee patients Layngectomee and other neck breathing patients breathe through a stoma in the neck.

A facemask or nasal cannula may be of little or no value. An appropriate method of administration must be considered that delivers oxygen to the stoma.

SIDE EFFECTS

Non-humidified O2 is drying and irritating to mucous membranes over a period of time.

In patients with COPD who rely upon hypoxic drive for respiration there is a small risk that high-flow oxygen may cause respiratory depression or respiratory arrest (refer to COPD guideline).

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ADDITIONAL INFORMATION

A pulse oximeter should always be used to measure O2 saturation whenever O2 is being administered (except in possible carbon monoxide poisoning where results may be artificially elevated). This is to monitor the effects of O2 therapy and the effectiveness of the patient’s ventilation.

Oxygen saturation levels • 95-100% normal • 90-95% evidence of hypoxia • 85-90% serious hypoxia • <85% critical hypoxia Hypoxic drive is found in COPD patients with chronic lung damage, where as a result of long standing respiratory failure, a higher than normal carbon dioxide (CO2) level is retained in the blood stream. This would normally trigger a persistent high respiratory rate to attempt to lower the CO2 level. To compensate, the body becomes less sensitive to raised CO2, and begins to react to a lowered O2 level, as a trigger to breathe. Giving high concentration O2 will raise the O2 level in the blood stream, and may prevent the natural lowering of O2 occurring to stimulate breathing. This in turn may cause respiratory depression or respiratory arrest. If this occurs, oxygen should be delivered through assisted ventilation or intermittent positive pressure ventilation and the patient removed rapidly to hospital with a Hospital Alert Message.

Most patients with acute asthma DO NOT have COPD and require high concentration O2 with a non-rebreathing mask with a reservoir bag and with an oxygen flow rate sufficient to keep the reservoir bag inflated before and after nebulisation.

Some elderly patients have a mixture of COPD, which causes irreversible bronchospasm, and asthma, which is reversible. The priority in treating these patients is to ensure adequate oxygenation. Less seriously ill or injured patients still require O2 therapy as per individual guidelines.

In cardiac arrest 100% O2 must be delivered via automatic ventilator or bag/mask/reservoir during ventilation.

In carbon monoxide poisoning administering 100% O2 increases the speed of elimination of CO from red cells.

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TRAMADOL Legal Status

Prescription Only Medicine (POM) This Patient Group Direction refers specifically to the administration of the medicine Tramadol. It applies solely to those named ambulance paramedics, who have received appropriate training and who are employed by an NHS Ambulance Service Trust. This Patient Group Direction is written in accordance with the Department of Health guidance on the Supply and Administration of Medicines under Patient Group Directions.

Presentation

Ampoule containing 100mg of tramadol in 2ml

Actions

Tramadol acts on the central nervous system by inhibiting the re-uptake of serotonin and noradrenaline, which are released by the brain in response to painful stimuli. It also binds weakly to the CNS mu-opioid receptor and so may, in theory, cause respiratory depression.

Indications

Moderate to severe pain in adults and children over 12 years.

Dosage and administration

Adults and children over 12 100mg IV slowly over 2-3 minutes.

Further 50mg boluses may be given every 15 minutes to a maximum of 200mg.

Children under 12 Not recommended

Side-Effects

Dizziness, nausea, constipation, headache and drowsiness. Occasionally, vomiting and agitation. Convulsions may be caused by too rapid intravenous infusion, especially in epileptics.

ContraIndications

• Head injury with decreased Glasgow Coma Score (<13) • Pregnancy and breast feeding • Patients taking monoamine oxidase inhibitors (Maplan, Nardil, Parnate, Parstelin) or having taken them in the previous 2 weeks.

Special Precautions

• Epilepsy • Alcohol ingestion • Patients already receiving opioid drugs • Transient nausea may occur following administration. An anti-emetic should be considered prophylactically. Necessary equipment (e.g. suction) should be readily to hand to help prevent aspiration of vomit.

• Each bolus of Tramadol should be given over 2-3 minutes to reduce the risk of convulsions.

Exclusion from Patient Group Direction

• Any patient who does not fit the Indications for use • Any patient with contra-indications as stated • Any patient in whom a doctor has requested that it should not be given

Further Advice

If the Paramedic is uncertain of the clinical findings, or whether the patient fulfils the requirements then they MUST seek advice from a doctor at the receiving unit.

Follow Up

Any patient treated with a drug under this PGD must be transported to hospital and left in the care of a suitably qualified nurse or doctor.

Record Keeping.

Details of administration must be entered onto the Patient Report Form in accordance with local Trust policies. The receiving hospital must be informed of the fact that this medicine has been administered.

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Salbutamol (Ventolin) PRESENTATION

Nebules containing salbutamol 2.5 milligrams/ 2.5ml or 5 milligrams/2.5 ml.

ACTIONS

Salbutamol is a selective beta2-adrenoreceptor stimulant drug. This has a relaxant effect on the smooth muscle in the medium and smaller airways, which are in spasm in acute asthma attacks. If given by nebuliser, especially if oxygen powered, its smooth-muscle relaxing action, combined with the airway moistening effect of nebulisation, can relieve the attack rapidly.

CAUTIONS

Salbutamol should be used with care in patients with: • • • • •

ADDITIONAL INFORMATION

hypertension angina overactive thyroid late pregnancy (can relax uterus) Severe hypertension may occur in patients on beta-blockers and half doses should be used unless there is profound hypotension

In acute severe or life threatening asthma ipratropium should be given concurrently with the first dose of salbutamol. In acute asthma or COPD unresponsive to salbutamol alone a single dose of ipratropium may be given concurrently with the second or later dose of salbutamol.

Salbutamol often provides initial relief. In more severe attacks however, the use of steroids by injection or orally and further nebuliser therapy will be required. Do not be lulled into a false sense of security by an initial improvement after salbutamol nebulisation.

INDICATIONS

Acute asthma attack where normal inhaler therapy has failed to relieve symptoms.

Expiratory wheezing associated with allergy, anaphylaxis, smoke inhalation or other lower airway cause.

Exacerbation of chronic obstructive pulmonary disease (COPD). Shortness of breath in patients with severe breathing difficulty due to left ventricular failure (secondary treatment).

CONTRAINDICATIONS

None in the emergency situation.

SIDE EFFECTS

Tremor (shaking).

Tachycardia.

Palpitations.

Headache.

Feeling of tension.

Peripheral vasodilatation.

DOSAGE AND ADMINISTRATION

NOTE: Ensure pre- and post-nebulisation observations including peak flow readings are taken and documented.

Route: Nebulised with 6-8 litres per minute oxygen.

AGE DOSE Adult (>12-years) 5 milligrams 6 to <12 years 5 milligrams <12-months 2.5 milligrams

CONCENTRATION 2.5 milligrams in 2.5ml VOLUME 5.0ml 5.0ml 2.5ml

CONCENTRATION 5 milligrams in 2.5ml VOLUME 2.5ml 2.5ml 1.25ml

Salbutamol is less effective in children <12 months and a single dose of 2.5 milligrams should be administered. If this is ineffective, further doses should not be given.

In severe attacks nebulisation may need to be repeated as necessary. The pulse rate in children may exceed 140 after significant doses of salbutomol. This is not usually of any clinical significance and should not usually preclude further use of the drug.

Otherwise there is no limit on the maximum number of nebulised doses a patient may have.

Repeat doses should, however, be discontinued if the side effects are becoming significant (e.g. tremors, tachycardia >140 beats per minute in adults etc.)

This is a clinical decision by the ambulance clinician.

If there is no improvement in peak flow after 5 minutes, administer a further 5 milligrams, nebulised with 6-8 litres per minute oxygen.

In life threatening or acute severe asthma – do not delay further care. LOAD & GO to NEAREST SUITABLE RECEIVING HOSPITAL and provide nebulisation en-route

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Sodium Chloride (Physiological Saline) 0.9% PRESENTATION

500ml and 1,000ml packs of sodium chloride intravenous infusion 0.9%. 5 and 10ml ampoules for use as flushes.

ACTIONS

Crystalloid solution for fluid replacement.

To establish and maintain the patency of a cannula or for flushing drugs through.

INDICATIONS

May be used as an alternative to sodium lactate intravenous infusion for blood and fluid loss, to correct hypovolaemia and improve tissue perfusion.

Dehydration.

Fluid replacement in hyperglycaemic ketoacidotic diabetic coma and pre-coma.

As a flush after drug administration.

As a flush when an intravenous cannula is in situ and where drug therapy may not be desirable.

CONTRAINDICATIONS

None.

SIDE EFFECTS

Infusion of an excessive volume may overload the circulation and precipitate heart failure (evidenced by increased breathlessness, wheezing and distended neck veins). Volume overload is unlikely if the patient is correctly assessed initially and it is very unlikely indeed if patient response is assessed after initial 250 ml infusion and then after each 250 ml of infusion.

If there is evidence of this complication, the patient should be transported rapidly to nearest suitable receiving hospital whilst administering high concentration oxygen. No further fluid should be given.

DOSAGE AND ADMINISTRATION

In hypovolaemia, Medical Emergencies (e.g. anaphylaxis, GI bleeding, heat exhaustion).

Route: IV rapid infusion.

Concentration â&#x20AC;&#x201C; 0.9%.

AGE Adult

DOSE 250ml

VOLUME 250ml

ADULTS â&#x20AC;&#x201C; Monitor physiological response; re-assess perfusion, pulse, respiratory rate and blood pressure wherever possible. If these observations improve, slow the infusion rate. If no improvement administer further 250ml boluses (maximum 2 litres).

AGE 11 years 10 years 9 years 8 years 7 years 6 years 5 years 4 years 3 years 2 years 18 months 12 months 9 months 6 months 3 months 1 month Birth

Medical Emergencies 20ml/kg

DOSE 700ml 640ml 570ml 520ml 460ml 410ml 370ml 330ml 290ml 240ml 220ml 200ml 180ml 160ml 120ml 90ml 70ml

VOLUME 700ml 640ml 570ml 520ml 460ml 410ml 370ml 330ml 290ml 240ml 220ml 200ml 180ml 160ml 120ml 90ml 70ml

Medical Emergencies initial volume 5ml/kg

DOSE 180ml 160ml 140ml 130ml 120ml 100ml 90ml 80ml 70ml 60ml 60ml 50ml 50ml 40ml 30ml 20ml 20ml

VOLUME 180ml 160ml 140ml 130ml 120ml 100ml 90ml 80ml 70ml 60ml 60ml 50ml 50ml 40ml 30ml 20ml 20ml

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DOSAGE AND ADMINISTRATION CONTINUED

ADULTS – In hypovolaemia: If the patient remains hypotensive despite repeated 250ml boluses AND the patient is trapped on scene, request on-line clinical support. Excessive rise of blood pressure may cause re-bleeding and further haemorrhage. Aim to maintain a systolic blood pressure of 90mmHg, measured accurately where possible or estimated by the presence of a radial pulse where time is critical.

CHILDREN – In hypovolaemia: If necessary a further dose of up to 20ml/kg may be administered as above. If still hypovolaemic seek on-line medical help.

CHILDREN – In hyperglycaemia: Generally emergency IV fluids should be minimised or avoided because of serious side effects that may occur. See paediatric diabetic ketoacidosis.

Route: IV flush AGE Adult or Child >5years Adult or Child >5years Child: Neonatal <5years Child: Neonatal <5years

DOSE 2ml-5ml 2-5ml 10ml-20ml (when infusing glucose) 2ml 10ml (when infusing glucose)

VOLUME 10-20ml 2.0ml 10-20ml

If infusion is established as a precaution – administer by slow rate to “keep vein open.”

TRANEXAMIC ACID (TXA) (POM) PROPRIETARY NAME

Cyklocapron

DRUG CLASS

Anti-fibrinolytic

INDICATIONS

Life threatening internal or external haemorrhage which cannot be stopped

CONTRA-INDICATIONS

Venous or arterial thrombosis, isolated head injury

INTERACTIONS

Anticoagulants, oral contraceptives

SIDE-EFFECTS

Diarrhoea, nausea, vomiting, allergic reaction

DOSE

1 gram IV/IO once only

SPECIAL INSTRUCTIONS

Draw up the contents of two vials and administer at a rate of 1ml per minute.

Therefore the complete dose takes 10 minutes to administer. For best patient outcomes the hospital should follow up with a TXA infusion.

PRESENTATION

500mg in 5ml

ONDANSETRON (POM) PROPRIETARY NAME

Zofran

DRUG CLASS

Anti-emetic

INDICATIONS

Nausea and vomiting due to injury/illness/medication

CONTRA-INDICATIONS

Allergy to ondansetron or Long QT syndrome

INTERACTIONS

Beta blockers and drugs which alter heart rhythm

SIDE-EFFECTS

Constipation, headache, flushing

DOSE

4mg IV/IO repeated every 4 hours as necessary. Maximum daily dose 16mg

SPECIAL INSTRUCTIONS

Administer slowly

PRESENTATION

4mg in 2ml flexiamp (plastic vial

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NON STEROID ANTI INFLAMMATORIES IBUPROFEN PROPRIETARY NAME

IBUPROFEN

DRUG CLASS

Analgesic

INDICATIONS

Mild to moderate pain in musculo-skeletal disorders, post operative analgesia, migraine, fever and pain in children.

CONTRA-INDICATIONS

Aspirin/ NSAID allergy. History of asthma. Gastro Intestinal ulceration.

INTERACTIONS

SSRI antidepressants, Aspirin.

SIDE-EFFECTS

Gastro intestinal discomfort, nausea, diarrhoea and occasional bleeding and ulceration.

DOSE

400mg oral tablets repeated three times per day. Maximum daily dose of 1.2g This can be increased if necessary to a maximum daily dose of 2.4g.

SPECIAL INSTRUCTIONS

Take after food. Can be taken with Paracetamol and is a potent analgesic combination for moderate pain. Compound presentations are available with codeine.

A good option for moderate plus pain, however may have difficulty importing in some countries with prescription.

PRESENTATION

Coated tablets in 200 mg, 400 mg and 600 mg. Available over the counter.

DICLOFENAC SODIUM (POM) PROPRIETARY NAME

VOLTAROL. VOLTAROL RETARD.

DRUG CLASS NSAID

(analgesic).

INDICATIONS

Pain & inflammation in musculoskeletal disorders.

CONTRA-INDICATIONS

Aspirin/NSAID allergy. History of asthma. GIulceration.

INTERACTIONS

Other NSAIDS (inc. aspirin). Ciproloxacin: risk of convulsions

SIDE-EFFECTS

GI discomfort, Nausea, diarrhoea, Hypersensitivity reactions, Rashes, Photosensitivity, Headache, Hearing disturbances.

DOSE

50mg three times per day OR 75mg twice per day (Maximum daily dose 150mg).

SPECIAL INSTRUCTIONS

Preferably with or after food. Swallowed whole not chewed.

PRESENTATION

25mg, 50mg, 75mg tablets

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Other Drugs Useful In Remote Area Analgesia Acetysalicylic Acid (Aspirin) Aspirin as an NSAID is good for mild to moderate pain and fever. It is a good painkiller and anti-inflammatory drug, however some people are allergic to it and it may cause stomach irritation. Dose is 1 to 3 tablets (300 – 900 mg) 4 – 6 hourly. No more than 4 g in 24 hours.

Naproxen Another NSAID that can be a good choice because it combines good efficacy with a low incidence of side effects.

Used mainly for Musculo-skeletal disorders and period pain. Dose is 0.5 – 1 g daily in 1 – 2 divided doses. Acute MS disorders and period pain, 500 mg initially then 250 mg every 6 – 8 hours as required. Max dose after 1st day 1.25 g daily.

Buprenorphine Buprenorphine is relatively safe opioid available as a sublingual preparation. When administered nausea is common and it interferes with the effectiveness of morphine if that drug is subsequently used due to its partial agonist effect.

Fentanyl Fentanyl is an opioid analgesic with a potency 80 times that of morphine. The most useful variation of this drug is Actiq, which is a recently developed solid formulation on a lollipop stick that dissolves slowly in the mouth for transmucosal absorption. It is most effective when consumed within 15 minutes. This product has been used by US Special Forces for haemodynamically stable patients with uncomplicated extremity wounds. The improvement in the pain score at 15 minutes was statistically significant.

Methoxylurane Methoxylurane is a anaesthetic agent with significant analgesic properties at subanaesthetic concentrations. It is available as a single use, hand held, self administering device that is not yet available in the UK. The Penthrox inhaler and First-Relief Inhaler has been used extensively in Australia and New Zealand. Inspired concentrations are 0.2% to 0.4% for the devices. Both devices provide between 25 - 60 minutes of analgesia with continuous use. However, patient’s use the device intermittently and therefore gives a greater period of up to 4 hours. Medical staff using these devices when they become available should be trained in the use of these devices before attempting to use them.

Ketamine Ketamine hydrochloride is an intravenous anaesthetic that when given in sub-anaesthetic doses in a potent and effective analgesic. It is often a good choice for medical professionals as an analgesic agent.

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CHAPTER 17: Antibiotics And Infection Despite improved methods of treating and preventing infection such as potent antibiotics, rigorous immunisations, and modern sanitation, infection still accounts for large amounts of serious illness, even in Western countries. In developing countries, infection remains one of the most pressing health problems, firstly for the indigenous population but also for the traveller and worker.

What is infection?

Infection is the invasion and multiplication of microorganisms in or on body tissues that produce signs and symptoms as well as an immune response. Such reproduction injures the host by cellular damage from microorganism produced toxins or intracellular multiplication. The host’s own immune response may compound the tissue damage, with damage being localised or systemic. The infection’s severity varies with the pathogenicity and number of the invading microorganisms and the strength of host defences.

Why are the microorganisms that cause infectious diseases so hard to overcome?

• Some bacteria develop resistance to antibiotics • Some microorganisms—the influenza virus, for example—have so many strains that a single vaccine can’t provide protection against them all.

• Most viruses resist antiviral drugs.

• Some microorganisms localise in areas that make treatment difficult, such as the central nervous system or bone.

• Travel can expose people to diseases for which they have little natural immunity.

Kinds of infections The varied forms of microorganisms responsible for infectious diseases include bacteria, spirochetes (a type of bacteria), viruses, rickettsiae, chlamydiae, fungi, and protozoa. Larger organisms, such as helminths (worms), also may cause disease.

Bacteria Single-cell microorganisms with well-defined cell walls; bacteria can multiply independently on artificial media without the need for other cells. In developing countries, where poor sanitation heightens the risk of infection, bacterial diseases commonly cause death and disability. Worldwide they are still the most common fatal infectious diseases.

Bacteria can be classified by shape. Spherical bacterial cells are called cocci; rod-shaped bacteria, bacilli; and spiralshaped bacteria, spirilla. They also can be classified by their response to staining (gram-positive, gram-negative, or acid-fast bacteria), their motility, their tendency toward capsulation, their capacity to form spores, and their oxygen requirements (aerobic bacteria need oxygen to grow; anaerobic bacteria don’t).

Spirochetes Types of bacteria, spirochetes are flexible, slender, undulating spiral rods that have cell walls. Most are anaerobic. The three forms pathogenic in humans include Treponema, Leptospira, and Borrelia.

Viruses Viruses are subcellular organisms made up of only a ribonucleic acid (RNA) or a deoxyribonucleic acid (DNA) nucleus covered with proteins. They are the smallest known organisms, so tiny that they’re visible only through an electron microscope. Viruses can’t replicate independent of host cells. Rather, they invade a host cell and stimulate it to participate in the formation of additional virus particles. The estimated 400 viruses that infect humans are classified according to their size, shape (spherical, rod-shaped, or cubic), or means of transmission (respiratory, faecal, oral, or sexual).

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Rickettsiae Relatively uncommon, these small, gram-negative bacteria-like organisms frequently induce life-threatening infections.

Like viruses, they require a host cell for replication.

Chlamydia Larger than viruses, chlamydia have recently been found to be intracellular bacteria. Unlike other bacteria, they depend on host cells for replication; unlike viruses, they’re susceptible to antibiotics.

Fungi These single-cell organisms have nuclei enveloped by nuclear membranes. They have rigid cell walls like plant cells but lack chlorophyll, the green matter necessary for photosynthesis. They also show relatively little cellular specialisation.

Fungi occur as yeasts or moulds. Depending on the environment, some fungi may occur in both forms.

Protozoa Protozoa are the simplest single-cell organisms of the animal kingdom, but they show a high level of cellular specialization. Like other animal cells, they have cell membranes rather than cell walls, and their nuclei are surrounded by nuclear membranes.

Helminths The three groups of helminths that invade humans include nematodes, cestodes, and trematodes. Nematodes are cylindrical, unsegmented, elongated helminths that taper at each end; this shape has earned them the designation roundworm. Cestodes, better known as tapeworms, have bodies that are flattened front to back with distinct, regular segments. Tapeworms also have heads with suckers or sucking grooves. Trematodes have flattened, unsegmented bodies. They are called blood, intestinal, lung, or liver flukes, depending on their infection site.

Modes of transmission Most infectious diseases are transmitted in one of four ways.

• In contact transmission, the susceptible host comes into direct contact (as in sexually transmitted diseases) or indirect contact (contaminated inanimate objects or the close-range spread of respiratory droplets) with the source.

• Airborne transmission results from inhalation of contaminated evaporated saliva droplets (as in pulmonary tuberculosis), which sometimes are suspended in airborne dust particles or vapours.

• In enteric (faecal-oral) transmission, the organisms are found in faeces and are ingested by susceptible victims, often through contaminated food or water.

• Vector-borne transmission occurs when an intermediate carrier (vector), such as a lea or a mosquito, transfers an organism.

How Bacteria Damage Tissue Bacteria and other infectious organisms constantly infect the human body. Some are beneficial, such as the intestinal bacteria that produce vitamins. Others are harmful, causing illnesses ranging from the common cold to lifethreatening septic shock.

To infect a host, bacteria must first enter it. They do this either by adhering to the mucosal surface and directly invading the host cell or by attaching to epithelial cells and producing toxins that invade host cells. To survive and multiply within a host, bacteria or their toxins adversely affect biochemical reactions in cells. The result is a disruption of normal cell function or cell death. In addition, as some organisms multiply, they extend into deeper tissue and eventually enter the bloodstream.

Some toxins cause blood to clot in small blood vessels. The tissues supplied by these vessels may be deprived of blood and damaged.

Other toxins can damage the cell walls of small blood vessels, causing leakage. This fluid loss results in decreased blood pressure, which in turn impairs the heart’s ability to pump enough blood to vital organs.

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Antibiotics There are several classes of antibiotic drug available commercially, all of which are prescription only medications, therefore need to be “prescribed” by a clinician. Due to the nature of remote area medical support a clinician rarely present to provide this. However any medication in this class (POM) that is administered by a remote medical provider who is not a qualified doctor should be able to refer to a doctor in order to gain the necessary prescription (either via electronic means or hard copy) either before administration, or in occasional cases, retrospectively dependant upon protocols or clinical directives signed of by the referral clinician/clinical head.

Types of Antibiotic Penicillin These are bactericidal in nature and absorb well into the body, although absorption into the CSF is poor unless the meninges are inflamed. A common side effect with penicillin is hypersensitivity, which can cause rashes and anaphylaxis.

Examples of penicillin’s used in remote areas include: Benzylpenicillin – emergency treatment for meningitis Phenoxymethlypenicillin – Tonsillitis, otitis media Flucloxacillin – Impetigo, Otitis externa, and other Staphylococci infections Co-Amoxiclav (Augmentin) – Respiratory tract infection, GU infections, animal bites Cephalosporins These are broad-spectrum antibiotics that work similarly to that of penicillins, resulting in approximately 10% of penicillin sensitive patients being hypersensitive to Cephalosporins. Due to increasing resistance the older generation Cephalosporins have reduced ability to fight bacterial infections.

The common (currently) used cephalosporin used in remote areas is Ceftriaxone. This is a third generation cephalosporin and due to is long half-life it only needs once daily administration, reducing quantity carried. It is a first line antibiotic in traumatic injuries as a prophylactic, but can also be used for septicaemia, pneumonia and meningitis.

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CEFTRIAXONE (POM) PROPRIETARY NAME

Rocephin

DRUG CLASS

3rd generation cephalosporin antibiotic

INDICATIONS

Prophylaxis against infection after a traumatic injury

CONTRA-INDICATIONS

Allergy to ceftriaxone or penicillin

INTERACTIONS

Chloramphenicol, Anticoagulants, Fluconazole, other antibiotics

SIDE-EFFECTS

Diarrhoea

DOSE

1 gram IV/IO

SPECIAL INSTRUCTIONS

Dissolve one vial of ceftriaxone in 10ml water for injection. Draw up the solution and administer slowly over 2-4mins. Once reconstituted, the solution will retain its stability for 24 hours at or below 25OC

PRESENTATION

Vial containing 1g powder for reconstitution

Tetracyclines Another broad-spectrum antibiotic, but one that has a reduced use due to resistance. They do remain the antibiotic of choice for chlamydia infections, rickettsiae (Q-fever) and spirochaete infections (Lyme disease). With these in mind and it’s use as a malarial and scrub typhus prophylactic ensures it’s place in a remote medical kit for a medical professional.

Aminoglycosides These are bactericidal in nature and are not absorbed well from the gut so are generally seen as injections or as topical application such as Gentamycin ear drops. Treatment with Aminoglycosides should not usually last longer than 7 days due to their toxicity.(including typhoid fever), and gonorrhoea and septicaemia caused by sensitive.

Macrolides Erythromycin is the common macrolide and has an antibacterial spectrum that is similar to penicillin resulting in its use as an alternative in penicillin-allergic patients. Indications for erythromycin include respiratory infections, whooping cough, legionnaires’ disease, and campylobacter enteritis.

Metronidazole Metronidazole has a high activity against anaerobic bacteria and protozoa and is therefore considered with abdominal injuries due to its effectiveness against colonic anaerobes, and in other dirty penetrating injuries; Metronidazole by the rectal route is an effective alternative to the intravenous route when oral administration is not possible. Intravenous metronidazole is used for the treatment of established cases of tetanus.

Quniolones Ciproloxacin is the common quinolone carried by remote medical providers and is active against both Gram-positive and Gram-negative bacteria. It is particularly active against Gram-negative bacteria, including salmonella, shigella, campylobacter, neisseria, and pseudomonas and is active against chlamydia. However most anaerobic organisms are not susceptible.

Uses for ciproloxacin include infections of the respiratory tract, of the urinary tract and of the gastro-intestinal system (including typhoid fever), and gonorrhoea and septicaemia caused by sensitive organisms. It is commonly used for prolonged diarrhoeas.

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CHAPTER 18: Anatomical Terminology Anatomical positions When describing anatomical positioning the terminology is based on a subject standing erect with feet lat on the floor, arms placed at the side with palms facing forward as shown below.

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Directional Terms Medial Lateral Proximal Distal Inferior Superior Cephalad or Cranial Caudal Anterior Posterior/Dorsal Superficial Deep

Toward the midline of the body Away from the midline of the body Nearer to the attachment of a limb to the trunk, nearer to the point of origin Farther from the attachment of a limb to the trunk, further from the point of origin Lower or below Upper or above Head Tail, tail end Toward the front Toward the back Towards the surface Away from the surface

Movement Flexion Extension Abduction Adduction Supination Pronation

The act of bending a part, or of the condition of being bent The movement that brings the part of a limb into a straight position Movement away from the midline Movement towards the midline External rotation of the arm so that the palm faces forward Internal rotation of the arm so that the dorsum (back) of the hand faces forward

Common Terminology The medical world is enshrined with its own language that has evolved from Latin and Greek, enabling a medical practitioner to accurately describe what is going on without ambiguity and verbosity. These terms can be broken down into 3 components parts, the prefix, the combining words and the suffix. Below is a list of common terminology used in the remote environment, this list is not exhaustive.

A-, Ab- Ad- Adeno- Aer(o)- Ambi- Angio- Ante- Anti- Arterio- Arthro- -asthenia -aemia -aesthesia

an- Absence of, without Away from Towards Gland Air -algia Pain Both sides Blood vessels Before Against Artery Joint Weakness of the blood Feeling, sensation

Bi- Brachio- Brady- Broncho-

Twice, both Arm Slow Bronchi

Cardio- Carpo- -centisis Cephalo- Cerebro- -cide Circum-

Heart Wrist Puncturing Head Brain Killing of Around

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Co- Contra- -costal Crani- Cyst- -cyte, cyto-

Together, with Against Rib Skull Bladder Cell

Dento- Dermato- Dia- Dorso- Dys-

Tooth Skin Through Back Abnormal, painful, difficult

Ecto- -ectomy Endo- Entero-

Out of Surgical removal Within Intestines

Haemo- Hepato- Hyper- Hypo-

Blood Liver Above Below, deficient

-iasis Infra- Inter- Intra-

State, condition Beneath Between Within

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Iso- -itis

Equal inlammation

Laryngo- Leuco-

Larynx White

Macro- Mal- Mega- -megaly Meningo- Micro- Myo-

Large Bad, poor enlargement

Narco- Naso- Necro- Nephro- Neuro- Nocte-

Numbness, sleep Nose Death Kidney Nerve Night

Occulo- Oligo- -ology -oma -opia Orchi- Ortho- -osis Osteo- -ostomy Oto- -otomy

Eye Few Science of Tumour, swelling of Vision testicle Straight Disease, abnormal condition Bone Surgical opening Ear Cutting into

Para- -paraesis -pathy Peri- -phagia Pharyngo- Phlebo- -phobia Photo- Phren- Pleuro- -pnea Pneumo- Post- Procto- Pyo- Psych- Pulmo-

Beside Weakness Disease Around Swallowing, eating Pharynx, throat Vein Fear Light Diaphragm Pleura Breathing Breath, air, lung After Rectum Pus Mind Lungs

Quad-

Four

Reno- Retro-

Kidney Behind, back of

Meninges Small Muscles

Rhino- -rrhage -rrhea

Nose Excessive low Profuse low

Sclero- Sero- Spleno- -stasis Super- Supra-

Hardness Watery Spleen Stopping of Above

Tachy- Thoraco- Thrombo- Trans-

Fast Chest, thorax Clot Across, over

Uni- -uresis -urea

One Urination Of the urine

Vaso- Ven, veni-

Vessel Of the vein

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The anatomical cavities The cavities, or spaces, of the body contain the internal organs, or viscera. The two main cavities are called the ventral and dorsal cavities. The ventral is the larger cavity and is subdivided into two parts (thoracic and abdominopelvic cavities) by the diaphragm.

Thoracic cavity The upper ventral, thoracic, or chest cavity contains the heart, lungs, trachea, esophagus, large blood vessels, and nerves. The thoracic cavity is bound laterally by the ribs (covered by costal pleura) and the diaphragm caudally (covered by diaphragmatic pleura).

Abdominal and pelvic cavity The lower part of the ventral (abdominopelvic) cavity can be further divided into two portions: abdominal portion and pelvic portion. The abdominal cavity contains most of the gastrointestinal tract as well as the kidneys and adrenal glands. The pelvic cavity contains most of the urogenital system as well as the rectum.

Dorsal cavity The smaller of the two main cavities is called the dorsal cavity.

As its name implies, it contains organs lying more posterior in the body. The dorsal cavity, again, can be divided into two portions. The upper portion, or the cranial cavity, houses the brain, and the lower portion, or vertebral canal houses the spinal cord.

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M.I.R.A. Trauma Bergen Contents List Description

Gloves Nitrile size Large per pair

Qty 20

Oropharyngeal Airways size 3

1

Oropharyngeal Airways size 4

1

Nasopharyngeal Airways size 6

1

Nasopharyngeal Airways size 7

1

Nasopharyngeal Airway size 8

1

Aquagel

3

igel size 3

1

igel size 4

1

igel size 5

1

Surgical Airway 6.0mm cuffed

1

Thermovent Heat and Moisture Exchanger

1

Scalpel disposable size 10

2

Syringe 10ml

5

Syringe 5ml

5

Syringe 20ml

2

Suction Easy Device

1

Laerdal Stifneck Select collar

1

Bag, valve, mask incl reservoir bag

1

Decompression needle

2

Bolin Chest Seal

2

Stethoscope Littmann Classic 2

1

Cathater Mount

1

First Care Emergency Bandage 6â&#x20AC;?

5

Combat Application C-A-T tourniquet

2

Celox Haemostatic Gauze

2

Kerlix Gauze large roll

2

Gauze 7.5cm x 7.5cm sterile

10

Celox 35g

1

Burnshield Dressing 10cm x 10cm

1

Burns Gel 125ml

1

Burns cling ilm

1

Jelonet Parain Gauze Dressing 5cm x 5cm

5

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