NTACC

© 2020 The ATACC Group Ltd. All Rights Reserved. TAG015_NTACC-MANUAL_V1.1 For further information Call: 03333 222 999 Email: [email protected] www.ataccgroup.com

The NTACC course is provided by The ATACC Group Nurse Trauma & Critical Care Manual

© 2020 The ATACC Group Ltd. All Rights Reserved. For further information Call: 03333 222 999 Email: [email protected] www.ataccgroup.com Empowering people to save lives.

For further information Call: 03333 222 999 Email: [email protected] www.ataccgroup.com © 2020 The ATACC Group Ltd. All Rights Reserved.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 1 Nurse Trauma and Critical Care Core material Chapter 1 - Background Chapter 2 - TQuINs Competencies Chapter 3 - The Trauma Team Receiving Care Chapter 4 - Team Delivery and Human Factors Chapter 5 - The M.A.R.C.H Algorithm 5.1 - M: Massive External Haemorrhage 5.2 - A: Airway Management 5.3 - R: Respiratory Management 5.4 - C: Circulatory Management 5.5 - H: Head Trauma and Other Serious Injuries Chapter 6 - Paediatric Trauma Chapter 7 - Silver Trauma Chapter 8 - Death of a Trauma Patient Chapter 9 - NTACC Trauma Skills Table of Contents: The NTACC manual and educational material is subject to the laws of copyright. The material cannot be copied or reproduced without prior approval of the author or The ATACC Group. In the event that any obvious plagiarism or copy is made without such prior consent. The ATACC Group reserves the right to take action through legal process. Copyright

2 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Nurse Trauma and Critical Care Preface – Enhanced casualty care The ATACC Group are hugely excited to launch our new Nurse Trauma & Critical Care course (NTACC), which has been developed by the ATACC Faculty, in response to numerous individual and Network requests, for a course that is specifcally aimed at meeting the Trauma Nurse competencies (formally the TQuINS). Developed over the last two years by our leading nurse faculty members and myself, NTACC is a purely ‘in hospital’ course, delivered in a unique scenario based, innovative style which lends itself perfectly to delivery in an interactive immersive space. Although primarily aimed at nurses, the course still completely supports the ATACC ethos of the multidisciplinary care and focusses on the role of Trauma nurses either delivering care, supporting and assisting medical staf or even leading the Trauma Team. In typical ATACC style, the course builds from a simple standard approach, that can be adopted for every trauma call, through a set of progressively more complex or specialised scenarios, which cover all aspects of trauma care in a modern trauma system. The course is ideal for any nurse or allied healthcare professional that works in a major trauma centre or trauma unit and provides a comprehensive grounding in all core knowledge and skills. NTACC will ultimately run seamlessly into our forthcoming advanced level, multidisciplinary, ITACC in-hospital trauma course for those that wish to progress their skills to the highest available standards. Enjoy the course, with it’s relaxed atmosphere, get yourself involved with the scenarios delivered by our passionate Faculty and experience why ATACC has proved so popular over the last 20 years. Dr Mark Forrest Medical Director The ATACC Group The NTACC Course

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 3 Chapter 1. Background The ATACC Group has gained a reputation for educational excellence by delivering ground breaking and innovative trauma and casualty care courses. NTACC is a fully immersive 2-day program specifically tailored to meet the needs of all nursing professionals working in Trauma Units and Major Trauma Centres. Nurses play a vital role within the multi-disciplinary trauma team however, at present they have limited educational options. Whilst some courses restrict access for nurses and others fail to meet the required standards, NTACC meets all of the competencies specified by the National Major Trauma Nursing Group (2016). NTACC fully immerses the candidate in a multi-disciplinary environment whilst still focussing on their role, interaction and support of the whole team. NTACC candidates will complete a number of high fidelity scenarios over the two day course. These will range from the fundamental principles of establishing the trauma team to more complex issues. This is designed to enhance practical skills, critical decision making and human factors. NTACC is delivered by a small team of experienced faculty. Each scenario will be directed by the faculty but fully managed by candidates giving them the opportunity to assume each role within the trauma team. NTACC not only enhances their individual role but gives them an insight into the roles of their colleagues with a view to making them a better team member. Dr Mark Forrest Medical Director The ATACC Group Miss Elizabeth Midwinter Nurse Clinician Emergency Medicine ATACC Faculty Mr Alistair Greenough Clinical Educator in Emergency Department ATACC Faculty Chapter 1. Background

4 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Chapter 2. TQuINs Competencies

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 5 Chapter 2. TQuINs Competencies In line with the competencies set out by the National Major Trauma Nursing Group the following assessment criteria will be met during the course. CATASTROPHIC HAEMORRHAGE MANAGEMENT • Demonstrate use of direct pressure, Haemostatic agents, special dressings, tourniquets, pelvic binder, traction splints. • Implement Massive haemorrhage protocol, use rapid transfuser and blood warmer, initiate Point Of Care (POC) testing. • Understand use of reversal agents for anticoagulants AIRWAY MANAGEMENT • Lead simple airway management. • Understanding of need for Rapid Sequence Induction (RSI) and able to act as assistant. • Understanding of need for surgical airway and able to assist. SPINAL IMMOBILISATION • Can safely manage a c-spine, provide immobilisation, and coordinate a log roll. • Can safely use scoop/extrication board/vacuum mattress. BREATHING AND VENTILATION • Understands life threatening chest injury. • Can anticipate need and physiology of thoracostomy, set up and assist in procedure. • Can anticipate need for chest drain, can set up and assist in procedure. • Understands indications for ED thoracotomy and can set up and assist procedure. CIRCULATION AND HAEMORRHAGE CONTROL • Understands fve main sites of bleeding in the trauma patient. • Able to safely monitor patients’ vital signs. • Has an understanding of the use of eFAST/POCUS in trauma. • Is able to set up for arterial/central line insertion and understands the indications for it. • Has an understanding of fuid resuscitation in the trauma patient. • Understands the principles of damage control surgery. • Understands the need for urinary catheterisation in thetrauma patient. DISABILITY • Is able to undertake neurological observations including GCS, AVPU, pupil size and reactivity, limb movement. • Can relate fndings to underlying physiology i.e. subdural bleed, spinal cord injury, presence of neurogenic shock. • Is able to manage pressure area care in the patient with spinal injury. • Has an understanding of ICP, Cerebral perfusion pressure and Monro-Kellie hypothesis. • An understanding of neuro interventions such as patient positioning, use of mannitol/hypertonic saline, and monitoring of PCO2. • Understands principle of management of a patient with Traumatic Brain Injury (TBI) including removal of c-spine collars, glycaemic control, normothermia. EXPOSURE AND TEMPERATURE CONTROL • Understands negative impact of hypothermia on the trauma patient. • Can perform exposure of patient whilst maintaining temperature control and dignity. TQuINs Competencies

6 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com TQuINs Competencies PAIN • Understanding of pain management guidelines in the trauma patient • Understanding of use of regional block. SPECIAL CIRCUMSTANCES • Aware of considerations for silver trauma patient including low threshold for Mechanism Of Injury (MOI), lower threshold for pain management, possibility of dementia or delirium. • Can appropriately care for the pregnant trauma patient, understands need for positioning to release vena cava pressure, is aware of indications for peri-mortem c-section. • Has working knowledge of treatment for burns, how to contact regional centre, and diferent types of burns and their management. Can also identify risk of airway burns or CO2 poisoning and how to use ToxBase. • Can lead in safe transfer of a bariatric patient. • Can lead in the management of an agitated and aggressive patient and understands indications for sedation. SECONDARY SURVEY • Ensures secondary survey is complete, appropriate tests requested and acted upon prior to transfer. TEAMWORK • Leads a team efectively • Works as part of a team efectively • Actively works to overcome barriers to efective team working • Provides emotional support and debriefng where necessary. COMMUNICATION • Communicates efectively with other team members, the patient, and outside organisations. SAFE TRANSFER • Ensures the patient can be safely moved from ambulance stretcher, to radiology, and to other units or to theatre/ITU. SITUATIONAL AWARENESS • Can recognise the rapidly deteriorating patient and expedite interventions where necessary • Can recognise signs of stress in other team members or the possibility of becoming task focused and intervene as appropriate • Understands the roles of diferent team members and can recognise adverse events. HANDOVER • Can efciently take and relay the pre-alert to the team • Can liaise with HEMS or ambulance crews • Can safely hand over care of the patient to the relevant specialty/theatres/ITU/MTC. DEATH OF THE TRAUMA PATIENT • Awareness of local policies regarding organ and tissue donation • Demonstrates the ability to break bad news to relatives. • Is aware of local protocols with regards to death of trauma patients • Demonstrates ability to liaise with grieving relatives and coroners’ ofcer and ensure appropriate documentation is completed. Chapter 2. TQuINs Competencies

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 7 Throughout the NTACC course we will be working as a trauma team with a team approach, which allows a degree of simultaneous activity under the direction and coordination of the team leader. The trauma team leader should be identifed at the start of the shift so they can be as prepared as possible. Human factors play an important part in how the team leader works and subsequently how the team can function. For example, crowd control is an important element to an efective team. The literature would suggest that having too many people in a team can impair its function. Studies have suggested that the optimum team size is six people, exceeding this number means the number of tasks that can be achieved per unit of time decrease. Additionally, simple communication errors may result in life threatening consequences. For example, if the team leader is not kept aware of where the ED doctor is in their initial assessment, the patient may get all the way through to scan before somebody has noticed an open fracture. This can become more likely when more people become involved and are working simultaneously. In NTACC this is all part of what we call the ‘Standard routine’ and we will walk the candidates through this at the beginning of the course, then expect to see it on every scenario throughout the two days. This will reinforce the importance of building muscle memory and ultimately the efciency in those frst few minutes of the Trauma Call. Chapter 3. The Trauma Team Receiving Care

8 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com It is of vital importance that the Trauma Team has an overview of the patient they are receiving so that appropriate arrangements can be made. For example, if the ambulance crew states a large volume of blood loss the massive haemorrhage protocol can activated in advance. The pre-alert should be recorded by the receiving hospital on the front page of the trauma documentation so that it forms part of the patient notes. There are many communication and handover tools available however, for the purposes of NTACC we will be using ATMIST: Pre-Alert A.T.M.I.S.T A AGE OF CASUALTY T TIMINGS OF INCIDENT (INCIDENT, YOUR ATTENDANCE) M MECHANISM OF INJURY I INJURIES IDENTIFIED S SYMPTOMS AND SIGNS ON ASSESSMENT T TREATMENT The trauma team should gather prior to the arrival of the patient. They should introduce themselves, put on their personal protective clothing and clear identifcation such as named tabards. They should all be made aware of the condition of the incoming patient by ensuring they have read the pre-alert from the Pre-hospital Team. Some units have footmarks on the foor in the resuscitation bay, but these are not really necessary and as the patient arrives there will often need to be movement around the resuscitation area. However, every team member should know their designated area to stand and their responsibility. A typical UK trauma team will consist of: • Team Leader (at the foot of the trolley initially) • Anaesthetist (head end of trolley) • ODP/Airway Assistant • Emergency Medicine Clinician (side of patient) • Nurse 1 • Surgical Doctor (opposite side of patient) • Nurse 2 • Scribe (stood next to Team Leader) • Orthopaedic Surgeon (stood within the trauma bay) The Trauma Team Chapter 3. The Trauma Team Receiving Care

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 9 The Trauma Team Since the introduction of the NICE major trauma guidelines many hospitals have implemented the role of ‘Key Worker’. This person becomes the single point of contact for that patient and follows them on their journey from arrival to hospital, to the major trauma ward, through to discharge. Prior to the introduction it was found that major trauma patients often became ‘lost in the system’ as they were under multiple diferent specialties. This may have devastating consequences for the patient. For example, if their main consultant was neurosurgery for their head injury they will be listed as such and therefore may not receive routine fracture clinic follow up with the orthopaedic team for their broken wrist. If this were to go unnoticed then, whilst their head injury may recover fully, they may have a permanent loss of functionality to their dominant hand. Other team members may be added as required as the situation dictates e.g. • Radiologist • Radiographer • Paediatrician • Cardiothoracic surgeon • Neurosurgeon It is also vital to have a porter as part of the team so that clinicians are not lost to collect blood products or deliver samples etc. Only the Trauma Team should be within the bed space and the Team Leader should ask anyone without a tabard to step back outside. Before Patient Arrival Each team member should introduce themselves and sign in, following this there will be a quick briefng. At this point, roles should be allocated, and likely interventions and contingencies should be discussed. Each member should then check and prepare any necessary equipment that they are likely to need based on these discussions and these should be open and prepared in the more major cases, with known injuries. Drugs should be drawn for analgesia, sickness or rapid sequence induction. Paediatric doses should be pre-calculated and recorded. There is some evidence that for paediatric trauma, having a pharmacist involved or using an ‘App’ to simplify calculations, will decrease the rate of drug errors in paediatric cases. The CT department should be informed, and the radiographer prepared. Some trauma systems allow for the bypass of the emergency department altogether and the pre-hospital team can go straight to scan. If necessary, the Emergency theatre should also be given advanced notice of a potential immediate transfer to their department. The Team Leader should also make it clear to the team how the handover process will run, as there are a number of ways. Chapter 3. The Trauma Team Receiving Care

10 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Patient Arrival As the patient is wheeled in on the trolley, the awaiting trauma bay should clear for the ambulance team. The Team Leader should identify himself or herself and ask who is in charge from the ambulance crew. At this point the Team Leader will ask if there are there any immediately life-threatening problems or concerns. If there are then these will be addressed immediately, if not then the team can proceed as normal The ambulance crew should state: • The patient’s name • The patient’s age • What incident has occurred and when Eg: ‘This is John, who is approximately 25 years old. He was knocked of his bicycle by a heavy goods vehicle and he appears to have a signifcant head injury’ Photographs from scene are always useful to emphasise mechanisms: • The patient is then moved into the bay and transferred onto the ED trolley All team members should remain ‘hands-of’ whilst the handover is given. • Once the handover is completed the Team Leader will give a short summary to the team and ask them to commence their roles, whilst highlighting any key actions required e.g. “Anaesthetist – can you assess the airway and consider if RSI and intubation is required.” The ambulance crew should be asked to stay during the following primary survey in case there are more questions to ask them or onward transfer is required e.g. Trauma Unit to Major Trauma Centre. Simultaneous Activity We will now see a great deal of simultaneous activity whilst the team completes a primary survey and evaluates anything suggested by the ambulance team. The ideal placement of Trauma Team Members around a patient, should maximize access and ensure staf are not inhibiting each other’s assessment. The monitoring will ideally be at the head end of the patient. TRAUMA TEAM LEADER (TTL) The trauma team leader should ideally not get hands on the patient. They should stand back and rarely needs gloves on, as they are ‘conducting the orchestra’ and not providing interventions. If they have to get involved, then ideally someone else should take over the leadership role. All communication should come through the team leader and this will be discussed further in the next chapter, as will the role of the scribe who stands at the shoulder of the TTL recording all times, events and actions. ANAESTHETIST AND ODP/ANAESTHETIC ASSISTANT – AIRWAY The anaesthetist is responsible for the patient’s airway and by default of this position, the c-spine (c-spine management is discussed further in other chapters). Their position at the head-end of the patient, means any movement of the patient should be done under their coordination. The traditional log-rolling in the primary survey to ‘check the back’ has been removed, in all but penetrating trauma, in view of the potential risks of dislodging pelvic or intra-abdominal blood clots, especially as all but the most unstable major traumas will be getting a pan CT scan anyway and it is a poor way of assessing potential spinal injury. However, in penetrating trauma a full body search for wounds should be conducted which will require a log roll and examination of the back, sides and at risk areas such as armpits and groins. Chapter 3. The Trauma Team Receiving Care

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 11 It may also be necessary to move the patient to remove clothing or protective equipment which will not only cause prolonged patient discomfort if left insitu but also show as artefact on the CT, i.e. motorbike leathers. The Team Leader should make a balanced judgement on this for each case, but in most cases, it is no longer necessary nor is the traditional PR examination during the log-roll. As they are in the best position to talk to the patient the anaesthetist is also the ideal person to monitor the patient’s level of consciousness, although they should avoid peering over the patient from above the head, upside down. Any fndings and subsequent interventions should be fed back to the Trauma Team Leader. In the more unstable patients with the ODP/anaesthetic assistant they will complete interventions such as the placement of large bore resuscitation lines, nasogastric tubes(NG) tubes and in some cases arterial lines, as long as they do not delay essential transfer and care. The ODP/ Anaesthetic assistant will be responsible for assisting with set-up and placement of these lines, as well as other equipment such as level one infusers, Bair Huggers and removal of clothes, supporting the ED Nurses. The ODP is also the ideal person to assist in completing pre-RSI checklists as they are most familiar with difcult airway equipment. ED CLINICIAN AND NURSE 1 The ED Clinician is responsible for undertaking the primary top-to-toe survey and feeding all fndings back to the Team Leader. If any intervention is necessary, for example a chest drain, the ED clinician, if appropriately trained, should perform these interventions. Whilst this happens the nurse should ensure appropriate venous access is obtained, ideally a large bore cannula on each side of the patient and take appropriate blood samples including cross match/Group and save, and a venous gas sample. The venous blood gas (VBG) is sent immediately to the departments’ blood gas analyser, ideally with the patient’s temperature and this will provide us with the some of the necessary information to make decisions about damage control elements of resuscitation. This includes as minimum: • Acid- base status; pH • Ventilation – pCO2 • Base defcit • Lactate • Blood sugar • Haemoglobin Laboratory bloods will also include urea and electrolytes, urgent x-match, full blood count, pregnancy test if female and clotting. If a viscoelastic haemostatic essay (VHA) machine such as TEG or ROTEM is available then get a small sample to test in the department, as soon as possible. As members of ED staf it is usually most appropriate for these team members to ensure the appropriate blood tests and images are requested. SURGEON AND NURSE 2 The surgeon is responsible for identifying any signs of massive haemorrhage, including assessment of the abdomen and pelvis. This clinician should also assess if pelvic binders, CAT tourniquet’s and other haemorrhage control devices are in place, adequately positioned and maintaining efective haemorrhage control. If abdominal trauma is found or suspected then the surgeon, or if necessary, the ED clinician, should perform a FAST scan, if the patient is not going immediately to CT. A positive FAST, together with clinical signs, may mean that the patient goes straight to theatre, a negative FAST does not exclude major bleeding. All fndings must be fed back to the TTL. The nurse is responsible for ensuring that the patient is comfortable, and especially, kept warm as their clothes will have been removed fully by now. Simultaneous Activity Chapter 3. The Trauma Team Receiving Care

12 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com ORTHOPAEDIC DOCTOR Reduction of limb threatening injuries, and subsequent traction or splinting, should be performed at the earliest safe opportunity. Once the initial primary survey has been completed, the Orthopaedic clinician should ensure a secondary survey has been completed to evaluate any fractures, deformities, dislocations, degloving injuries. They should also complete a full neurological examination of all limbs and ensure pulses and/or defcits are documented. Any injuries which need immediate splinting should have appropriate splints and packaging applied then reassessment of neurovascular status should be completed by the orthopaedic team member. Any fndings or limb injuries which needed to be included in the CT scan should be fed back to the Team Leader. THE SCRIBE The scribe will be positioned next to the Team Leader and is responsible for ensuring that all fndings and orders are documented, including timings of important decisions. They should ensure that, if possible, patient details have been obtained and recorded. The scribe should also ensure the patient has appropriate wrist bands on to identify them. A log of and drugs, fuids and, importantly, blood products and time of administration should be kept. The scribe is responsible for ensuring all trauma documentation is completed in a timely manner and is often responsible for chasing other members of the team to ensure the documentation is completed before any team member leaves the room. FLUIDS AND RESUSCITATION Blood is now the primary resuscitation fuid in major trauma. If we are thinking blood then we should also be thinking fresh frozen plasma (FFP), platelets and checking that they have been given Tranexamic acid (TXA) by the paramedics. Our main aim is to prevent further loss of blood and to preserve circulation wherever possible, rather than to replace it. Where fuid resuscitation is necessary, and blood is not immediately available, then warmed crystalloid is given in 250ml aliquots, and blood should be requested to replace the saline as early as possible. If necessary, activate the Massive Haemorrhage Protocol with the laboratory. A ‘Code Red’, request may have been made by the pre-hospital team, which means that they will be requiring blood available immediately on their arrival. SITUATION REPORT (SIT-REP) As the previous steps have been completed, all information should have been fed back to the trauma team leader. If the team is functioning well, then only one person at a time should have been talking therefore, at this point, most of the team will be aware of the current situation. However, it is good practice, once all initial and secondary surveys are completed, to have a brief time-out, so that team members can summarise their fndings. At this point the Trauma Team Leader will decide whether the patient needs to go to CT, Emergency Theatre, the Major Trauma Ward or have further interventions performed in the ED. In a Trauma Unit this decision may be to transfer to the Major Trauma Centre. After the sit-rep, other specialties including neurosurgeons and orthopaedic doctors may be asked to provide a secondary assessment. Simultaneous Activity Summary The above is just one way of managing the Trauma Team approach, and clinicians should always be aware of local guidelines and variations to practice. However, the key lesson here is to ensure a systematic, concise and familiar approach is followed. If teams function well together then this should be a clear and efcient practice. However, multiple factors, including poor communication and leadership, can result in missed injuries and can therefore result in devastating long-term consequences for patients. Chapter 3. The Trauma Team Receiving Care

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 13 As a team we can achieve incredible things, which would be impossible if working alone. In this chapter we will examine both internal and extraneous variables that may impact on the functionality of your trauma team. Trauma is a complex and evolving entity that requires a leader, who can direct and focus the team members of varying skill level, in a somewhat fraught environment. When we all work together, even the most challenging cases can be well managed and potentially salvaged. However, even the simplest of cases can become an insurmountable challenge without efective team-work and guidance. Chapter 4. Team Delivery and Human Factors

14 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com With this in mind, let’s consider examples of leadership and team work outside the hospital setting. One expert team that you may be familiar with is the formula pit crew. These team work tirelessly and practice constantly to achieve specifed standards. Some of the best pit-crews need to be seen to be believed with records of 1.92 seconds which include 4 wheels changed, refuelling and the car back in the race. However, this fuidity in which these teams perform would be unattainable without the team leader and the key team members. This is where the comparisons between the formula 1 pit-crew and the trauma team can be made and there are key lessons in precision and team management we can learn from this high-performance industry. However, there is a signifcant diference between the pit-crew and the trauma team. The pit-crew do the same thing every time the car pulls in for a pit stop in trauma this does not happen every patient is diferent and carries with them their own individual set of contraindications. During the trauma scenario there are many elements to be conducted at any one time therefore to operate in the Team Leader role it is crucial to have this well-developed sense of ‘situational awareness’ as many clinical errors may be linked back to some element of reduced situational awareness e.g. missed results of fndings, failure to check and x-ray, failure to listen to the team or colleagues. Additionally, it is also important to note that failures and errors may not always be linked to the Team Leaders lack of ‘situational awareness’. Consider the picture below, the young driver of this digger which is now sinking into the swamp. Is this due to lack of ‘situational awareness’ or are there other variables involved? Have we considered the task or environmental factors? For example, overwork or exhaustion, there may be alarms fashing and sounding in the cab, the boss may be on the radio screaming instructions and warnings and while all these thing are happening the digger continues to sink. Then other human factors develop such as fear of drowning and thoughts of consequences etc. All of these can easily be blamed on situational awareness, but in fact, what is more likely to be happening is total sensory overload, leading to further panic and misjudgement which can then develop into a downward spiral of forced errors. In the trauma situation, it can very easy for the Team Leader to become completely overwhelmed in this manner, with information coming all angles and this is when mistakes are made, and you barrel toward the spiral of forced errors. This is often termed ‘saturation of bandwidth’. There are various methods used to manage this situation and to ‘ofoad’ other team members to avoid becoming saturated or over-stimulated. This may involve the Team Leader delegating work to sub-team leaders or having a shared approach to situational awareness. A strong example of delegation or shared situational awareness can be found in the aviation industry. In this profession the terminology is Crew Resource Management or CRM, this is the system adopted by pilots and their crews to interact efectively and safely during fight operations. From the minute that the crew prepare for fight the process commences and whilst a clear rank and leadership structure exists, there is also a defned process for raising concerns or questioning decisions, which can be escalated in various pre-determined ways using challenge checklists. Within this industry there are standardise operational protocols which are adhered to when key decisions are to be made, such as pre-fight checks. At this time there should be minimal or no distraction this is known as the ‘Sterile cockpit’ rule. These processes and systems avoid errors, forgotten details, distractions and also provide a systematic approach that can be adopted when the situation begins to veer of course or the stress of the situation is greatly elevated. These protocols optimised communication in order to avoid time wasting, whilst keeping all essential team members fully briefed. The Pit-Crew Chapter 4. Team Delivery and Human Factors

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 15 Team roles Let’s consider the specifc team roles starting with the team leader, he or she is best placed, stood back in an overseeing position. However, whilst observing the team, the process and the progress they are still part of the ‘team’ and must remain approachable and involved in said process. This can be a challenge and suitable leadership skills are essential, striking a balance between listening, assertiveness, aggression, calm, well-paced and numerous other traits! The role of Team Leader requires someone with the skills and ability to gather all the information before them, including visual information, fndings from team members, safety concerns and other feedback then assimilate and process the information, sifting out the key details. From these important decisions are then made and fed back to the team. The team leader is clearly identifable, and all team communications pass through the team leader to and from the other team members. In high performing teams, speech is kept to an absolute minimum to ensure that key messages do not get missed. However, it is crucial to remember that the Leader, does not have to have all the answers and they do not have to be an ‘expert’ in everything, they merely ‘conduct the orchestra’. The opinions and guidance of all the expert team members can be obtained to support the leader’s decision-making process. If we revisit the pit-crew, we can identify that each team member has one single job to focus on and this role is entirely predictable. If we map this to the trauma team, we can also identify that within each individual’s role there are a limited number of specifc procedures typically performed by each team member. For example, the anaesthetist concentrates on securing the airway, the orthopaedic surgeon concentrates on fractures and the general surgeon on the abdomen and they can all work simultaneously, rather than one after another. This is described as the horizontal approach, with a focus on continuous uninterrupted activity. As part of the mental rehearsal and thought processes of the Team Leader they will develop what is often termed a ‘Mental model’ which is their vision of how the team should proceed. This model may be the perfect solution to the situation, but it will only ever be efective if shared with the team (28,29) Analysing many disaster and team failures, there has been a clear breakdown in this process of ‘sharing the mental model’ with team members who have been ‘left out of the loop’ (a term coined from the OODA loop concept by Boyd). Ensuring that this happens in ad hoc teams is major challenge and we must use key strategies to ensure that communication is efective as possible: 1. NAMES AND IDENTIFICATION An essential part of efective team working, and communication is knowing who you are working with, so either during the daily team brief or in the pre-brief, all team members need to quickly introduce themselves by name and role. Stickers are a great way to do this as you can add your name (preferably your frst name) to your designation. These badges can be colour coded for each sub-section of the team and if you aren’t wearing a badge then you are outside the designated bay, observing until invited in by the Team Leader. 2. LANGUAGE AND APPROACH When stating the expectations, Team Leader and Team members should be very clear and avoid using non-specifc, demeaning or vague instructions. These instructions should also be frmly directed to the relevant individuals and avoid general requests to the team such as: • ‘would someone mind checking the abdomen’ • ‘can someone book the CT scan please’ These would be far better if individuals were specifcally asked by name, to complete a clear task, which they can then report back as completed. Mental Models Chapter 4. Team Delivery and Human Factors

16 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com • ‘John, can you please examine the abdomen and let me know what you fnd’ • ‘Jane, can you please book a CT Pan-scan’ The process of giving and instruction and then receiving feedback is called ‘closed loop communication’ and it has 3 parts. • Deliver the order to a specifc individual • The individual selected acknowledges and confrms the order • Individual confrms that the order is completed Without all three elements, a key task could be missed and to be absolutely sure, for the most important tasks, ideally, we also seek confrmation that the completed task has been done correctly, which usually requires a second individual to check completion and report back. In its most basic form, simply repeating back instructions and reports, immediately after they are given, is good safe practice, that requires minimal training and can improve patient safety. 3. CHALLENGING DECISIONS – GRADED ASSERTIVENESS We mentioned earlier that the Team leader will not necessarily have all the answers and Team members need to be able to question decisions or plans, but without argument or unnecessary delay. The aviation industry has an excellent way to do this, even for when addressing senior ranks called ‘Graded assertiveness’ (30). This technique uses a 2-challenge approach based on the acronym ‘C-U-S’ (concerned – uncomfortable – safety/stop): For example: I am concerned that this patient is too unstable to go to CT I am uncomfortable taking this patient to CT as they are clearly highly unstable This is a safety issue: this patient is bleeding internally and needs immediate surgical intervention An alternative is the ‘PACE approach’: • PROBE – “Do you know that…?” • ALERT – “Just to confrm that…?” • CHALLENGE – “I am not comfortable with...” • EMERGENCY – “STOP what you are doing!” 4. CHECK-LISTS Check-lists are playing an ever-increasing part in our everyday healthcare lives and they are not just about handing over information, or checking equipment, but they support a major shift in safety mentality whereby we aim for the provision of safety as an achieved norm, rather than the current objective of achieving no errors. For example, there is a signifcant risk to patient safety when administering an anaesthetic. This is where checklist come into their own all leading Trauma and pre-hospital teams around the world are adopting a checklist system in relation to the administration of anaesthetic, particularly when it come to Rapid Sequence Induction (RSI). The ATACC RSI challenge checklist has been based on a number of other similar ones drawn from specialist teams from around the world, but they are all very similar. The checks take approximately three minutes, which also provides time for good simultaneous pre-oxygenation. The grey shaded areas are for use on the rare occasions where the patient is not breathing adequately or is deteriorating rapidly requiring immediate intubation. This is obviously a degree of compromise but constitutes the absolute minimum pre-anaesthetic checks for out of theatre RSI. 5. NON-VERBAL COMMUNICATION We all communicate non-verbally consciously and sub-consciously and this can have both positive and negative efects. Typically, our non-verbal signals are used to reinforce what we have said and they can include facial expressions or hand gestures for example. As we suggested earlier, for us to establish all of these principles of team working, leadership, CRM, checklists etc we need to gather the whole team regularly and promote training together. Even applying the methods that we have presented, without suitable rehearsal or practice, we cannot expect a group of strangers to come together on an infrequent basis and suddenly perform like an F1 team. We therefore need to identify the team members, encourage them to fully adopt a systematic approach to trauma care and then come together, with all their core skills, on a regular basis to practice, full integration as team and to ensure that the environment and their standard operating procedures (SOPs) actually work. Mental Models Chapter 4. Team Delivery and Human Factors

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 17 INDICATION FOR RSI RESPONSE PRE-OXYGENATE – add Nasal Prongs Check Oxygen cylinder more than 1/2 full or Wall source available Check Spare cylinder available Check Connect Water’s Circuit with Face Mask and Filter to Oxygen Check End Tidal CO2 Monitoring connected into circuit – aim 4 to 4.5 Kpa Check SUCTION working Check Back-up suction available Check BVM available Check Oral & 2 Nasal airways available? Check LMA available if we fail to intubate on 2nd attempt? Check Surgical airway kit visible? Check IV Running with access port connected Check 2nd cannula in situ or IO available Check Drugs for Induction, what dose? Response Paralysing agent, what dose? Response What maintenance drugs are we using? Response Emergency drugs available? Response LARYNGOSCOPE working Check Back-up Laryngoscope working Check Bougie Check Tube size Response Alternate tube size Response Test tube cufs Check Tube tie or tape Check Check Monitoring, what is the O2 Saturation? Response What is the Blood Pressure Now? Response What is the Heart Rate? Response Brief drug administrator Briefng Brief In-line immobiliser Briefng Perform Cricoid brief Briefng All stop and listen to failed airway plan Briefng Optimise patient position Ready Check Complete Proceed RSI CHECK-LIST READ EVERY WORD AND WAIT FOR RESPONSE BEFORE MOVING TO NEXT LINE 6. DE-BRIEFING: Whether it be a simulation or a real incident, a crucial part of our learning is the de-brief afterwards. These are an excellent opportunity to discuss not only the incident, but also our response and behaviours to said incident. For example; Why did the team make a particular choice or decision? Was it right or was it wrong? Do we need adapt our equipment, our SOP or our training? Is there specifc learning outcomes for the whole team? De-briefng during training is typically very structured and formalised, to provide constructive responses and learning. In contrast, ‘hot’ debriefs, immediately after incidents may focus on how the team feel and any immediate issues. A very useful source of simulations are real incidents that have occurred, or conficts that have arisen during de-briefs. The solutions may come through discussion or re-running the scenario as a detailed simulation. De-briefs and the responses that arise should be recorded in some form, as they become a crucial part of the clinical governance process of continuous improvement and ongoing learning. Mental Models Chapter 4. Team Delivery and Human Factors

18 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Chapter 5. The M.A.R.C.H Algorithm

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 19 B.L.S. PROTOCOL NOT BREATHING (10secs) NO SIGNS OF LIFE (10secs) Re-assess SAFE APPROACH TIME CRITICAL HAEMORRHAGE CONTROL D.D.T Wound Packing / Haemostatics / Tourniquets Not more than 60 secs if single rescuer AIRWAY MANEOUVRES • Jaw Thrust/Chin LIft • Oxygen 15L/min - Target Sats > 94% on 02 • Suction • NP/OP • i-Gel RESPIRATORY SUPPORT • Oxygen 15L/min • Chest seal (wounds) • RR <8/min - BVM - Pocket mask • Bad side upper most • Consider sitting up CIRCULATORY SUPPORT • Re-assess D.D.T/Bandage CONSIDER: • ‘Scoop and Run’ • Pelvic Strap • Gentle handling • Traction Splints • Head to Toe survey • Elevate Legs INJURY SUPPORT HEAD INJURY (Consider Medical Causes) • Keep patient talking • Monitor Airway/breathing SPINAL INJURY AND FRACTURES • Immobilise/Splint • Pain: Penthrox BURN INJURY • Active Cooling • Cling-flm/bags ENVIRONMENT • Keep warm • Package for Transport MASSIVE HAEMORRHAGE AIRWAY PROBLEM? • Unconscious • Airway at Risk • Obstructed • Cx spine: if 2 persons • Sats <92% or less on air HEAD & OTHER INJURIES • AVPU • Abnormal Pupil Reaction • Pain or numbness • GCS <12/15 • Burns/Cold • Others, e.g fractures RESPIRATORY PROBLEM? • RR >20/min • Difculty in breathing • RR <8/min • Sats <91% air / <94% 02 • Open Wounds • Unequal Movement CIRCULATION PROBLEM? • Unconscious • Radial Pulse absent • CRT > 3secs • Radial Pulse >110/min Chapter 5. The M.A.R.C.H Algorithm The M.A.R.C.H Algorithm

20 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The term massive external haemorrhage refers to a major bleed that will rapidly become life-threatening, (e.g. a lacerated femoral artery which can bleed as much as 1 litre/min). When it occurs, it must be ‘aggressively’ addressed before any other patient assessment takes place. The body has only a limited volume of circulating blood (fve litres in an average adult), and once a large amount is lost (approximately three litres), it can be too late or simply inefective trying to replace it with intravenous fuids or a blood transfusion. The ATACC method of care focuses on what we call ‘circulation preservation’ (aiming to preserve your own blood in your circulation rather than replace it). Massive external haemorrhage control should be a provider's initial focus. However, provider's should ideally manage such haemorrhage control within one minute and then move on to the next step in the M.A.R.C.H algorithm, to address other critical concerns, such as airway, which can also lead to fatalities if not managed rapidly. As the initial focus is massive haemorrhage control, we must identify it as early as possible by quickly scanning the scene and casualty for any obvious external bleeding. Provider's should look for spurting arterial bleeds, blood soaked clothing, or pools of blood collecting on the foor (see fgure 1). Remember that this is not just any wounds or bleeding but rapid torrential bleeding in large volumes. The source of such major bleeding should be rapidly identifed, by exposing the wounds and then managing it ‘aggressively’ to minimise further loss. If such bleeding is not immediately obvious, then rapidly move on in the M.A.R.C.H algorithm. Internal massive haemorrhages (inside the body) may not be obvious or easily identifed by provider's. However, they may be suspected based on the kinematics of the incident (e.g., penetrating trauma or high- speed blunt trauma) or become evident later during the further M.A.R.C.H assessment as signs of shock are identifed. When internal bleeding is suspected, providers should continually reassess the casualty, looking for developing signs of shock, such as increasing heart rate or deteriorating conscious level. Internal bleeding and shock are discussed in greater detail in Chapter 5.4. 5.1 / M: Massive external haemorrhage Figure 1.: MASSIVE EXTERNAL HAEMORRHAGE. Chapter 5.1 / M: Massive external haemorrhage

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 21 Signs and symptoms of massive haemorrhage Signs and symptoms of haemorrhaging include: • Obvious major blood loss • Spurting blood or rapidly pooling blood (always be aware of clothing that can become saturated or ground that may absorb any blood loss) • Anxiety or confusion (especially if getting worse) • Deteriorating conscious level or unconsciousness (Going quiet!) • Loss of radial pulse or pulse rate > 110 beats per minute • Capillary refll time > 3 seconds • Respiratory rate > 20 breaths per minute. An average adult has approximately fve litres of blood circulating around the entire body. Blood can be lost into the chest, abdomen, or pelvis without any external sign of bleeding. A signifcant amount can also be lost into the large muscles of the buttocks, thighs or lower leg. Managing haemorrhaging For many years, the main focus in the management of blood loss involved replacement with intravenous fuids, but preservation is now deemed far better than replacement for all levels of responder. The steps for controlling haemorrhaging can be remembered by the phrase I-DiD-iT, which stands for: I – Indirect pressure Di – Direct Pressure Di – More direct pressure (2nd time) T – Tourniquet application To protect the responder from contamination, gloves and appropriate PPE should always be worn whilst controlling any haemorrhaging. Chapter 5.1 / M: Massive external haemorrhage

22 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Applying indirect direct pressure Some skilled providers may include ‘indirect pressure’ on major arteries, but research and our experience has revealed that this is often done badly by those unfamiliar with anatomy and valuable time and blood can be lost trying this method. As such NTACC providers should stick to DiD-iT direct pressure and tourniquet, which is highly efective. However, for those skilled and familiar with the anatomy, indirect pressure can be useful to control bleeding when you don’t have access to the bleeding point or any protective PPE for example compressing the femoral artery against the bone of the pelvis at the top of the leg, the brachial artery against the humerus in the upper arm (runs in the groove between the biceps and triceps), (see fgure 2) or the popliteal artery compressed against the bone behind the knee. It is useful to familiarise yourself with these pulse locations when time allows, not in an emergency. Figure 2: Applying indirect pressure can be the frst step in the I-DiD-iT technique. Applying direct pressure After PPE is donned, the frst step of the DiD-iT technique involves fully exposing the bleeding point as it may actually be quite a small wound, despite all the blood we can see. (see fgure 3). We then apply frm and focused direct pressure to the wound. This can be achieved with a gloved fnger, thumb or fst or if immediately available by using a sterile trauma dressing, with frm direct pressure applied on top. If this is life threatening bleeding, do not delegate this role to a member of the public or lay responder, unless they understand the importance of their role and the pressure required. Reassure the patient as this pressure will be very uncomfortable, especially in an open wound or if there is an underlying broken bone. Be careful if there are obvious bone ends in the wound and use a good thickness of trauma dressing. This is NOT the time for bandaging, unless you have to move on to another patient or injury. Bandaging is fddly and you will fumble with the dressing unless you do this on a day-to-day basis. We will apply a frm pressure bandage later, as part of our ‘C’ assessment once we have control of the major bleeding. If using a trauma dressing, it may be left rolled up and simply used as an absorbent roll. Common feld dressings have a bandage with an absorbent dressing fxed to one end, which can be placed directly onto the wound, but do not start bandaging. If you do not have a bandage then simply use your gloved hand, fngers or thumbs to apply the direct pressure. Chapter 5.1 / M: Massive external haemorrhage

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 23 If bleeding continues and blood soaks through the dressing, more direct pressure should be applied by applying another dressing on top of the existing one and continuing to apply direct pressure. Do not remove the frst dressing, as this may cause further bleeding. If the second direct pressure attempt fails to achieve haemorrhage control and the bleeding is still life-threatening, it may be necessary to apply a tourniquet if possible. Be sure to strive for adequate control of haemorrhaging within one minute. This requires a real degree of urgency and we often describe it as ‘aggressive’ haemorrhage control. If the frst dressing saturates with blood within seconds, apply a second dressing or go straight for a tourniquet. Applying direct pressure I SAW IT I EXPOSED IT I DiD iT Figure 4: Fully exposing the bleeding point. Figure 3: Controlling haemorrhaging using I-DiD-iT: Chapter 5.1 / M: Massive external haemorrhage

24 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 4.1. Apply frm, focused direct pressure to the bleeding point in the wound with thumbs or fngers. 4.2. Apply frm, if the wounding is larger then apply frm direct pressure using the heal of the hand or an absorbent sterile dressing. 90% of external haemorrhaging can be controlled with well performed direct pressure, so application of a tourniquet is rarely necessary. 4.3. If bleeding continues, frmly apply a second sterile dressing or consider a tourniquet. DON PROPER PPE TO PROTECT YOURSELF FULLY EXPOSE BLEEDING POINT DID-IT to manage a massive haemorrhage 4.4. Bandaging is part of C-Circulatory management and not normally part of Massive Hemorrhage control. Chapter 5.1 / M: Massive external haemorrhage

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 25 A tourniquet is a device used to occlude blood supply to a limb by compressing the artery against a bone or by compressing a muscle compartment around an artery. (see fgure 1.5). The indication for using a tourniquet is when haemorrhage cannot be controlled by more basic techniques, and the failure to immediately stop this bleeding would cause a life-threatening situation. The very prolonged application of a tourniquet may cause tissue damage which in the most extreme situations (greater than 6hrs) could result in loss of a limb. However, not applying a tourniquet may mean loss of life, as the casualty could bleed to death. Military studies have demonstrated that tourniquets on for two hours have no demonstrable adverse efect. Four hours may leave some temporary numbness and only after six hours is there a risk of some long term detectable damage (see below). Tourniquets work most efectively in the middle of the limb (mid-shaft), on the long bones of the upper arm and leg. However, despite previous teaching, they are also efective in the lower leg and arm, as although the arteries run between the bones in this region, they can still be compressed by pressure around their surrounding muscle compartments. Tourniquets should be applied as far down the limb as possible or approximately 3-4 cm above the injury, (although care should be taken with traumatic and blast amputations as the injury can sometimes extend up the limb from the stump and may require higher placement of the tourniquet). • Tourniquets should not be applied over joints (e.g knee and elbow etc) as they will be far less or totally inefective • Tourniquets are not applied over the wound or dressings, unless this is the only way to maintain efective pressure – essentially using it as a pair of hands. In some situations, it may be appropriate to go straight for a tourniquet rather than I-DiD-iT, for example where an injury cannot be reached, direct pressure cannot be provided, or you have other issues or multiple casualties to manage. Tourniquets, must be inelastic and slip-resistant, because the tightness around the limb is the key to controlling bleeding. There are many commercial tourniquets available that are relatively simple and easy to use. Military-style tourniquets are designed to be efective and simple and simple and easy to apply. Some can even be applied with one hand by the patient themselves. If a tourniquet is not available, other improvised devices such as belts, ties, or clothing may be used; however, these improvised tourniquets may be slow to apply and difcult to tie-of, allowing bleeding to continue. Some studies have shown that they are often completely inefective or blood loss has been considerable whilst improvising. Many of the best commercial devices are windlass based, to create the necessary tension in the device and then to secure it without it coming loose, as such they are very uncomfortable. Good direct pressure will be better than a poor slowly applied improvised tourniquet. SOFFT Two modern emergency tourniquets, the SOFFT and the CAT (research has demonstrated that the latter is a more efective device) CAT Applying a tourniquet to control haemorrhage Chapter 5.1 / M: Massive external haemorrhage

26 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Tell the patient what you are doing and explain that this device, which is often very uncomfortable, is an essential tool for controlling their bleeding and can save their life. All clothing should be cut of prior to arrival at the hospital and the tourniquet must be identifable. The tourniquet needs to be checked for damage and all clinicians made aware it is in sith. Figure 5: Applying a tourniquet to the arm. Applying a tourniquet to control haemorrhage Step 1: Slide up tourniquet or wrap around the limb. Step 2: Pull the tourniquet tight by hand. Step 3: Secure the retaining buckle. Step 4: Use the windlass mechanism to apply tension and continue until the bleeding is controlled. Step 5: Secure the windlass under the retainer. Step 6: Pull over the white retaining strap. Step 7: Record the time of application and the site of the tourniquet. Chapter 5.1 / M: Massive external haemorrhage

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 27 Tourniquets are not usually applied directly over the wound, but if it is difcult to maintain pressure on the dressing where access is limited or during extrication, tourniquets can be considered for this purpose. (Basically acting like a hand to apply pressure). As discussed above, under normal circumstances, a tourniquet should not be left in place for more than two hours due to the potential risk of nerve or muscle damage. It is not appropriate to release the tourniquet unless medical assistance is on hand. In this situation, leave the tourniquet in place and make every efort to get the patient to hospital as safely and quickly as possible. The tourniquet could cause serious risk to the limb if it is not released within six hours. The pressure of the tourniquet will be VERY uncomfortable for the patient, but it is a potentially life-saving measure and should not be removed simply due to discomfort. Applying a tourniquet to control haemorrhage Tourniquets are used as a life-saving intervention and as such, they should only be removed when the major bleeding has stopped, been controlled or we are in a location with a clinician is advising us on what to do. Extensive use in warzones and in recent years, in civilian practice has clearly demonstrated that tourniquets can be left in place for many hours without serious adverse efect. As a rough guide, after: As you can see, in the vast majority of situations, after 2 hours we would hope to be in a suitable medical facility and we should consider releasing the tourniquet to see if bleeding is controlled, as it often will be through spasm of the artery, or the benefts of a well applied pressure dressing. If on release, serious bleeding/life threatening haemorrhage re-occurs then immediately apply direct pressure and consider immediate re-application of the tourniquet. Beyond 2 hours, we should be constantly considering release whenever safe to do so, but reassured that within 4 hours, we are still unlikely to risk permanent damage or loss of the limb. On releasing a tourniquet, do not release gradually, it must be fully removed rapidly to avoid venous congestion and swelling of the limb. How long can a tourniquet be safely left in place? 2 Hours: We should aim to remove the device and restore circulation to the limb but no adverse efects should be evident 4 hours: This may result in some numbness and risk to tissues, but this will largely, if not fully recover 6 hours: We are now at risk of some potential long-term signifcant damage to tissues in the limb. However, if bleeding still continues, or the situation does not ofer a safe environment to release the tourniquet and assess the limb then it may have to be left, as we are saving the life, not a limb. Chapter 5.1 / M: Massive external haemorrhage

28 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Large cavity wounds may have a bleeding point deep inside, which can be identifed by scooping out the blood and the applying frm, focussed direct pressure to the obvious source of blood loss with your fngers or thumb. We do not try to apply clips or clamps. If it proves impossible to control the bleeding point or there is no single obvious source of bleeding with loss from all over the open wound cavity, then we cannot simply apply point pressure and even direct pressure with a large pad may not be as efective in compressing all the bleeding points deep inside the wound. In these cases, the ideal technique to control the bleeding is packing of the wound. Wound packing refers to the process of feeding in a long bandage into the wound and gradually flling the cavity up from the bottom of the wound, starting at one end and rapidly flling the whole cavity before applying frm direct pressure on top of the lacked dressing. Technique: • Explain to the casualty that this may be painful, but bleeding must be controlled • Gently but swiftly scoop out any liquid blood from the wound, looking for a bleeding point and assessing the depth of the wound • Ideally this is a two-person technique where one individual packs while a second provides a constant feed of dressing. (If working alone, you can feed the dressing from a clean pocket) • Place the end of the dressing in the bottom corner/end of the wound and gradually feed in more and more dressing, whilst maintaining frm pressure on the bandage already in place in the wound • Continue this process until the whole wound is completely flled with frmly packed in bandage dressing • The apply frm direct pressure on top of the packing, as with any other wound • When re-assessed in the ‘C’ phase of M.A.R.C.H, we may apply an elastic combat dressing over this packing. Note: if the packing is entering a hole in the torso and keeps feeding in, always leave a good length of dressing outside the wound, to demonstrate to the hospital that there is a bandage inside the patient. Do not work, about the dressing going inside, as long as you make it obvious what you have done, record it and hand it over. There are new dressing which are designed for packing wounds, called haemostatics. They are highly efective, but expensive, but they are used in the same way. Wound packing Chapter 5.1 / M: Massive external haemorrhage

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 29 NTACC level providers will be equipped with some of the latest generation of haemostatic dressings that support clot formation and will efectively stop even life threatening arterial bleeding. The early agents such as TraumaDex were not very efective, but the later generations such as Haemchon (Chitosan-shrimp shells) patches and the powdered agents such as Quickclot powder (Volcanic rock/Zeolite), and Kaolin were found to be highly efective both in animal experiments and clinical trials. However, they were not without problems, Haemchon was difcult to apply and manipulate into to some cavities and wounds, as it was a cardboard like, less malleable patch until it became warm and wet, but it was very efective once applied. Similarly, the frst generation Quickclot had problems as it produced a very exothermic (releases heat) reaction with blood or moisture and could actually produce skin burns, blisters or eye injuries which as powders made them very difcult to use in windy conditions pre-hospital, but yet again, once in the wound they did control life-threatening bleeding. The next generation of Quickclot agents solved the exothermic problems and also increased the particle size from a powder to a granular form which came in a porous ‘tea-bag’. This could be packed into wounds or cut open and tipped in before packing. Some US animal research work has suggested potential serious complications with the powders/ granule type products, as they may theoretically enter larger holes in blood vessels and circulate the body, which could cause dangerous complications. Since then the technology has moved on still further with haemostatic agents and they are now being impregnated onto gauze type dressings and pads e.g. Celox gauze (Chitosan) and Quickclot gauze (Kaolin) which avoid the problems with powders and also allow more efective application into cavity wounds. They are constantly in development, but current clinical experience favours the Chitosan impregnated dressings. However, laboratory research demonstrates that they are all efective, including several other alternatives, such as alginate and cellulose dressings (e.g Woundstat). These agents do not generate heat and are efective even in hypothermic patients and those on anticoagulant drugs such as heparin and warfarin. The modern dressings are ideal for controlling bleeding as they employ the principles of: • The haemostatic agent • Wound packing where there is a cavity. Used correctly, these can control lethal major arterial bleeds very efectively. The key phrase here is if ‘used correctly’. They are not miracle drugs, they cannot simply be packed into a wound and left. Once applied onto or into the wound, then efective direct pressure must be applied and maintained for at least 5-10 minutes or the agents will not work. Haemostatics I SAW IT I EXPOSED IT I DiD iT Chapter 5.1 / M: Massive external haemorrhage

30 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com There is an ever increasing number of these dressings on the market, but the use is the same, employing the haemostatic agents and then applying pressure. These agents and techniques are demonstrated on the courses for candidates with the specifc requirement for these skills, e.g. frearms ofcers, tactical medics and high risk industry staf etc. They are not necessary for all bleeding especially as they are costly. They are typically only to be used for massive or uncontrollable bleeds and large cavity wounds that are bleeding. Finally, alternative new agents are being developed, some of them mimic the substance inside our body between cells (Vetigel), whilst others act like the natural elements in a blood clot (Polystat). Finally, there are physical agents that allow rapid packing of wounds with expanding sponge pellets that very quickly and efectively produce even pressure throughout a wound (e.g. XSTAT) but these all need more research to validate their efectiveness. Haemostatics Chapter 5.1 / M: Massive external haemorrhage Celox Rapid, Haemostatic Z-Fold Gauze Axiostat, Advanced Woundcare Dressing QuikClot, Combat Gauze Xstat, Expanding Pellets

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 31 • Massive haemorrhage control is the frst step in the M.A.R.C.H assessment and treatment protocol • Responders’ eforts should focus on control of any massive external bleeding and preserving circulation • Massive haemorrhage control should take no more than one minute • Gloves and other appropriate personal protective equipment should always be worn before handling the casualty • Fully expose the bleeding point • The technique used to control haemorrhaging is DiD-iT, which stands for direct pressure (D), more direct pressure (D), and tourniquet application (T) • An absorbent pad or dressing should be used to apply direct pressure to the wound. Alternatively, the thumbs or heel of a gloved hand may be used • Additional direct pressure (another layer of dressing) may be needed to control bleeding. When necessary, apply this dressing on top of the frst and continue focused, direct pressure • If the second direct pressure attempt does not successfully control bleeding, a tourniquet may be necessary • Tourniquets can be applied to a limb to stop massive blood loss and potentially save lives • It is essential that tourniquets are placed above the wound on the injured limb(s) and are applied tightly to ensure any haemorrhage is controlled • Tourniquets are painful when applied to control bleeding • The tourniquet should not be taken of out of hospital unless medical assistance is present • Haemostatic impregnated dressings will control potentially lethal bleeds, but only if applied correctly with frm direct pressure. Summary: Chapter 5.1 / M: Massive external haemorrhage Circulation preservation: Principle of care focusing on minimizing blood loss rather than fuid replacement. DiD-iT: A technique used to control external bleeding; the mnemonic DiD-iT outlines the three steps of this technique: application of direct pressure, more direct pressure, and a tourniquet. Tourniquet: Device used to occlude blood supply to a limb by compressing the artery against a bone or by squeezing vessels within a muscle compartment. Massive external haemorrhage: A major life-threatening bleed on the outside of the body. Haemostatic: A chemical agent which promotes the formation of a blood clot in a wound with massive haemorrhage. Vital vocabulary

32 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Understanding airway concerns Airway compromise is the second major cause of deaths in pre-hospital trauma. Loss of the airway can deprive the brain and organs of vital oxygen and can lead to death in less than fve minutes. The airway in its normal state is described as ‘open’ or ‘clear,’ but in some forms of trauma or reduced consciousness, it can become partially or totally obstructed. In a partially obstructed airway, the fow of air to the lungs is restricted, but air still moves in and out through the obstruction, resulting in noisy breathing or a harsh, high pitched noise known as stridor. The patient may also cough and gag (which at least indicates that some air is passing around the obstruction) and they may even be able to speak but with difculty. Coughing and speech are impossible without air moving in and out the lungs. In a totally obstructed airway, no sounds of breathing can be heard, and no air is able to move in or out, even when there may be good respiratory efort. (Do not be fooled by the appearance of breathing, as air may not actually be moving in and out unless felt at the lips). Speech is impossible with an obstructed airway and the patient may have a silent chest or no cough. If the airway is completely obstructed, the patient will lose consciousness in three to four minutes. Both types of obstructions are common among trauma victims, especially in unconscious patients who lose the normal tone and refexes that protect the airway. When this happens, if they are lying on their back the tongue may fall backwards and block the airway. (see fgure 6). The other common types of airway compromise are due to foreign material or swelling of the mouth, tongue or lining of the airway as can be seen in burns above the shoulders, or smoke inhalation. Despite the “Urban Myth” the tongue, cannot be ‘swallowed,’ but it simply drops backwards with gravity, when the normal muscle tone in the throat is lost. The tongue then flls the space at the back of the throat, as a large lump of muscle, as illustrated in (fgure 6). 5.2 A: Airway Management Chapter 5.2 / A: Airway Management Figure 6: The tongue can drop backwards in the throat and is the common cause of airway obstruction. LUNGS NOSE TONGUE MOUTH

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 33 All elements of patient assessment must be reassessed regularly, especially the airway, as conditions may change rapidly. For patients who appear stable, you should reassess approximately every fve minutes. If any change or deterioration is noted, reassessment should be more frequent, as often as once a minute or even more frequently if change is rapid. In patients with severe, life threatening injuries, reassessment should be continuous. Any patient who is not breathing requires immediate life support. To assess a patient’s airway, we use the look, listen, and feel approach. Assessing airway – Ongoing Look Look for any obvious signs of facial or airway trauma (e.g. bruising, bleeding, swelling, or wounds). Additional warning signs of airway obstruction include: • Facial burns (e.g. redness, blistering, peeling skin) • Loss of facial hair • Swelling of the lips or mouth or tongue • Soot in the airway (smoke inhalation) • Blood in the mouth • Foreign bodies in the mouth (e.g. broken teeth, scene debris). The presence of any of these signs should raise serious concerns about potential airway problems which will require regular reassessment and close monitoring. When an oxygen mask is used, the mask will usually fog every time the casualty breathes out if they have an adequate open airway. This simple visual method of airway assessment allows the responder to also count the respiratory rate over a minute and may be especially useful if access to the patient is limited and some reassurance is required that they are breathing efectively. We must also look at the chest movement: If air cannot get in and out, the movements will often be exaggerated or appear very abnormal, looking as if being sufocated, with a hand over the mouth. This breathing is often described a ‘looking the wrong way around’ or ‘paradoxical’ with lots of abdominal movement and minimal chest expansion. This is clearly a seriously alarming sign and needs urgent intervention, as despite the efort, no air is entering the lungs. Listen As well as looking at the breathing, one of the best ways to identify a compromised airway is to listen to the patient’s breath sounds from the mouth (see fgure 7). Normal breathing and respiratory efort, is basically soft or silent and indicates a clear airway. However, as discussed previously, if an airway is partially obstructed, the patient’s breathing may be noisy with signs of laboured breathing. A totally obstructed airway often results in no breath sounds, but there may still be a great deal of respiratory efort, trying to get air into the lungs, at least until they become exhausted or have a respiratory or cardiac arrest. The ability to talk normally immediately tells you that the airway is clear. This simple assessment can even be used when assessing the inaccessible casualty Chapter 5.2 / A: Airway Management

34 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com After looking and listening, we feel for breathing on your cheek as you listen for breath sounds and eyeball the chest for rise and fall. Alternatively, you may, pull back your glove and hold the palm or back of your hand over the casualty’s nose and mouth. When using supplemental oxygen you can confrm that breathing is occurring by checking for fogging of the oxygen mask. Figure 7 : Listen and feel for breathing and to confrm and open airway. Feel Signs and symptoms of airway concerns Signs and symptoms of airway concerns include: • Difcult or laboured breathing • Inability to speak or vocalise • Hoarse voice or stridor (noisy breathing) • Swelling of the lips, tongue, or mouth • Burns above the level of the shoulders • Cuts or wounds in the mouth with or without bleeding • Foreign material in the mouth. Listen If no breath sounds are heard, and the casualty shows no signs of respiratory efort, this indicates apnoea (a respiratory arrest / not breathing) and is a time critical injury. If there are no signs of life, (including, no obvious normal breathing) this is a cardiac arrest requiring immediate CPR. In a trauma case with multiple injuries, the patient’s airway must be managed efectively before moving onto further steps in the algorithm. If not addressed rapidly, the brain will be starved of oxygen and will result in irreparable damage which can prove fatal within minutes. Chapter 5.2 / A: Airway Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 35 Chapter 5.2 / A: Airway Management An obstructed airway must be rapidly managed. Secretions and blood should be removed with: • Careful suction under direct vision • Postural drainage (positioning the patient to allow the material to run out of the mouth). For a partially obstructed airway, you should encourage the casualty to cough. Coughing is the most efective way of expelling a foreign object. If the casualty is unable to expel the object by coughing (if, for example, a bone is stuck in the throat), but the patient is still able to breathe easily, arrange for urgent transport to hospital and continually monitor the casualty carefully as a partial obstruction may become a total or complete obstruction, at any time until the foreign body is removed. If the airway is completely obstructed by the foreign body and they are unable to breathe, follow the techniques for managing choking. POSITIONING When the patient does not require active support of the airway or breathing (i.e. no airways, airway manoeuvres or bag-valve mask ventilation necessary) but they have a reduced conscious level, then the recovery position can be employed to maintain the airway and preventing the tongue dropping backwards. (See fgure 8). Many fully conscious casualties with airway problems will much prefer to remain in a seated position, as they will fnd breathing easier. They can support themselves and use the muscles of the neck and shoulders to help them to breathe (see fgure 9). However, those with facial trauma and bleeding may be better in a prone position, lying on their front and supported by their elbows, which allows blood and saliva etc., to drain out safely. If they are unconscious, but with blood and secretions, try to suction the airway in the recovery position or, if necessary, fat on their backs, where we can use suction under direct vision and then place back into recovery position. In hazardous or dangerous situations, where it may be difcult to provide more detailed care, the simple act of rolling a casualty into the prone facedown or semi-prone (partially face down) position until he or she can be efectively extricated may a be life-saving measure, allowing mouth contents to drain out and to encourage the tongue to fall forward, opening the airway. This is only a stop gap solution until the situation is safe, but it may be life-saving in some cases. Managing airway concerns If a patient remains unconscious in the recovery position for more than 30 minutes, consider turning him or her onto the opposite side to relieve the pressure on the lower arm and body. Figure 8: The recovery position. Figure 9: Patient receiving high fow oxygen therapy, and using her arms and neck muscles to help with her breathing.

36 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Chapter 5.2 / A: Airway Management When positioning the patient, always consider the possibility of spinal injury and handle the patient carefully. If more than one clinician is present, then cervical spine management should be performed before repositioning the patient. With only one clinician, assessment of spinal injury and immobilisation should be delayed until the “H” step of the algorithm. (as you cannot do it on your own whilst also managing bleeding and other injuries). Either way, the airway control must take priority over cervical spine. In an unresponsive, unconscious patient, the most common cause of airway obstruction is the tongue blocking the airway. Clinicians should manually manipulate the casualty’s airway to keep it open. For example, if we push the jaw forwards with a jaw thrust, as the tongue is attached to the inside of the jaw in the mouth, then this will also move forward and ‘open’ the airway. One of the following techniques may be used to achieve this: • The jaw-thrust manoeuvre • The head tilt-chin-lift manoeuvre • Airway adjunct devices, e.g. Nasal airway. The jaw-thrust manoeuvre is generally the preferred method used to clear the airway, because it involves minimal neck movement and protects the cervical spine by avoiding excessive neck movement. If this technique is insufcient, then another airway management technique may prove efective e.g. the head tilt– chin lift manoeuvre or insertion of adjunct devices such as oral or nasal airways. All NTACC providers will be skilled in providing supplemental oxygen, which is an important technique for managing casualties with airway concerns. Managing airway concerns Jaw-thrust manoeuvre If you suspect that the patient has the potential for a cervical spine injury, open his or her airway using the jaw-thrust manoeuvre. If spinal injury is not suspected, then you may use the head tilt–chin lift manoeuvre presented in the following section. To perform the jaw-thrust manoeuvre, use the following steps (see fgure 10) 1. With the patient in a supine position, kneel at the top of the head and gently take hold of either side of the head 2. Look at the patient and try to talk to them and explain what you are doing if they are conscious 3. Place the muscle area at the base of your thumbs on their cheek bones. Hook the tips of your fngers under and around the bony angle of the patient’s jaw, in the indent below each ear 4. While holding the patient’s head still, move the jaw upward and if possible open the mouth with your thumb tips. (usually their Jaw will protrude a few millimeters). There may not be a lot of movement, but even a few millimetres will improve the situation considerably. Figure 10: Jaw thrust. The jaw-thrust manoeuvre should open the airway without extending the patient’s neck signifcantly.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 37 Chapter 5.2 / A: Airway Management The head tilt-chin lift manoeuvre is a very simple, yet efective way of opening a patient’s airway and is used when there is no potential for a cervical spine injury or if the jaw thrust alone has not worked. To perform the head tilt-chin lift manoeuvre (see fgure 11). 1. With the patient in a supine position, kneel beside the head 2. Place your hand under the head and assist a backwards tilt of the head from a hand under the jaw 3. At the same time, place the fngertips of your other hand under the bony part of the chin, taking care to avoid compressing the soft tissue under the chin as this may block the airway 4. Lift the chin upwards, bringing the entire lower jaw with it, and helping to tilt the head back 5. Air should be then heard or felt moving in and out of the mouth, if not, and the airway is open, ventilation will also be required. Figure 11: Opening the airway with a chin life manoeuvre is usually very efective, but it does extend the neck considerably and therefore is avoided in potential neck injuries unless there is no other option. Head tilt–chin lift manoeuvre Airway adjuncts If these manoeuvres are unsuccessful, it may be necessary to use an airway adjunct device to keep the patient’s airway open. There are two main types of mechanical devices: nasal (NP) and oral (OP) airways. A nasal airway is a soft plastic tube which is inserted through the nostril into the back of the throat, thereby allowing passage of air from the nose to the lower airway (see fgure 12). It is often better tolerated than an oral airway in responsive conscious patients, who still have an intact gag refex or who are biting or have clenched teeth. Nasal airways do not go down the throat quite as far as oral airways, so they may not be quite as good at opening the airway, but they can be inserted even when fully conscious and do not cause as much gagging. Nasal airways can be used in both nostrils simultaneously and can also be used with an oral airway too if tolerated and necessary. Nasal airways should only be used gently to avoid trauma to the inside of the nose and with caution on a casualty with suspected skull fracture (if blood or fuid is coming out of nose or ears).

38 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Chapter 5.2 / A: Airway Management Figure 12 Inserting a Nasal Airway STEP 1: Size and then lubricate the airway with gel. STEP 2: Introduce airway into the best nostril, which appears clear and large enough for the airway. (Commonly the right one because of the angle on the airway tip). STEP 4: Nasal airway fully inserted. The airway stays in place and the safety cuf avoids the need for safety pins to stop the airway slipping further into the nose. If the casualty coughs or gags excessively, pull the airway out slightly and also check the mouth for any bleeding from the back of the nose. If there is bleeding, suck it out of the mouth, but leave the airway in place if it is working well. STEP 3: Gently advance the airway along the foor of the nose. This should not require anything more than fnger and thumb pressure. The lining of the nose is delicate and has some thin bones called turbinates which can produce a slight crunching feeling. If the airway passes with minimal pressure then proceed. DO NOT FORCE THE AIRWAY – Just steady gentle pressure. To insert a nasal airway, use the following steps: 1. Ensure you have selected the appropriate size; measure the distance from the tip of the nose to the bottom attachment of the ear. The diameter of the tube is often compared to that of the patient’s little fnger in training manuals, but simply looking at the nostril is probably a far more reliable indicator. If a nostril is obviously obstructed then choose the other side. 2. Lubricate the airway with a water-soluble gel and place the airway in the largest nostril. The cut bevel on the nasal airway lends itself to insertion in the right nostril, but it can go into either. The curvature of the device will follow the curve of the foor of the nose, and on the right with the bevel facing the septum. 3. Place the tip of the bevel to the septum and insert it gently along the nasal foor, parallel to the mouth. (Remember that the bevel is usually cut for the right nostril but can be used in either). Do not insert the airway upwards towards the brain, but rather directed towards the back of the head. 4. When completely inserted, the safety fange should rest against the nostril to stop it slipping further into the nose and down the throat. The older designs used a safety pin for this purpose, but this is a sharp which is best avoided with the newer designs. Do not force the airway, just use fnger and thumb and gentle pressure. If you feel any resistance, withdraw it a few centimetres and try again. If it will still not advance, remove the airway and try to insert it in the other nostril. Airway adjuncts

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 39 Figure 13 Sizing and inserting an Oral Airway conventionally or inverted STEP 1: Size the airway from the corner of the mouth to the angle of the jaw or the tragus of the ear. STEP 2: Insert the airway over the chin and into the mouth, ensuring that it passes OVER the tongue and does not push it backwards. STEP 4: Oral airway in place and then feeling for breathing with the wrist. This airway must now be constantly monitored as it can pop-out or fall out if unattended. If the patients gags or coughs repeatedly, they are not tolerating the airway and it should be removed. Consider a nasal airway if necessary. STEP 3: As the airway reaches the back of the mouth it may just drop into place, but sometimes a gentle jaw thrust is required. Note: The plastic rim stays outside of the mouth and lips. An oral airway is a hard, curved plastic device that extends from the lips to just over the back of the tongue. It is designed to hold the tongue away from the back of the throat, keeping the airway open and enabling good passage of air into the lower airway. It should only be used on a patient who is unresponsive and does not have a gag refex and has a relaxed jaw (see fgure 13). If inserted in anyone conscious with an intact gag then they are likely to cough or vomit. Unconscious and relaxed lower jaw (moves up and down without force) To insert an oral airway, use the following steps: 1. To select the proper size, measure the horizontal distance from the angle of the jaw (corner of the jaw just below the ear) to the centre of the casualty’s front teeth or the corner of the mouth to the lower attachment of the ear. 2. Open the patient’s mouth with the fngers of one hand. (Avoid putting your fngers in the mouth, as patients can bite)! Do not force the mouth open. 3. Suck out any noticeable debris from the mouth that can be seen to avoid pushing this in with the airway. 4. Insert the airway OVER THE TONGUE from below, the natural curve of the device will bring it in over the chin. 5. Alternatively, hold the airway upside down and insert the airway with the tip facing the roof of the mouth. Mid mouth rotate the airway 180°, fipping it over the tongue. (This does require good mouth opening) (see fgure 14). 6. Once over the tongue and in the back of the mouth, then a simple jaw thrust will open the airway at the back of the throat by moving the tongue forward, allowing the oral airway to drop a little further down into the mouth (sometimes needs a gentle push) to sit in place and create the open airway. 7. When inserted properly, the airway will rest in the mouth, with the curvature of the airway following the contour of the tongue. The fange should rest against the lips outside the mouth – if it protrudes then it is either not in or too big. Airway adjuncts Chapter 5.2 / A: Airway Management

40 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Figure 14: Traditional inverted method of inserting oral airways. Step 1: Insert the correct size airway upside down along the rough of the mouth over the tongue. Step 2: At the back of the mouth, rotate the airway and drop into place behind the tongue. This method is not preferred by NTACC as although it avoids pushing the tongue backwards it requires reasonable mouth opening (~2cm) and can be awkward. Choking treatment Choking occurs when a foreign body lodges and partially, or even worse, totally obstructs the airway, resulting in an inability to breathe efectively despite good respiratory efort. The frst step in managing a conscious person who may be choking, with a blocked airway, is to simply ask, “Are you choking?” or something similar. If the patient can answer your question, at least some air is moving in and out allowing them to speak and the airway would seem to be only partially blocked. Encourage them to lean forward and cough in an attempt to clear the obstruction. Until the object has gone, there is still concern as it could progress to complete obstruction at any time. This still warrants very urgent action as this is a time critical situation. If the patient is unable to speak or cough, the airway is probably totally blocked. This is a life-threatening emergency and needs immediate action. Airway adjuncts Chapter 5.2 / A: Airway Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 41 Signs and symptoms of choking include: • Attack occurs while eating • Patient clutches his or her neck and looks terrifed (universal choking sign). Signs and symptoms of partial airway obstruction include: • Still able to speak, cough, and breathe • Gagging. Signs and symptoms of total airway obstruction include: • Inability to speak or vocalise • Inability to breathe or wheezy breathing • Silent cough • Cyanosed (blue around lips and mouth) • Unconsciousness. To treat choking in a conscious victim, frst try to encourage them to cough. If they are unable to cough or breathe, immediately commence the following rescue techniques. The rescuers should provide alternating back blows (see fgure 15) and abdominal thrusts (see fgure 16) in blocks of fve until the obstruction is relieved or the patient deteriorates and becomes unconscious. To provide ‘back blows’ 1. Stand to the side and slightly behind the patient. 2. Supporting the chest with one hand, lean the casualty forward. This position will make it more likely that the foreign body comes out of the patient’s mouth rather than fall further down the airway once dislodged. 3. Position the heel of your other hand between the patient’s shoulder blades and provide up to fve sharp, frm, back blows to clear the airway obstruction. 4. After each blow, check to see whether the foreign body has been dislodged (no more than a second or two). If the fve back blows fail, do not relieve the airway obstruction. Responders should provide up to fve ‘abdominal thrusts’. To perform abdominal thrusts: 1. Stand behind the patient. 2. Place both your arms around the upper part of the patient’s abdomen and lean the casualty forwards. 3. Place your fst against the patient’s abdomen, with the thumb side facing in, just above the casualty’s navel and grasp the fst with your other hand. 4. Provide up to fve abdominal thrusts, pulling sharply inwards and upwards. 5. After each blow, check to see if the foreign body has been dislodged. Figure 15: Providing Back Blows and then checking the mouth. Choking Chapter 5.2 / A: Airway Management

42 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com If the fve abdominal thrusts do not relieve the airway obstruction, clinicians should continue to provide an alternating sequence of fve back blows and fve abdominal thrusts. The ERC/UK Resuscitation Council guidelines for choking treatment are outlined in (see fgure 17). If these eforts do not relieve the airway obstruction and the patient becomes unconscious, clinicians should carefully lay the patient on the ground and immediately call for help, 999/112 and begin CPR. Figure 16: Providing Abdominal Thrusts and then checking the mouth Choking Chapter 5.2 / A: Airway Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 43 The same algorithm can be used in children down to the age of one year of age. Below this age (infants) the abdominal thrusts are replaced with chest thrusts/compressions. Small children can be placed across the lap for back blows and infants can be cradled in the arms (head down along the forearm). Another key diference for children is if the child becomes unconscious, we then commence paediatric life support which starts with fve rescue breaths before chest compression starts. In cases of choking abdominal thrusts should not be used in infants (children under 1 year of age) – chest compressions are used instead. Figure 17: Adult choking algorithm (based on UK and European Resus Council guidelines) Assess the severity of the choking Conscious Five back blows Five abdominal thrusts Repeat until choking relieved or unconscious Mild Choking able to speak or cough Encourage to cough Severe Choking unable to cough Unconscious: Start CPR Choking in children Chapter 5.2 / A: Airway Management

44 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Under normal circumstances, a person’s body can operate efciently using the amount of oxygen found in normal room air. However, in some situations, such as in major blood loss from a traumatic injury, (as the oxygen is carried by red blood cells) insufcient oxygen may be delivered to the cells of the body, which can result in shock, death, or serious long term disability. This can also occur if the breathing is compromised and oxygen does not reach the blood from the lungs. Administering supplemental oxygen to a patient should increase the amount of oxygen delivered to the cells of the body and often makes a positive diference to the patient’s outcome. Room air contains 21% oxygen, whereas an oxygen cylinder contains pure oxygen (100%). In some situations and medical conditions, oxygen can theoretically worsen the condition of a patient, e.g. COPD and therefore it is important to assess the patient’s oxygen status, and their general health before giving oxygen. However, all patients with major traumatic injuries are likely to require supplemental oxygen through a reservoir mask or nasal prongs (cannulae) at a fow rate sufcient to maintain oxygen saturations of 94% or more. If they have COPD then >88% may be sufcient. A pulse oximeter should be available, to check the oxygen saturation and compare the levels before and after oxygen therapy, to assess the response. If the patient improves, you may consider reducing the oxygen fow rate. Aim for a target saturation of between 94–98% in the average adult casualty, but if unsure or their condition is unstable e.g. • Head injury • Features of shock • Difculty in breathing, e.g. asthma, then the higher fow rate should be used. The British Thoracic Society guidelines were initially produced for medical conditions. However, the latest version is far wider reaching, identifying that high levels of oxygen administration are not benign or without risk to some. We now deliver oxygen to maintain saturations as described above: aim for 94-98% in most patients. In NTACC managing serious illness or injury we are more likely to risk harm by withholding oxygen, rather than administering it. See section on COPD for exception. Oxygen should be used to treat hypoxaemia (low oxygen levels in the blood) and not simply breathlessness. (see fgure 18). A pulse oximeter is very simple to use.A sensor probe is clipped on to the patient’s fnger and a LED is shone through the fnger, giving the fndings on the screen. Most commonly the pulse and oxygen saturation will be recorded, but newer models may also provide other information as well such as a pulse waveform. Figure 18: Apply the pulse oximeter early, almost like your ‘hand-shake’, to assess the oxygen status and pulse of the patient. Supplementary oxygen Chapter 5.2 / A: Airway Management Ventilation using a pocket mask provides 16–18% oxygen. Bag-valve mask ventilation with room air 21% oxygen. Oxygen cylinder delivered at 15 L/min through a non-rebreathing mask with a reservoir bag provides 60–80% oxygen. Bag-valve masks, with oxygen 15L/min and reservoir provides 100% oxygen (need to check manufacturer/type as some don’t provide spontaneous breathing)

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 45 There are times when we may wish to limit the amount of oxygen that we give to our casualties. We do this by reducing the fow on the oxygen cylinder from 15 L/min in steps: 15 to 10, 6 or 2 L/min. COPD & CHRONIC CHEST DISEASE PATIENTS NTACC providers should be aware that there are a small percentage of patients with severe chronic obstructive pulmonary disease (COPD) or chronic chest disease who can deteriorate or become drowsy if given oxygen. This is called ‘Hypoxic drive’ and high levels of oxygen will depress their breathing (see fgure 19). They are far less common than some healthcare training suggests. Many of these patients are aware of their condition and will inform clinicians. Our target oxygen saturation in these patients with COPD is 88-92%. If the patient does not mention COPD or warnings about too much oxygen, then continue as normal but if any of these occur: • They become drowsy • Find breathing more difcult • Respiratory rate drops below 12/min. Then reduce the fow of oxygen on the cylinder fowmeter from 15 L/min to 6 L/min the oxygen and continue to monitor the patient with a target oxygen saturation >88%. If they continue to deteriorate in any of the above ways then try discontinuing the oxygen for a minute or two, but if the conditions still worsens (Oxygen saturation less than 88%), then resume oxygen therapy at 6 L/min. Be aware that far more patients die from a lack of oxygen than oxygen toxicity. If you are unsure and the patient has low oxygen saturations (<92%) then administer oxygen at 15 L/min and monitor the casualty. CARDIAC PATIENTS Cardiac patients potentially having a heart attack are another group to whom we no longer administer excessive amounts of oxygen. In patients with severe chest pain and those with a suspected heart attack we simply aim to keep the oxygen saturation >94% by adjusting the fow of oxygen, usually between 4 and 15 L/min. To avoid confusion in NTACC, we simply aim for an oxygen saturation >94%. In cardiac arrest we always deliver 100% oxygen at 15 L/min in all patients. This can be reduced after they are successfully resuscitated based on their oxygen saturations and any other health conditions. Supplementary oxygen – Adjusting oxygen fow Chapter 5.2 / A: Airway Management

46 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Figure 19: Safe administration of Oxygen guideline Supplementary oxygen – Adjusting oxygen fow Chapter 5.2 / A: Airway Management *Reassess patients every 2 min If Drowsy & RR falling <12 Sats <88% NOTE: Continually monitor the patient visually when administering Oxygen, however formally reassess oxygen sats and clinical condition every 2 mins at least and adjust the Oxygen fow accordingly (L/min). If Drowsy & RR falling <12 Sats <88% If Drowsy & RR falling <12 Sats <88% If Sats >94% If Sats fall below 94% Try stopping Oxygen If getting worse or sats still falling 15 L/min and support breathing with BVM Check pulse oximeter Sats on air EXCHANGE PRONGS FOR NON RE-BREATHING MASK APPLY NASAL PRONGS APPLY NON RE-BREATHING MASK ALL OTHER PATIENTS Sats <92% SEVERE COPD/CHEST DISEASE Sats <88%