NTACC

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 47 ALL MAJOR TRAUMA VICTIMS GET INTIALLY 15L/min HIGH FLOW OXYGEN FROM A NON-REBREATHING MASK (equivalent to 100% oxygen) if the saturation is <94% Oxygen is compressed and stored in portable cylinders. Standard steel oxygen cylinders are flled to 137 barometers. Newer Kevlar wrapped lightweight cylinders are charged to 200 to 300 bar pressure, depending on the manufacturer or supplier. In older style cylinders, a gasket or ‘O’ ring was required between the pressure regulator/fowmeter and the cylinder; this ensures a tight seal and maintains the high pressure inside the cylinder). In the new style cylinders (see fgure 20), the pressure regulator and fowmeter are an integral part of the cylinder apparatus and no assembly is needed prior to oxygen administration. This efectively minimises fash and explosion risks, which can occur when changing and opening regulators on oxygen cylinders, if there is dust or grease present. Oxygen is now viewed as a drug (POM-prescription only medicine) and must be prescribed appropriately by a clinician. A generic prescription or SOP/SIS/PGD can be written by a Medical Director for emergency care providers who have been suitably trained. All administration of oxygen of oxygen must be: • Recorded on the patient report form or other documentation • Monitored with a pulse oximeter: before and during delivery (in absolute emergency this is not essential). All oxygen supplies should be checked on each shift, including contents, regulator valves, and fow-meters. For cylinders with a separate regulator, if it is necessary to change the regulator, ensure that the valves are free of grease, oil, and dust. Before ftting the regulator, the cylinder should be opened slightly for a fraction of a second to clear any dust or debris from the outlet port. Always “crack” or open cylinders slowly as there is always a small risk of fre or explosion. As we discussed above, there is often some confusion about the British Thoracic Society Guidelines for oxygen administration. However, when considering major life-threatening trauma our guidelines are very clear. Figure 20: High pressure oxygen cylinder and use of a high fow non-rebreathing oxygen mask Oxygen equipment Chapter 5.2 / A: Airway Management

48 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com When we use a pulse oximeter, the oxygen saturation is considered ‘Time critical’ if <91% on air or < 94% on oxygen. A patient who is not breathing will require support for their breathing or ‘ventilating’ with either a pocket mask or a bag- valve mask (see fgure 21). Bag-valve masks require a clinician to squeeze the bag to push air through a one-way valve, into the mask, held frmly to seal it on the face and then into the patient’s airway and lungs - the chest will visibly rise. After each ‘ventilation’ the bag is released and the patient passively exhales - the chest will visibly fall. The “used” air empties back into the mask and escapes through holes before the one-way valve, to avoid it being blown back into the patient with the next ‘ventilation’. (This is discussed in more detail below) Bag-valve masks are single-use and should be disposed of after use. Paraquat overdose is quoted as a key contraindication for oxygen therapy. In confrmed cases of paraquat overdose, avoid oxygen unless the patient has sustained a major injury or is in extremis (e.g. has a respiratory rate more than 30/min, oxygen sats <91%, unconscious, in arrest or time critical). In such cases, oxygen should be given, as in any resuscitation. Figure 21: Using a pocket mask with oxygen mask Oxygen equipment NASAL PRONGS/CANNULAE Nasal prongs/cannulae are very well tolerated way of delivering up to 60% oxygen in adults and children. They are very useful when the patient will not tolerate a face mask or if they are using Penthrox for analgesia and requires supplementary Oxygen to keep their saturation above 94% The oxygen is delivered in Litres/min from as little as 1-2L.min up to 15L/min from a cylinder. Chapter 5.2 / A: Airway Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 49 Oxygen does not burn or explode by itself. However, it supports combustion and can quickly turn a small spark or fame into a serious fre. Therefore, all sparks, heat, fames, and oily substances must be kept away from oxygen equipment. Smoking should never be permitted around oxygen equipment. The pressurised cylinders are also hazardous as the high pressure in an oxygen cylinder can cause an explosion if the cylinder is damaged. Oxygen cylinders should be stored securely to protect the cylinder and the regulator/ fowmeter, especially during transit. (see fgure 22). Ensure the cylinder is handled carefully and not exposed to any damage. Flat bottomed cylinders, should not be stood next to the patient, where they could fall and injure them. It is important to note the amount of oxygen remaining in the cylinder to ensure that it will not run out while treating a patient. A normal portable oxygen cylinder contains between 340 and 1,000 L. The fow rate in Litres/min will determine how long the cylinder will last for and all clinicians should be aware of this capacity and time. Clinicians should monitor the gauge and seek additional cylinders before they are needed. The contents are a gas and will drop proportionally as the contents are used. If further cylinders are not available, providers may reduce the fow rate to 10 L/min (or less) based on the oxygen saturation. Although this will signifcantly reduce the percentage of oxygen being delivered to the patient, it still is supplemental oxygen and will hopefully keep the saturations >94% The patient should be monitored with a pulse oximeter to ensure that the oxygen saturation is kept greater than 94%. If it falls below this level, the fow will need to be increased. Figure 22: Oxygen cylinder safely stored. Safety considerations Chapter 5.2 / A: Airway Management During the airway management phase, providers should consider the possibility of spinal injury. If more than one clinician is present and spinal injury is suspected, providers should manually immobilise the neck—whilst ensuring an open airway—before proceeding on to the next step in the M.A.R.C.H algorithm. When solo responding, cervical spine management is impossible with other injuries to manage as well. A solo responder should focus on other time critical injuries frst. Cervical spine management

50 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com I-Gel These notes have been adapted for NTACC from the Intersurgical User Guide INTRODUCTION The I-gel ofers a simple and easy to use airway adjunct for unconscious patients. Originally developed for anaesthetic use, the I-gel has rapidly become the emergency airway of choice in many situations where unconscious casualties are encountered, e.g. serious head injuries or cardiac arrests. Familiarisation and training in the use of the device takes no more than a few hours and even in inexperienced hands it is likely to ofer a superior airway to the alternatives of nasal and oral airways and face masks and can be inserted in seconds. Unlike the other airway devices it also stays in place without constant attention and does not require the infation of any cufs as it is simply advanced into place and immediately provides an efective airway. BACKGROUND The I-gel supraglottic airway management device, is made of a medical grade thermoplastic elastomer, which is soft, gel-like and transparent. This device has been developed after extensive literature searches related to airway devices dating back as far as the 5th century. The I-gel is a truly anatomical device, achieving a mirrored impression of the pharyngeal, laryngeal without causing compression or displacement trauma to the tissues and structures in the vicinity. The I-gel has evolved as a device that accurately positions itself over the larynx, providing a reliable seal and therefore no cuf infation is necessary. This has several potential advantages, including easier insertion, minimal risk of tissue compression and stability after insertion (i.e. no position change with cuf infation). The I-gel is designed as a latex free, sterile, single patient use device. The tube section is frmer than the soft bowl of the device. The frmness of the tube section and its natural oropharyngeal curvature allows the device to be smoothly inserted by grasping the proximal end of the I-gel which helps glide the leading edge against the hard palate into the pharynx. It is not necessary to insert fngers into the mouth of the patient to achieve full insertion. The smooth under surface of the device allows it to easily slide posteriorly along the hard palate, pharynx and into correct position. An integrated gastric channel can provide an early indication of regurgitation, facilitates venting of gas from the stomach and allows for the passing of a nasogastric tube to empty the stomach contents. SOFT NON-INFLATABLE CUFF The novel soft non-infatable cuf fts snugly over the laryngeal inlet. The tip lies in the proximal opening of the oesophagus, isolating the oesophageal opening from the laryngeal inlet. Chapter 5.2 / A: Airway Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 51 GASTRIC CHANNEL The gastric channel runs through the device from its proximal opening at the side of the distal tip of the non-infatable cuf. Since the distal tip of the device fts snugly and anatomically correctly into the upper oesophageal opening, the distal opening of the gastric channel allows for the passing of a nasogastric tube to empty the stomach contents (not an NTACC skill at present) and can facilitate the active venting of gas from the stomach. The gastric channel can also provide an early indication of regurgitation. moving out of the upper oesophagus. The I-gel’s shape follows the mouth and throat curvature of the patient. It is anatomically widened and concaved to eliminate the possibility of it turning over when in position, thereby reducing the risk of malposition. It also provides vertical strength to aid insertion. USES The I-gel has been primarily developed for maintain the airway during general anaesthesia. However, whilst it has not been formally evaluated in prehospital and other domains, there is increasing evidence and recommendations that it is ideal for these situations providing a simple and easy to use, but highly efective emergency airway device, as an alternative to the endotracheal tube. At least one study has actually described improved outcomes in cardiac arrest if used instead of intubation in the frst 15 mins post arrest. CONTRA-INDICATIONS • Not trained in the use of the device • Patient is conscious or awake • Trismus, limited mouth opening, throat/mouth abscess, trauma or mass • Do not use excessive force to insert the device • Patient will not tolerate as too ‘awake’ which may lead to coughing, bucking, excessive salivation and retching • Do not reuse or attempt to reprocess the I-gel • Patient is vomiting • Use with caution in patients with an increased risk of a full stomach e.g. hiatus hernia, sepsis, morbid obesity, pregnancy, unless in an emergency • Care should be taken with patients who have poor broken or loose teeth. PATIENT SELECTION In NTACC the I-gel can be used for adult and child resuscitation and airway maintenance. It is suitable for casualties who: • Are unconscious • Have a relaxed and foppy lower jaw. I-gel must be lubricated according to the instructions for use. The patient should always be in the ‘snifng the morning air’ position prior to insertion with the assistant helping to open the patient’s mouth, unless head/neck movements are considered inadvisable or are contraindicated. • The leading edge of the I-gel’s tip must follow the curvature of the patient’s hard palate upon insertion. I-Gel Chapter 5.2 / A: Airway Management

52 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com SIZE SELECTION NTACC providers use the I-gel in adults and children. PRE-USE CHECKS • Inspect the packaging and ensure it is not damaged prior to opening • Inspect the device carefully, check the airway is patent and confrm there are no foreign bodies or a BOLUS of lubricant obstructing the distal opening of the airway or gastric channel • Carefully inspect inside the bowl of the device, ensuring surfaces are smooth and intact and also that the gastric channel is patent • Discard the device if the airway tube or the body of the device look abnormal or deformed. PRE-INSERTION PREPARATION - ADULT I-GEL. Sizes 3, 4 and 5. • Always wear gloves • Open the I-gel package, and on a fat surface take out the protective cradle containing the device • Place a small bolus of a water-based lubricant, such as K-Y Jelly, onto the middle of the smooth surface of the cradle in preparation for lubrication. Do not use silicone based lubricants • Grasp the I-gel along the integral bite block and lubricate the back, sides and front of the cuf with a thin layer of lubricant • Check that lubricant remains in the bowl of the cuf or elsewhere on the device. Avoid touching the cuf of the device with your hands • If not used immediately, place the I-gel back into the cradle in preparation for insertion • Remove dentures or removable plates from the mouth before attempting insertion of the device • NB. The I-gel must always be separated from the cradle prior to insertion. The cradle is not an introducer and must never be inserted into the patient’s mouth. PRE-INSERTION PREPARATION - PAEDIATRIC I-GEL. Sizes 1, 1.5, 2 and 2.5 • Always wear gloves • Open the i-gel package, and take out the cage pack containing the device. Place a small bolus of a water based lubricant, such as K-Y Jelly, onto the smooth inner surface ready for use. Do not use silicone based lubricants • Grasp the I-gel along the integral bite block and lubricate the back, sides and front of the cuf with a thin layer of lubricant. Ensure after lubrication has been completed, that none remain in the bowl of the cuf or elsewhere on the device • Avoid touching the cuf of the device with your hands • Place the I-gel back into the cage pack if not used immediately. Currently size 3 and size 4 will be recommended I-GEL SIZE PATIENT SIZE PATIENT WEIGHT (KG) 1 Neonate 2-5 1.5 Infant 5-12 2 Small paediatric 10-25 2.5 Large paediatric 25-35 3 Small adult 30-60 4 Medium adult 50-90 5 Large adult 90+ THE GREEN AREA DEFINES THE MOST COMMON ADULT SIZES I-Gel Chapter 5.2 / A: Airway Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 53 INSERTION OF THE I-GEL A profcient user can achieve insertion of the I-gel in less than fve seconds. • Grasp the lubricated I-gel frmly along the integral bite block. Position the device so that the I-gel cuf outlet is facing towards the chin of the patient • The patient should be in the ‘snifng the morning air’ position with head extended and neck fexed. The chin should be gently pressed down before proceeding to insert the I-gel • Introduce the leading soft tip into the mouth of the patient in a direction towards the hard palate • Glide the device downwards and backwards along the hard palate with a continuous but gentle push until a defnitive resistance is felt. WARNING: Do not apply excessive force on the device during insertion. • It is not necessary to insert fngers or thumbs into the patient’s mouth during insertion • If there is early resistance during insertion a ‘jaw thrust’ is recommended • At this point the tip of the airway should be located into the upper oesophageal opening and the cuf should be located against the laryngeal framework. The incisors should be resting on the integral bite-block. WARNING: In order to avoid the possibility of the device moving up out of position prior to being secured in place, it is essential that as soon as insertion has been successfully completed, the I-gel is held in the correct position until and whilst the device is secured. • Sometimes a feel of ‘give-way’ is felt before the end point resistance is met, due to the passage of the I-gel through the narrow part at the back of the throat • Once resistance is met and the teeth are located on the integral bite block, do not repeatedly push I-gel down or apply excessive force during insertion • A horizontal line (Adult sizes 3, 4 and 5 only) at the middle of the integral bite-block represents the correct position of the teeth. If the teeth are located lower than the distal tip of the bite block, it is likely the device has been incompletely inserted. CHECKING CORRECT POSITION • Once inserted and secured, remove the face mask from the Bag valve mask and connect the BVM directly onto the I-gel • Gently squeeze the bag. The rise and fall of the chest should be seen • If the chest does not rise and fall or the casualty is struggling to breathe, suspect that the I-gel is misplaced, remove it and try again • NO more than three attempts to site the I-gel should be made and if these fail, return to face mask with airway adjuncts, e.g. nasal and oral airways. REMOVAL OF THE I-GEL • If at any stage the patient starts to gag, cough or wake up with the I-gel in place, immediately remove the securing tape of straps and prepare to pull it out gently and smoothly. On occasions the casualty may bite on the I-gel, but at some point they will cough it out if sufciently awake that they don’t need it any more. Source: Inter-surgical I-gel user guide, www.i-gel.com I-Gel Chapter 5.2 / A: Airway Management

54 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com RSI stands for Rapid Sequence Induction of anaesthesia. In an ideal world all general anaesthetics would be given after a period of preparation and starvation. However, an unconscious, paralysed patient under a general anaesthetic is at risk of regurgitation of stomach contents, which could cause life-threatening consequences until airway is defnitely protected, usually with a cufed endotracheal tube. Most major trauma cases are rarely fasted and in this situation, where emergency airway stabilisation is required then RSI is the recommended choice to protect the patient. RSI CHECK-LIST READ EVERY WORD AND WAIT FOR RESPONSE BEFORE MOVING TO NEXT LINE 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 Rapid Sequence Induction Chapter 5.2 / A: Airway Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 55 Rapid Sequence Induction The process involves pre-oxygenation, optimisation of the patient position, preparation of the team, the administration of an induction agent, which produces rapid anaesthesia, then a neuromuscular blocking agent which causes full muscular relaxation within 30-60 seconds. This can be a high-risk intervention and needs to be performed safely with skilled assistance, which could be by a trained ED nurse. We have provided you with an established RSI checklist, which has been produced by the ATACC faculty. The literature supports the use of checklists in high pressure situation, helping to reduce the mental load of the team and facilitating the safe completion of the task. Throughout NTACC we will be emphasising the important of the RSI checklist. As an NTACC provider we are happy for you to use this checklist, however, most trusts will have developed their own checklist or use the 'Difcult Airway Society' ones which are similar. Although, nurses will not be undertaking RSI independently it is important to be familiar with the process and the induction drugs as required. As this is a supportive role that you may be asked to undertake. Table 5 – Drugs for induction of Anaesthesia DRUG STAGE DOSE ROUTE ONSET DURATION Ketamine Induction 2mg/kg IV 60-90 secs 10-20 mins Ketamine Induction in shocked pt 1mg/kg IV 60-90 secs 10-20 mins Rocuronium Induction 1.5mg/kg IV 60 secs 15-25 mins Table 6 – Drugs for Maintenance of Anaesthesia DRUG STAGE DOSE ROUTE ONSET DURATION Midazolam Maintenance 0.05 – 0.1mg/kg IV Sedation 15-30 mins Propofol Maintenance 2-4 mg/Kg/hr Infusion Sedation N/A Ketamine Maintenance 0.1 – 0.3mg/kg IV Sedation 10-20 mins Rocuronium Maintenance 150mcg/Kg IV Relaxant 10-15 mins Once the patient is anaesthetised, they will need to be kept asleep and we would typically use the following drugs for such maintenance of anaesthesia: Chapter 5.2 / A: Airway Management

56 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com • Loss of the airway can result in death within minutes if it is not properly managed • The airway should be regularly assessed in all patients, as conditions may change rapidly • A partially obstructed airway restricts the fow of air and can result in a harsh, high pitched noise known as stridor • A totally obstructed airway allows no sounds of breathing efort to be heard • The look, listen, and feel approach is used to assess airway problems • Look for chest rise and any obvious signs of facial or airway trauma • Listen for breathing efort • Feel for breath • Various positions may be used to try and relieve airway obstruction including the recovery position, sitting position, or prone position • The tongue may be blocking the airway in unresponsive, unconscious patients. The jaw-thrust should be used in this situation to open the airway. Alternatively, if there is no potential for spinal injury, the head tilt-chin-lift manoeuvre may be used • Nasal or oral mechanical airway devices can be inserted into the mouth or nose to assist breathing • Choking occurs when a foreign body lodges and obstructs the airway, resulting in an inability to breathe efectively • For a conscious choking patient, provide up to fve back slaps. If these fail to dislodge the obstruction, provide up to fve abdominal thrusts. Alternate between back slaps and abdominal thrusts until the obstruction is dislodges or the casualty becomes unconscious • For an unconscious patient who has been choking, inspect the airway (look into the mouth); provide 30 chest compressions and two ventilations. Continue this cycle, checking the airway before delivering the breaths each time • All major trauma patients should receive supplemental oxygen at a rate of 15 L/min • A hypoxaemic patient requires high concentration oxygen until the oxygen saturation reaches 94–98%. • Oxygen equipment includes an oxygen cylinder, pressure regulator, fow meter, and a range of face masks or bag-valve masks • Always take appropriate safety precautions when working with or around supplemental oxygen to avoid combustion or damaging the cylinder • If a patient is not breathing, he or she should be given ventilated breaths with a bag-valve-mask device • If more than one clinician is present, the spine should be immobilised whilst securing the airway, before proceeding to the next step in the M.A.R.C.H assessment process. Summary: Chapter 5.2 / A: Airway Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 57 Chapter 5.2 / A: Airway Management Apnoea: Condition where the patient is not breathing. Bag-valve mask: A device used to deliver supplemental oxygen to a patient who is not breathing. Oxygen is squeezed from the bag, through a one way valve and into the mask applied to a casualty’s face. Head tilt–chin lift manoeuvre: Opening the airway by tilting the head backward and lifting the chin forward, bringing the entire lower jaw with it. Hypoxaemia: Low levels of oxygen in the blood. Jaw-thrust manoeuvre: Opening the airway by bringing the jaw forward without extending the neck. I-Gel: Type of Supraglottic airway for unconscious patients. Nasal airway: An airway adjunct that is inserted into the nostril of a patient who is not able to maintain a natural airway; also called a nasopharyngeal airway. Oral airway: An airway adjunct that is inserted into the mouth to keep the tongue from blocking the upper airway; also called an oropharyngeal airway. Pulse oximeter: A machine consisting of a monitor and a sensor probe that measures the oxygen saturation in the blood. Recovery position: A side-lying position that helps an unconscious patient maintain an open airway. Stridor: Harsh, unmistakable noise that indicates airway obstruction. Vital vocabulary

58 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Understanding respiratory problems Many trauma patients have respiratory or breathing problems, as a result of direct blunt or penetrating chest injuries as well as also other less obvious causes, e.g. head injuries, shock or a medical cause such as asthma. In patients with serious chest trauma, the distress or difculty in breathing can be very obvious, but in lesser trauma there may be few, if any, signs initially, but they may slowly develop and progressively get worse. Where there are injuries to the upper chest, the frst and second ribs are very strong and ofer protection to the structures of the neck and upper chest. If these ribs are fractured, it strongly suggests a major impact and likely underlying serious trauma with possible internal injuries. Such cases should be managed with a high index of suspicion and requires careful and regular reassessment. Wounds, especially penetrating wounds, (e.g. stabbings or gunshots) in the neck or around the collar bone can indicate serious internal injury to many of the important structures inside. This can make them challenging to manage in the feld due to the presence of large blood vessels, nerves, and the trachea. When lacerated or torn by injury, many of these structures can retract into the chest or up the neck, increasing the risk of death. However, spinal injuries in penetrating trauma of the neck are far less common and should not delay rapid management of bleeding and airway issues. 5.3 / R: Respiratory Management To assess respiratory problems, yet again we use the look, listen, and feel approach. This process must be repeated frequently in any major chest trauma as part of the regular patient reassessment. The frequency of the assessments is normally every fve minutes. However, it will depend upon obvious injuries and the rate of change in the patient’s condition. In the most serious cases, it may be necessary to do almost continuous reassessments for increasing respiratory compromise. Assessing respiratory complications Chapter 5.3 / R: Respiratory Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 59 Look If there are no ‘M’ or ‘A’ issues to manage, then quickly focus your assessment on the chest especially if the patient complains of pain from an injury (such as broken ribs) which restricts breathing and may indicate serious underlying injury. Always fully expose the chest to look for: • Areas of bruising • Open wounds • Penetrating objects • Deformity of the chest • Flail segments (where multiple broken ribs move in and out abnormally) (see fgure 23). A fail segment always looks abnormal and can be very compromising as a result of pain, impaired ventilation mechanics and potential underlying lung injury. This does not require immediate stabilisation or strapping but we can encourage the patient to support or ‘hold themselves’ as this will help reduce pain and improve their breathing. We would only strap up the chest if this was essential to facilitate extrication from difcult access. Major chest trauma cases must be carefully observed as a fail, multiple rib fractures or lung injury can easily become a time critical problem. Deterioration will usually present with a considerable increase in respiratory rate, difculty in breathing, pain or a signifcant fall in oxygen saturation. Figure 23: Chest fail segments: multiple ribs broken in more than one place move independently of the rest of the rib cage and can seriously compromise breathing. Listening to the breathing, even without equipment such as a stethoscope, can provide valuable information about a patient’s respiration. Firstly, listening for air movement serves as a valuable method to verify that the casualty is breathing, as discussed in the airway chapter. Similar to when assessing the airway, assessing the patient’s ability to speak quickly gives us a lot of useful and reliable information. If the patient is able to speak comfortably in full sentences they are unlikely to have a signifcant chest injury. In addition, you may hear some of the following additional sounds: • Wheeze: Caused by narrowed airways deep inside the lungs. Can be caused by smoke inhalation and burns, or medical conditions such as asthma and severe allergic reaction • Sucking or bubbling: May be due to air entering a sucking chest wound • Crackling or gurgling: Indicative of fuid (or infection) within the lungs, such as a casualty with non fatal drowning. Listen Chapter 5.3 / R: Respiratory Management

60 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Figure 24 : Exposure of the chest to look and feel for injuries in the four areas Remember to always feel up and down the back of the chest and look for blood on your gloves The next step in our assessment is to get your hands on and ‘feel’ the chest. Before putting your hands on the chest, ask the patient whether they are happy for you to help them and if they have any pain in the chest. If they do, start away from the pain, gently but thoroughly, feel over all four areas of the chest wall including the front, both sides and the back for any pain, abnormal sensations, movements (e.g. ribs moving inwards when the patient breathes in) or wounds. Imagine the chest as a ‘box’ that has a front, two sides, a top (above collar bones and neck area) and back. Ideally the chest should be fully exposed, but we should at least try to preserve the dignity of the patient. This can be performed by exposing selected areas in turn, working around the chest, but ensure that all areas, including the back and sides are assessed. A key area that often gets missed and must always be checked, especially in tactical incidents or assaults are the armpits, which must be fully explored (see fgure 24) – these are vulnerable areas even when wearing body armour. Feel Chapter 5.3 / R: Respiratory Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 61 Managing respiratory problems A high respiratory rate usually indicates a signifcant problem. Fast breathing (> 20 breaths/min) may simply be due to pain or anxiety, but it may also indicate a more serious concern such as chest injury, major haemorrhaging, or head injury. OXYGEN THERAPY Supplemental oxygen will not improve the patient who is in pain or anxious, but is essential for those sufering major trauma (see Chapter 5.2). Providers should use a pulse oximeter to assess the efectiveness of oxygen therapy and titrate it in response to keep saturations >94%. (Remember: Oximetry is unreliable in smoke inhalation/CO poisoning). SITTING UP Another simple but highly efective measure in chest trauma is to simply sit the casualty up. This will often greatly help the patient with the breathing compared to having them strapped to a fat board or scoop. This may be a balance of risks between spinal immobilisation and breathing and much like airway, breathing must take priority if they are struggling, so gently sit them up. Signs and symptoms of respiratory concerns include: • Extremely fast breathing (>20 breaths/min) • Extremely slow breathing (<8 breaths/min) • Grossly unequal chest movement when comparing both sides • Badly deformed chest • Open or “sucking” chest wounds. NTACC providers can use a more comprehensive assessment method: As a simple aid or reminder for examining the chest we use the acronym ‘R U IN SHAPE.’ R – Respiratory rate U – Unequal chest movement IN – Injuries, e.g. wounds, pain S – Search the chest H – Hands to feel all areas A – Ausculate or listen P – Percuss over chest E – Everywhere (all four sides of the chest – area not already checked) Signs and symptoms of respiratory problems - ‘Time critical’ Unlike blunt trauma, in penetrating trauma, wherever possible we log roll the patient and search the back directly. If this is not possible, at the very least get your hands up and down the sides at the back, looking for tenderness or blood on your gloves. Examine the chest for equal movement on both sides; remember that the chest efectively has four sides (front, back and two sides). Carefully feel all over the chest and up into the armpits for wounds, areas of boggy swelling, or a crisp, crunchy sensation (like walking on fresh snow) which suggest serious chest trauma and a leak or hole in the lung. If any of these characteristics are present, the patient may quickly become time critical, so regular reassessment is again crucial. Gently place your hands on the front left and right sides of the chest, ask the patient to take a big breath, in and out, as best they can and watch that the rise and fall corresponds with breathing: • Is it equal? • Does the movement look ‘right?’ Serious problems will usually very obvious and although the cause may be not as obvious, it will clearly look unequal or abnormal. Feel Chapter 5.3 / R: Respiratory Management

62 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com REASSURANCE Finally, reassurance is often under-estimated and an efective way to manage chest trauma victims who are scared when they cannot breathe. Encourage them to take slow steady breaths rather than big breaths, which may be impossible. If necessary, and if they have pain, suggest that they support their chest or ribs to minimise pain. PAIN RELIEF Penthrox is ideal for managing moderate to severe pain in chest trauma. Remember: Entonox cannot be used safely in chest trauma and is contraindicated. Before the use of IV administered pain relief. Any trauma patient breathing at less than eight breaths/min requires ventilation support with a bag-valve-mask device. This is increasingly reported for a short period after major blows to the head and is called sudden impact brain apnoea. Simply supporting their breathing for a short period can be life-saving. Extremely slow breathing (< 8 breaths/min) may also indicate a serious problem such as a drug overdose, e.g. Fentanyl or heroin. If the patient has a decreased level of consciousness or is unresponsive, the clinicians should support the patient’s breathing by using a bag-valve mask with supplemental oxygen attached (see Chapter 5.2). Clinicians should aim to raise the patient’s respiratory rate to normal levels (12–14 breaths/min). For example, if the patient is breathing at a rate of six breaths/min, the rescuers should provide 6–8 breaths/min. Managing respiratory problems Penetrating chest injury, although less common in the UK than blunt trauma, is sadly increasingly common in many parts of the modern world especially with stabbings, terrorism and active shooter incidents. The chest cavity has two sides, which are separate sealed chambers, with a lung in each side (like two balloons). Inside the chest is normally at slightly below atmospheric pressure to keep the lungs infated. However, if a hole is created in the chest wall, air will move in from outside and can collapse the lung on that side. The other lung should remain unafected, unless the hole also enters that side of the chest too. If ft and well, the casualty can survive with one collapsed lung, although they will experience some breathlessness, especially if they exert themselves. However, if the patient has any chest disease or limited respiratory reserves, then they will not do so well and may quickly become short of oxygen and very distressed with a high respiratory rate. SUCKING CHEST WOUNDS Sometimes air can be heard going in and out of the hole in the chest. If the hole allows air in but not out, this is called a ‘sucking chest wound’ (see fgure 25) and the risk is that air will get in and accumulate, unable to get out. This can lead to a build of pressure in the chest, which is called a ‘Tension’ pneumothorax and can be life threatening. When spontaneously breathing this is usually slow to develop. If we are supporting the breathing with ventilation, e.g. BVM, I-gel etc then this “tension” can occur far more quickly and we should be aware of that risk with holes in the chest when ventilating. Dressing chest wounds - Penetrating trauma Figure 25: Typical open chest wound which may be ‘sucking’ and should be chest sealed. (This hole may be into either the chest or abdomen It doesn’t matter, just seal it). Chapter 5.3 / R: Respiratory Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 63 d) Peel of backing to expose the adhesive side of chest seal and apply over the wound. Figure 26: Use of chest seal. a) Assess the chest wall and identify any open wounds (front, sides or back). b) Open the chest seal dressing pack. c) Dry the area around the hole with the gauze swab in the pack to give the dressing the best chance to stick to the skin around the wound. The main aim of NTACC care is to cover or seal the hole, ideally with a specialist dressing, with a ‘one way’ non-return valve that will allow air to pass out of the chest but not go back in. This should avoid any risk of tension pneumothorax and will also help the collapsed lung to re-expand. Such dressings are called CHEST SEALS and there are many diferent types. Some of the early ones will not stick well if there is moisture, sweat or blood on the chest. The Asherman type can also get blocked with blood and clot. The modern versions are Bolin, Russell or SAM seals. Some seals do not have valves and simply stop air entering but does not allow it to leave. A chest seal sticks directly over the hole (see fgure 26) Dressing chest wounds - Penetrating trauma Chapter 5.3 / R: Respiratory Management

64 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Chest seals with valves act as one-way air valves, allowing air to leave the chest cavity without getting sucked back in. These dressings can help prevent more serious complications and minimise lung collapse. In traditional tactical medicine, an improvised three-sided dressing, was the frst aid measure of choice. However, these have a poor record for efectiveness as they take time to create, often don’t stick well or don’t act as an efective valve. Chest seals should be applied to any wound or ‘hole’ in the torso, as in penetrating upper abdominal wounds it may also involve the chest cavity, e.g. an long knife wound to the stomach. Chest seals will not stick to the chest wall efectively unless the chest is thoroughly dried before application. Many manufacturers include a single gauze swab to dry the chest before application. Regularly check that the dressing is still adherent. Manufacturers have worked hard to produce efective adhesive dressings and the modern versions stick far more efectively. In some situations, more than one wound may exist. Multiple seal dressings should be placed to cover all the patient’s wounds. If the patient has a very large wound, single chest seals or dressings may not provide adequate coverage. In this case, air trapping and tension in the chest is unlikely, so providers should simply attempt to control any bleeding with dressings and keep the area free from contamination by foreign debris. Cling-flm can be used for this purpose. If there are multiple wounds or you have no seal then apply an improvised three sided dressing: 1. Place a square of non-porous material (such as plastic dressing packaging) over the wound 2. Tape the dressing on the top and both sides using adhesive tape 3. Leave the bottom of the dressing free, to act as a one-way fap valve and allow any blood to drain out of the chest. Figure 27: Improvised 3 sided dressing in place over a chest wound on the back (arrow indicates the ‘open’ edge) - poor alternative compared to a chest seal. e) Ensure a good seal of the dressing. If it does not fully cover the wound or is not big enough, a sheet of cling-flm or a damp saline soaked swab can be used (If the wound is large it is unlikely to be sucking and trapping air, but the lung will still be collapsed inside). Figure 26: Use of chest seal. Dressing chest wounds - Penetrating trauma Chapter 5.3 / R: Respiratory Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 65 Providing supplemental ventilation Ventilating a casualty with a bag-valve-mask is considered a core skill by many providers, but it is one that is often performed badly and inefectively. It is very easy to simply squeeze the bag, thinking that you are doing a good job, but without actually having any positive efect on the patient. This is a key part of the reasoning behind ‘hands-only’ CPR, as time wasted providing poor ventilation to the patient, could be better used performing high quality chest compressions. This is discussed further in the ‘cardiac arrest’ chapter. USE OF A BAG-VALVE MASK Firstly, it is important to select the correct sized face mask for a good seal between the face and the mask. The mask should sit with the top narrow part over the bridge of the nose and the bottom wider part between the lip border and chin (see fgure 28). Secondly, it is important to achieve an adequate seal. 1. Form a ‘C’ shape with the index fnger and thumb of your dominant hand. 2. Place this around the mask connector and press it down onto the face (thumb over nose and fnger over lower edge of mask (chin). 3. Place your other three fngers behind the ‘angle’ of jaw and pull jaw into mask and to open the airway by pulling the jaw forward. 4. The challenge is to press down the mask creating a seal, whilst keeping the airway open. 5. If you achieve this then you can ventilate by squeezing the bag with the other hand. This can be relatively easy or it can be extremely difcult, even for experienced airway experts. Figure 28: Applying a non-breathing face mask (left) and checking that the reservoir bag infates right. POSITIONING CHEST TRAUMA - BAD SIDE UP OR DOWN? A famous trauma myth is that chest trauma cases should be managed ‘Bad side down’ - This was proposed to avoid blood spilling from the upper bad lung into the lower healthy lung, but this is wrong for a number of reasons: • Contamination from the bad lung to the good one is very unlikely to be an issue • It is painful to lie on the injured side • We cannot monitor the wound if the casualty lies on it • Physiologically, the blood volume in the lungs follow gravity and needs to be in the best working lung, it should therefore be the undamaged one lower-most, with the injured lung upper-most should be on the top side. Therefore, always manage chest trauma cases either sat up or ‘Bad side UP’. Dressing chest wounds - Penetrating trauma Chapter 5.3 / R: Respiratory Management

66 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com With training and practice/regular use, even a single provider can ventilate a patient using a bag-valve-mask device; however, the two person technique is a far more efcient way of providing supplemental ventilation +/- oxygen to the patient in less experienced hands. (see fgure 29). TO USE A BAG-VALVE MASK WITH TWO PROVIDERS 1. Choose the correct size of mask to cover the nose and mouth. 2. Position the mask on the patient’s face and ensure an adequate seal. 3. Place the thumbs on either side of BVM connector on the mask and with the fngers open either side like making a ‘butterfy’. 4. With the fngers feel for the angle of the jaw on each side and slide the fngers behind to pull the jaw forward (plus if necessary and safe, a gentle head tilt if required). 5. Press down with the thumbs and pull up with the fngers to seal the mask on the face whilst keeping the airway open. 6. The second provider then squeezes the bag, for approximately one second and both providers watch for a visible chest rise. 7. Release the bag and watch the chest fall. 8. Allow the bag to re-infate slowly and completely. 9. Repeat at 12-15 breaths per minute in an adult. Ensure that you do not squeeze the bag too hard. Normal chest rise and fall should be observed and used as a guide of how much to squeeze. By looking at the amount of chest movement the ventilation volume (squeeze of the bag) can be adjusted so that even a large adult bag can be safely used on small adults and children if a suitable BVM is not available. Using the bag-mask device requires proper training and practice, for those who do not use it frequently it should be a two person technique. Providing supplemental ventilation Chapter 5.3 / R: Respiratory Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 67 Figure 29: Two person use of a Bag valve and mask Providing supplemental ventilation Chapter 5.3 / R: Respiratory Management

68 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Air can enter the chest cavity abnormally from: • A hole in the chest wall and possibly the lung too from something that penetrates from outside e.g knife or broken rib. • A hole in the lung from inside (usually from blast injuries or high pressure inhalation). Remember that the lungs are like two balloons inside the chest cavity and there are two sides to the chest, that are isolated unless breached by a penetrating object. If this air enters the chest cavity from outside or from a hole in the lung, but is then trapped in the cavity, and unable to escape, pressure will start to build in the chest and the lung will be squashed down, like a collapsed balloon. If this air trapped in the chest cavity continues to increase, then pressure continues to build up. When breathing is spontaneous, this happens slowly in most cases, but if ventilated with a BVM or through an I-gel then this can happen much more quickly. Eventually the pressure can reach such a high level that it squashes the veins in the chest and pushes the heart to the opposite side of the chest which restricts the output of the heart. This can result in a life-threatening drop in blood pressure and severe difculty breathing. This is called a ‘Tension pneumothorax’ and is a life-threatening condition – this is high pressure inside the chest that needs to be released as quickly as possible and is a ‘Time critical’ situation. This is done with a needle inserted into the chest or by opening up a hole in the chest, to decompress the chest cavity, allowing the heart to function and the lung to re-infate. Therefore, if ventilating a patient or supporting their breathing then be aware that this may accelerate the process and look for signs of deterioration including: • Falling oxygen saturations • Increasingly unequal movement of chest • Abnormal side of chest looking bigger or over-infated • Increasing respiratory rate if spontaneously breathing • Worsening signs of shock • Cardiac arrest. If this deterioration occurs when you have sealed a hole with a chest seal: • If the seal has a valve, then make sure that the valve is not blocked, e.g. with blood, and rapidly attempt to clear it or remove/replace it. • If it cannot be cleared or you have simply sealed the hole with a normal dressing, then peel back the edge of the dressing to expose the hole and listen for a sudden release of air as the tension escapes. Whether this works or not, this is now a time critical emergency and requires immediate advanced medical treatment and hospital e.g; • Needle Decompression (Spontaneous breathing or ventilated) • Thoracostomy (Ventilated) • Chest Drain (Spontaneous breathing or ventilated) Tension pneumothorax Chapter 5.3 / R: Respiratory Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 69 The look, listen, and feel approach is used to assess respiratory complications and should be repeated as part of reassessment. • Look around all four sides of the chest for any wounds, bruising, or fail segments. Think of it as a box • Listen to the patient’s ability to speak and any wheezing or sucking sounds from the chest • Feel for any wounds, pain, broken ribs, or signs of chest trauma • The following conditions are all considered time critical: extremely high or low respiratory rates, difculty breathing, inability to complete full sentences, low oxygen saturation rates, penetrating chest wounds, fractures to the frst or second ribs and gross chest deformity • Open or “sucking” chest wounds may indicate lung collapse and should be dressed with a chest seal or three-sided dressing • If a chest wound is too large for a single dressing, aim to control bleeding and keep the area clean. A patient sufering major trauma with any of the following is considered time critical: • Respiratory rate > 20 breaths/min • Respiratory rate < 8 breaths/min • Difculty breathing • Unable to complete full sentences • Oxygen saturation less than 91% on air, 94% on oxygen (or 88% with known underlying chest disease) • Penetrating chest wound • Fractures to frst and second ribs • Gross deformity to chest wall • Manage chest trauma sat up or bad side up. Vital vocabulary Chest seal: Specialised circular, adhesive dressing used to cover open or sucking chest wounds. Pneumothorax: Collapsed lung. Respiratory rate: Number of breaths per minute. Tension pneumothorax: Life-threatening emergency from a build of pressure in the chest. Three-sided dressing: Type of square dressing traditionally used to cover open or sucking chest wounds that is taped to the patient on only three-sides, with the fourth side left open to serve as a one-way air valve. There are now much better alternatives. Summary: Chapter 5.3 / R: Respiratory Management

70 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Understanding circulatory concerns We have already discussed the measures to control massive external haemorrhage and taking steps to control any life-threatening external bleeding. If the bleeding is not controlled or cannot be controlled, (e.g. if is ‘internal bleeding’ - inside the body), the patient may gradually go into a state of shock. This can take hours or as little as a few minutes in major bleeding. Shock is failure of the circulation in which the organs in the body, (e.g. brain, kidneys etc) do not receive the essential oxygen and substrates they need to survive. Initially the skin is afected and we turn pale and cold to touch, as blood is diverted from the skin, but eventually the essential organs such as the heart, brain, lungs and kidneys get insufcient blood supply. The total blood volume of an average adult is approximately fve litres. As blood loss reaches 1000 ml, the casualty may already start to show signs of shock. The efects of signifcant blood loss on a healthy patient can vary massively (see table 1). The actual amount of blood lost may be difcult to estimate based on blood on the foor or their appearance alone; therefore eforts should be made to assess the patient’s consciousness, capillary refll time, and pulse rate to determine the extent of blood loss. 5.4 / C: Circulatory Management Table 1 – Efects that signifcant blood loss can have on a healthy patient. AMOUNT OF BLOOD LOSS (IN ML) SIGNS/SYMPTOMS <500 ml Little serious efect, light-headedness, feeling a little faint 1000–1500 ml Shock, fast pulse rate, fainting, anxiety, restlessness, agitation, drowsy, going quiet 2000–2500 ml Extremely fast pulse rate, breathlessness, confusion, reduced consciousness > 3000 ml Coma and ultimately death Remember that massive blood loss can occur internally with minimal, if any external signs. Do not expect to see the abdomen or parts of the body swelling as signifcant or fatal volumes of blood can be lost with long bone fractures, (e.g. thigh bone/femur) and into the major body cavities such as the chest, abdomen and pelvis without such signs externally. When these injuries are suspected, eforts should be made to: • Handle the patient gently (minimal log rolling especially) • Immobilise fractures in the injured area to prevent further blood loss • Keep the patient warm Signs and symptoms of blood loss: Chapter 5.4 / C: Circulatory Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 71 Signs and symptoms of shock As we saw from the above table, there are many signs of shock and blood loss including: • Changes in mental status • Confusion, restlessness, or anxiety • Cold, clammy, sweaty, pale skin • Rapid breathing (as shock progresses, breathing may become more rapid and shallow). • Rapid, weak pulse or loss of pulse • Increased capillary refll time • Nausea and vomiting • Weakness or fainting • Thirst • Coma and death. Assessing circulatory problems The indicators that NTACC use to rapidly assess the circulation are consciousness, capillary refll time, presence of pulses and pulse rate. Individually, they may not provide sufcient information, but if they are used in combination we obtain a more reliable simple assessment of the circulation status. CONSCIOUSNESS Consciousness is a useful indicator of the severity of shock. If an adult patient is conscious and fully oriented, talking and making sense, he or she is not in a signifcant state of shock. However, if the patient appears confused or agitated, this may be an indication of shock, especially if there is no other obvious cause. Patients in this state, if due to shock, should be considered potentially time critical and in need of close observation and reassessment. Severe confusion, drowsiness and ultimately unconsciousness may indicate severe shock and should always be considered time critical. This explains the commonly used term – ‘always worry about the quiet ones’ or patients who start to go quiet. Continue to regularly monitor for change at all times as shock may develop or get worse if bleeding continues. CAPILLARY REFILL TIME Capillary refll time is the time required to restore the colour to the skin. This is due to return of blood to the small capillary blood vessels after it has been squeezed out of the skin. Since many factors can afect capillary refll time, (e.g. being cold, poor circulation as well as shock), this indicator alone is a not a reliable assessment tool. Capillary refll time should be considered in conjunction with other methods of assessing circulation, such as pulse rate and level of consciousness. To check a person’s capillary refll time: • Press your thumb on the patient’s nail bed or forehead for fve seconds. (If the environment is very cold, use the skin over the sternum or breastbone – compare with yourself) • Release your pressure and watch how long it takes the colour to return. After releasing your thumb the colour should return to the area within two seconds, indicating appropriate blood circulation and volume. A prolonged capillary refll time is anything over two seconds and indicates a possible state of shock (see table 2). If it is more than four seconds, this is very prolonged and further suggests serious shock. Chapter 5.4 / C: Circulatory Management

72 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Assessing circulatory problems Table 2 – Capillary Refll Time STATE OF CAPILLARY REFILL TIME TIME UNTIL NORMAL COLOUR RETURNS Normal <2 seconds Prolonged (potentially time critical) 2–4 seconds Signifcantly delayed (time critical) >4 seconds It may be difcult to assess capillary refll time in situations with poor lighting, in cold environments, and on casualties with dark skin or severe burns. The pulses (pressure waves down an artery as the blood pumps from the heart) are felt most easily where an artery runs superfcially over a bone, e.g. radial pulse at the wrist, but they may be felt at many diferent locations on the body. The most common pulse points used in trauma and resuscitation are the radial (wrist) (see fgure 30) and carotid (neck) (see fgure 31). In children, the brachial pulse (inside of the elbow) should be used (see fgure 32). To determine the pulse rate in beats per minute (if a pulse oximeter is not available or recording) fnd the patient’s pulse with your fngers: • Count the number of beats for 15 seconds • Then multiply this by four. In a normal adult, the resting pulse rate is 60–100 beats per minute. If the patient appears unwell and the pulse rate is faster than 110 beats per minute or there is no detectable pulse and the patient is clearly unwell, this indicates a time critical situation. Signs and Symptoms of potential Circulatory problems include: • Pallor (pale skin) • Cold, clammy skin • Increased pulse rate • Prolonged capillary refll time • Loss of a radial pulse • Confusion or coma. Pulses and pulse rate Chapter 5.4 / C: Circulatory Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 73 Figure 30: Radial pulse: Feel the radial pulse if the casualty is conscious or you have successfully found a carotid pulse. Figure 31: Feeling for the Carotid pulse on the right: Feel the carotid pulse if the casualty is unconscious or there is no radial pulse. Figure 32: Locating the Brachial pulse: Here it is located under the fngers of the patient carers left hand. This is often useful and easier to fnd in children. If no radial pulse is palpable then immediately feel for a carotid pulse. If the carotid pulse is absent or you are unsure and the casualty is unconscious, with no signs of life or normal breathing, then immediately commence chest compressions and life support (CPR). If in doubt, commence CPR in the unconscious/unresponsive patient. Pulses and pulse rate No Radial | Brachial Feel for carotid No Carotid / No signs of life Life Support CPR " The NTACC techniques concentrates on the fundamental principles of ‘circulation preservation’ (focusing on preventing further blood loss):" • Rapidly identifying any ongoing bleeding, signs of worsening shock using external haemorrhage control • Gentle handling • Splinting of fractures & pelvis These actions are all simple, but potentially life-saving, measures which can minimise serious blood loss and considerable pain. Managing circulatory problems Chapter 5.4 / C: Circulatory Management

74 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Circulation preservation CIRCULATION PRESERVATION INCLUDES SEVERAL KEY STEPS. The frst step is to ensure that massive external haemorrhage has been controlled. As we now consider the C’ stage in the algorithm, providers should recheck the patient for any further external bleeding and if necessary, use the DiD-iT technique of direct pressure, direct pressure, and tourniquet application to control bleeding. C – Is now time for bandaging When controlling external major haemorrhage in ‘M’ we DO NOT BANDAGE as this takes too long and is fddly and difcult, when working under pressure and when your hands are wet or shaking with adrenaline. Once we have managed the massive haemorrhage (I-DID-IT) we can then consider bandaging to cover the wound and to control any ongoing oozing or lesser bleeding. Ideally we use an elastic combat dressing, with an absorbent pad attached, for this purpose. These allows us to maintain frm pressure, uniformly over the wound without ongoing manual direct pressure. Gentle handling is particularly important when massive internal haemorrhaging is suspected, as rough handling and movement may dislodge blood clots which have plugged or reduced the bleeding, e.g. pelvic bleeds. As bleeding into the pelvic cavity can be life-threatening, early application of a pelvic binder, whenever a pelvic injury is suspected, is a “Circulation” measure to reduce blood loss from movement in the fractured pelvis. Splinting: As well as splinting the pelvis, we should also aim to splint the fractures, especially of the long bones such as a femoral fracture. This should be viewed as an essential part of reducing haemorrhage. ELEVATION OF LEGS NTACC does not recommend elevation of the legs in major trauma unless pelvic and spinal injuries have been excluded. In such patients, if there is no suspected head injury once the casualty is on a scoop/long board a slight head down tilt can be used (raise leg-end of the board by 10 - 15cm, e.g. a pillow under the end of the board) if they are feeling very faint. Chapter 5.4 / C: Circulatory Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 75 Scoop-and-run evacuation Scoop-and-run, early and rapid evacuation is the currently recommended alternative to the old school ‘stay and play’ approach. Prehospital providers should only stay on scene if they are still performing any essential action (usually life-saving) or if the patient transport has not arrived. On rare occasions, if a patient is time critical and deteriorating and a hospital is close by if the ambulance is signifcantly delayed, then a decision could be made to transport the patient in a suitable alternative vehicle, e.g. Police car or fre appliance. This should always be discussed with those on scene and a senior ofcer. Advice could also be obtained from the major trauma centre Trauma Team Leader, via the hospital Red phone. The aim of providers should be to rapidly collect the patient and transfer him or her to a suitable hospital or equivalent as quickly as possible (see fgure 33). Ofering unnecessary advanced medical skills at the scene may delay transfer to hospital signifcantly and could compromise the patient, if not appropriate. Under certain circumstances and with the correct team and equipment complex life saving procedures may be required before transfer. Figure 33: Rescuers prepare the patient for a rapid evacuation in the ambulance. Whilst aiming for a rapid transfer, it is still very important to keep all movements smooth and controlled with gentle handling to avoid increasing bleeding or pain. The casualty must be continually reassessed for any signs of ongoing blood loss or worsening shock. To miss a patient who is deteriorating from worsening shock would be a catastrophe, so with a seriously ill or injured patient we must stay vigilant. Signs of worsening shock include: • Deteriorating conscious level • Increasing pallor • Cold, clammy skin • Increasing breathing rate • Increasing pulse rate • Loss of palpable pulses • Poor or no signal on the pulse oximeter. Paramedics will usually give a clot promoting drug called TXA (Tranexamic acid) to such patients, and some medical teams will now even give blood on scene, rather than the traditional saline drips. Identifying signs of worsening shock Chapter 5.4 / C: Circulatory Management

76 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Vital vocabulary Capillary refll time: The time taken for the circulation to return to the capillary blood vessels in the skin after it has been squeezed out by the rescuer. Shock: Failure of the cardiovascular system in which the body is not getting the essential oxygen and substrates it needs to survive. Pulse: The wave of pressure created by the heart as it contracts and forces blood into the major arteries and around the body. • If bleeding is not adequately controlled, the patient may go into shock. • Signs and symptoms of shock include: changes in mental status; confusion or agitation; cold, clammy, sweaty, pale skin; rapid breathing; rapid, weak pulse; increased capillary refll time; nausea and vomiting; weakness or fainting and thirst • The extent of blood loss is difcult to determine based on appearance alone • The human body contains about fve litres of blood. The body compensates well for small amounts of blood loss (under 1000 ml) but large amounts may lead to shock • To assess the volume of blood lost, providers should examine the patient’s state of consciousness, capillary refll time, and pulse rate • Unconsciousness or severe confusion may indicate severe shock and should be considered time critical • To check a person’s capillary refll time, press your thumb on the patient’s nailbed or forehead and squeeze for fve seconds. If it takes more than 2 seconds for colour to return, this may indicate shock • The radial (wrist) pulse should be used for conscious patients. The carotid (neck) pulse should be used for unconscious patients. The brachial pulse (inside the elbow) should be used for infants and children • To determine the pulse rate either use the pulse oximeter reading or fnd the patient’s pulse with your fngers and count the number of beats for 15 seconds, then multiply by four • In a normal adult, the resting pulse rate is 60–100 beats per minute. More than 110 beats per minute or less than 40 beats per minute indicates a time critical situation • The NTACC method concentrates on circulation preservation using assessment DiD-iT, gentle handling of the patient, and immobilising the injured area • Providers should examine patients for signs of worsening shock. Summary: Chapter 5.4 / C: Circulatory Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 77 Understanding other trauma concerns The last step in the M.A.R.C.H algorithm addresses head trauma and other serious injuries, including spinal injuries, fractures, abdominal injuries and burns. When appropriate, providers should perform a full-body ‘head to toe’ and ‘front, back and sides’ examination of the patient to determine the presence of any trauma or injuries. Always try to maintain a high level of respect for the patient’s dignity in performing this assessment and take the necessary precautions to prevent heat loss during the examination. 5.5 / H: Head Trauma and Other Serious Injuries Chapter 5.5 / H: Head Trauma and Other Serious Injuries Head trauma is a common cause of death or long-term disability. The initial “primary injury” has already occurred, but providers aim to prevent or limit further damage or ‘secondary injury’ as a result of problems such as an obstructed airway, lack of oxygen, inadequate breathing, low blood pressure/shock, or falling level of consciousness. SIGNS AND SYMPTOMS OF HEAD TRAUMA Signs and symptoms of head trauma include: • Reduced level of consciousness • Wounds or obvious deformity to the head • Watery fuid coming out of the ears or nose • Enlarged pupil in one eye (usually a serious sign) • Combativeness or other abnormal behaviour • Seizures • Low respiratory rate (< 8 breaths per minute). It is essential to detect any changes in a patient’s level of consciousness, as this can indicate the severity of any injury to the brain (see table 3). Change over time or a trend tells us far more than just an isolated assessment. By using the AVPU scale, a provider can ascertain the extent of injury and any improvement or deterioration in the patient’s condition. For patients who are ‘A’ or ‘V.’ Attempt to keep the patient talking to continually reassess consciousness. All patients that are ‘P’ or ‘U’ should be considered time critical. Head trauma

78 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com For patients who are ‘A’ or ‘V.’ Attempt to keep the patient talking to continually reassess consciousness. All patients that are ‘P’ or ‘U’ should be considered time critical. Table 3 – AVPU Assessment Table ASSESSMENT RESPONSE / COMMANDS A ALERT V RESPONSE TO VOICE P RESPONDS TO PAIN TIME CRITICAL U UNRESPONSIVE TIME CRITICAL Head trauma For time critical providers, rescuers should provide efective supportive measures such as providing supplemental oxygen, maintaining an open airway, ensuring adequate respiration and preserving circulation. Any delays increase the risk of a poor outcome. Current UK standards aim to have all head trauma casualties in hospital for a CT scan within one hour from the time of injury and, if required, in a specialised neurological unit within four hours. If a patient is sufering from concussion, they will be conscious but may be impaired, confused, or dizzy. Mild head injuries typically do not cause any long-term damage to the brain but may be unnerving for the patient or those with them, especially if memory of the incident is lost. Providers should assess the patient using the AVPU system and, if alert, permit a responsible adult or relative to monitor the patient noting that if the patient develops a headache, nausea, vomiting or blurred vision. Any sports players with concussion should cease playing until reviewed by a medical professional. If the level of consciousness is falling, rapid transport to ED should be arranged. Consider all patients with head injury to have a neck injury until they can be clinically cleared on scene or assessed and examined in hospital. Chapter 5.5 / H: Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 79 In this section we will consider some of the NTACC level skills that can be used to assess and reassess patients with head injury or reduced level of consciousness. This will include supplemental examination techniques and also some clinical management. NEUROLOGICAL ASSESSMENTS These tests need to be: • Simple to perform • Reproducible, even by diferent people • Repeatable to follow trends and identify change • Sensitive. In NTACC we are going to consider two additional ways to assess neurological function: • Glasgow Coma Scale • Pupil response. PUPIL RESPONSE The normal pupils (the black area in the centre of the eye) respond to light conditions. In bright light they shrink to 2-4mm but in low light or darkness they will fully dilate upto 8mm. This reaction is very rapid although it does slow in the elderly. Both pupils should be the same size, although some long standing conditions can alter the shape and size of one pupil (ask the patient if you see a diference). Interestingly when one pupil ‘reacts’ to changing light conditions, then the other eye does refexly too, so they should always be the same size. Therefore when we test each eye, we assess the response to light twice, frst looking at the one with the light shining in and then a second time looking at the other eye. If they are not equal, then there is some disruption of the light detection or the light response pathways in the head. Procedure for testing pupils: • If possible reduce the ambient light • Look and compare the pupils, they should be mid sized and equal • Record the size as ‘pin-point’, ‘mid-size’ or ‘dilated’ • If conscious then ask the casualty to look at a distant object • Using a pen torch or focussed low intensity light source move the light from the cheek and onto one the frst eye for 3-4 seconds • Watch the pupil, which should constrict immediately • Move the light of the frst eye, back onto the cheek (pupil should enlarge again) • Shine the frst eye again, but this time watch the second eye which should react the same as the frst eye did • Repeat this process shining the light into the second eye. This examination should take less than a minute to complete and can be repeated if conscious level changes or as part of your repeated assessment (e.g. every 15 mins). If the patient is unconscious then we will need to gently lift the eyelids with your fngers, resting your hand on the forehead. Shine the light with your other hand. Pupils can be individually abnormal or both abnormal here are some common changes with some causes: • Both pupils dilated, and unresponsive - drugs, serious head injury, death • Both pupils dilated but react to light - fear, excitement • Both pupils pin-point small - opiod overdose (check breathing rate), very bright light • SIngle pupil enlarged and not responding - potential brain injury, Time-critical. Extended management of head injuries: Chapter 5.5 / H: Head Trauma and Other Serious Injuries

80 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com GLASGOW COMA SCALE. This scale has now been in clinical use around the world for over 40 years and is based on simple tests of eye opening, speech and movement (motor) response. For each of these we look at various levels of stimulus and the associated response. (see fgure 34). This is scored against a simple chart and the sum of the scores out of a potential total of 15. • A score of 15/15 is fully conscious • A score of 3/15 is totally unresponsive (it is not possible to score lower than 3/15). Figure 37 demonstrates each part of the scale and how the latest recommendations describe the process of: • Check • Observe • Stimulate • Rate. Once the test is completed and the score is obtained, it gives us a ‘snapshot’ indication of the current status of the patient. This can then be reassessed and compared accurately at any later stage to look for deterioration or improvement. A GCS less than 12/15 will typically require some close airway monitoring and if less than 8/15 they require urgent advanced airway management to protect their lungs from regurgitated stomach contents as the natural protective gag refex will be impaired. Extended management of head injuries: Pen Tourch Equal pinpoint pupils Normal mid sized equal pupils Equally enlarged pupils Unequal pupils Chapter 5.5 / H: Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 81 Best Motor Response CRITERION RATING SCORE Obey 2-part request OBEYS COMMANDS 6 Brings hand above clavicle to stimulus on head neck LOCALISING 5 Bends arm at elbow rapidly but features not predominantly abnormal NORMAL FLEXION 4 Bends arm at elbow, features clearly predominantly abnormal ABNORMAL FLEXION 3 Extends arm at elbow EXTENSION 2 No movement in arms / legs, no interfering factor NONE 1 Paralysed or other limiting factor NON TESTABLE NT Verbal Response CRITERION RATING SCORE Correctly gives name, place and date ORIENTATED 5 Not orientated but communication coherently CONFUSED 4 Intelligible single words WORDS 3 Only moans / groans SOUNDS 2 No audible response, no interfering factor NONE 1 Factor interferring with communication NON TESTABLE NT Eye Opening CRITERION RATING SCORE Open before stimulus SPONTANEOUS 4 After spoken or shouted request TO SOUND 3 After finger tip stimulus TO PRESSURE 2 No opening at any time, no interfering factor NONE 1 Closed by local factor NON TESTABLE NT SITES FOR PHYSICAL STIMULATION FEATURES OF FLEXION RESPONSES Modifed with permission from Van Der Naalt 2004 Ned Tijdschr Geneeskd Abnormal Flexion Slow Sterotyped Arm across chest Forearm rotates. Thumb clenched Leg extends Normal Flexion Rapid Variable Arm away from body Finger tip pressure Trapezius Pinch Supraorbital notch OBSERVE Eye opening, content of speech and movements of right and left sides. STIMULATE Sound: spoken or shouted request. Physical: Pressure on fnger tip, trapezius or supraorbital notch. RATE Assign according to highest response observed. CHECK For factors Interfering with communication, ability to respond and other injuries. Figure 34: Glasgow COMA Scale. Chapter 5.5 / H: Head Trauma and Other Serious Injuries

82 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com A spinal injury can have catastrophic consequences, including long term paralysis of limbs or even the acute inability to breathe efectively. However, if efectively managed after the primary or initial injury, much like brain injuries, the risks of any further damage can be minimised. The spinal cord extends from the base of the brain to the lower back and is protected by the vertebral column of bones which comprises of 33 individual bones called vertebra (see fgure 35). These extend from the base of the skull at the neck through the chest and back to the base of the spine. Injuries to the spine may involve fractures to any of these vertebra or tears to their supporting ligaments, that hold them together in a ‘stack’. Such a fracture does not always mean that there is an injury to the spinal cord or paralysis. The cord runs up and down the back within a bony tunnel created by all of the vertebrae and there is a small amount of space around the cord in the tunnel, which allows for some bony movement or bleeding without compression of the cord. The management of spinal injury aims to: • Identify or exclude spinal injury and to ‘clear’ the spine • Avoid causing secondary spinal injuries and making things worse. To identify spinal injury, frst consider the mechanism of injury of the incident—ascertain what has happened to the casualty (e.g. ejection from a vehicle, fall from height etc) and for any clues at the scene, that may suggest spinal injury (e.g. cracked windscreen). • Listen to the patient regarding pain, pins and needles funny sensation or an inability to move, these may all be signs of spinal or spinal cord injury. Injuries to the spine are more common in the following situations: • Rapid deceleration (e.g. fall from height, road trafc collision) • Direct blows to the head, neck, or back • Injuries close to the spine (e.g. penetrating stab wound to neck) • Extreme twisting or traction injuries to the head, neck, or back • Injuries resulting in unconsciousness. Figure 35: Three views of the human spine. Note that it is not straight, but actually has several natural curves. As a result, neither the scoop, long-board nor the KED are the ideal ‘spine protectors’ as they are hard, fat and uncomfortable. As such, they should be seen more as an extrication tool, a spinal splint or short-term transport devices. These devices are commonly used for extrication in the prehospital phase of care. Spinal injury Chapter 5.5 / H: Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 83 To manage spinal injuries, the primary focus of rescuers is to prevent further injury. This is especially important, in the situation described in the section above, when the back is ‘broken’ or fractured, but the spinal cord still appears undamaged and intact (that is, the patient has no abnormal sensations or weakness). Early recognition of the injury and careful handling could mean the diference between full recovery and lifelong paralysis. Spinal injuries can only be managed efectively with two or more rescuers. A single rescuer can do little alone to manage a spinal injury, other than to hold the head, reassure the patient and to tell them not to move. This is less problematic now that we increasingly appreciate that conscious patient will often protect their spines far more efectively than we can. This means that the single provider is better focused on haemorrhage control, airway, respiration and circulation. If two or more providers are present and spinal injury is suspected, the cervical spine should be manually immobilised immediately after the airway is secured. All providers with signs or symptoms of spinal injury should be considered time critical. A spinal injury can have catastrophic consequences including paralysis of limbs or even the inability to breathe efectively. Remember that being smooth and gentle, avoiding rotation or bending the spine is key. However, it is important to remember that as long as you are gentle your handling actions will be trivial compared to the initial injury or impact. SIGNS AND SYMPTOMS OF SPINAL INJURY Signs and symptoms of spinal injury include: • Sharp, severe neck or back pain • Limited mobility of the neck • Feelings of “pins and needles” • Numbness or weakness of the arms or legs • Deformity of the back • Abnormal posturing • Unconsciousness • Paralysis or weakness • Loss of bladder or bowel control • Persistent penile erection • Unexplained signs of shock. The spine should not be immobilised if any of the following conditions are present: • Immobilisation of the spine would obstruct or prevent airway management • The patient forcibly refuses to be immobilised • The trauma is only very minor or isolated (e.g. a limb injury, stabs, gunshots) • A clinician has efectively “cleared” the cervical spine. If you suspect or identify a spinal injury at any level, immobilise the entire spine. Always consider pelvic injury if any mid or lower spinal injury is suspected. If you are unsure about the presence of a spinal injury, be cautious and fully immobilise the entire spine. Spinal injury Chapter 5.5 / H: Head Trauma and Other Serious Injuries

84 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com There is now considerable debate about spinal immobilisation and the traditional approach of collar blocks and scoop/board is not considered as ‘gold standard’ any more as a vac-mat is considered better, but they are still used by most providers as simple and familiar. This is likely to change in the next few years with more frequent ‘clearance’ of spines, avoiding immobilisation and use of devices such as vac-mats. The current view is that if it is necessary to immobilise the spine, the following equipment is required: • Adjustable cervical collar (the current national guidance still supports the use of collars at present although this may soon change) • Scoop/Longboard with spider straps • Bilateral head blocks with chin and forehead tapes • Vac-mat if available. If blocks are not available then SAM splints, fuid bags, sand bags, or folded cardboard may be used as improvised alternatives. To immobilise the spine, frst gently move the spine into a neutral position by straightening the neck, if it is not already in its normal forward-facing position. However, if this adjustment results in pain or numbness or the neck does not move easily to accommodate a cervical collar, then immobilise the spine in its current position without the collar (see fgure 36, 37). Figure 36: Manually immobilising a cervical spine, taking care not to cover the casualty’s ears Spinal injury Figure 37: Manually immobilising the neck supporting the head in a neutral in-line position Chapter 5.5 / H: Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 85 THE CERVICAL SPINE (NECK AND SPINE PROTECTION) As mentioned above hard collars are currently under serious review by the medical world. However, currently for NTACC providers they are still recommended for cervical spines that have not been cleared and in unconscious or obtunded (under infuence of alcohol or drugs) patients. Avoiding immobilisation and Pre-hospital ‘Clearance’ of the cervical spine and extrication. The patient who is fully conscious will protect their own spine to a signifcant degree. This does not mean that there is no injury and x-rays may still be required but immobilisation can often be avoided in the following situations: Clearing the cervical spine and extrication: • If the patient is keen to self-extricate and able, let them • If they are out of the vehicle or up and walking around, they do not need immobilising. A hard collar must be sized according to the manufacturer’s recommendations and then adjusted to ft before application (see fgure 38). Figure 38: A, B, C: sizing and application of a hard collar in an RTC victim. Spinal injury Chapter 5.5 / H: Head Trauma and Other Serious Injuries

86 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com ALL PATIENT-MOVEMENT COMMANDS HAVE TWO PARTS A question and the order for movement: • Rescuer One says, “The command will be ‘Roll!” when everyone appears ready to roll the patient • Rescuer One asks “Is anyone not ready?” (followed by a short pause to allow for response from any team member) • Rescuer One will then command - “Ready, brace, roll!”. Always try to move the casualty as one unit and keep their head in a neutral position at all times. Do not allow the head to rotate, move backward (extend), or move forward (fex). SCOOPING OFF THE FLOOR OR A LONG-BOARD • Prepare and brief the team as for log-rolling • Break the scoop into two halves • Ideally remove all bulky clothing that may foul the scoop • Align one half of scoop with casualty and adjust its size • Lead by person holding head • Nominate person to insert scoop, rest of team on other side • Minimal lift/log roll to insert scoop half • Adjust other half and swap team over • Lower then minimal lift other way for other half • Clip scoop together • Secure casualty to scoop • Secure head in blocks. Sometimes this is simply stated as, “Keep the nose in line with the belly button at all times.” Once the patient is immobilised, immediate evacuation and transfer should be initiated. En route, the casualty should be continually assessed and monitored, and reassurance given due to the restrictive nature of the longboard immobilisation equipment. Always fully immobilise the body on the long-board/scoop BEFORE strapping the casualty’s head into head blocks on the board. Spinal injury Chapter 5.5 / H: Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 87 In NTACC we use a simple process to clinically clear the spine for extrication. This is based on a combination of the Canadian rules, NEXUS guidelines, the Faculty of pre-hospital care and ATACC consensus guidelines. Spinal injury If there is severe pain in the neck or back or they have any strange sensations, e.g pins and needles or other serious injury, e.g broken legs then they require full immobilisation. INDICATIONS TO FULLY IMMOBILISE CHECK LIST FOR IMMOBILISATION YES NO Q.1 Is clearance required? (i.e unable to self-extricate or get up and walk) Q.2 Are they over 65yrs Q.3 Is this a serious mechanism of injury, e.g. roll over RTC, fall downstairs etc? Q.4 Is there any neck or back pain? Q.5 Is there any abnormal sensation e.g. pins and needles, weakness or numbness? Q.6 Is there any tenderness when gently pressing down neck and then back? Q.7 Is there pain or limitation rotating the head to right and left? If the answer to all of these questions is NO, the spine does NOT need to be immobilised If any answer is YES then spinal immobilisation should be seriously considered (especially if multiple YES answers) If there is any doubt, immobilise fully or await decision of the doctor. The presence of any distracting injury is still often included in the clearance process, but this has been demonstrated as unnecessary as even severe traumatic injuries will not mask pain from spinal injury. Chapter 5.5 / H: Head Trauma and Other Serious Injuries

88 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Fractures Fractures (broken bones) are painful, often unpleasant to look at, but they are rarely fatal unless they damage adjacent blood vessels, such as the thigh bone (femur) and the large femoral artery that spirals around it or the pelvis and the huge network of veins and arteries that run all over the inside of the pelvis to supply all the organs and the legs with blood. If the bones break the skin, this is described as an open fracture and is likely to produce more external bleeding and a considerably greater risk of infection. These need hospital urgently and are usually ‘fxed’ in some way within a few hours of hospitalisation. Fractures that damage adjacent blood vessels and nerves may create a time critical situation or could lead to a long-term disability. They may also indicate the severity of trauma and potential injury, especially with rib fractures which may puncture the lungs or with pelvic fractures which, as described above, may involve massive blood loss. Dislocations and other soft-tissue injuries may be as painful as fractures, and a few are ‘limb threatening’ – in other words they risk loss of the limb because the dislocation afects or cuts of the blood supply. However, they are less likely to be time critical in terms of life threatening. The features, signs and symptoms of fractures can also be seen in dislocation, and the pre-hospital management is efectively the same. SIGNS AND SYMPTOMS OF FRACTURES Signs and symptoms of fractures include: • Pain at the site of injury • Deformity • Bruising • Swelling • Inability or unwillingness to move the injured body part. Possibly: • Loss of pulses in the afected limb • Crepitus or grating sensation if bone ends move against each other • Fracture blisters on the skin • Nausea and/or vomiting. MANAGEMENT OF FRACTURES In simple basic trauma terms, the whole management of most fractures is immobilisation by splinting. At more advanced levels, with access to efective pain relief, we can also gently align and reduce fractures. Splinting limits movement of the injury, reduces pain, helps control bleeding, and decreases the risk of damage to the nearby nerves and vessels. Many diferent materials can be used as splints. Commercially available splints ofer the best support and come in diferent types and sizes. If a commercial splint is unavailable, improvised splints such as pieces of wood, the good leg and even folded cardboard can be used with good results. All that a splint does is to minimise further movement of the fracture. Chapter 5.5 / H: Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 89 MANAGEMENT OF FRACTURES One simple yet efective, commonly available commercial splint is the SAM splint— fexible aluminium sheets covered by foam which can be moulded to ft any shape limb or injury (see fgure 39). Other rigid splints exist made from frm materials and they are all applied to the sides and back of a limb, creating a gutter for the injured limb to be secured against, with a soft bandage. A more expensive but very efective alternative is the vacuum splints, which come in all shapes and sizes and mould to the injured limb as the air is sucked out of them, forming a stif, rigid splint. However, they are bulky to carry and require a pump or suction to make then work. (see fgure 41). Finally, a simple alternative for upper limb injuries is a broad arm sling. (see fgure 40). Figure 39: Multiple use of a malleable SAM splint and a crepe bandage Fractures Figure 40: Board arm sling With a long bone fracture, (e.g. thigh or lower leg), the simplest technique is to pad generously between the legs and then fasten them together at multiple levels, using the good leg efectively as a splint. Alternatively use a large fexible SAM splint bandaged to support and immobilise the fracture or a gutter/box splint. Chapter 5.5 / H: Head Trauma and Other Serious Injuries

90 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The largest vac-splits are full mattresses. Once the air is drawn out, they conform to the spine extremely well, provide a high degree of immobilisation and probably represent the current ‘gold standard’ for spinal immobilisation. They allow us to immobilise the whole spine in this manner and is useful if normal alignment is not possible or there is serious deformity of the back. However, they are bulky, heavy and can be torn or punctured. As such they are not as efective or widely used in the UK. While certain fractures require specialised splinting techniques (outlined below), splinting usually follows the same general principles: 1. Ideally, do not move the patient before splinting, unless there is an immediate danger to the casualty or the clinician 2. If movement is required, manually immobilise and support the injury 3. Remove clothing from the injured limb to inspect for open wounds, deformity, swelling, bruising, and to assess capillary refll 4. Note and record the pulse, capillary refll time, and sensation in the injured limb below the site of injury or fracture, both before and after splinting 5. Cover all open wounds with a non-adhesive, absorbent dressing before applying the splint 6. Immobilise the joint above and the joint below the injury site 7. Pad all rigid splints 8. When applying the splint, use your hands to support the injury site and minimise movement of the limb until splinting is completed 9. Splint the limb in the position in which it is found, unless it is easy to align or necessary for extrication 10. When in doubt, splint – especially the pelvis 11. Recheck distal circulation below the site of injury. Avoid turning or rolling casualties with fractures onto the side of the injury if at all possible. Figure 42: Simple use of a triangular bandage to form a sling for injured arm immobilisation. Fractures Figure 41: Use of a Vac-splint to immobilise a neck that cannot be moved into a neutral position for application of a hard collar. Chapter 5.5 / H: Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 91 The ideal pre-hospital immobilisation device for a long bone is a traction splint such as a Kendrick traction device or a CT6, if they are carried by your service (see fgure 43). These lightweight and highly efective devices will not only immobilise the limb, but also hold the leg out to its correct length and reduce the risk of impaired blood supply beyond the fracture. If major fractures of the lower limbs are present, always consider the need for pelvic strapping and spinal immobilisation as well. After application check for foot pulses, and capillary refll in the toes. If they are now absent, then consider releasing the traction and see if it improves. Figure 43: Applying a Kendrick traction splint for the lower leg A) Attaching the hip strap B) Adjusting the pole to length C) Inserting pole in hip strap socket D) Attaching ankle strap (well beyond foot) E) Attach Trafc light straps (RYG) F) Traction to foot and then pull straps tight Fractures – Traction splints Chapter 5.5 / H: Head Trauma and Other Serious Injuries

92 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Any degree of immobilisation will greatly reduce the pain of the injury and also the amount of bleeding from an unstable fracture. RIB FRACTURES For rib fractures, provider's should be careful to handle the patient gently and continually reassess for developing respiratory compromise, as there will be pain and potentially underlying ling injury. If the patient is experiencing difculty breathing, unless there are real concerns about spinal injury, providers should sit then up and provide supplemental oxygen. Lying them fat on a board could result in serious compromise and a lack of oxygen or inability to breathe. PRE HOSPITAL Strapping the chest is no longer recommended as it may actually restrict breathing, as does the KED extrication device, favoured by some ambulance providers for vehicle extrication. That said, some casualties may fnd relief in holding the ribs themselves, as if hugging themselves, manually splinting their injury, especially if they cough. PELVIC FRACTURES Pelvic fractures require special treatment, as they are injuries that often involve severe and potentially lifethreatening blood loss as the broken bones can easily lacerate the large blood vessel networks that run directly adjacent to the pelvic bones. The other risk factor is the potential for concealed bleeding and developing life-threatening shock with little, if any, external sign. In view of the potential catastrophic consequences of missing a pelvic injury, if suspected from the kinematics or pain/deformity, then the pelvis should be immobilised as early as possible with a pelvic splint. As a result we always consider the possibility of pelvic or long-bone fractures when assessing ‘C’ for circulation. Movement of the pelvic bones can greatly increase bleeding and disrupt any clot that may be forming. Therefore, we must not frmly press on or ‘spring’ the pelvis, as is still often described in trauma courses, as this may tear vessels or disrupt blood clots and be life threatening. To stabilise the pelvis, apply a broadly folded triangular bandage or pelvic/frac strap around the hips and fasten frmly, but not overly tight (see fgure 44). The strap is passed behind the knees or lower back and then moved into position with a side to side ‘sawing action.’ Try not to lift or move the pelvis or spine during this process. The correct position is at the level of the hips (top of the femurs/thigh bones), which is about a hand’s-breadth below the bony top of the pelvis felt at the waist. Apply an additional strap around the feet and ankles to keep them together (fgure of ‘8’ strapping is ideal) and stop them splaying outwards, putting rotational force on the pelvis. Do not “spring” or manually assess for pelvic instability or movement, as this can produce life threatening bleeding. Fractures Figure 44: Positioning of a pelvic or frac-strap for suspected pelvic fracture Chapter 5.5 / H: Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 93 The abdomen lies between the chest and the pelvis and contains the intestines, stomach, liver, kidneys, pancreas, and the spleen (see fgure 45). Injuries to the abdomen can have serious consequences such as major bleeding and perforation of the bowels. To recognise an abdominal injury, consider the kinematics of the situation (e.g. stabbing or blunt abdominal trauma) and look for any signs such as wounds or external bruising. Signs of internal bleeding may not be initially obvious as things such as abdominal distension are quite a late sign and can be unreliable. Internal bleeding is far more likely to be detected by developing signs of shock and blood loss with still no obvious signs of external bleeding. The kinematics of the situation may be the best indicator to alert rescuers as to the possibility of internal bleeding and they can then check for signs of shock. Figure 45: Organs in the abdomen. LIVER PANCREAS LARGE INTESTINE SMALL INTESTINE APPENDIX GALL BLADDER ESOPHAGUS Abdominal injury STOMACH Chapter 5.5 / H: Head Trauma and Other Serious Injuries

94 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com To examine a casualty for abdominal injury: 1. Try and lie the patient fat if possible 2. Explain what you are going to do to the casualty 3. Expose and visually inspect the abdomen 4. Ask the casualty if they have any pain anywhere 5. Look around the sides of the abdomen 6. Feel along the back on each side of the abdomen, checking for wounds or bleeding 7. If the patient is conscious, starting away from any painful area, apply gentle pressure with the fat of your hand in each of the four quadrants of the abdomen (see fgure 46) asking the casualty if this causes pain or discomfort, looking for any complaint of pain or grimacing on the patient's face. If there is no signifcant discomfort, then repeat the examination a second time, pressing a little more frmly, keeping your fngers fat on the abdominal wall. SIGNS AND SYMPTOMS OF ABDOMINAL INJURY Signs and symptoms of abdominal injury include: • Abdominal wounds • Bruising on the abdomen • Abdominal pain • Broken lower ribs • Blood in vomitus • Bleeding from the anus or urinary tract • Distension (bloating of the stomach). When abdominal wounds are present and time permits, eforts can be made to control external haemorrhaging with simple pressure dressings, chest seals, or—for larger wounds—cling-flm. However, there is also likely to be similar amounts, or even more, internal bleeding, especially if there are features of shock. If any abdominal contents have eviscerated (spilled out of the wounds), they can be gently covered with cling-flm or saline-soaked swabs. DO NOT try and push them back into the abdomen. Gently handle or move any patient with a possible internal injury or bleeding to minimise the bleeding and discomfort. Consider a pelvic strap before any movement, if necessary. Abdominal injury Figure 46: 4 Quadrants of the abdomen to examine LEFT UPPER QUADRANT LEFT LOWER QUADRANT RIGHT UPPER QUADRANT RIGHT LOWER QUADRANT Chapter 5.5 / H: Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 95 Figure 47: Diagram to describe depth of skin burns SUPERFICIAL SUPERFICIAL DERMAL DEEP DERMAL FULL THICKNESS EPIDERMIS DERMIS SUBCUTANEOUS Burns can vary from minor redness to a life-threatening situation, depending on the depth and location of the burn (see fgure 47). Superfcial burns: (frst-degree burns) are the most minor type of burn and are characterised by reddened and painful skin, but without blistering, e.g. sunburn or a minor scald. The injury is confned to the outermost layers of skin, and the patient experiences minor to moderate pain. A superfcial burn usually heals in about a week, with or without treatment. Partial-thickness burns, dermal (second-degree burns) are somewhat deeper, do not damage the deepest layers of the skin, but are the most painful. Blistering is typically present, although they may not form for several hours in some cases. There may be some fuid loss and usually moderate to severe excruciating pain because the nerve endings in the skin are fully exposed to contact and the air. Partial-thickness burns require medical treatment and usually heal within two to three weeks and may result in some form of scarring. Full-thickness burns (third-degree burns) damage all layers of the skin. In some cases, the damage is deep enough to injure and destroy underlying muscles and other tissues. There is often less pain than expected because the nerve endings have actually been destroyed. However, there is typically some marginal or associated partial thickness burn too, which will produce severe pain. Without the protection provided by the skin, patients with extensive full-thickness burns lose large quantities of body fuids and are susceptible to shock and infection. All full thickness burns require hospital review. Burns All burn patients should receive high fow oxygen to meet the body’s increased metabolic demand for oxygen, avoid confusion, agitation, and combat the efects of any carbon monoxide poisoning. Chapter 5.5 / H: Head Trauma and Other Serious Injuries

96 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com It is not always possible or necessary to determine the exact degree or depth of a burn. Burns should be always considered time critical if they: • Cover more than 10% of an adult’s body surface area or more than 5% of the body surface area of a child (under 16 years) – remember that the casualty’s hand (palm & fngers) = approx 1% of skin area • Afect the airway • Are found in a paediatric or elderly casualty (extremes of age) • Are found in a casualty with other serious medical or trauma conditions • Involve the face, hands, feet, genitalia, perineum or major joints • Are located above the shoulders • Are circumferential ( i.e. go all the way around a limb or body part) • Are electrical or chemical burns • Involve fumes or smoke inhalation. All major or time critical burns patients should receive high fow oxygen (15 L/min) to meet the body’s increased metabolic demand for oxygen, avoid confusion, agitation, and combat the efects of any carbon monoxide poisoning. FOR TIME CRITICAL BURN PATIENTS, RAPID TRANSPORT IS ESSENTIAL. Burns are also categorised by the source of the injury: • Thermal • Chemical • Electrical. The signs, symptoms, and treatment of each type vary, as outlined in the following sections. More accurate assessment of burn area: Traditionally burns have been assessed using simple charts such as the Lund and Browder and the ‘Rule of Nines’ but an accurate and far simpler version now exists with the ‘Mersey Burns’ application produced by one of the UK’s leading Burns and Plastics units at Whiston Hospital in Merseyside. This ofers a very simply method to record and size the burn based on the size, weight and age of the patient. Burns Remember to cool the burn efectively for at least 20 minutes, but avoid signifcant hypothermia if the burn is very extensive. Recommendation: Mersey Burns App St Helens & Knowsley Teaching Hospitals NHS Trust Chapter 5.5 / H: Head Trauma and Other Serious Injuries