BTACC

Basic Trauma & Casualty Care © 2019 The ATACC Group Ltd. All Rights Reserved. TAG015_BTACC-Manual_V1.0 For further information Call: 03333 222 999 Email: [email protected] www.ataccgroup.com

BasicTrauma&CasualtyCareBasic Trauma & Casualty Care The BTACC course is provided by The ATACC Group

© 2019 The ATACC Group Ltd. All Rights Reserved. For further information Call: 03333 222 999 Email: [email protected] www.ataccgroup.com

For further information Call: 03333 222 999 Email: [email protected] www.ataccgroup.com © 2019 The ATACC Group Ltd. All Rights Reserved.

Integrated Emergency Care Programme (IECP) Author: Dr Mark Forrest Medical Director of The ATACC Group Medical Director of Cheshire Fire & Rescue Medical Director of Hampshire Fire & Rescue Medical Director of NW Police Collaboration (incl Firearms & Public Order) – GMP, Merseyside, Lancashire, Cumbria Police Consultant in Anaesthetics, Critical & Pre-hospital care NHS Clinical Director Urgent & Emergency Care Consultant Helimed 29 –Lincolnshire & Nottingham air ambulance Basic Trauma and Casualty Care BTACC Basic Trauma and Casualty Care The BTACC manual and educational material is subject to the laws of copyright. The material cannot be copied or reproduced without prior approval of the author or The ATACC Group. The BTACC algorithm is also subject to copyright as a unique flow-chart for the management of major trauma. In the event that any obvious plagiarism or copy is made without such prior consent. The ATACC Group reserves the right to take action through legal process. Copyright

4 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The BTACC Course is part of a the ATACC Groups Integrated Emergency Care Programme (IECP) which is a progressive series of emergency care courses developed by The ATACC Group that runs seamlessly from basic to through to the advanced level. Basic Trauma and Casualty Care The ATACC Group Integrated Emergency Care Programme (IECP) ATACC is currently the most advanced trauma & critical care course in the life-support style available in the world. Developed over the last 20 years by a large international faculty, ATACC is world renowned for it’s high quality lectures, ground breaking immersive simulation with a focus on human factors and team development. The course is aimed at advanced level providers and covers both pre-hospital (up to FPHC PHEM level H) and in-hospital Major Trauma Centres standards. FTACC Emergency (1 Day) is a Royal College Of Surgeons of England (RCS England) accredited course that meets the Faculty of Pre-hospital Care (FPHC), Pre-hospital Emergency Medicine (PHEM) guidelines level B of The Royal College of Surgeons Edinburgh and is equivalent to Emergency First Aid at Work (EFAW). The objective of FTACC is to provide learners with basic first aid skills in a new and exciting way. FTACC (3 Day) is a Royal College Of Surgeons of England (RCS England) accredited course that meets the Faculty of Pre-hospital Care (FPHC), Pre-hospital Emergency Medicine (PHEM) guidelines level B of The Royal College of Surgeons Edinburgh and is equivalent to First Aid at Work (EFAW). The objective of FTACC is to provide learners with basic first aid skills in a new and exciting way. The 3 day course provides more enhanced knowledge of basic first aid. BTACCis a Royal College Of Surgeons of England (RCS England) accredited course that meets the Faculty of Pre-hospital Care (FPHC), Pre-hospital Emergency Medicine (PHEM) guidelines level D of The Royal College of Surgeons Edinburgh. The objective of BTACC is to provide learners with a basic knowledge of casualty care and goes beyond First Aid at Work, giving learners the skills and knowledge to deal with life threatening situations. The course introduces blended learning and uses scenarios and immersive training to enhance the candidates experience and provide them with the confidence to use their new skills to save lives. RTACC is a Royal College Of Surgeons of England (RCS England) accredited course that meets the Faculty of Pre-hospital Care (FPHC), Pre-hospital Emergency Medicine (PHEM) guidelines level E of The Royal College of Surgeons Edinburgh. The objective of the course is to prepare learners to deal with more serious medical and trauma incidents in an immersive and engaging manner while developing their knowledge, skills and confidence. The learner will extend their knowledge beyond basic trauma and this course has the added benefit of being bespoke to meet the individual requirements of your organisation.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 5 Part 1: Core material Chapter 1 - BTACC Approach Chapter 2 - M - Massive External Haemorrhage Chapter 3 - A - Airway Management Chapter 4 - R - Respiratory Chapter 5 - C - Circulation Chapter 6 - H - Head and other injuries Chapter 7 - Cardiac Arrest / Life Support Table of Contents: Basic Trauma and Casualty Care Part 2: First Aid & Medical Chapter 8 - First Aid & Medical Emergencies – B.U.R.P.S Chapter 9 - Medical Devices Part 3: Appendices Appendix A: Clinical Updates Appendix B: BTACC Algorithm Appendix C: BTACC Trauma kit

6 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Preface – Enhanced casualty care BTACC offers a highly focused, well researched and totally current emergency care course for individuals who may potentially face casualties with life threatening trauma and medical conditions. The course has been developed as the second ‘enhanced’ level of the ATACC Group’s four part ‘Integrated Emergency Care Programme’ (IECP) and has been written by specialists in the field of pre-hospital and critical care medicine. The IECP level one, two and three courses are accredited by Qualsafe. The advanced level of IECP is the ATACC course which has been running for nearly 20 years, has a considerable international reputation and is fully accredited and approved by the Royal College of Surgeons, London (Re-assessed and accredited in 2016-17). The BTACC course extends beyond First Aid at Work and provides the students with the skills necessary to aid a seriously injured casualty or save a life, even in the most difficult situations and environments. We aim to bridge the gap until additional higher-level medical support arrives. BTACC uses tried and tested casualty care methods defined by our International expert Medical Advisory Group, who have a wealth of pre-hospital and in-hospital experience. The skills and information in the course has been developed over 20 years by the ATACC Faculty and they work, as such by adopting and embracing them. Empowering People to Save Lives. Dr Mark Forrest, The ATACC Group, Medical Director The BTACC Course Basic Trauma and Casualty Care

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 7 Congratulations! You are about to embark on one of the most exciting and up to date casualty care courses in the world. This course is not for ‘tick boxing’ first aid training and it does not get bogged down in unnecessary anatomy and physiology. It is a tried and tested methodology that will neither let you nor the casualty down, even in the most challenging situations. After completing the course, you will be surprised at the complexity of injuries and conditions you will be able to confidently manage. As described in the preface, Basic Trauma and Casualty Care (BTACC) is part of the Integrated Emergency Care Programme (IECP) and is designed to introduce participants to the concepts of assessment and care of the seriously unwell or injured casualty. Anyone who has successfully completed a BTACC course will have the knowledge and ability to make a life-saving difference. BTACC is part of our Integrated Emergency Care Programme (IECP) which has been adopted by many Emergency services and high-risk industries as it offers a progressive and highly effective approach to comprehensive casualty care. BTACC training has been developed to allow easy and rapid identification of casualties who are considered “time critical” (those requiring immediate life-saving actions) and those who are stable enough to simply monitor, delaying further care until medical assistance arrives. BTACC explains how to approach a casualty safely and to use the principles of kinematics to identify the type and severity of any injuries. BTACC provides a systematic method of recognising and managing time critical injuries such as massive haemorrhage, obstructed airway, chest trauma, serious injuries or common medical emergencies. The secret of BTACC is it’s simplicity. It does not overly complicate the training with unnecessary, technical aspects and detailed anatomy or physiology as even simple techniques, such as haemorrhage control or airway manoeuvres can prevent many fatalities and make a real difference. Conversely, advanced interventions (such as IV drips and endotracheal intubation) do not reduce mortality significantly as compared to simple measures performed well, as in BTACC. Carefully applying the methods outlined in this text in a focused and deliberate fashion, could mean the difference between life and death. Introduction Basic Trauma and Casualty Care

8 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Pre-requisites Students taking this BTACC courses should ideally have already completed the FTACC or a First Aid course, however this is not essential. For anyone that is completely new to casualty care we do offer an additional foundation element to provide some background and medical knowledge in preparation for the course. The BTACC courses are designed for those who could potentially need to deal with life threatening major trauma or seriously ill casualties, in challenging siutations on a regular basis or as part of their everyday work e.g. Fire Fighters, Police Officers and specialised Industries. Timeline BTACC is a minimum of three days but can be up to five days, if more special modules are added. The course includes: • BTACC elements • First Aid (meets all HSE requirements). • Medical Devices. MARCH, BURPS and our programme methodology First aid and trauma courses have adopted the ‘DRABC’ approach for many years. Whilst this is a simple logical approach, we feel that it has become somewhat stale and almost over-familiar. The key focus of our training is to stimulate and enthuse our candidates, whilst giving them the confidence to take the necessary action, no matter what the situation they face. We have learned from years of experience and watching many other first aid and trauma courses, where candidates simply attend, switch off, and then simply ‘tick the box’ and then forget it for another year. Our courses are for those individuals who may genuinely hold a life in their hands, or be looking after seriously injured casualties and they will have a desire to be engaged and empowered rather than simply ‘tick-boxed’. Theory is always necessary and we are often constrained by defined course time limits and costs, so some typical Powerpoint materials are unavoidable. However, we try and use lots of pictures, images, videos and simple memory aids such, as the ‘BURPS’ approach that we use in First Aid which offers a tried and tested problem based, focus when assessing and managing a casualty. In our more advanced courses we use M.A.R.C.H, a well-established alternative acronym, developed for UK special Forces by one of our Faculty members, which re-engages our casualty carers thought processes. The second and more important reason that we prefer MARCH is the increased recognition that for many trauma causalities massive haemorrhage may kill before airway and the traditional ‘DrABCD’ becomes ‘DRCAcBCD.’ which starts to get really confusing with so many ‘C’s. M.A.R.C.H is simple and clear and is the core of our initial assessment process for trauma, even in our most advanced ATACC course. M.A.R.C.H actually will also works for all the initial assessment of all patients. M – Massive external haemorrhage A – Airway with cervical spine R – Respiration C – Circulation H – Head and other injuries Basic Trauma and Casualty Care

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 9 Basic Trauma and Casualty Care MARCH, BURPS, and our programme methodology For first aid, medical condition patients, or casualties where M.A.R.C.H has not identified a traumatic injury, but a medical problem, then we apply B.U.R.P.S. Why change? B.U.R.P.S is a completely unique new approach to assess a casualty. Primarily developed for first aid and medical conditions, it will also work to identify trauma patients. B.U.R.P.S defines the key problem facing the carer, rather than searching through body systems. The acronym represents the following: B – Bleeding U – Unconscious or reduce conscious level R – Difficulty breathing P – Pain or altered sensation S – Skin changes What makes this unique, is that it describes what actually you find, rather than simply working through body systems to identify abnormalities, with ABC. B.U.R.P.S is a far simpler way to identify serious problems and then deal with conditions which can affect the whole body. M.A.R.C.H. and B.U.R.P.S. have been tried and tested on numerous organisations at all levels over the last 15 years by ATACC and they have proved to not only be effective, but also easy to remember. This is why we also have other simple pneumonics such as TRIPS in Elderly care and SAMURAI LASER in extrication. In BTACC, if individuals still wish to use DRCABC, rather than M.A.R.C.H, then we are not rigid or didactic about it, as basically they are the same, but we hope that candidates will embrace our whole methodology for the good reasons that we offer.

10 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Refresher training Local or agency specific training requirements may vary, but as a minimum, we would recommend that scenario-based refresher training must be provided every 12 months to remain BTACC qualified. Ideally, casualty care is also incorporated in regular operational training at some point during the session, e.g. life support of a drowning victim after a water rescue. Dedicated refresher training days should be run once a year (min 6 hours), which includes selected scenarios which will not only refresh the existing skills, but also address any updates or new training needs identified from new guidelines or operational feedback. Any unit or group providing specialist care or care in difficult or extreme environments needs to carefully focus their refresher training to ensure that a high standard of care is maintained and that it is relevant for such situations and not imply refreshed in the classroom. All BTACC Training must be relevant and real to the role of the providers. As such classroom-based sessions are of limited value in terms of improving clinical management in challenging situations and they should be limited as much as possible on BTACC refresher days. A new and more robust alternative to annual recertification is to establish an ongoing rolling programme to demonstrate competency and minimise skill fade. This can be extended into operations so that whenever a skill is performed effectively, either in training or operationally, under the direct supervision of an instructor, then this is logged as a rolling ‘demonstration of competence’ and held on a ‘witnessed competency record’ – the instructor should offer a short debrief and feedback whenever the situation allows and can be individual or team based. A structured framework needs to exist to ensure that in any given year each individual will have an opportunity to demonstrate all their core competencies from BTACC. Similarly, regular familiarisation with the casualty care kit is an essential part of being prepared to provide a high standard of care in stressful and difficult circumstances. As such, the standard BTACC casualty care kit should be opened and used throughout training and operationally, always checked and sealed ready for use. Basic Trauma and Casualty Care

11 Basic Trauma and Casualty Care Clinical governance All trauma care should be supported by an appropriate governance structure. Such governance is an ongoing process that protects both the casualties and the provider, ensuring that standards of training, care, and follow-up are in place and are constantly improving in response to ongoing audit, feedback and demand. All emergency services should have a credible Medical Director or adviser, leading this process, who is supported by a governance group consisting of trauma instructors, members of the management team, and local medical and ambulance representatives. Clinical governance has existed in the NHS and other healthcare systems for many years, but it is now appropriate that any organisation that delivers trauma or casualty care on a regular basis, has such a system in place. Initial training approval alone is not enough; skills must be monitored and audited on a day-to-day and ongoing basis. Casualty details and any therapies or interventions must be recorded on a patient report form (see Appendix A), reviewed regularly and relevant lessons learned. Governance is not designed to be restricting, but to support the ongoing development of the Service, identifying any necessary training or equipment needs to meet the casualtycare requirements of your role. For example, for the administration of oxygen, which is now classed as a drug, must also be supported and approved by a suitable Medical Director or advisor. However, before this takes place we need to establish: • A need for oxygen should be identified • The training requirements • The training resources are produced and approved • How that training will be delivered • Equipment needs • Monitoring of use and delivery (secure records) • Feedback for Governance • Modification if required This is typical of how the clinical governance process should work and can be applied to new methods, equipment as well as incident investigation, learning and feedback. Governance is an ongoing process of constant improvement, rather than simply being an insurance policy. Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com

12 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Chapter 1: The BTACC Approach Mechanism of injury BTACC embraces the analysis of Mechanism of Injury to guide the process of scene and injury assessment (sometimes termed Kinematics). Kinematics is actually the science of how matter moves under the influence of forces and how such objects interact in collisions. By initially standing off or by taking a step back at any incident, responders can look at the scene and assess what forces and energy has been involved, what has happened and then consider what injuries may be present based on this information. Whilst not fool proof it gives us a starting point for further assessment. Kinematics teaches responders to consider three aspects of the injury: 1. Energy transfer (the amount of energy involved) 2. Point of impact (on the casualty’s body) 3. Nature of the insult (e.g. stabbing, fall from height) Even if the casualty appears uninjured, kinematics may lead a responder to consider or identify a serious injury.

13 Mechanism of injury Energy Transfer Energy transfer an produce injuries. That energy can be kinetic (movement) or potential (height), which then transfers to kinetic as the object falls. As such any moving object possesses kinetic energy, which directly relates to the weight (mass) and the speed (velocity) of an object. Kinetic energy, measured in units known as joules, can be determined using the equation below: Velocity (which is squared in the equation) is the greatest factor in determining energy. For example, an average sized 80 kg person travelling at 30 mph would produce an impact energy of 36,000 joules. The same person travelling at 60 mph would produce on impact of 144,000 joules. A person weighing only 40 kg travelling at 60 mph would still represent 72,000 joules. When a moving object impacts another object, the energy of the moving object is transferred to the secondary object. This focuses on the energy and the rate of transfer to determine the likely cause of injury For example, if a car hits a fence, the car is designed to protect the occupants by dissipating this energy and diverting it away from passengers. However, if the passengers are not properly restrained when the vehicle impacts, they will be thrown forward, with the kinetic energy, until they hit something, such as the dashboard, windscreen, or an external object which may result in death or serious injury. Once the passenger stops moving, inside the body the internal organs continue to thrust forward until they hit the body wall and stop. Meanwhile, any other loose objects in the car will also be moving forward towards the casualty, with some considerable energy, potentially causing further injury. The transfer of energy from these impacts can cause damage to the car, the driver, and the passengers. BTACC teaches providers to examine the kinematics — by looking at the damage to the car and the fence as well as the initial speed and the rate of deceleration — to determine the extent of energy transfer involved and likelihood and severity of injuries. Image 1.1 Consider the amount of energy transfer to suggest the nature and extent of injuries Chapter 1: The BTACC Approach Kinetic energy = mass x velocity2 KE = ½ MV2 2 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com

14 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com point of impact The point of impact is another important consideration in determining the presence and extent of injury. If energy is transferred over a large area of the body, the energy is dispersed resulting in a potentially less severe injury than if the same energy impacts over a small area of the body. A simple example of this effect is to consider a woman walking on the snow wearing wide snowshoes, her weight (energy) would be spread over a wider area, and she would not sink into the snow. However, if the same woman wore high-heeled shoes, she would sink into the snow. Considering trauma, if a casualty is punched with a fist the energy is spread over the hand and may cause bruising or fractures. However, if exactly the same energy is focused at the tiny point of a knife in a stabbing, it will breach the skin and penetrate into the body and possibly the internal organs. Another example to consider is an individual falling from height. If he lands flat on his back, the area, or point of impact, is far greater and potentially less damaging when compared to that of him landing on a much smaller area, such as a railing or fence, which focuses the energy into a smaller area. Nature of the Insult By considering the amount of energy, its rate of transfer and distribution, a BTACC provider can identify potential injuries that would not otherwise be obvious. These considerations would raise the concerns of a provider with a casualty in a high-speed motor vehicle collision in comparison to a pedestrian in collision with a cyclist. However, we must also consider other factors, such as the ‘tolerance’ of any insult. For example, a Rugby League player will be far more tolerant of an impact and energy in comparison to an elderly lady and this must also be considered. Such elderly & frail patients, handle impacts, forces and energy, badly resulting in the significant healthcare focus on the so called ‘silver-trauma’ in this age group. Taking another view, blood loss, severe pain and other obvious injuries can distract the responder, but by considering the mechanism, providers can identify the potential for injuries that otherwise could easily be missed. In addition, even if these injuries are difficult or impossible to manage in the field, early identification can facilitate rapid extrication and transfer to a hospital for the necessary care. Such urgency alone may be a life saving measure in some cases, such as internal bleeding. The M.A.R.C.H algorithm The M.A.R.C.H algorithm is a systematic pathway for the approach and management of traumatic injury that is used across our IECP courses (See figure 1.2). The BTACC algorithm will be used to prioritise our casualty management and to guide us through each stage in the following chapters. Moving down the left hand column, the algorithm is designed to help responders identify concerns and to determine whether the injury is potentially life-threatening - “time critical” If they are then the right column defines the appropriate treatment measures before moving back to the left column and continuing the assessment. Although the algorithm is primarily driven by traumatic injuries, it will also support resuscitation and the ATACC ‘B.U.R.P.S’ approach to medical conditions, which we describe in the First aid (FTACC) section of this manual. The BTACC algorithm is available as an ATACC Group check card. Chapter 1: The BTACC Approach Mechanism of injury

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 15 Figure 1.2_M.A.R.C.H algorithm Chapter 1: The BTACC Approach B.L.S. Protocol NOT BREATHING (10secs) NO SIGNS OF LIFE (10secs) Re-assess SAFE APPROACH TIME CRITICAL HAEMORRHAGE CONTROL D.D.T Not more than 60 secs if single rescuer AIRWAY MANEOUVRES • Jaw Thrust/Chin LIft • Oxygen 15L/min - Target Sats > 94% on 02 • Suction • NP/OP • Cx spine immobilisation RESPIRATO RY SUPPORT • Oxygen 15L/min • Chest seal (wounds) • RR <8/min - BVM - Pocket mask • Bad side upper most • Consider sitting up CIRCULATO RY SUPPORT • Re-assess D.D.T/Bandage CONSIDER: • ‘Scoop and Run’ • Pelvic Strap • Gentle handling • Elevate Legs • Head to Toe survey INJURY SUPPORT HEAD INJURY (Consider Medical Causes) • Keep patient talking • Monitor Airway/breathing Spinal Injury and Fractures • Immobilise/Splint Burn Injury • Active Cooling • Cling-film/bags Environment • Keep warm • Package for Transport MASSIVE HAEMORRHAGE AIRWAY PROBLEM? • Unconscious • Airway at Risk • Obstructed • Cx spine: if 2 persons • Sats <92% or less on air HEAD & OTHER INJURIES • AVPU • Pain or numbness • Burns/Cold • Others, e.g fractures RESPIRATORY PROBLEM? • RR >20/min • Difficulty in breathing • RR <8/min • Sats <91% air / <94% 02 • Open Wounds • Unequal Movement CIRCULATION PROBLEM? • Unconscious • Radial Pulse absent • CRT > 3secs • Radial Pulse >110/min

16 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The first step in the BTACC algorithm is a safe approach. In any area of emergency care, trauma management or rescue, it is essential to avoid becoming a casualty yourself. This should be at the forefront of your mind as you arrive at the scene. Ask yourself: 1. Do I fully understand the hazards in this environment? 2. Do I have adequate information and skills necessary for this situation? 3. Have the necessary emergency services been alerted? 4. Have I considered all the medical implications? The answers to all these questions must be “yes” before you begin caring for the casualty. It is vitally important to understand the difference between a rescue and a recovery. A “rescue” involves a casualty who can be potentially saved by your interventions and constitutes a true emergency, whereas a “recovery” typically involves a dead body and should not be considered an emergency if it puts lives at risk. In these situations, you cannot reverse the misfortune of the victim and therefore it is essential to make sure that you do not add to the problem by placing yourself or others in jeopardy unnecessarily. Determining Hazards As you approach the emergency scene, do you own risk assessment, as you may be the first to arrive. Scan the entire area (360 degrees) carefully to determine what hazards are present, such as: • Traffic (and road traffic collisions) • Electrical hazards including railways • Working at height • Fire • Chemicals or hazardous materials • Weapons or sharp objects • Environmental conditions • Animals • Assailants • Terrorists. Always approach a scene cautiously and carefully, scanning for any possible hazards to reduce the potential for injury to yourself and other providers. Obey the advice of your senior officer or team leader if he or she has identified potential hazards at the scene, and always follow your training guidelines or standard operating procedures. In special situations (such as chemical plants, railways, sewers or tactical situations) the safest option will usually be to wait for the dedicated maintenance or specialised rescue personnel to ensure your safety. Discrete hazards are less obvious, but may be just as dangerous. Examples include shallow but swift running water, live electric cables, or an unknown powder on casualties. These could easily be missed without careful thought and consideration as you approach the scene and may result in potential injury or even death. If you do nothing else, avoid becoming a casualty yourself! Resisting the overwhelming urge to rush in to help a casualty in danger can be one of the most difficult tasks in casualty care, but establishing a safe approach must take priority. Chapter 1: The BTACC Approach Safe approach If you are in doubt about the safety of a scene, do not approach the casualty. Wait until help arrives and a safe approach has been established.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 17 Chapter 1: The BTACC Approach PPE & Infection Control An important part of a safe approach is assessing the need for personal protective equipment (PPE). This will vary depending upon the situation and your organisation. As an absolute minimum, disposable examination gloves As an absolute minimum, disposable nitrile gloves should be worn before making direct contact with a casualty, (3 pairs of nitrile gloves offer sufficient protection from all known agents for upto 15 minutes). The need for additional PPE is specific to the situation; further information on appropriate PPE is provided by the Health and Safety Executive (HSE) and other governing/advisory bodies. The Department of Health has also developed guidelines for PPE in conjunction with the Health Protection Agency, for the management of casualties. PPE may include: • Helmet • Safety specs or goggles • Ear defenders • Dust masks • Breathing apparatus • High-visibility clothing • Chemical, waterproof, fire or ballistic protection • Disposable overalls or aprons • Gaiters or leggings • Safety footwear. If you are unsure about the effectiveness of your PPE in a particular environment, seek advice about the proper protocol before proceeding. Additional PPE and precautions are not only to protect you, but also to protect casualties, rescuers and bystanders from possible hazards, such as infectious diseases. Gloves must also be worn before contacting the casualty and should be disposed of properly in a biohazard bag if they become contaminated due to contact with blood or other body fluids (see image 1.3). Other than scene related risks, blood and body fluids present the most significant risk to the first aider. Everyone needs to have an awareness of these risks to protect themselves adequately. (see figure 1.4). Body fluids can potentially transmit infection and the most significant risks are from the blood borne viruses such as Hepatitis B, C and HIV. However, the highest risks occur from needle-stick injuries. Getting blood onto your skin is highly unlikely to cause a serious infection unless you have cuts and open wounds, in which case you should wash your hands with soap and water or antiseptic wipes and if still concerned seek medical advice if contaminated, but even then the risk of catching infections in the UK and Europe are low. In addition to wounds and cuts, there is a risk to what is called ‘mucous membrane contamination’, which is basically any area of your skin that has a moist lining, e.g. mouth, eyes. If infected body fluids or blood come into contact with these areas of your body, then you should also seek medical advice. The incidence of BBV infections in the UK population is less than 1%, so the vast majority of casualties will present no serious risk to you. However, it is impossible to predict that risk. We should be aware that IV drug abusers or known infected patients do present a higher risk but you may not have this information when you reach a casualty. Heavy extrication or rigging gloves can become contaminated with dirt, grease, oil, glass, dust, and other agents. These types of gloves should not be used for direct casualty care. Safe approach

18 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The key is to protect yourself: • Use gloves • Eye or face-shields if there is a risk of splash or spurting • Care when cleaning up contaminated areas and equipment • Dispose of contaminated dressings and single use devices, e.g. suction, airways etc. In a suitable container of bag for incineration eg yellow BIO Hazard Bag. Clear guidance is available on the HSE websites which should be read and adapted for the potential risks in your working environment. The following points apply, regardless of the scale of the spill: • Gloves should be worn throughout and should be discarded safely after use. • If there is broken glass present, it is essential that the fragments are not gathered up by hand either before or after treatment with disinfectant. Bunches of paper towels or newspaper, pieces of card or a plastic dustpan should be used to remove the fragments to a sharps container without risk of sharps injury. Small spots of blood or small spills: • Gloves should be worn and lesions on exposed skin covered with waterproof dressings • Contamination should be wiped up with a paper towel soaked in freshly prepared hypochlorite solution containing 10,000ppm available chlorine • Towels and gloves should be placed in a clinical waste bag for incineration and hands washed. Procedure for larger spills other than urine (unless bloodstained) • Gloves should be worn and lesions on exposed skin covered with waterproof dressings. If spillage is extensive: • Disposable plastic overshoes or rubber boots may be necessary • If splashing is likely to occur while cleaning up, other protective clothing should be worn • Liquid spills should be covered with dichloroisocyanurate granules and left for at least two minutes before clearing up with paper towels and/or a plastic dustpan • Alternatively, the spill may be covered with paper towels and the contaminated area gently flooded with hypochlorite solution containing 10,000ppm available chlorine* (again this should be left for at least two minutes before attempting to clear up) • Towels, gloves, disposable overshoes and contaminated clothing should be placed in a waste bag for incineration and hands washed; (rubber boots may be decontaminated with dilute disinfectant) • Finally, the area should be washed with water and detergent and allowed to dry • *Note that urine may promote the release of free chlorine from the treated area when hypochlorite or other chlorine-containing compounds are applied. Ventilation of the area will be necessary • In open areas, for example playgrounds and roadways etc, the spillage should be hosed down with large amounts of water unless there is an environmental risk, e.g. tanker spill. If in doubt, then seek advice from the emergency services or the Environment agency. Heavily contaminated clothing should be considered high risk and should be professionally laundered to remove all risk of infection transmission. Figure 1-3: Biohazard waste disposal bag. Safe approach Chapter 1: The BTACC Approach

19 Useful references and advice: http://wwwhse.gov.uk/pubns/indg342.pdf Immunisation against infectious diseases – ‘The Green Book’, 2006 Edition, HMSO, ISBN 9780113225286. Hepatitis B information is available at link: www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_ FILE&dID=11 5985&Rendition=Web) A summary of requirements designed to protect health care workers from BBV exposure is provided in The Health Act 2006: Code of practice for the prevention and control of healthcare associated infections - known as the Hygiene Code. Guidance on Personal Protective Equipment at Work Regulations 1992. L25 HSE Books 2005 ISBN 0 7176 6139 3 Health Protection Agency - Reporting of occupational exposure to blood borne viruses – history and how to report Safe Management of Healthcare Waste (2007). Royal College of Nursing. ISBN 978 1 904114 76 5. www.rcn.org.uk/__data/assets/pdf_file/0013/111082/003205. pdf Safe approach Chapter 1: The BTACC Approach Figure 1-4: WHO ‘Five Moments for Hand Hygiene’ Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com

20 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Traditional resuscitation and trauma courses use the CABC approach—which stands for Catastrophic Bleeding, Airway, Breathing, and Circulation—to aid the responder in identifying and managing life-threatening issues. BTACC adopts a modified approach which focuses initially on life threatening issue of massive external haemorrhage before addressing other concerns. The MARCH acronym was originally developed by an ATACC faculty member for UK Special Forces. (see figure 1.5). The M.A.R.C.H approach includes all the same components as the classical ABC first aid approach (which stands for airway, breathing, and circulation). M.A.R.C.H also shares the same principles as the updated, alternative of cAcBCDE approach, which adds the concepts of catastrophic haemorrhage, cervical spine, disability, and exposure/ examination. This mnemonic may be difficult to remember and confusing with so many C’s. While the underlying principles remain the same, we believe that the M.A.R.C.H algorithm is the simplest and easiest method to follow as an alternative. Chapter 1: The BTACC Approach The ‘M.A.R.C.H.’ assessment M.A.R.C.H M MASSIVE EXTERNAL HAEMORRHAGE A Airway R Respiratory C Circulatory H Head trauma and other serious injuries Figure 1-5: M.A.R.C.H acronym.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 21 At each stage of the M.A.R.C.H algorithm, responders should carefully look for signs of any time critical injuries. These injuries are serious and potentially life-threatening, such as airway obstruction or falling level of consciousness. Time critical concerns must be addressed and managed as a matter of urgency. A casualty can be deemed time critical for more than one reason. For example, a casualty may have both a severe airway obstruction and a reduced conscious level or both massive external haemorrhage and a penetrating chest wound. The time critical concept allows responders to not only identify life threatening injuries, but to also establish the degree of urgency and, if necessary, indicate the speed of extrication required (see Special Situations, Chapter 7). Once a time critical problem has been identified, responders should stop their assessment and take action before moving on. Responders should not move to the next stage of M.A.R.C.H until the time critical problem has been managed effectively unless working as a team using a horizontal approach. Once the problem has been addressed, the responder can move to the next step in the M.A.R.C.H algorithm to look for other time critical concerns. All time critical concerns must be constantly reassessed and reported clearly when care is handed over to other providers. All relevant information about the casualty and any treatment provided should be given to medical staff who ultimately take over care of the casualty. This will be covered in the handover section (see page 20). After an incident, pass on all information to Emergency Services about any injuries and care provided. Also check yourself for injuries or contamination by bodily fluids. The time critical concept Chapter 1: The BTACC Approach

22 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Handover Once paramedics or medical staff are present, responders should work to ensure a succinct and effective handover. They should convey essential information about the scene and the casualty and outline any interventions and any changes in the casualty’s condition. There are numerous ways to provide this information. The simplest may be to go through each stage of the M.A.R.C.H algorithm and describe what has been found at each step. Alternatively some kind of handover or first report acronym can be used. The commonest one used is ‘A.T.M.I.S.T’ (see figure 1.6) An alternative and widely used in healthcare is “ISBAR” (see figure 1.7) The patient report form (see Appendix A) may also serve as a useful guide in delivering this information in a systematic and logical manner. Chapter 1: The BTACC Approach I.S.B.A.R I I AM S SITUATION B BACKGROUND A ASSESSMENT R RESPONSE / RECOMMENDATION Figure 1.7: I.S.B.A.R acronym. A.T.M.I.S.T A Age of casualty T Timings of incident (incident, your attendance) M Mechanism of injury I Injuries identified S Symptoms and signs on assessment T Treatment Figure 1.6: A.T.M.I.S.T acronym.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 23 • BTACC focuses on assessment and care of the seriously injured • The study of kinematics—the science of how matter moves and interacts in collisions—guides the process of scene and injury assessment • Kinematics focuses on three key aspects of injury: energy transfer, point of impact, and nature of the insult • The BTACC algorithm provides a systematic pathway for the assessment and management of trauma • At each stage in the algorithm, responders are asked to identify potential problems, determine the severity of injury, and provide appropriate care • The first step in the M.A.R.C.H algorithm is a safe approach, scanning the scene for potential hazards • Personal protective equipment (PPE) varies depending upon the specific emergency and organisational guidelines • The acronym M.A.R.C.H stands for: Massive external haemorrhage control, Airway management, Respiratory management, Circulatory management Head trauma and other serious injuries • Identifying time critical casualties, those who require immediate life-saving actions, is a central concept in the BTACC method. • Responders should immediately stop assessment to address time critical problems and should not continue to the next step of M.A.R.C.H until the concerns has been managed appropriately. • After an incident, pass on all information to Emergency Services about any injuries and care provided. Also check yourself for injuries or contamination by body fluids. • Finally, the BTACC provider should give a clear and effective handover to ambulance or medical services. • ‘ATMIST’ is a useful acronym to remember the elements of your handover. Summary: Chapter 1: The BTACC Approach

24 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Vital vocabulary M.A.R.C.H algorithm: A flowchart which guides providers through the BTACC system of assessment and trauma care. Energy transfer: The process through which kinetic or potential energy is distributed to an object or person during an impact. Kinematics: The science of how matter moves and interacts in collisions. M.A.R.C.H the BTACC acronym for casualty assessment and care, which stands for: M – Massive external haemorrhage A – Airway with cervical spine R – Respiration C – Circulation H – Head and other injuries Personal protective equipment (PPE): Specialised equipment worn or used to protect rescuers from injury and infection. Time critical: Serious and potentially life-threatening situation. Revision: 1. The main focus of the BTACC method is: A That haemorrhage is not a priority in trauma. B To manage any respiratory problems before airway. C A detailed knowledge of anatomy. D The application of simple but effective treatment measures. ANSWERS 1 : D Chapter 1: The BTACC Approach

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 25 Revision: Chapter 1: The BTACC Approach 2. Injuries which are ‘time critical’ are: A Those which occur after a shooting. B Only present in casualties who cannot be rapidly extricated. C Recognised as serious or potentially life-threatening. D Can only occur in one system, e.g. respiration or circulation. ANSWERS 2 : C 3. Kinematics studies the: A Calculation of energy at a given speed divided by size B Amount of blood lost from a trauma injury C Type of injuries found inside the body. D Mechanism or mode of injury. ANSWERS 3 : D

26 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Revision: Chapter 1: The BTACC Approach 4. Which factor has the greatest effect on increasing the kinetic energy of a moving object? A Weight B Mass C Velocity D Force ANSWERS 4 : C 5. Which of the following is NOT included in the World Health Organization’s Five Moments for Hand Hygiene? A Before contact with patient surroundings. B Before any patient contact. C After body fluid exposure risk. D After patient contact. ANSWERS 5 : A

27 Massive external haemorrhage The term massive external haemorrhage refers to a major bleed that rapidly becomes life-threatening, (e.g. a lacerated femoral artery which can bleed as much as 1 litre/min). When it occurs, it must be ‘aggressively’ addressed before any other casualty assessment takes place. The body has only a limited volume of circulating blood (five litres in an average adult), and once a large amount is lost (approximately three litres), it can be too late or simply ineffective trying to replace it with intravenous fluids or a blood transfusion. The BTACC method of care focuses on what we call ‘circulation preservation’ (aiming to preserve your own blood in your circulation rather than replace it). Massive external haemorrhage control should be a responder’s initial focus. However, responders should ideally manage such haemorrhage control within one minute and then move onto the next step in the M.A.R.C.H algorithm, to address other critical concerns, such as airway, which can also lead to fatalities if not managed rapidly. As the initial focus is massive haemorrhage control, we must identify it as early as possible by quickly scanning the scene and casualty for any obvious external bleeding. Responders should look for spurting arterial bleeds, blood soaked clothing, or pools of blood collecting on the floor (see figure 2.1). Remember that this is not just any wounds or bleeding but rapid torrential bleeding in large volumes. Chapter 2: M: Massive External Haemorrhage Control Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com

28 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The source of such major bleeding should be rapidly identified, by exposing the wounds and then managing it ‘aggressively’ to minimise further loss. If such bleeding is not immediately obvious, then rapidly move on in the M.A.R.C.H algorithm. Internal massive haemorrhages (inside the body) may not be obvious or easily identified by responders. However, they may be suspected based on the kinematics of the incident (e.g., penetrating trauma or high- speed blunt trauma) or become evident later during the further M.A.R.C.H assessment as signs of shock are identified. When internal bleeding is suspected, providers should continually reassess the casualty, looking for developing signs of shock, such as increasing heart rate or deteriorating conscious level. Internal bleeding and shock are discussed in greater detail in Chapter 5. However, in such cases, rapid and efficient rescue, with urgent transfer to hospital, may be all that we can offer, as the casualty may need surgery or complex medical care to stop the bleeding. As such we can still make a difference as BTACC responders by facilitating this process with good communication and keeping the casualty warm. Figure 2.1: Massive external haemorrhage. Signs and symptoms of massive haemorrhage Signs and symptoms of haemorrhaging include: • Obvious major blood loss • Spurting blood or rapidly pooling blood (always be aware of clothing that can become saturated or ground that may absorb any blood loss) • Anxiety or confusion (especially if getting worse) • Deteriorating conscious level or unconsciousness (Going quiet!) • Loss of radial pulse or pulse rate > 110 beats per minute • Capillary refill time > 3 seconds • Respiratory rate > 20 breaths per minute An average adult has approximately five litres of blood circulating around the entire body. Blood can be lost into the chest, abdomen, or pelvis without any external sign of bleeding. A significant amount can also be lost into the large muscles of the buttocks, thighs or lower leg. Chapter 2: M: Massive External Haemorrhage Control

29 Managing haemorrhaging For many years, the main focus in the management of blood loss involved replacement with intravenous fluids, but preservation is now deemed far better than replacement for all levels of responder. Even in the hospital we will only use blood as a life saving measure and not simply as routine replacement. The steps for controlling haemorrhaging can be remembered by the phrase I-DiD-iT, which stands for: I – Indirect pressure Di – Direct Pressure Di – More direct pressure (2nd time) T – Tourniquet application To protect the responder from contamination, gloves and appropriate PPE should always be worn whilst controlling any haemorrhaging. Applying indirect direct pressure Chapter 2: M: Massive External Haemorrhage Control Figure 2.2: Applying indirect pressure can be the first step in the I-DiD-iT technique. More skilled providers may include ‘indirect pressure’ on major arteries, but as research and our experience has revealed that this is often done badly by those unfamiliar with anatomy and valuable time and blood can be lost trying this method. As such BTACC providers should stick to DiD-iT direct pressure and tourniquet, which is highly effective. However, for those familiar with the anatomy, indirect pressure can be useful to control bleeding when you don’t have access to the bleeding point or any protective PPE for example compressing the femoral artery against the bone of the pelvis at the top of the leg, the brachial artery against the humerus in the upper arm (runs in the groove between the biceps and triceps), or the popliteal artery compressed against the bone behind the knee. (see figure 2.2). It is useful to familiarise yourself with these pulse locations when time allows, not in an emergency. Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com

30 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Applying direct pressure After PPE is donned, the first step of the DiD-iT technique involves fully exposing the bleeding point as it may actually be quite a small wound, despite all the blood we can see. (see figure 2.3). We then apply firm and focused direct pressure to the wound. This can be achieved with a gloved finger, thumb or fist or if immediately available by using a sterile ambulance dressing, with firm direct pressure applied on top. If this is life threatening bleeding, do not delegate this role to a member of the public or lay responder, unless they understand the importance of their role and the pressure required. Reassure the casualty as this pressure will be very uncomfortable, especially in an open wound or if there is an underlying broken bone. Be careful if there are obvious bone ends in the wound and use a good thickness of ambulance dressing. This is NOT the time for bandaging, unless you have to move on to another casualty or injury. Bandaging is fiddly and you will fumble with the dressing unless you do this all of the time. We will apply a firm pressure bandage later, as part of our ‘C’ assessment once we have control of the major bleeding. If using an ambulance dressing, it may be left rolled up and simply used as an absorbent roll. Common field dressings have a bandage with an absorbent dressing fixed to one end, which can be placed directly onto the wound, but do not start bandaging. If you do not have a bandage then simply use your gloved hand, fingers or thumbs to apply the direct pressure. If bleeding continues and blood soaks through the dressing, more direct pressure should be applied by applying another dressing on top of the existing one and continuing to apply direct pressure. Do not remove the first dressing, as this may reopen the wound and cause further bleeding. If the second direct pressure attempt fails to achieve haemorrhage control and the bleeding is still life-threatening, it may be necessary to apply a tourniquet. Be sure to strive for adequate control of haemorrhaging within one minute. This requires a real degree of urgency and we often describe it as aggressive haemorrhage control. If the first dressing saturates with blood within seconds, apply a second dressing or go straight for a tourniquet. Controlling Haemorrhaging Using I-DiD-iT: Chapter 2: M: Massive External Haemorrhage Control I SAW IT I EXPOSED IT I DiD iT Figure 2.3: Fully exposing the bleeding point.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 31 90% of external haemorrhaging can be controlled with well performed direct pressure, so application of a tourniquet is rarely necessary. Don proper PPE to protect yourself Fully expose bleeding point DID-IT to manage a massive haemorrhage Chapter 2: M: Massive External Haemorrhage Control 2.3.1. Apply firm, focused direct pressure to the bleeding point in the wound with thumbs or fingers. 2.3.2. Apply firm, if the wounding is larger then apply firm direct pressure using the heal of the hand or an absorbent sterile dressing. 2.3.3. If bleeding continues, firmly apply a second sterile dressing or consider a tourniquet. 2.3.4. Bandaging is part of C- Circulatory management and not normally part of Massive Hemorrhage control.

32 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com A tourniquet is a device used to occlude blood supply to a limb by compressing the artery against a bone or by compressing a muscle compartment around an artery. (see figure 2.4). The indication for using a tourniquet is when haemorrhage cannot be controlled by more basic techniques, and the failure to immediately stop this bleeding would cause a life-threatening situation. The very prolonged application of a tourniquet may cause tissue damage which in the most extreme situations (greater than 6hrs) could result in loss of a limb. However, not applying a tourniquet may mean loss of life, as the casualty could bleed to death. Military studies have demonstrated that tourniquets on for two hours have no demonstrable adverse effect. Four hours may leave some temporary numbness and only after six hours is there a risk of some long term detectable damage (see below). Tourniquets work most effectively in the middle of the limb (mid-shaft), on the long bones of the upper arm and leg. However, despite previous teaching, they are also effective in the lower leg and arm, as although the arteries run between the bones in this region, they can still be compressed by pressure around their surrounding muscle compartments. Tourniquets should be applied as far down the limb as possible or approximately 3-4 cm above the injury, (although care should be taken with traumatic and blast amputations as the injury can sometimes extend up the limb from the stump and may require higher placement of the tourniquet). • Tourniquets should not be applied over joints (e.g knee and elbow etc) as they will be far less or totally ineffective • Tourniquets are not applied over the wound or dressings, unless this is the only way to maintain effective pressure – essentially using it as a pair of hands. In some situations, it may be appropriate to go straight for a tourniquet rather than DiDiT, for example where an injury cannot be reached, direct pressure cannot be provided, or you have other issues or multiple casualties to manage. Tourniquets, must be inelastic and slip-resistant, because the tightness around the limb is the key to controlling bleeding. There are many commercial tourniquets available that are relatively simple and easy to use. Military-style tourniquets are designed to be effective and simple and some can even be applied with one hand by the patient. If a tourniquet is not available, other improvised devices such as belts, ties, or clothing may be used; however, these improvised tourniquets may be difficult to tie-off, allowing bleeding to continue. Some studies have shown that they are often completely ineffective or blood loss has been considerable whilst improvising. Many of the best commercial devices are windlass based, to create the necessary tension in the device and then to secure it without it coming loose. Good direct pressure will be better than a poor slowly applied improvised tourniquet. Applying a tourniquet to control haemorrhage Chapter 2: M: Massive External Haemorrhage Control SOFFT Two modern emergency tourniquets, the SOFFT and the CAT (research has demonstrated that the latter is a more effective device) CAT

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 33 Applying a tourniquet to control haemorrhage Chapter 2: M: Massive External Haemorrhage Control Tell the casualty what you are doing and explain that this device, which is often very uncomfortable, is an essential tool for controlling their bleeding and can save their life. (All clothing will be cut off in the hospital and the tourniquet will then be identified, but it may be cut or damaged during this process, so relaying it’s presence is crucial at handover. or marking the casualty (e.g a “T” on their forehead at the very least). Figure 2.4: Applying a tourniquet to the arm. Step 1: Slide up tourniquet or wrap around the limb. Step 2: Pull the tourniquet tight by hand. Step 3: Secure the retaining buckle. Step 4: Use the windlass mechanism to apply tension and continue until the bleeding is controlled. Step 5: Secure the windlass under the retainer. Step 6: Pull over the white retaining strap. Step 7: Record the time of application and the site of the tourniquet.

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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 35 • Massive haemorrhage control is the first step in the MARCH assessment and treatment protocol • Responders’ efforts should focus on control of any massive external bleeding and preserving circulation • Massive haemorrhage control should take no more than one minute • Gloves and other appropriate personal protective equipment should always be worn before handling the casualty • Fully expose the bleeding point • The technique used to control haemorrhaging is DiD-iT, which stands for direct pressure (D), more direct pressure (D), and tourniquet application (T) • An absorbent pad or dressing should be used to apply direct pressure to the wound. Alternatively, the thumbs or heel of a gloved hand may be used • Additional direct pressure (another layer of dressing) may be needed to control bleeding. When necessary, apply this dressing on top of the first and continue focused, direct pressure • If the second direct pressure attempt does not successfully control bleeding, a tourniquet may be necessary • Tourniquets can be applied to a limb to stop massive blood loss and potentially save lives • It is essential that tourniquets are placed above the wound on the injured limb(s) and are applied tightly to ensure any haemorrhage is controlled • Tourniquets are painful when applied to control bleeding • The tourniquet should not be taken off out of hospital unless medical assistance is present • Haemostatic impregnated dressings will control potentially lethal bleeds, but only if applied correctly with firm direct pressure. Summary: Chapter 2: M: Massive External Haemorrhage Control

36 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Circulation preservation: Principle of care focusing on minimizing blood loss rather than fluid replacement. DiD-iT: A technique used to control external bleeding; the mnemonic DiD-iT outlines the three steps of this technique: application of direct pressure, more direct pressure, and a tourniquet. Tourniquet: Device used to occlude blood supply to a limb by compressing the artery against a bone or by squeezing vessels within a muscle compartment. Massive external haemorrhage: A major life-threatening bleed on the outside of the body. Haemostatic: A chemical agent which promotes the formation of a blood clot in a wound with massive haemorrhage. Revision 1. Massive haemorrhage control focuses primarily on: A Managing external bleeding. B Recognising signs of shock. C Bandaging wounds. D Checking for pulses. ANSWERS 1 : A 2. The entire amount of time devoted to controlling haemorrhaging before moving on to airway care should be as little as possible but ideally: A One Minute or Less. B Two Minutes. C Three Minutes or Less. D As long as necessary. ANSWERS 2 : A Vital vocabulary Chapter 2: M: Massive External Haemorrhage Control

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 37 Revision 3. Which of the following is NOT a step in I-DiD-iT? A Direct pressure B Pelvic strapping C More direct pressure D Tourniquet application ANSWERS 3 : B 4.Haemostatic powders and dressings are: A Always generate heat B Will stop bleeding without direct pressure C Cannot be used for major bleeding from veins D Can be safely be used to pack neck wounds ANSWERS 4 : D 5. Tourniquets are necessary: A Only to control bleeding in the pelvis and lower limbs. B In approximately 30% of casualties with massive external haemorrhaging. C For all casualties who may be in shock D When direct pressure fails to control haemorrhaging from a limb ANSWERS 5 : D Chapter 2: M: Massive External Haemorrhage Control

38 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com M.A.R.C.H algorithm – MASSIVE HAEMORRHAGE Chapter 2: M: Massive External Haemorrhage Control B.L.S. Protocol NOT BREATHING (10secs) NO SIGNS OF LIFE (10secs) Re-assess SAFE APPROACH TIME CRITICAL HAEMORRHAGE CONTROL D.D.T Not more than 60 secs if single rescuer MASSIVE HAEMORRHAGE A H R C

39 Understanding airway concerns Airway compromise is the second major cause of deaths in pre-hospital trauma. Loss of the airway can deprive the brain and organs of vital oxygen and can lead to death in less than five minutes. The airway in its normal state is described as ‘open’ or ‘clear,’ but in some forms of trauma or reduced consciousness, it can become partially or totally obstructed. In a partially obstructed airway, the flow of air to the lungs is restricted, but air still moves in and out through the obstruction, resulting in noisy breathing or a harsh, high pitched noise known as stridor. The casualty may also cough and gag (which at least indicates that some air is passing around the obstruction) and they may even be able to speak but with difficulty. Coughing and speech are impossible without air moving in and out the lungs. Chapter 3: A: Airway Management Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com

40 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com In a totally obstructed airway, no sounds of breathing can be heard, and no air is able to move in or out, even when there may be good respiratory effort. (Do not be fooled by the appearance of breathing, as air may not actually be moving in and out unless felt at the lips). Speech is impossible with an obstructed airway and the casualty may have a silent chest or no cough. If the airway is completely obstructed, the patient will lose consciousness in three to four minutes. Both types of obstructions are common among trauma victims, especially in unconscious casualties who lose the normal tone and reflexes that protect the airway. When this happens, the tongue may fall backwards and block the airway. (see figure 3.1). The other common types of airway compromise are due to foreign material or swelling of the mouth, tongue or lining of the airway as can be seen in burns above the shoulders, or smoke inhalation. Despite the “Urban Myth” the tongue, cannot be ‘swallowed,’ but it simply drops backwards with gravity, when the normal muscle tone in the throat is lost. The tongue then fills the space at the back of the throat, as a large lump of muscle as illustrated in (figure 3.1). Figure 3.1: The tongue can drop backwards in the throat and is the commonest cause of airway obstruction. LUNGS NOSE Understanding airway concerns Chapter 3: A: Airway Management All elements of casualty assessment must be reassessed regularly, especially the airway, as conditions may change rapidly. For casualties who appear stable, you should reassess approximately every five minutes. If any change or deterioration is noted, reassessment should be more frequent, as often as once a minute or even more frequently if change is rapid. In casualties with severe, life threatening injuries, reassessment should be continuous. Any patient who is not breathing requires immediate life support (see Chapter 7). To assess a casualty’s airway, we use the look, listen, and feel approach. Assessing airway – Ongoing

41 Look Look for any obvious signs of facial or airway trauma (e.g. bruising, bleeding, swelling, or wounds). Additional warning signs of airway obstruction include: • Facial burns (e.g. redness, blistering, peeling skin) • Loss of facial hair • Swelling of the lips or mouth or tongue • Soot in the airway (smoke inhalation) • Blood in the mouth • Foreign bodies in the mouth (e.g. broken teeth, scene debris). The presence of any of these signs should raise serious concerns about potential airway problems which will require regular reassessment and close monitoring. When an oxygen mask is used, the mask will usually fog every time the casualty breathes out if they have an adequate open airway. This simple visual method of airway assessment allows the responder to also count the respiratory rate over a minute and may be especially useful if access to the casualty is limited and some reassurance is required that they are breathing effectively. We must also look at the chest movement: If air cannot get in and out, the movements will often be exaggerated or appear very abnormal, looking as if being suffocated, with a hand over the mouth. This breathing is often described a ‘looking the wrong way around’ or ‘paradoxical’ with lots of abdominal movement and minimal chest expansion. This is clearly a seriously alarming sign and needs urgent intervention, as despite the effort, no air is entering the lungs. Listen Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com If no breath sounds are heard, and the casualty shows no signs of respiratory effort, this indicates apnoea (a respiratory arrest / not breathing) and is a time critical injury. If there are no signs of life, (including, no obvious normal breathing) this is a cardiac arrest requiring immediate CPR. In a trauma case with multiple injuries, the casualty’s airway must be managed effectively before moving onto further steps in the algorithm. If not addressed rapidly, the brain will be starved of oxygen and will result in irreparable damage which can prove fatal within minutes. The ability to talk normally immediately tells you that the airway is clear. This simple assessment can even be used when assessing the in accessible casualty Chapter 3: A: Airway Management As well as looking at the breathing, one of the best ways to identify a compromised airway is to listen to the casualty’s breath sounds from the mouth (see figure 3.2). Normal breathing and respiratory effort, is basically soft or silent and indicates a clear airway. However, as discussed previously, if an airway is partially obstructed, the casualty’s breathing may be noisy with signs of laboured breathing. A totally obstructed airway often results in no breath sounds, but there may still be a great deal of respiratory effort, trying to get air into the lungs, at least until they become exhausted or have a respiratory or cardiac arrest.

42 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Signs and symptoms of airway concerns Signs and symptoms of airway concerns include: • Difficult or laboured breathing • Inability to speak or vocalise • Hoarse voice or stridor (noisy breathing) • Swelling of the lips, tongue, or mouth • Burns above the level of the shoulders • Cuts or wounds in the mouth with or without bleeding • Foreign material in the mouth. After looking and listening, we feel for breathing on your cheek as you listen for breath sounds and eyeball the chest for rise and fall. Alternatively, you may, pull back your glove and hold the palm or back of your hand over the casualty’s nose and mouth. When using supplemental oxygen (see “Using Supplemental Oxygen” below), you can confirm that breathing is occurring by checking for fogging of the oxygen mask, as described above. Figure 3.2 : Listen and feel for breathing and to confirm and open airway. Feel Chapter 3: A: Airway Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 43 An obstructed airway must be rapidly managed. Secretions and blood should be removed with: • Careful suction under direct vision • Postural drainage (positioning the patient to allow the material to run out of the mouth). For a partially obstructed airway, you should encourage the casualty to cough. Coughing is the most effective way of expelling a foreign object. If the casualty is unable to expel the object by coughing (if, for example, a bone is stuck in the throat), but the casualty is still able to breathe easily, arrange for urgent transport to hospital and continually monitor the casualty carefully as a partial obstruction may become a total or complete obstruction, at any time until the foreign body is removed. If the airway is completely obstructed by the foreign body and they are unable to breathe, follow the techniques for managing choking. Positioning When the casualty does not require active support of the airway or breathing (i.e., no airways, airway manoeuvres or bag-valve mask ventilation necessary) but they have a reduced conscious level, then the recovery position can be employed to maintain the airway and preventing the tongue dropping backwards. (See figure 3-3). Many fully conscious casualties with airway problems will much prefer to remain in a seated position, as they will find breathing easier. They can support themselves and use the muscles of the neck and shoulders to help them to breathe (see figure 3.4). However, those with facial trauma and bleeding may be better in a prone position, lying on their front and supported by their elbows, which allows blood and saliva etc., to drain out safely. If they are unconscious, but with blood and secretions, try and suck them out in the recovery position or if necessary flat on their backs on the floor, where we can use suction under direct vision and then place back into recovery position. In hazardous or dangerous situations, where it may be difficult to provide more detailed care, the simple act of rolling a casualty into the prone facedown or semi-prone (partially facedown) position until he or she can be effectively extricated may a be life-saving measure, allowing mouth contents to drain out and to encourage the tongue to fall forward, opening the airway. This is only a stop gap solution until the situation is safe, but it may be life-saving in some cases. If a casualty remains unconscious in the recovery position for more than 30 minutes, consider turning him or her onto the opposite side to relieve the pressure on the lower arm and body. Figure 3.3: The recovery position. Figure 3.4: Casualty receiving high flow oxygen therapy, and using her arms and neck muscles to help with her breathing. Managing airway concerns Chapter 3: A: Airway Management

44 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Jaw-thrust manoeuvre If you suspect that the casualty has the potential for a cervical spine injury, open his or her airway using the jaw-thrust manoeuvre. (If spinal injury is not suspected, then you may use the head tilt–chin lift manoeuvre presented in the following section). To perform the jaw-thrust manoeuvre, use the following steps (see figure 3.5) 1. With the casualty in a supine position, kneel at the top of the head and gently take hold of either side of the head 2. Look at the casualty and try to talk to them and explain what you are doing if they are conscious 3. Place the muscle area at the base of your thumbs on their cheek bones. Hook the tips of your fingers under and around the bony angle of the casualty’s jaw, in the indent below each ear 4. While holding the casualty’s head still, move the jaw upward and if possible open the mouth with your thumb tips. (usually their Jaw will protrude a few millimetres). There may not be a lot of movement, but even a few millimetres will improve the situation considerably. Figure 3.5: Jaw thrust. The jaw-thrust manoeuvre should open the airway without extending the casualty’s neck significantly. When positioning the casualty, always consider the possibility of spinal injury and handle the casualty carefully. If more than one responder is present, then cervical spine management (outlined in Chapter 6) should be performed before repositioning the patient. With only one responder, assessment of spinal injury and immobilisation should be delayed until the “H” step of the algorithm. (as you cannot do it on your own whilst also managing bleeding and other injuries). Either way, the airway control must take priority over cervical spine. In an unresponsive, unconscious casualty, the most common cause of airway obstruction is the tongue blocking the airway. Responders should manually manipulate the casualty’s airway to keep it open. For example, if we push the jaw forwards with a jaw thrust, as the tongue is attached to the inside of the jaw in the mouth, then this will also move forward and ‘open’ the airway. One of the following techniques may be used to achieve this: • The jaw-thrust manoeuvre • The head tilt-chin-lift manoeuvre • Airway adjunct devices, e.g. Nasal airway. The jaw-thrust manoeuvre is generally the preferred method used to clear the airway, because it involves minimal neck movement and protects the cervical spine by avoiding excessive neck movement. If this technique is insufficient, then another airway management technique may prove effective e.g. the head tilt– chin lift manoeuvre or insertion of adjunct devices such as oral or nasal airways. All BTACC providers will be skilled in providing supplemental oxygen, which is an important technique for managing casualties with airway concerns. Managing airway concerns Chapter 3: A: Airway Management

45 The head tilt-chin lift manoeuvre is a very simple, yet effective way of opening a casualty’s airway and is used when there is no potential for a cervical spine injury or if the jaw thrust alone has not worked. To perform the head tilt-chin lift manoeuvre (see figure 3.6). 1. With the casualty in a supine position, kneel beside the head 2. Place your hand under the head and assist a backwards tilt of the head from a hand under the jaw 3. At the same time, place the fingertips of your other hand under the bony part of the chin, taking care to avoid compressing the soft tissue under the chin as this may block the airway 4. Lift the chin upwards, bringing the entire lower jaw with it, and helping to tilt the head back 5. Air should be then heard or felt moving in and out of the mouth, if not, and the airway is open, ventilation will also be required. Figure 3.6: Opening the airway with a chin life manoeuvre is usually very effective, but it does extend the neck considerably and therefore is avoided in potential neck injuries unless there is no other option. Airway adjuncts If these manoeuvres are unsuccessful, it may be necessary to use an airway adjunct device to keep the casualty’s airway open. There are two main types of mechanical devices: nasal (NP) and oral (OP) airways. A nasal airway is a soft plastic tube which is inserted through the nostril into the back of the throat, thereby allowing passage of air from the nose to the lower airway (see figure 3.7). It is often better tolerated than an oral airway in responsive conscious casualties, who still have an intact gag reflex or who are biting or have clenched teeth. Nasal airways do not go down the throat quite as far as oral airways, so they may not be quite as good at opening the airway, but they can be inserted even when fully conscious and do not cause as much gagging. Nasal airways can be used in both nostrils simultaneously and can also be used with an oral airway too if tolerated and necessary. Nasal airways should only be used gently to avoid trauma to the inside of the nose and with caution on a casualty with suspected skull fracture (if blood or fluid is coming out of nose or ears). Head tilt–chin lift manoeuvre Chapter 3: A: Airway Management Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com

46 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Figure 3.7 Inserting a Nasal Airway Step 1: Size and then lubricate the airway with gel. Step 2: Introduce airway into the best nostril, which appears clear and large enough for the airway. (Commonly the right one because of the angle on the airway tip). Step 4: Nasal airway fully inserted. The airway stays in place and the safety cuff avoids the need for safety pins to stop the airway slipping further into the nose. If the casualty coughs or gags excessively, pull the airway out slightly and also check the mouth for any bleeding from the back of the nose. If there is bleeding, suck it out of the mouth, but leave the airway in place if it is working well. Step 3: Gently advance the airway along the floor of the nose. This should not require anything more than finger and thumb pressure. The lining of the nose is delicate and has some thin bones called turbinates which can produce a slight crunching feeling. If the airway passes with minimal pressure then proceed. DO NOT FORCE THE AIRWAY – Just steady gentle pressure. To insert a nasal airway, use the following steps: 1. Ensure you have selected the appropriate size; measure the distance from the tip of the nose to the bottom attachment of the ear. The diameter of the tube is often compared to that of the casualty’s little finger in training manuals, but simply looking at the nostril is probably a far more reliable indicator. If a nostril is obviously obstructed, choose the other side. 2. Lubricate the airway with a water-soluble gel and place the airway in the largest nostril. The cut bevel on the nasal airway lends itself to insertion in the right nostril, but it can go into either. The curvature of the device will follow the curve of the floor of the nose, and on the right with the bevel facing the septum. 3. Place the tip of the bevel to the septum and insert it gently along the nasal floor, parallel to the mouth. (Remember that the bevel is usually cut for the right nostril but can be used in either). Do not insert the airway upwards towards the brain, but rather towards the back of the head. 4. When completely inserted, the safety flange should rest against the nostril to stop it slipping further into the nose and down the throat. The older designs used a safety pin for this purpose, but this is a sharp which is best avoided with the newer designs. Do not force the airway, just use finger and thumb and gentle pressure. If you feel any resistance, withdraw it a few centimetres and try again. If it will still not advance, remove the airway and try to insert it in the other nostril. Airway adjuncts Chapter 3: A: Airway Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 47 Figure 3.8 Sizing and inserting an Oral Airway conventionally or inverted Step 1: Size the airway from the corner of the mouth to the angle of the jaw or the tragus of the ear. Step 2: Insert the airway over the chin and into the mouth, ensuring that it passes OVER the tongue and does not push it backwards. Step 4: Oral airway in place and then feeling for breathing with the wrist. This airway must now be constantly monitored as it can pop-out or fall out if unattended. If the patients gags or coughs repeatedly, they are not tolerating the airway and it should be removed. Consider a nasal airway if necessary. Step 3: As the airway reaches the back of the mouth it may just drop into place, but sometimes a gentle jaw thrust is required. Note: The plastic rim stays outside of the mouth and lips. An oral airway is a hard, curved plastic device that extends from the lips to just over the back of the tongue. It is designed to hold the tongue away from the back of the throat, keeping the airway open and enabling good passage of air into the lower airway. It should only be used on a casualty who is unresponsive and does not have a gag reflex and relaxed jaw (see figure 3.8). If inserted in anyone conscious with an intact gag then they are likely to cough or vomit. Unconscious and relaxed lower jaw (moves up and down without force) To insert an oral airway, use the following steps: 1. To select the proper size, measure the horizontal distance from the angle of the jaw (corner of the jaw just below the ear) to the centre of the casualty’s front teeth or the corner of the mouth to the lower attachment of the ear. 2. Open the casualty’s mouth with the fingers of one hand. (Avoid putting your fingers in the mouth, as casualties can bite)! Do not force the mouth open. 3. Suck out any noticeable debris from the mouth that can be seen to avoid pushing this in with the airway. 4. Insert the airway OVER THE TONGUE from below, the natural curve of the device will bring it in over the chin. 5. Alternatively, hold the airway upside down and insert the airway with the tip facing the roof of the mouth. Mid mouth rotate the airway 180°, flipping it over the tongue. (This does require good mouth opening) (see figure 3.9). 6. Once over the tongue and in the back of the mouth, then a simple jaw thrust will open the airway at the back of the throat by moving the tongue forward, allowing the oral airway to drop a little further down into the mouth (sometimes needs a gentle push) to sit in place and create the open airway. 7. When inserted properly, the airway will rest in the mouth, with the curvature of the airway following the contour of the tongue. The flange should rest against the lips outside the mouth – if it protrudes then it is either not in or too big. Airway adjuncts Chapter 3: A: Airway Management

48 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Figure 3.9: Traditional inverted method of inserting oral airways. Step 1: Insert the correct size airway upside down along the rough of the mouth over the tongue. Step 2: At the back of the mouth, rotate the airway and drop into place behind the tongue. This method is not preferred by BTACC as although it avoids pushing the tongue backwards it requires reasonable mouth opening (~2cm) and can be awkward. Choking treatment Choking occurs when a foreign body lodges and partially, or even worse, totally obstructs the airway, resulting in an inability to breathe effectively despite good respiratory effort. The first step in managing a conscious person who may be choking, with a blocked airway, is to simply ask, “Are you choking?” or something similar. If the casualty can answer your question, at least some air is moving in and out allowing them to speak and the airway would seem to be only partially blocked. Encourage them to lean forward and cough in an attempt to clear the obstruction. Until the object has gone, there is still concern as it could progress to complete obstruction at any time. This still warrants very urgent action as this is a time critical situation. If the patient is unable to speak or cough, the airway is probably totally blocked. This is a life-threatening emergency and needs immediate action. Airway adjuncts Chapter 3: A: Airway Management