BTACC

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 247 The most severe allergic reaction is anaphylaxis and produces anaphylactic shock, which can effectively result in cardiac arrest. The features are much the same as milder forms, but much more exaggerated. ALLERGIC SHOCK – ANAPHYLAXIS Symptoms develop very rapidly and the airway can quickly swell plus there will be signs of shock as a result of the sudden opening up of the circulation with all of the histamine release. SWELLING OF MOUTH, TONGUE OR LIPS Anyone with any kind of lip, tongue or mouth swelling, difficulty breathing, wheeze or collapse is an immediate 999 emergency. IF THEY HAVE AN EPI-PEN OR ANA-PEN - ADRENALINE Many patients with severe allergies will carry Epi-pens or an Ana-pen, which are self-administration devices for adrenaline and are life-saving drugs required for such conditions. If a staff member has one, you, as a first aider, should know about this. If you are asked to see a member of the public who is unwell they may ask you to look for it in their bag. They may also be wearing a med-alert bracelet to describe their allergy. Skin vessels wide open Short of blood volume Heart pumping hard HOT FLUSHED DROWSY FAINT UNCONSCIOUS Severe or Anaphylaxis Chapter 11: First Aid & Medical Emergencies – Skin & Temperature - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com ABNORMAL DRUG REACTION Drug reactions can be similar to allergic reactions with florid and itchy rashes or severe shock or they can be bizarre and atypical, as seen with many of the illegal recreational drugs. URGENT MEDICAL ATTENTION - HOSPITAL These can present with a casualty who is often fit and well, but presents with sweating, burning hot, thirsty and with palpitations or a racing heart rate. They may still be having psychological manifestations with euphoria, depression agitation or delirium. Pupils are often large or can be pinpoint small and they may rapidly fall unconscious. These all need urgent medical attention and are clearly a 999 emergency. RISK TO LIFE Summary NON-BLANCHING RASH VERY HOT & DROWSY BURNS ABOVE THE NECK DRUG REACTION: MILD TO SEVERE IN SUMMARY The skin demonstrates many conditions which affect the body and are a good indicator of ill-health. Certain signs which suggests concern and need immediate medical help, include: non-blanching rash, overheating, drowsiness, burns to airway or above the neck, allergic or drug reactions with mild to severe symptoms developing. Allergic reactions ABNORMAL REACTIONS Chapter 11: First Aid & Medical Emergencies – Skin & Temperature - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 249 LIGATURE REMOVAL & HANGING EXCITATION DELIRIUM SYNDROME (EDS) INFESTATION Special Circumstances Attempted self-harm or hanging is something that officers may face both in the community and also in custody if correct procedures are not followed. The casualty will usually have some kind of improvised ligature around the neck which can be made from anything including: • Rope, string, washing line • Wire or cable • Clothing, laces and belts • Others including: seatbelts, curtain ties, blind-cords etc. The injuries will usually consist of: • Asphyxiation from lack of oxygen and compression of the blood supply in neck • Spinal injury in the neck from the drop • Bleeding of lacerations from the ligature or noose • Other injuries such as self-harm or overdose In judicial hangings, death is facilitated with a ‘long drop’ and a noose knot to the side, under the jaw. This typically results in a rapid loss of consciousness as a result of catastrophic neck injury, associated massive drop in blood pressure and a faint, followed by slower actual brain death over 5-20 minutes. If there is little, if any ‘drop’ and especially if the bodyweight remains supported, asphyxiation is more likely and death may not be as rapid. The priority is to support the individuals weight, calling for help to get them down as quickly as possible and then to release the ligature before commencing life support if required. RESPONSE TO FINDING SOMEONE WITH A LIGATURE Call for assistance immediately and if required, request for an ambulance to attend. Support the person’s body weight (if safe to do so) as soon as possible, to release the tension on the ligature. A person does not need to be suspended or clear of the floor to be using a ligature. Keep the body weight supported and/or the tension off the ligature until the ligature has been cut. Even simply supporting the body may allow some blood to flow to the brain, while you await help and assistance. Much is talked about removal of the ligature and there are special devices on the market for this. However, as so many things can be used for self-harm, no single device will be enough. The priority is to loosen and ideally remove the ligature as quickly as possible. If specialist devices are not available, anything should be used that will cut through the ligature, even if there is a risk of cutting the underlying skin. This is a life-saving measure and small cuts to the skin are a lesser concern. Where the ligature is very tight and cutting into the skin, the softer area on each side of the front of neck may be the easiest area to approach. In situations where the person resists attempt to remove the ligature, it may be necessary for an officer to use appropriate physical intervention. It is expected that the officer will employ techniques to help ensure the safe removal of the ligature. In this situation they still have signs of life. Ligature removal & hanging Chapter 11: First Aid & Medical Emergencies – Special Circumstances

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Ligature removal & hanging If the body is limp or there are no signs of life, commence life support as soon as physically possible, on a firm surface or the floor, supporting the neck as best you can, but without delay, during the lowering to the floor. Manage this like all other cardiac arrests, but with gentle handling/ minimal movement of the neck during airway manoeuvres. If the casualty is struggling to breathe because of neck injury or blood in the mouth or airway, sit them up if conscious or place in the recovery position and monitor if unconscious. For all Officers involved in suicide or other emotionally traumatic incidents always consider their welfare in the ensuing period as per service protocol. Other related conditions and terms: Excitation Behavioural disorder, Acute Confusional State, Acute Behavioural Disorder. The typical situation is a young male who may have a history or drug, alcohol or mental health problems who is semi-naked and being incredibly violent and aggressive. There may be a history of substance abuse, changed medication or recent illness. Delerium is a state of confusion or agitation with a relatively short onset and duration of hours or days. This can be produced by a number of things including: • Recreational drugs • Mental Health medication • Withdrawal states e.g. alcohol, drugs • Lack of oxygen • Abnormal reaction to drugs • Serious infection or septicaemia • Chronic fatigue. Delirium can also produce a sluggish and drowsy state. These are typically easier to manage in terms of patient handling, but still require urgent medical review. In its most extreme state, Excitation Delirium Syndrome (EDS) accounts for a number of deaths in the UK each year and this risk is increased with Police custody or forcible restraint. In EDS they may display: • Agitated or aggressive • Totally uncontrollable behaviour • Removing clothing (as they are very hot) • Tireless • Antisocial behaviour • Ranting or incoherent rambling • Disorganised thoughts • Delusions, hallucinations and paranoia • Disorientation • Unusual attraction to glass or mirrors. They often demonstrate incredible ‘superhuman’ strength or fight and even relatively small cases may overwhelm several officers in terms of restraint. Excitation Delirium Syndrome (EDS) Chapter 11: First Aid & Medical Emergencies – Special Circumstances

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 251 Tasers are frequently discussed and implicated in the deaths of cases of EDS. However, evidence is lacking to support this at present and Tasers may actually be relatively ineffective for more than a few seconds as the individuals are unlikely to feel pain. As a result, once the muscle spasm has passed they may simply continue fighting. This could lead to longer sustained use of the Taser, against recommendations with potentially more risk of harm, especially in casualties who feel burning hot or sweating, as they are having an even more extreme type of reaction. Deaths result from multiple factors, the primary one being EDS. However, an accumulation of additional factors gradually increases that risk e.g. duration, restraint, Taser positioning. Prone restraint, hog-tie or sitting on the individual will not specifically cause death, unless they prevent breathing (e.g. sitting on chest or abdomen, which they should never do) but will increase overall risk and may accelerate the process. The safe plan of action is based on early recognition and summoning medical assistance, whilst using minimal restraint to keep everyone safe. • Safety of officers and the public is paramount • Keep the casualty as calm as possible • Recognise potential EDS early and especially not skin temperature if possible • This is a Medical Emergency • Use as little forcible restraint as possible especially If very hot to touch • Monitor breathing constantly during any forcible restraint • Call for ambulance or medical assistance early with drug therapy • Use Taser early and within protocols and guidance but try to avoid in these cases if possible, especially if burning hot • Avoid seclusion rooms, monitor continuously. Excitation Delirium Syndrome (EDS) Chapter 11: First Aid & Medical Emergencies – Special Circumstances RISK TO LIFE BURPS – Excitation Delirium B NO MAJOR BLEEDING U VERY AGITATED R FAST BREATHING P RESISTANT TO PAIN S FLUSHED, BURNING HOT, PROFUSE SWEATING

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com A number of parasites can infest the body. Many are related to poor hygiene and living in poor conditions, whilst others can occur even in clean conditions, e.g. head lice. Most of them will require decontamination by removing clothing and bedding, washing down and then treating with an appropriate shampoo or agent. It is essential to clean down the infected area, change the linen and bedding, vacuum the area floors and furniture and disinfect and personal product such as combs or brushes. MAGGOTS Maggots are the larvae of the common fly. They hatch within a day of a fly laying the eggs wherever there is a reliable food supply. This can include open wounds on humans. They will eat the rotten and decaying tissue and have been used medically to ‘clean up’ ulcers and wounds that will not heal. However, these are sterile maggots with no infection, whereas normal maggots from fly eggs in open wounds run the risk of creating localised skin infections and further maggots or larvae under the skin. In most circumstances, simply removing clothing and washing will clear the infestation unless they are colonising a wound, in which case they will need hospital treatment. LICE INFESTATION Lice are tiny, wingless parasitic insects that feed on the blood. It is a fairly common occurrence, especially among young schoolchildren. Hundreds of millions of cases occur all over the world. They are contagious by way of direct contact or sharing belongings. Although contagious, they do not usually spread diseases among their hosts. These lice usually cause no serious problem amongst their hosts, but still need to be treated nonetheless. TYPES OF LICE INFESTATION IN THE BODY Several types of lice may exist in the body. They live on the surface of their hosts and need these hosts to be able to reproduce. They are highly contagious insects. There are various ways of acquiring lice infestation in the body. Lice are usually classified by their location in the body: Infestation Chapter 11: First Aid & Medical Emergencies – Special Circumstances

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 253 HEAD LICE • Most common • Develop in the scalp • Easiest seen at the nape of the neck and over the ears. Head lice can be spread through sharing hairbrushes, combs, pillows, headphones or hats. They are nothing to do with personal hygiene and although unpleasant they are usually asymptomatic. BODY LICE • Slightly larger than head louse • Thrive in clothing and bedding • Move on to the skin to feed • Usually occur in individuals who do not bathe regularly or change clothing everyday. Poor hygiene with irregular changing of clothes or beddings. They are frequently associated with poverty and overcrowding in unhealthy conditions PUBIC LICE • Commonly called crabs • Found in the skin and hair of the pubic area • Rarely, they occur on coarse body hair, e.g. eyebrows, eyelashes, chest hair • For adults, intimate and/ or sexual contact with someone who has crabs • For children, nonsexual transmission from parents. SYMPTOMS OF LICE INFESTATION An adult-sized louse is the same size of sesame seed or slightly larger. However, the common symptoms of lice infestation include: • Intense itching • Tickling sensation from movement in the hair or body • Small, red bumps on the scalp, neck and shoulders • Presence of lice eggs (nits), which look like small pussy willow buds and cannot be brushed off the hair easily. TREATMENT OF LICE INFESTATION Although lice may have already been killed and washed away, itching may persist due to an allergic reaction from their bites. There are different ways to treat the three types of lice infestation in the body. The steps to be mentioned below do not substitute for medical advice or professional first aid training. • Head lice • It is easier to look for lice when the hair is wet • Use a fine-toothed comb, magnifying glass, clear tape and strong light to search for lice. This should be done every two to three days over a two-week period • If lice are found, use anti-lice shampoo. Follow the directions given my manufacturer o Check all household members for louse and wash all bed linens and clothing that come into contact with the infected person. Use warm water. Vacuum floors and furniture • Disinfect combs and brushes in hot water • Body lice o Thoroughly wash the body with soap and water. o Check all household members for louse. o Wash all bed linens and clothing that come into contact with the infected person. Use warm water. Vacuum floors and furniture. o If there is itching, use over-the-counter antihistamines. o Pubic lice • Treat twice using anti-lice agents and again after a week • Remove nits • Wash all bed linens and clothing that come into contact with the infected person. Use warm water. Vacuum floors and furniture. Infestation Chapter 11: First Aid & Medical Emergencies – Special Circumstances

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com FLEAS Even though fleas prefer to feed on the blood of pets rather than humans, these wingless parasites will not hesitate to bite humans within their jumping distance. Most victims of flea bites will suffer from an itchy annoyance on the affected area, but bites on humans can eventually progress to serious health issues. An effective tactic for managing flea bites involves the elimination of the source of infestation as well as implementing preventive methods in order to ensure that the house and pets are free from fleas. Fleas are small, brown oval-shaped insects that feed on the blood of various animals including dogs, cats, birds and wild animals. Fleas do not have wings but they can utilise their strong hind legs to jump significant distances in order to bite humans. Typical locations of bites in humans are the feet and legs. Flea bites tend to vary from one individual to another as some individuals, they do not experience any reaction while others have evident swelling, redness and severe itchiness in a matter of hours after bitten. Flea bites can even bleed or develop into small blisters or a wound, especially if scratched. The swelling usually occurs on the area surrounding the flea bite, but a rash can spread. The affected area can also develop a red coloured ring that turns white if pressed. Aside from the discomfort, flea bites can also progress to serious issues such as an allergic reaction to the substances that are present in the saliva of the flea or a severe infection. TREATMENT OPTIONS FOR FLEA BITES Avoid scratching bites and affected areas, since the skin can break and allow bacteria to enter, causing an infection to develop. Wash the site of the bite using an antiseptic soap to reduce the risk of infection and place an ice pack on the area to minimise the itchiness and swelling. The itchiness can also be reduced by using an over-the-counter hydrocortisone or calamine lotion. However, where there are many flea bites, it is best to consult a doctor so that antihistamines can be prescribed. INFECTED FLEA BITES Bacteria can enter the skin via flea bites which can lead to a serious skin infection such as cellulitis, where pus can drain from the wounds. Common symptoms include swelling, pain, warm skin, redness and even generalised fever. Any of these symptoms, especially if getting worse, require review by a doctor. PREVENTING FLEA BITES Pets must be treated as well as soft furnishings and carpets using the appropriate insecticide. Carpets should be vacuumed on a regular basis. Eliminating a flea infestation involves several attempts but if the infestation persists, it is best to contact a professional pest control service. Infestation Chapter 11: First Aid & Medical Emergencies – Special Circumstances

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 255 GLOSSARY angina : Chest pain resulting from decreased blood supply to the heart apnoea : Condition where the casualty is not breathing. asthma : An acute clamping down or spasm of the smaller air passages. automated external defibrillator (AED) : Portable battery-powered device that recognises ventricular fibrillation and advises when a shock is indicated. The AED delivers an electric shock to a casualty in ventricular fibrillation AVPU scale : A scale to measure a casualty’s level of consciousness. The letters stand for alert, verbal, pain, and unresponsive. bag-valve mask : A device used to deliver supplemental oxygen to a casualty 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. basic life support (BLS) : Combination of CPR and AED to treat a casualty who has no signs of life (i.e. breathing, movement, or pulse). BTACC algorithm : A flowchart which guides providers through the BTACC system of assessment and trauma care. capillary refill time : The ability of the circulatory system to restore blood to the capillary blood vessels after it has been squeezed out by the rescuer cardiac arrest : Ceasing of breathing and a heartbeat. cardiopulmonary resuscitation (CPR) : The artificial circulation of the blood and movement of air into and out of the lungs. cervical collar : A neck support that partially stabilises the neck following injury. chest compressions : Manual chest-pressing method that mimics the squeezing and relaxation cycles a normal heart goes through; administered to a person in cardiac arrest. chest seal : Specialised circular, adhesive dressing used to cover open or sucking chest wounds circulation preservation : Principle of care focusing on minimizing blood loss rather than fluid replacement crush injury : A form of blunt trauma in which the body is compressed to an extent and duration that causes damage to the body’s tissues. diabetes : A disease in which the body is unable to use sugar normally because of a deficiency or total lack of insulin. 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. drowning : The process of experiencing respiratory impairment from submersion or immersion in a liquid. energy transfer : The process through which kinetic or potential energy is distributed to an object or person during an impact. entrapment : A situation in which a casualty cannot be immediately released or evacuated from the scene of injury. full-thickness burns : Burns that extend through the skin and into or beyond the underlying tissues; the most series class of burn. 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. heart attack : Interruption in the blood supply to the heart. hypoglycaemia : Low blood sugar level hypoxaemia : Low levels of oxygen in the blood. jaw-thrust manoeuvre : Opening the airway by bringing the jaw forward without extending the neck. Chapter 11: First Aid & Medical Emergencies – Glossary

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com GLOSSARY kinematics : The science of how matter moves and interacts in collisions. logrolling : A technique used to move a patient onto a longboard. MARCH : The BTACC acronym for casualty assessment and care, which stands for massive external haemorrhage control, airway management, respiratory management, circulatory management, and head trauma and other serious injuries. massive external haemorrhage : A major life-threatening bleed on the outside of the body. nasal airway : An airway adjunct that is inserted into the nostril of a casualty 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. paediatric face mask : A mask fitted over the child’s nose and mouth to assist in delivering supplemental oxygen. partial-thickness burns : Burns in which the outer layers of skin are burned; these burns are characterised by blister formation personal protective equipment (PPE) : Specialised equipment worn or used to protect rescuers from injury and infection. pulse oximeter : A machine that consists of a monitor and a sensor probe that measure the oxygen saturation in the capillary beds. pulse : The wave of pressure created by the heart as it contracts and forces blood into the major arteries and around the body. recovery position : A side-lying position that helps an unconscious patient maintain an open airway. scoop-and-run : Term for rapid evacuation to hospital, performed as quickly as possible. seizures : Episodes of uncontrolled electrical impulses in the brain that produce shaking movements shock : Failure of the cardiovascular system in which body is not getting the essential oxygen and substrates it needs to survive splinting : A means of immobilising an injured part by using a rigid or soft support. stridor : Harsh, high pitched noise that indicates airway obstruction. stroke :Interruption in the blood supply to the brain superficial burns : Burns in which only the superficial part of the skin has been injured; for example, a sunburn. suspension trauma : An injury in which a casualty is suspended in a harness motionless for long period of time. three-sided dressing : Type of square dressing used to cover open or sucking chest wounds that is taped to the casualty on only three- sides, with the fourth side left open to serve as a one-way air valve time critical : Serious and potentially life-threatening situation. tourniquet : Device used to occlude blood supply to a limb by compressing the artery against a bone. ventilations : Artificial means of breathing for a casualty. ventricular fibrillation (VF) : An uncoordinated muscular quivering of the heart; the most common abnormal rhythm causing cardiac arrest. Chapter 11: First Aid & Medical Emergencies – Special Circumstances

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 257 Chapter 9: Medical Devices B TAC C BA SIC TRAUMA & CASUALTY CA R E Basic medical equipment devices can be used to assess a casualty when ill or injured These devices are an aid to assessment in conjunction with other factors. We must look at the casualty as well as the device or monitor, to help us assess and develop an holistic approach to how a casualty may present. Having an understanding, familiarity and confidence with these devices will greatly assist our intentions, but we must also recognise any limitations and operate within our scope of practice safely.

258 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com We know that blood is vital to life. We know that it is a transportation system to deliver oxygen to the cells and tissues that need it. We term this perfusion. It is of value then to understand some fundamentals about blood pressure (BP), how we measure it and what it signifies as a diagnostic indicator in injury or illness. It is worth bearing in mind though, that BP can be inaccurate when using monitoring equipment. It’s a rule in measure as opposed to a rule out. This will be discussed later on in this section. When your heart beats, it pumps blood round through the cardiovascular system to supply the oxygen the cells need. As the blood moves, it pushes against the sides of the blood vessels. The strength of this pushing is blood pressure. Blood pressure is important as it is needed to drive the flow of blood, to the vital organs that need that oxygen rich supply. Blood pressure is measured in ‘millimetres of mercury’ (mmHg) and is written as two numbers. The first (or top) number is your systolic blood pressure. It is the highest level your blood pressure reaches when your heart beats. The second (or bottom) number is your diastolic blood pressure. (see figure 21.1). It is the lowest level your blood pressure reaches as your heart relaxes between beats. Any medical manual in the world will state an ideal blood pressure will be 120 over 80 – 120/80mmHg. If we know what is normal we can identify anything then that is abnormal or an indicator of concern. High blood pressure (hypertension) is identified when blood pressure readings are consistently 140 over 90, or higher, over several weeks. High blood pressure usually has no signs or symptoms, so the only way to identify it is to have blood pressure measured. A single high reading does not necessarily mean a person may have high blood pressure. It is often diagnosed by having it measured on several occasions over a period, maybe weeks. Hypertension if too high, can put extra strain on blood vessels, heart and other organs. Often people may have unrecognised hypertension as often its symptomless, and over time maybe years, can cause the heart to tire and lead to heart failure, strokes, heart attacks, peripheral arterial disease, aneurysms and many other co morbidities. Often hypertension and high cholesterol are evident and over time the two can have an adverse effect on health. Blood pressure and measurement 70 80 90 100 110 120 130 140 150 160 170 190 180 40 50 60 70 80 90 100 Low Ideal blood pressure Pre-high blood pressure High blood pressure Chapter 9: Medical Devices Figure 12.1: Typical blood pressure chart used to show range and how a simple monitor will display reading.

259 The build-up of lipids on the inner artery walls or cholesterol Blood pressure can be measured using a manual technique or with an automated device. If using an automated monitor as in image to the left the following is a process and good technique to adopt: • The patient should be seated in a chair with a back rest and feet on the floor for at least 5 minutes and relaxed and not speaking • Check the pulse. If any irregularity is found, use a manual device. A manual method of measurement should always be accessible • The arm should be supported at the level of the heart, resting on a cushion, pillow or arm rest. Ensure no tight clothing constricts the arm • Place the cuff on neatly 2cm above the brachial artery and aligning the ‘artery mark’. The bladder should encircle at least 80% of the arm but not more than 100% • Use the cuff size recommended by the manufacturer of the monitor • Some monitors allow manual blood pressure setting selection where you choose the appropriate setting. Other monitors will automatically inflate and re-inflate to the next setting if required. Warn the patient that this might happen to avoid alarm • Repeat 3 times and record measurement as displayed. Initially test blood pressure in both arms and use arm with highest reading for subsequent measurement. Blood pressure and measurement Chapter 9: Medical Device Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com

260 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Chapter 9: Medical Devices Blood pressure and measurement • The patient should be seated in a chair with a back rest and feet on the floor for at least 5 minutes, relaxed and not speaking • The arm should be supported at the level of the heart, resting on a cushion, pillow or arm rest. Ensure no tight clothing constricts the arm • Place the cuff on neatly 2cm above the brachial artery and aligning the ‘artery mark’. The bladder should encircle at least 80% of the arm but not more than 100% • Use the cuff size recommended by the manufacturer of the monitor • Estimate the systolic beforehand: o Palpate the brachial artery o Inflate cuff until pulsation disappears o Deflate cuff o Estimate systolic pressure • Then inflate to 30mmHg above the estimated systolic level to occlude the pulse • Place the stethoscope diaphragm over the brachial artery and deflate at a rate of 2-3mm/sec until you hear regular tapping sounds • Measure systolic (first sound) and diastolic (disappearance) to nearest 2mmHg. * NB There are alternative devices available such as wrist monitors and derivative devices for measuring blood pressure. These can be prone to inaccuracies and quite a strict international validation process is in place for devices that measure on the upper arm – such as the examples in images adjacent. Blood pressure is regulated and controlled by several body systems. The Autonomic Nervous System (Sympathetic and Parasympathetic nervous systems) are the systems in which blood pressure is controlled, which is the most rapidly responding regulator of blood pressure. These two systems work antagonistically. One causes an increase in vasodilation (widening of vessels) the other counteracts it by vasoconstriction (narrowing of vessels). The Autonomic Nervous system receives continuous information from the ‘baroreceptors’ (pressure sensitive nerve endings) situated in the carotid sinus and aortic arch of the heart. These are extrinsic factors along with hormones that control blood pressure. Whilst there are also local intrinsic controls such as metabolic controls that facilitate certain needs the body demands, by controlling how quickly or slowly the item is transported by influencing the pace of blood pressure. Blood loss from trauma or injury is the obvious cause of a loss of blood pressure. External haemorrhage as we know is managed aggressively, but internal blood loss can be subtle and can catch us out. It is important to recognise that blood pressure alone cannot be considered a totally reliable indicator of hypovolaemic shock. Manual technique using a Sphygmomanometer

261 We can over rely on monitoring equipment, which can be inaccurate. Looking and measuring systolic and diastolic BP, in these instances may give us inaccuracy. What is more accurate to measure is Mean Arterial Pressure (MAP) it is not always measured or understood. MAP is derived from an individual’s Systolic BP and Diastolic BP and it is a measure of the average pressure in the arteries in one cardiac cycle. To measure it effectively requires invasive techniques, such as an arterial line or requires a calculation of the formula of the Systolic and Diastolic pressure. * NB Most people need a MAP of at least 60 mmHg to ensure adequate perfusion of vital organs. Anything below 60 mmHg would be considered low. A high MAP would be over 100 mmHg. Either too low or high can be a sign of an underlying pathology. As an example, hypovolaemic (low blood volume) shock we understand these days does not present in a predictive way as once taught in the classification of shock stages 1 – 4. There is no one size fits all approach here. The key is to assess the ‘individual’ and consider all other factors that play a part; such as, age, fitness, medications, genetics, other illnesses and injuries will affect blood pressure and how shock may present. With injury and trauma, it may be best to assume the trauma casualty is in hypovolaemic shock until proved otherwise. Certainly, any event or medical history is important, a full 360 appraisal of the incident scene, the mechanism of injury and kinematics, any witnesses and how the casualty looks and presents. By considering all these factors it will help develop an index of suspicion. Blood pressure is useful and valuable, but by pooling it together with other factors and assessments – it can begin to build a picture of the situation and severity for the casualty. It is best though not to solely rely on it by itself. The body will use compensatory mechanisms for its injuries and insults. We must recognise these signs of compensation, such as: pain and injuries on exposure and examination, increase respiratory rate (assessed properly & not guessed), colour or pallor of skin, altered level of consciousness, delayed central capillary refill or lack of Sp02 (pulse oximetry trace), a fast heart rate (tachycardia), an absent radial pulse (both sides) and of course combine it all with a BP reading. SBP + 2 (DBP). 2 83 + 100. 3 183. 3 83 + 2 (50). 3 MAP = MAP = MAP = MAP = MAP = 61mmHg Chapter 9: Medical Device Blood pressure and measurement To calculate a mean arterial pressure, double the diastolic blood pressure and add the sum to the systolic blood pressure. Then divide by 3. For example, if a patient’s blood pressure is 83 mm Hg/50 mmHg, the MAP would be 61 mm Hg. Here are the steps for this calculation: Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com

262 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com A stethoscope is a remarkably simple piece of diagnostic equipment, which has value providing the user has some basic understanding of how to use it. However, the environment in which its going to be used must be considered. A dynamic noisy environment may mean immediately that this piece of equipment has no value in the real world. It would provide some value in a calm quieter environment and in skilled hands its highly beneficial. The Headset is self explanatory, the Chest piece is the part that contacts the patient, capturing sound. There are two sides of the chest piece. On one side is the diaphragm, a flat, metal disc that in turn contains a flat, plastic disc. The diaphragm is the larger component of the chest piece. On the other side is the bell, a hollow, bell-shaped piece of metal with a tiny hole on top. The bell is better at picking up low-pitch sounds, such as heart murmurs which sound like a ‘’whoosh”; the diaphragm is very effective identifying in the higher-pitch range, which includes normal breath sounds and heartbeats. The technical term for listening to lung, heart or bowel sounds is termed Auscultation. This forms part of the R U IN SHAPE respiratory assessment. The technique is best demonstrated and practiced essentially to gain experience and feel for use. Its takes practice and familiarity to become competent. Be honest with yourself, if you are not confident or sure about how to use the device or what to listen for, don’t waste time using it. There are other assessments and indicators that can be used, that may provide real world value. Provide a quiet environment. Make sure the area to be auscultated is exposed. Warm the stethoscope head in your hand. Close your eyes to help focus your attention. • Use the diaphragm to pick up high-pitched sounds, such as first (S1) and second (S2) heart sounds. • Hold the diaphragm firmly against the patient’s skin, using enough pressure to leave a slight ring on the skin afterward. • Use the bell to pick up low-pitched sounds, such as third (S3) and fourth (S4) heart sounds. • Hold the bell lightly against the patient’s skin, just hard enough to form a seal. Holding the bell too firmly causes the skin to act as a diaphragm, obliterating low-pitched sounds. • Listen to and try to identify the characteristics of one sound at a time. The Stethoscope Chestpiece Headset Tunable Eartip Diaphragm Stem Tubing Eartube Chapter 9: Medical Devices

263 Blood sugar levels are literally the amount of glucose in the blood, sometimes called the serum glucose level. Usually, this amount is expressed as millimoles per litre (mmol/l) and stay stable amongst people without diabetes at around 4-8mmol/L. Spikes in blood sugar will occur following meals, and levels will usually be at their lowest early morning. When it comes to people with diabetes, blood sugar fluctuates more widely. Diabetes is common around 4 million people in UK are currently diagnosed. There may be a great many people with pre-diabetic symptoms and not even know or recognise it. Diabetes is a metabolic disorder, the amount of sugar in the blood is controlled by a hormone called insulin, which is produced by the pancreas (a gland behind the stomach). When food is digested and enters your bloodstream, insulin moves glucose (a simple sugar) out of the blood and into cells, where it is broken down to produce energy. In a diabetic patient, your body is unable to break down glucose into energy. This is because there’s either not enough insulin to move the glucose, or the insulin produced doesn’t work properly. Diabetes is expected to exacerbate over the coming decades and increase likelihood of other disease processes such as Stokes and Heart attacks. TyPE 1 Type 1 diabetes is insulin dependent – causing the insulin producing beta cells in the pancreas to be destroyed, preventing the body from being able to produce enough insulin to adequately regulate blood glucose levels. It requires regular insulin administration by injection or by an insulin pump. TyPE 2 Type 2 diabetes is characterised by the body being unable to metabolise glucose. This leads to high levels of blood glucose which over time may damage the organs of the body. Type 2 diabetes is now becoming much more prevalent in young adults, teens and children and accounts for roughly 90% of all diabetes cases worldwide. This is often controlled by tablets or dietary changes. Knowing and understanding the symptoms of high and low blood sugar should be essential for both diabetics, family members, emergency services personnel, first aiders etc as its very common. It is one of the first routine tasks a paramedic may carry out on attending a patient if they suspect any underlying likelihood. High blood pressure and high cholesterol can also contribute to diabetes symptoms and effects. High blood sugar (Hyperglycaemia) occurs if a diabetic person may be eats too much and has too little insulin to regulate their blood sugar. Stress can sometimes also cause this. Common signs and symptoms maybe: the need for frequent urination, drowsiness, nausea, increased hunger or thirst and blurring of vision. Low blood sugar (Hypoglycaemia) which is more serious for a diabetic, occurs if a person has not eaten enough food or has too much insulin. This is commonly referred to as a ‘Hypo’ and symptoms may present as fast heat rate, shaking, sweating, anxiety, dizziness, increased hunger, tiredness or lethargy and irritability even aggressiveness/confusion. Understanding these symptoms can be essential as it may avoid a medical emergency and complications such as Diabetic Ketoacidosis (DKA). This is often mostly associated with Type 1 diabetes but type 2 could also be affected. DKA occurs when the body has insufficient insulin to allow enough glucose to enter cells, and so the body switches to burning fatty acids and producing acidic ketone bodies. A high level of ketone bodies in the blood can cause particularly severe illness. Symptoms can present as; vomiting, dehydration, deep laboured breathing (kussmual breathing) or hyperventilation, a fast heart rate, confusion/disorientation and eventually coma. Diabetes can also be a root cause of other complications such as retinopathy (effecting small blood vessels in eyes) and is a leading cause of visual impairment, neuropathy (sensory impairment of nerves) particularly effecting hands and feet. It can also cause kidney complications this is known as nephropathy, this is where the kidneys can begin to fail eventually over time. Badly managed diabetes can be devastating exacerbates and causes other problems and co-morbidities. Blood glucose measurement Chapter 9: Medical Device Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com

264 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com An example of testing meter and method. Blood glucose measurement Chapter 9: Medical Devices Prepare kit ready for testi ng This should include: PPE (gloves), meter, a test strip to hand (it may be advisable to have a spare strip to hand too), the finger pricker (lancing device), cotton wool (optional) and a PRF to record the results. • Ensure that the finger pricking device has been loaded with a new lancet • Wash and dry your hands - to ensure that the result is not influenced by any sugars that may be present on your fingers or the casualties • Put a test strip into the meter • Prick the finger with the lancing device at the sides of the finger as there are less nerve endings here than at the finger tips (World Health Organisation recommends the middle or ring fingers are used for blood glucose tests (second and third fingers). You may need to squeeze the finger a little until blood appears) • When blood appears, check the meter is ready and then transfer the blood onto the test strip and wait a few seconds – most meters these days provide a result within 10 seconds and often sooner • If the test is successful, clean any blood off your finger – with the cotton wool if necessary – if not successful repeat the process again • Record the result. Normal and diabetic blood sugar ranges for the majority of healthy individuals, normal blood sugar levels are as follows: • Between 4.0 to 5.4 mmol when fasting and up to 7.8 mmol 2 hours after eating For people with diabetes, blood sugar level targets are as follows: • Before meals: 4 to 7 mmol/L for people with type 1 or type 2 diabetes • After meals: under 9 mmol/L for people with type 1 diabetes and under 8.5mmol/L for people with type 2 diabete. Blood Glucose (sugar) monitor: Over 65 blood glucose meters are available in the UK Keeping an accurate idea of your blood glucose levels is an integral part of successful diabetes management. Blood glucose meters allow you to do this. Some blood glucose meters can also check for the presence of ketones which is useful for people with type 1 diabetes or those who are otherwise susceptible to ketoacidosis. Blood glucose testing, also known as blood glucose monitoring, is one of the main tools involved in controlling diabetes but is also an important assessment of any: • Semi or unconscious casualty • Unexplained confusion • Unwell diabetic. Blood glucose meters

265 Chapter 9: Medical Device Core body temperature is very important. It represents a balance between heat production and heat loss. If heat rate generated matches what is lost, then temperature remains stable. Core body temperature is found in the blood supplying the vital organs, such as the brain and those in the thoracic (chest) and abdominal cavities. Temperature can be affected by internal (intrinsic) factors and external (extrinsic) factors such as the environment. The normal range for core body temperature is between 36 degrees Celsius up to 37.5 degrees Celsius. The control centre for temperature is located within the Hypothalamus in the brain. This has a heat loss and heat promoting centre, which analyses and co-ordinates responses to maintain what is normal. Signals arrive at the Hypothalamus from varying pathways from sensory receptors in the skin and organs. The measurement of core body temperature may seem simple; however, several issues affect the accuracy of the reading. These include the measurement site, the reliability of the instrument and user technique. True core temperature readings can only be measured by invasive means, such as placing a temperature probe into the oesophagus, pulmonary artery or urinary bladder. Non-invasive sites such as the rectum, oral cavity, axilla, temporal artery (forehead) and external auditory canal (ear) are accessible and are believed to provide the best estimation of the core temperature. It is important to consider the indications and purpose for measuring temperature; to obtain a baseline set of observations to observe and measure, prevent or identify Hypothermia (low core temperature or Hyperthermia (high core temperature), it may indicate infection, it may indicate a reaction and it certainly may help identify shock. What must be borne in mind, is heat loss and environmental factors and hypothermia. This is much easier to prevent than to treat. It’s easy to forget this as a simple ‘actions on’ intervention. If you can maintain ‘normothermia’ to some degree in the trauma casualty it will potentially benefit functional outcomes later on. Non-Invasive sites for assessment include; oral cavity (within mouth), Tympanic temperature in the auditory canal of the ear, Axilla temperature (central position in armpit) & Temporal artery temperature. However, be aware that the temperature can vary across these sites and some are unreliable such as axilla measurement with a chemical thermometer. Tympanic assessment The tympanic thermometer senses reflected infrared emissions from the tympanic membrane through a probe placed in the external auditory canal of the ear. This method is quick <1 minute and minimally invasive and easy to perform. • Visually inspect the patient’s ear canal • Inspect the probe lens. If any debris is present, clean the probe tip per the manufacturer’s directions • Press the scan button to verify functionality and mode selection on the LCD screen. Install a probe cover by firmly inserting the probe tip into a probe cover. After the probe cover is installed, the thermometer will perform a system reset • Inspect the probe cover to make sure it is fully seated (no space between cover and tip base) and no holes, tears, or wrinkles are present in the plastic film • Place the probe in the ear canal and seal the opening with the probe tip. For consistent results, ensure that the probe shaft is aligned with the ear canal • Once positioned lightly in the ear canal press and release the scan button. Wait for the beep before removing the thermometer Measuring body temperature Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com

266 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Chapter 9: Medical Devices Tympanic assessment • Remove the probe from the ear as soon as the triple beep is heard • The patient temperature and the probe eject icons will be displayed • Press the eject button to eject the probe cover into a suitable waste receptacle. * NB Operator error and poor technique are frequently cited problems; therefore, training is recommended. Ear wax is also known to reduce the accuracy of readings. In the absence of any medical device – simple physiological vital signs are also a good indicator of temperature. One of the best, is the Swiss staging system of Hypothermia (see table 12.2). Measuring body temperature Each clinical stage is associated with an estimate of core body temperate. TABLE 12.2 – Swiss clinical staging of hypothermia Stage Brown et al, 2012 [1] Durrer et al, 2003 [4] Typical core temperature (C) 1 Conscious, shivering Clear consciousness with shivering 35 to 32 2 Impaired consciousness, not shivering Impaired consciousness with shivering <32 to 28 3 Unconscious, not shivering, vital signs present Unconsciousness <28 to 24 4 No vital signs Apparent death <24 An electrocardiogram, or ECG, measures heart’s rate, rhythm and electrical activity. An ECG is one of the most common heart tests. It is the only way of uncovering certain problems with the heart’s electrical impulses. There are a number of reasons why a patient may have an ECG; including an irregular heartbeat, shortness of breath when they exert themselves, significantly high blood pressure, palpitations or a suspected heart valve problem. It can also be a useful way of ruling out other problems. It is a simple test whereby ten electrodes used to record 12 different views of the heart’s electrical activity. There are 3 main types of ECG. A resting ECG, one that’s carried out when a patient is lying down in a comfortable position, an exercise or stress ECG - carried out on a bike or treadmill, and an ambulatory ECG – a small portable device that can be worn around waist, so heart activity can be monitored over a day or more. Electrocardiogram (ECG)

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 267 GATHER EQUIPMENT ECG Machine, ECG electrodes for attachment to patient, Razor maybe required to ensure good electrode contact with skin. Midclavicular line Horizontal plane of V4 – V6 ECG machine Anterior axilary line Midaxillary line V1 V2 V3 V4 RL LL Supplemental right precordial leads V5 V6 RA LA V1R V2R V3R V4R V6R V5 CHEST ELECTRODES V1 – V6 Place in position as image on left, ensure good skin contact Once electrodes applied attach the associated leads l V1 – 4th Intercostal space – right sternal edge. l V2 – 4th Intercostal space – left sternal edge. l V4 – 5th Intercostal space – mid clavicular line. l V3 – Midway between V2 and V4. l V5 – Left anterior axillary line – same level as V4. l V6 – Left mid-axillary line – same level as V4 and V5. LIMB ELECTRODE Place on a bony prominence on each limb l Red – (RA) right arm – ideally at ulnar styloid process of wrist. l Yellow – (LA) left arm – ideally at ulnar styloid process of wrist. l Green – (LL) left leg – ideally at ankle – medial/lateral malleolus. l Black – (RL) right leg – ideally at ankle – medial/lateral malleolus. RECORDING THE TRACE ECG machine can differ, familiarise with local equipment • Turn the ECG machine on – ensure paper is loaded • Double check all electrodes are attached in correct positions • Ask the patient to be still and not to talk during recoding of trace • See if the LCD screen (if device has one) is giving a trace, then press appropriate button • if the trace is poor, double check connections and skin contact and repeat process • An experienced health care professional will need to interpret the printout. Chapter 9: Medical Devices

268 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Peak flow is a simple measurement of how quickly you can blow air out of your lungs. It is limited by the size of your airways and your physical ability for forcefully exhale. It is often used to help diagnose and monitor asthma as when the airways go into spasm (bronchospasm) in asthma, they greatly restricts the flow of air in and out of the lungs, which creates the typical ‘wheeze’ and also increases the work of breathing. It is this increase work of breathing that can ultimately lead to the exhaustion and collapse of asthmatics. A peak flow test involves blowing as hard as you can into a small handheld device called a ‘peak flow meter’. This measures the flow of breath in Litres/minute. (Remember, this is a FLOW and not a volume, so although the number of litres may seem high, this is only delivered for a few seconds, but if extrapolated to a full minute then it will be large number). Eg a patient may forcefully breathe out 3 litres in 1 second, this is equivalent to 180 litres/minute. All diagnosed asthmatics will be familiar with these devices as it is a good way to monitor their condition. By measuring how fast you’re able to breathe out, your ‘peak flow score’ can indicate whether your airways are narrowed. It can then be used to assess if you are having and asthma attack and your response to treatment, such as a Ventolin inhaler. How to measure a peak flow Instructions for the casualty to measure their peak flow: • Find a comfortable position for the casualty, either sitting or standing • Attach a disposable mouthpiece/tube • Reset the peak flow meter so the pointer is pushed back to the first line of the scale – this is usually 60 • Hold the peak flow meter so it’s horizontal and make sure that your fingers are not obstructing the measurement scale • Breathe in as deeply as you can and place your lips tightly around the mouthpiece • Breathe out as quickly and as hard as you can • When you’ve finished breathing out, make a note of your reading. This should be repeated 3 times, and the highest of the 3 measurements should be recorded as your peak flow score. The casualty may well know what their normal peek flow is and can tell you how it compares. Peak flow test An example of peak flow meter Chapter 9: Medical Device

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 269 Your peak flow score Your peak flow score – also known as your ‘peak expiratory flow (PEF)’ – will be displayed on the side of your peak flow meter. This is given in litres of air breathed out per minute (l/min). What’s considered a normal score depends on your age, height and gender. Ask your GP or asthma nurse for more information on what would be considered a normal score for you. The result can be compared to what would usually be expected for someone of your age, height and gender. A big difference between their current and their best score could be a sign that their condition is becoming poorly controlled or that you’re having an asthma attack. We do not typically do Peak Flows in children less than 12 years. • Men have typical PEF of 500-600 or more • Less than 400 is of concern • Women 400-500 or more • Less than 300 is of concern. Less than 250 in anyone is of serious concern and warrants urgent medical opinion by Paramedic, Specialist nurse, GP or hospital, unless it is the normal for that individual. If the casualty is unable to perform a peak flow test, as they are too breathless, then this is a life threatening emergency and needs a ‘999’ response and escalation to ambulance control. Not everyone with diabetes will test their blood glucose levels but it is regarded as being very beneficial for helping to make diet and medication dosing decisions and most insulin dependent diabetics and many tablet controlled, will have a good idea what their normal blood sugar is and at what point that they start to feel ‘hypo’ (hypoglycaemic – low blood sugar). If blood sugars fall low enough to affect conscious level then this is a life threatening emergency and we may just treat this with sugar if we have no monitor. However, some diabetics can fall very unwell with high sugars. Giving more sugar is unlikely to make this worse and could be life saving in a hypo, but it is more useful if we can actually measure the sugar level in the blood. A blood test involves pricking the finger with a small safety needle called a lancet. This exposes the operator to a degree of infection risk, as you are using a sharp needle and drawing blood. Full sterile precautions, a sharps disposal container and suitable PPE are always required to avoid any risk to you or the patient. This is covered in the skill station where we demonstrate some of the safety needles designed to reduce pain for the casualty and risk to the operator. Draw a drop of blood from the finger, ideally without lots of squeezing and applying it to a test strip that has been engaged into a calibrated blood glucose meter. The calibration process and operating process are described with each individual machine, but we usually get a blood result within a few seconds. A ‘normal’ blood sugar is between 4 – 6 mmol/l, although after food it can rise to 7-8mmol/l Less than 4mmol/l is ‘hypo’ although some diabetics that normally have higher blood sugars normally, may feel hypo symptoms at a lower blood sugar. If the device indicates ‘out of range’ and the casualty is conscious, then assume that it is very high. If they are unconscious and ‘out of range’ then immediately treat as a ‘hypo’ with glucogel. Peak flow test Chapter 9: Medical Devices

270 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Appendix A: Clinical Updates Trauma and casualty care is constantly developing and changing and as part of the ATACC Group Governance process, we support this ongoing improvement by providing clinical updates. These give BTACC providers the latest evidence based guidance on specific questions or conditions based on the advice of the ATACC Group, Medical Director and Medical Advisory Group. When the next version of the manual is published, these current updates will be included within the core content, wherever possible. For specialist subjects such as excitation delirium, these may be left as a clinical update for quick reference. Ongoing developments, changes and updates

271 The most essential parts of effective cardiac resuscitation are: • Early recognition of cardiac arrest • Early commencement of chest compressions • Good quality, minimally interrupted chest compressions and early defibrillation. As you can see, ‘ventilation’ does not play a major part in this process, although if the cardiac arrest is due to hypoxia, this is more important (See ExCEPTIONS below) If we consider bag valve mask ventilation first. This is a challenging skill to do effectively, especially in a cardiac arrest victim. Research has shown that unless performed on a very frequent basis (weekly-monthly), then this skill is quickly lost. A two-person technique is better but still not ideal. Any time wasted struggling to deliver ventilations is time when there is no blood flow from chest compressions. In addition, whenever you stop chest compressions, even for a few seconds, it can take 18 compressions or more to restore the blood flow again afterwards. This is the rationale for continuous chest compressions, which are much better in terms of resuscitation. This is NOT against UK Resus council guidelines, as they clearly state that hands only approach is perfectly acceptable if you are not trained in ventilation (they do not defined ‘trained’ but based on the evidence above, we have made that decision). A recent study comparing hands only or ventilations with compressions by paramedics, demonstrated no real difference in outcome. In those less skilled with ventilation, hands only is likely to be better. Basically, it is the difference between going through the motions of compressions and ventilation but with a poor outcome or delivering high quality uninterrupted compressions only until defibrillation, which is likely to be far more successful in most cardiac arrests. EXCEPTIONS Cardiac arrests where a lack of oxygen is likely to be the cause DO STILL REQUIRE VENTILATION AT 30:2: • DROWNING • STRANGULATION • OVERDOSES • CHILDREN (ideally a 15:2 ratio, but if unsure then use 30:2 same as with adults). Clinical Update: A.1 Appendix A: Clinical Updates Q1: Why have we moved to hands only CPR and is this against the UK RESUS Council Guidelines? Q2: Are there any exceptions? Q3: What about children? Q4: Why are the paramedics still doing ventilation? Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com

272 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Extrication is changing as the medical world look more critically at many of the techniques that have been used for some considerable time. You will hear the terms clinical clearing’ the cervical spine and walking casualties out of the car if they have the following: • Fully conscious and not intoxicated • No pain in the neck or back • No strange sensations, e.g., pins and needles, numbness • No serious distracting injury (pain from another major injury). If these are not met and the casualty may have a spinal injury traditionally we would go for what has been the ‘gold standard’ of roof off and slide up the board (Route 1 or over the rear seat backwards). Our aim has been to maintain neutral alignment and to avoid rotation of the casualty, which is likely to twist the back and risk further injury. A recent study from Limerick University has reviewed all methods of extrication and this route with the board did not fare too well. Whilst not the worst, it did not appear to be the gold standard we all considered it to be. The KED was also considered and if this involved rotating the casualty, this was a very poor method. However, if it can be applied easily without excessive movement or delay and then a straight lift out the side is conducted, this is potentially a good method. However, the study was small and states that this should not be used to change current practice, which is why we will not change as a service, until more evidence is produced. However some paramedics have started to use the KED again more frequently and it will be promoted by them on scene. If it is used then the casualty MUST NOT BE ROTATED or SLID UP THE BOARD in the KED. It must always then be a straight lift out sideways onto a stretcher. The KED remains of limited value as is it is usually slow to apply, it restricts breathing and can be painful in chest or abdominal trauma. At present the long-board remains our primary extrication device of choice. Clinical Update: A.2 Q1: Why do we not recommend the use of the Kendrick Extrication Device (KED), compared to walk-out or full roof-off approach? Appendix A: Clinical Updates

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 273 In typical chest injuries e.g. rib fractures, bruised lungs or penetrating wounds the traditional first aid approach has always recommended placing the casualty bad side down. The reasons for this seem somewhat unclear, but suggestions include: • It avoids blood running from the bad lung down and across into the lower good lung • It allows better ventilation of the good lung when on top and not lying on it. There is no good physiological reason for this and the risk of blood contamination are being over-played in all but the most major bleeding into the airway, which would probably be rapidly fatal anyway. Throughout our training we teach the opposite – place the injured lung ‘BAD SIDE UPPERMOST’ – this is for a number of good physiological and clinical reasons including: • Blood supply and ventilation should ideally be matched. When lying on the side, blood follows gravity and there is therefore more in the lower lung. To match this with the best ventilation, we need the good lung lowermost • You do not want to lie the casualty on their injured side in view of the pain it may produce • You can only inspect and monitor any injury to the chest if you can see it, so it is always better uppermost. As you can see, there are clear clinical and practical reasons to manage casualties in this way and yet another historical first aid myth has been dispelled. Clinical Update: A.3 Q1: Explain the reason for managing chest trauma ‘bad side up’ when traditionally the opposite was recommended? Appendix A: Clinical Updates

274 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com SEAL ALL ABNORMAL HOLES IN THE TORSO Background: If the penetrating object or wound extends into the chest then atmospheric air can enter the chest cavity and result in a collapsed lung. This is worst with ‘sucking’ chest wounds; where air enters the chest wall but then get trapped in the chest and cannot escape. Air can also get into the chest from holes/leaks in a lung itself following a penetrating injury. Management: Traditionally, first aid training has encouraged the application of a ‘three-sided dressing’ to create a ‘non-return valve’ which allows air out but not into the chest. However, these can be unreliable, difficult to make and often don’t stick well. As a result, we now recommend the following: Option 1: Apply a chest seal: ideally use a purpose designed chest seal such as a Bolin, Russell or Sam seal Option 2: Seal and cover the hole with an adhesive dressing or occlusive tape (even Gaffer tape will do) Option 3: Cover the hole with a gloved hand We DO NOT recommend leaving the hole open as this will lead to collapse of the lung. Continue to monitor the casualt y. In the rare event that they describe increasing breathing difficulty and there is no obvious other reason, try uncovering the hole and see if it helps. ‘Tension’ pneumothorax: Some first aiders will have heard of the term ‘Tension’ or ‘Tension pneumothorax’ – this is somewhat more complicated and relatively rare and slow to develop in spontaneously breathing patients. However, for first aiders the management is still to simply seal the hole in the chest wall/torso. Clinical Update: A.4 Open Chest Wound Any hole in the torso is a potential serious injury. The ATACC Group guidance on such an injury is clear outlined below: Appendix A: Clinical Updates

275 The casualty will usually have some kind of improvised ligature around the neck which can be made from anything including: • Rope, string, washing line • Wire or cable • Clothing, laces and belts • Others items include: seatbelts, curtain ties, blind-cords etc. The injuries will usually consist of: • Asphyxiation from lack of oxygen and compression of the blood supply in the neck • Spinal injury in the neck from the drop • Bleeding of lacerations from the ligature or noose • Other injuries, such as self-harm or overdose. In judicial hangings, death is facilitated with a ‘long drop’ and a noose knot to the side, under the jaw. This typically results in a rapid loss of consciousness as a result of catastrophic neck injury, associated massive drop in blood pressure and a faint, followed by slower actual brain death over 5-20 minutes. If there is little, if any ‘drop’ and especially if the bodyweight remains supported, asphyxiation is more likely and death may not be as rapid. The priority is to support the individuals weight, calling for help to get them down as quickly as possible and then to release the ligature before commencing life support if required. RESPonSE To FInDInG SoMEonE WITH A LIGATURE Call for assistance immediately and if required, request for an ambulance to attend. Support the person’s body weight (if safe to do so) as soon as possible, to release the tension on the ligature. A person does not need to be suspended or clear of the floor to be using a ligature. Keep the body weight supported and/or the tension off the ligature until the ligature has been cut. Even simply supporting the body, may allow some blood to flow to the brain, while you await help and assistance. Much is talked about removal of the ligature and there are special devices on the market, but as so many things can be used for self-harm, no single device will be enough. The priority is to loosen and ideally remove the ligature as quickly as possible. If specialist devices are not available, anything should be used that will cut through the ligature, even if there is a risk of cutting the underlying skin. This is a life-saving measure and small cuts to the skin are a lesser concern. Where the ligature is very tight and cutting into the skin, the softer area on each side of the front of neck, may be the easiest areas to approach. In situations where the person resists attempts to remove the ligature, it may be necessary for an officer to use appropriate physical intervention. It is expected that the officer will employ techniques to help ensure the safe removal of the ligature. If the body is limp or there are no signs of life, commence life support as soon as physically possible, on a firm surface or the floor, supporting the neck as best you can, but without delay during the lowering to the floor. Manage this like all other cardiac arrests, but with gentle handling/minimal movement of the neck during airway manoeuvres. If the casualty is struggling to breathe because of neck injury or blood in the mouth or airway, sit them up if conscious or place in the recovery position and monitor for unconsciousness. For all officers involved in suicide or other emotionally traumatic incidents, always consider their welfare in the ensuing period as per service protocol. Clinical Update: A.5 Ligature removal and hanging Attempted self-harm or hanging is something that officers may face both in the community and also in custody if correct procedures are not followed. Appendix A: Clinical Updates Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com

276 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The management of burns has been simplified as much as possible, even at an advanced level. • Active cooling with cold/cool running water for 10 mins • Application of a burn-film (cling-film) in sheets or strips (not wrapped around) • For facial burns, we recommend the use of face-shield dressings after cooling with water • For hands and feet, we recommend freezer bags after cooling with water. Although many commercial gel dressings, e.g., water gel and hydro-gel exist they are not considered the recommended standard and are not recommended by the National Trauma Network Burns Units. There two reasons: • They do not offer active, ongoing cooling like running water does • The gel is difficult to remove from the raw burn in the hospital burns unit afterwards Many first aid kits still contain these gel dressings and they are widely marketed, but we would only ever recommend them if no running water is available. Clinical Update: A.6 Burns Dressing What is the position of The ATACC Group with regards to burns dressings as many courses and first aid kits still include them? Appendix A: Clinical Updates

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 277 There are lots of recommendations for alkalis, acids and other skin contaminants. There are also companies producing agents which claim to minimise the effects of the chemicals, but this guidance is based on the simple principles of: • Being safe • Dry decontamination • Immediate and prolonged irrigation with water • As soon as a casualty is identified, call for support and the other emergency services especially ambulance and fire & rescue • Ensure that both the rescuer and the casualty are not at further risk of attack DO NOT WORRY ABOUT THE TYPE & SPECIFICS OF THE AGENT INVOLVED AT THIS STAGE • Apply nitrile gloves and use eye protection if available • Ensure that you are in a well ventilated area and ideally outside. If indoors, open doors and windows and consider moving outside as early as possible in case fumes are released during decontamination. Self-aid decontami nati on • Try and calm the casualty, whilst encouraging them to urgently remove contaminated clothing, trying to keep their hands away from affected areas • If there are two casualties they can help each other • Place contaminated clothing into one area or a waste bin • Jewellery must also be removed from the affected area as corrosive agents can lie trapped underneath • Any remaining powder on the skin should be brushed off with clean clothes or paper towels. Water irrigati on for at least 20 minutes • Corrosive liquids will continue to burn into the skin and will need copious irrigation with water. Alkali agents can be more difficult to wash off and can take longer than 20 minutes, but the management of all agents is the same. • Ideally the water should be lukewarm or cold and from a clean source. However, in an emergency use whatever water is available and do not delay looking for clean water. • Large amounts of water will be required to ensure that irrigation continues for at least 20 minutes. This usually means getting urgent support from the Fire Service who can use water out of the appliance and then fresh water from the hydrants • Always consider where the ‘run-off’ water, which may still contain high concentrations of agent, is going in terms of: - Avoiding washing onto clean uncontaminated areas of the casualty - Forming pools that could affect others - Environmental pollution. • Try and get the contaminated part of the body as low as possible to avoid water running onto other areas. This also applies to the face, avoiding contamination from one eye to the other • The water should be free flowing from a tap or poured and not standing or pooled, such as a bath or lake, unless they are the only options • A garden or fire hose are ideal, but the pressure should be kept low to avoid driving the agent deeper into the skin and splashing yourself and others • There is a risk of hypothermia where extensive burns are present, so lukewarm water may help, but is rarely available. For most corrosive burns, the area is small and we can avoid healthy skin being cooled Clinical Update: A.7 Corrosive Attack – Immediate action for first-aiders This guidance will apply to all forms of irritant skin contamination. Appendix A: Clinical Updates

278 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Clinical Update: A.7 Continued Corrosive Attack – Immediate action for first-aiders • 20 minutes is a long time to irrigate the skin, but do not be tempted to stop earlier, unless the agent has been confirmed clear with litmus paper/pH test strips (e.g., urine dip sticks). We are aiming for a neutral pH of 7.0 • If burning continues after 20 minutes, then continue irrigation • Do not move to hospital too soon, as irrigation should not be interrupted within the first 20 minutes and the hospitals will often not be prepared to provide ongoing irrigation as soon as the casualty arrives • Wherever possible, try to preserve the dignity of the victim by moving onlookers and covering the casualty after decontamination with cling-film to the affected areas and loose clothing or cover to unaffected areas. The Eyes The eyes are very susceptible to corrosive agents, but once again, early and copious water irrigation can be very effective in protecting sight. A few key pointers will help the first aider: • If only one eye is affected then always irrigate away from the unaffected eye • The eyes must be opened during irrigation and the lids retracted to ensure that all the agent is washed away effectively • At least 20 minutes of irrigation with water will provide the best outcomes. Manageme nt of other age nts Questions are often asked about agents that release heat in contact with water including: • Sulphuric acid • Phosphorous • Metal elements, e.g., sodium. Some agents have other serious side effects and systemic toxicity including: • Phenol • Hydroflouric acid • Chlorine. Research has shown that all the special measures for these agents are rarely available and in practical terms offer no advantage over large volumes of water. Therefore water remains the agent of choice for ALL contaminants. Antidotes and Chemical treatme nts , e.g., Diphoterine • Several agents such as this have been promoted for emergency management of corrosive liquid burns. They are claimed to provide immediate relief and improve healing, but the evidence remains limited and anecdotal at present. The agents are expensive and typically in limited supply. However, they may have a practical role to play where water supplies are limited. However, the Fire Service can normally obtain emergency water supplies anywhere in the UK Appendix A: Clinical Updates

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 279 Clinical Update: A.7 Continued Corrosive Attack – Immediate action for first-aiders Summary Acid, alkali of corrosive attacks are increasing and although rarely fatal they are often mutilating and disfiguring with long terms scarring. Early and urgent first aid action can dramatically reduce the severity of the injury and even prevent scarring. • Call for help and remember to call the Fire Service for decontamination • Protect yourself with distance, gloves and good ventilation • Manage all agents the same way • Encourage self-decontamination by removal of the casualty’s clothing and jewellery • Brush off other powder contamination with paper or clean clothes • Liquid or gel corrosive agents require water irrigation for 20 minutes or more • Decontaminate the face and eyes first • Do not wash contaminant onto unaffected skin or the eyes • Do not cut the time or move to hospital too soon as this is the mainstay of treatment • Specialist treatments and reversal agents have not current value over copious water • Preserve the warmth and dignity of the casualty wherever possible. Appendix A: Clinical Updates

280 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com There has been a dramatic increase in the use of drugs often described as ‘synthetic cannabis,’ e.g., K2, Black Mamba, Bombay Blue, Genie, Zohai, Fake weed, Skunk, Moon Rocks, Yucatan Fire and Bliss. ‘Synthetic cannabis or marijuana’ is a serious misnomer, as these drugs are very different from natural cannabis, but they act on the same receptors in the body, and are far more potent and totally unpredictable in their action as the actual constitution constantly varies. They are often marketed as ‘legal highs’ or ‘natural incense’ but they have been illegal in the UK since 2016. They are typically smoked, but can be ingested a ‘herbal tea’ or inhaled from e-cigarettes. The symptoms of spice intoxication are very non-specific, but some common effects include: • Excessive sweating • Agitation • Hallucinations • Nausea and vomiting • Seizures • Slurred speech • Shakiness • Greatly increased hunger or thirst • A number of deaths have been associated with Spice. Mental effects • Increased risks of schizophrenia with: • Increased anxiety • Delusions and paranoia • Erratic or even violent behaviour • Absence of appropriate emotional responses • Reduction of co-ordination and ability to move. Spice cannot be detected by routine drug tests for cannabinoids. Withdrawal from Spice can have any of the following typical features: • Headaches • Anxiety or depression • Irritability • Drug craving • Seizures • Respiratory difficulty • Elevated temperature. Differentiati on from Excitati on Delirium This may be difficult in some cases, but Spice related cases tend to be more often incapacitated and helpless rather than violent and aggressive. Clinical Update: A.8 Spice & Synthetic Cannabinoids Abuse Short Summary Guidance: ‘Spice’ intoxication Update Appendix A: Clinical Updates

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 281 The typical very high temperatures and associated removal of clothing is not as common with Spice. Unfortunately, none of these things are totally reliable as the consistency of Spice varies so much and therefore it’s effects are so diverse. Treatme nt Simple supportive measures: • Maintain airway • Suction • Oxygen as required • Support breathing if required • Calm observed environment while they ‘sleep it off’ – typically two to three hours • Reassurance • Resuscitation if required • Try an avoid restraint unless unavoidable, although the risks associated with excitation delirium and restraint, do not appear to be as common. Medical support • Simple sedatives such as benzodiazepines relieve anxiety and agitation symptoms • Ketamine or Haloperidol may help • Treat other symptoms as required but try to avoid further psycho-active agents wherever possible Clinical Update: A.8 Spice & Synthetic Cannabinoids Abuse Appendix A: Clinical Updates

286 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Appendix B: M.A.R.C.H Algorithm 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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 283 BTACC Kit List Description M - massive haemorrhage Ambulance Dressing No.3 Ambulance Dressing No.4 Emergency Care Bandage - 15cm (6”) CAT Tourniquet - Orange Recommended types Intersurgical Intersurgical Intersurgical NasoSafe NasoSafe NasoSafe Hudson Hudson Intersurgical Intersurgical A - airway Suction Easy OP Airway - Size 3 OP Airway - Size 4 OP Airway - Size 5 NP Airway - Size 6 NP Airway - Size 7 NP Airway - Size 8 Non-Rebreathing Oxygen Mask - Adult Non-Rebreathing Oxygen Mask - Child Pocket Mask BVM - Adult Paediatric face mask (for Adult BVM) Aquagel Lubricant Sachet Pulse Oximeter Quantity 1 1 2 2 1 1 1 1 1 1 1 2 1 1 1 1 2 1 Appendix C: BTACC Kit List

284 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Description Cx - cervical spine Adjustable Hard Collar – adult R - Respiratory Stethoscope Russell Chest Seal C – Circulation T-POD Pelvic Splint (Recommended) If unavailable use Prometheus Pelvic Splint Triangular bandages H – head and other injuries Pen Torch with Pupil Gauge Cling Film Burns Face Shield Aluminium Foam Splints - SAM Crepe Bandages - 10cm Microporous Tape - 2.5cm x 10m Eye Wash - 250ml Saline Pods - 20ml Quantity 1 Recommended types 1 2 1 2 T-POD 1 1 1 1 1 1 1 2 Large Appendix C: BTACC Kit List BTACC Kit List