BTACC

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 49 Signs and symptoms of choking include: • Attack occurs while eating • Casualty clutches his or her neck and looks terrified (universal choking sign). Signs and symptoms of partial airway obstruction include: • Still able to speak, cough, and breathe • Gagging. Signs and symptoms of total airway obstruction include: • Inability to speak or vocalise • Inability to breathe or wheezy breathing • Silent cough • Cyanosed (blue around lips and mouth) • Unconsciousness. To treat choking in a conscious victim, first try to encourage them to cough. If they are unable to cough or breathe, immediately commence the following rescue techniques. The rescuers should provide alternating back blows (see figure 3.10) and abdominal thrusts (see figure 3.11) in blocks of five until the obstruction is relieved or the casualty deteriorates and becomes unconscious. To provide ‘back blows’ 1. Stand to the side and slightly behind the casualty. 2. Supporting the chest with one hand, lean the casualty forward. This position will make it more likely that the foreign body to comes out of the casualty’s mouth rather than fall further down the airway once dislodged. 3. Position the heel of your other hand between the casualty’s shoulder blades and provide up to five sharp, firm, back blows to clear the airway obstruction. 4. After each blow, check to see whether the foreign body has been dislodged (no more than a second or two). If the five back blows fail, do not relieve the airway obstruction. Responders should provide up to five ‘abdominal thrusts’. To perform abdominal thrusts: 1. Stand behind the casualty. 2. Place both your arms around the upper part of the casualty’s abdomen and lean the casualty forwards. 3. Place your fist against the casualty’s abdomen, with the thumb side facing in, just above the casualty’s navel and grasp the fist with your ot her hand. 4. Provide up to five abdominal thrusts, pulling sharply inwards and upwards. 5. After each blow, check to see if the foreign body has been dislodged. Figure 3.10: Providing Back Blows and then checking the mouth. Choking Chapter 3: A: Airway Management

50 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com If the five abdominal thrusts do not relieve the airway obstruction, responders should continue to provide an alternating sequence of five back blows and five abdominal thrusts. The ERC/UK Resuscitation Council guidelines for choking treatment are outlined in (see figure 3.12). If these efforts do not relieve the airway obstruction and the casualty becomes unconscious, responders should carefully lay the casualty on the ground and immediately call for help, 999/112 and begin CPR (see Chapter 7). Figure 3.11: Providing Abdominal Thrusts and then checking the mouth Choking Chapter 3: A: Airway Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 51 The same algorithm can be used in children down to the age of one year of age. Below this age (infants) the abdominal thrusts are replaced with chest thrusts/compressions. Small children can be placed across the lap for back blows and infants can be cradled in the arms (head down along the forearm). Another key difference for children is if the child becomes unconscious, we then commence paediatric life support which starts with five rescue breaths before chest compression starts. In cases of choking abdominal thrusts should not be used in infants (children under 1 year of age) – chest compressions are used instead. Figure 3.12: Adult choking algorithm (based on UK and European Resus Council guidelines) Assess the severity of the choking Conscious Five back blows Five abdominal thrusts Repeat until choking relieved or unconscious Mild Choking able to speak or cough Encourage to cough Severe Choking unable to cough Unconscious: Start CPR Choking in children Chapter 3: A: Airway Management

52 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Ventilation using a pocket mask provides 16–18% oxygen. Bag-valve mask ventilation with room air: 21% oxygen. Oxygen cylinder delivered at 15 L/min through a non-rebreathing mask with a reservoir bag provides 60–80% oxygen. Bag-valve masks, with oxygen 15L/min and reservoir provides 100% oxygen (need to check manufacturer/type as some don’t provide spontaneous breathing) Under normal circumstances, a person’s body can operate efficiently using the amount of oxygen found in normal room air. However, in some situations, such as in major blood loss from a traumatic injury, (as the oxygen is carried by red blood cells) insufficient oxygen may be delivered to the cells of the body, which can result in shock, death, or serious long term disability. This can also occur if the breathing is compromised and oxygen does not reach the blood from the lungs. Administering supplemental oxygen to a casualty should increase the amount of oxygen delivered to the cells of the body and often makes a positive difference to the casualty’s outcome. Room air contains 21% oxygen, whereas an oxygen cylinder contains pure oxygen (100%). In some situations and medical conditions, oxygen can theoretically worsen the condition of a casualty, e.g. COPD and therefore it is important to assess the patient’s oxygen status, and their general health before giving oxygen. However, all casualties with major traumatic injuries are likely to require supplemental oxygen through a reservoir mask or nasal prongs (cannulae) at a flow rate sufficient to maintain oxygen saturations of 94% or more. If they have COPD then >88% may be sufficient. A pulse oximeter should be available, to check the oxygen saturation and compare the levels before and after oxygen therapy, to assess the response. If the casualty improves, you may consider reducing the oxygen flow rate. Aim for a target saturation of between 94–98% in the average adult casualty, but if unsure or their condition is unstable e.g. • Head injury • Features of shock • Difficulty in breathing, e.g. asthma, then the higher flow rate should be used. The British Thoracic Society guidelines were initially produced for medical conditions. However, the latest version is far wider reaching, identifying that high levels of oxygen administration are not benign or without risk to some. We now deliver oxygen to maintain saturations as described above: aim for 94-98% in most patients. In BTACC managing serious illness or injury we are more likely to risk harm by withholding oxygen, rather than administering it. See section on COPD for exception. Oxygen should be used to treat hypoxaemia (low oxygen levels in the blood) and not simply breathlessness. (see figure 3.13). A pulse oximeter is very simple to use. A sensor probe is clipped on to the casualty’s finger and a LED is shone through the finger, giving the findings on the screen. Most commonly the pulse and oxygen saturation will be recorded, but newer models may also provide other information as well such as a pulse waveform. Figure 3.13: Apply the pulse oximeter early, almost like your ‘hand-shake’, to assess the oxygen status and pulse of the casualty. Supplementary oxygen Chapter 3: A: Airway Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 53 ALL MAJOR TRAUMA VICTIMS GET INTIALLY 15L/min HIGH FLOW OXYGEN FROM A NON-REBREATHING MASK (equivalent to 100% oxygen) if the saturation is <94% Oxygen is compressed and stored in portable cylinders. Standard steel oxygen cylinders are filled to 137 barometers. Newer Kevlar wrapped lightweight cylinders are charged to 200 to 300 bar pressure, depending on the manufacturer or supplier. In older style cylinders, a gasket or ‘O’ ring was required between the pressure regulator/flowmeter and the cylinder; this ensures a tight seal and maintains the high pressure inside the cylinder). In the new style cylinders (see figure 3.15), the pressure regulator and flowmeter are an integral part of the cylinder apparatus and no assembly is needed prior to oxygen administration. This effectively minimises flash and explosion risks which can occur when changing and opening regulators on oxygen cylinders if there is dust or grease present. Oxygen is now viewed as a drug (POM-prescription only medicine) and must be prescribed appropriately by a clinician. A generic prescription or SOP/SIS/PGD can be written by a Medical Director for emergency care providers who have been suitably trained. All administration of oxygen of oxygen must be: • Recorded on the patient report form or other documentation • Monitored with a pulse oximeter: before and during delivery (in absolute emergency this is not essential). All oxygen supplies should be checked on each shift, including contents, regulator valves, and flow metres. For cylinders with a separate regulator, if it is necessary to change the regulator, ensure that the valves are free of grease, oil, and dust. Before fitting the regulator, the cylinder should be opened slightly for a fraction of a second to clear any dust or debris from the outlet port. Always “crack” or open cylinders slowly as there is always a small risk of fire or explosion. As we discussed above, there is often some confusion about the British Thoracic Society Guidelines for oxygen administration. However, when considering major life-threatening trauma our guidelines are very clear. Figure 3.15: High pressure oxygen cylinder and use of a high flow non-rebreathing oxygen mask Oxygen equipment Chapter 3: A: Airway Management

54 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com When we use a pulse oximeter, the oxygen saturation is considered ‘Time critical’ if <91% on air or < 94% on oxygen. A casualty who is not breathing will require support for their breathing or ‘ventilating’ with either a pocket mask or a bag- valve mask (see figure 3.16). Bag-valve masks require a responder to squeeze the bag to push air through a one-way valve, into the mask, held firmly to seal it on the face and then into the casualty’s airway. After each ‘ventilation’ the bag is released and the casualty passively exhales. The used air empties back into the mask and escapes through holes before the one-way valve, to avoid it being blown back into the patient with the next ‘ventilation’. (This is discussed in more detail below) Bag-valve masks are single-use and should be disposed of after use. Paraquat overdose is quoted as a key contraindication for oxygen therapy. In confirmed cases of paraquat overdose, avoid oxygen unless the casualty has sustained a major injury or is in extremis (e.g. has a respiratory rate more than 30/min, oxygen sats <91%, unconscious, in arrest or time critical). In such cases, oxygen should be given. Figure 3.16: Using a pocket mask with oxygenmask Oxygen equipment Nasal prongs/cannulae Nasal prongs/cannulae are very well tolerated way of delivering up to 60% oxygen in adults and children. They are very useful when the casualty will not tolerate a face mask or if they are using Penthrox for analgesia and requires supplementary Oxygen to keep their saturation above 94% The oxygen is delivered in Litres/min from as little as 1-2L.min up to 15L/min from a cylinder. Chapter 3: A: Airway Management

55 Oxygen does not burn or explode by itself. However, it can quickly turn a small spark or flame into a serious fire. Therefore, all sparks, heat, flames, and oily substances must be kept away from oxygen equipment. Smoking should never be permitted around oxygen equipment. The pressurised cylinders are also hazardous as the high pressure in an oxygen cylinder can cause an explosion if the cylinder is damaged. Oxygen cylinders should be stored securely to protect the cylinder and the regulator/ flowmeter, especially during transit. (see figure 3.17). At the scene of an incident, ensure the cylinder is handled carefully and not exposed to any damage during an extrication attempt. Flat bottomed cylinders, should not be stood next to the casualty, where they could fall and injure them. It is important to note the amount of oxygen remaining in the cylinder to ensure that it will not run out while treating a casualty. A normal portable oxygen cylinder contains between 340 and 1,000 L. The flow rate in Litres/min will determine how long the cylinder will last for and all responders should be aware of this capacity and time. Responders should monitor the gauge and seek additional cylinders before they are needed. The contents are a gas and will drop proportionally as the contents are used. If further cylinders are not available, providers may reduce the flow rate to 10 L/min (or less) based on the oxygen saturation. Although this will significantly reduce the percentage of oxygen being delivered to the casualty, it still is supplemental oxygen and will hopefully keep the saturations >94% The casualty should be monitored with a pulse oximeter to ensure that the oxygen saturation is kept greater than 94%. If it falls below this level, the flow will need to be increased. Figure 3.17: Oxygen cylinder safely stored. Safety considerations Chapter 3: A: Airway Management During the airway management phase, providers should consider the possibility of spinal injury (discussed in detail in Chapter 6). If more than one responder is present and spinal injury is suspected, providers should manually immobilise the neck—whilst ensuring an open airway—before proceeding on to the next step in the M.A.R.C.H algorithm. When solo responding, cervical spine management is impossible with other injuries to manage as well. A solo responder should focus on other time critical injuries first. If a second responder is present, the cervical spine management should not be ignored and should be performed according to BTACC guidelines. Cervical spine management . Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com

56 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com • Loss of the airway can result in death within minutes if it is not properly managed • The airway should be regularly assessed in all casualties, as conditions may change rapidly • A partially obstructed airway restricts the flow of air and can result in a harsh, high pitched noise known as stridor • A totally obstructed airway allows no sounds of breathing effort to be heard • The look, listen, and feel approach is used to assess airway problems • Look for chest rise and any obvious signs of facial or airway trauma • Listen for breathing effort • Feel for breath • Various positions may be used to try and relieve airway obstruction including the recovery position, sitting position, or prone position. • The tongue may be blocking the airway in unresponsive, unconscious casualties. The jaw-thrust should be used in this situation to open the airway. Alternatively, if there is no potential for spinal injury, the head tilt-chin-lift manoeuvre may be used. • Nasal or oral mechanical airway devices can be inserted into the mouth or nose to assist breathing. • Choking occurs when a foreign body lodges and obstructs the airway, resulting in an inability to breathe effectively • For a conscious choking casualty, provide up to five back slaps. If these fail to dislodge the obstruction, provide up to five abdominal thrusts. Alternate between back slaps and abdominal thrusts until the obstruction is dislodges or the casualty becomes unconscious • For an unconscious casualty who has been choking, inspect the airway (look into the mouth); provide 30 chest compressions and two ventilations. Continue this cycle, checking the airway before delivering the breaths each time • All major trauma patients should receive supplemental oxygen at a rate of 15 L/min • A hypoxaemic casualty requires high concentration oxygen until the oxygen saturation reaches 94–98%. • Oxygen equipment includes an oxygen cylinder, pressure regulator, flow meter, and a range of face masks or bag-valve masks • Always take appropriate safety precautions when working with or around supplemental oxygen to avoid combustion or damaging the cylinder • If a casualty is not breathing, he or she should be given ventilated breaths with a bag-valve-mask device • If more than one responder is present, the spine should be immobilised whilst securing the airway, before proceeding to the next step in the MARCH assessment process. Summary: Chapter 3: A: Airway Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 57 Apnoea: Condition where the casualty is not breathing. 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. Head tilt–chin lift manoeuvre: Opening the airway by tilting the head backward and lifting the chin forward, bringing the entire lower jaw with it. Hypoxaemia: Low levels of oxygen in the blood. Jaw-thrust manoeuvre: Opening the airway by bringing the jaw forward without extending the neck. I-Gel: Type of Supraglottic airway for unconscious casualties. 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. Pulse oximeter: A machine consisting of a monitor and a sensor probe that measures the oxygen saturation in the blood. Recovery position: A side-lying position that helps an unconscious patient maintain an open airway. Stridor: Harsh, unmistakable noise that indicates airway obstruction. Revision: 1. A casualty with an airway problem should be assessed A Only during the initial MARCH assessment B Regularly, based on the severity of the casualty’s condition C Every 10 minutes. D Every 2 minutes by your watch ANSWERS 1: B 2. Which of the following is NOT a sign of potential airway obstruction following trauma? A Swollen lips B Loss of facial hair following a fire C Confusion & memory loss D Blood in the mouth ANSWERS 2: C Vital vocabulary Chapter 3: A: Airway Management

58 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 3. The ability to talk is a sign that the casualty’s airway is: A Clear B Not at risk C Totally obstructed D Is not going to swell ANSWERS 3: A 4. To treat an unconscious adult who is choking, a responder should first: A Attempt five back blows followed by five abdominal thrusts B Attempt one abdominal thrust followed by five back blows C Encourage the casualty to cough D Commence CPR ANSWERS 4: D 5. Oxygen should be provided to a casualty suffering major trauma at a rate of: A 2000 psi B 20 breaths/min C 15 L/min D Delivery is based on the cylinder size ANSWERS 5: C Revision: Chapter 3: A: Airway Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 59 M.A.R.C.H algorithm – Airway management Chapter 3: A: Airway Management 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 MASSIVE HAEMORRHAGE AIRWAY PROBLEM? • Unconscious • Airway at Risk • Obstructed • Cx spine: if 2 persons • Sats <92% or less on air H R C

60 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Understanding respiratory problems Many trauma patients have respiratory or breathing problems, as a result of direct blunt or penetrating chest injuries as well as also other less obvious causes, e.g. head injuries, shock or a medical cause such as asthma. In casualties with serious chest trauma, the distress or difficulty in breathing can be very obvious, but in lesser trauma there may be few, if any, signs initially, but they may slowly develop and progressively get worse. Where there are injuries to the upper chest, the first and second ribs are very strong and offer protection to the structures of the neck and upper chest. If these ribs are fractured, it strongly suggests a major impact and likely underlying serious trauma with possible internal injuries. Such cases should be managed with a high index of suspicion and requires careful and regular reassessment. Wounds, especially penetrating wounds, (e.g. stabbings or gunshots) in the neck or around the collar bone can indicate serious internal injury to many of the important structures inside. This can make them challenging to manage in the field due to the presence of large blood vessels, nerves, and the trachea. When lacerated or torn by injury, many of these structures can retract into the chest or up the neck, increasing the risk of death. However, spinal injury in penetrating trauma of the neck is far less common and should not delay rapid management of bleeding and airway issues. Chapter 4: R: Respiratory Management

61 To assess respiratory problems, yet again we use the look, listen, and feel approach. This process must be repeated frequently in any major chest trauma as part of the regular casualty reassessment. The frequency of the assessments is normally every five minutes. However, it will depend upon obvious injuries and the rate of change in the casualty’s condition. In the most serious cases, it may be necessary to do almost continuous reassessments for increasing respiratory compromise. Look If there are no ‘M’ or ‘A’ issues to manage, then quickly focus your assessment on the chest especially if the casualty complains of pain from an injury (such as broken ribs) which restricts breathing and may indicate serious underlying injury. Always fully expose the chest to look for: • Areas of bruising • Open wounds • Penetrating objects • Deformity of the chest • Flail segments (where multiple broken ribs move in and out abnormally) (see figure 4.1). A flail segment always looks abnormal and can be very compromising as a result of pain, impaired ventilation mechanics and potential underlying lung injury. This does not require immediate stabilisation or strapping but we can encourage the casualty to support or ‘hold themselves’ as this will help reduce pain and improve their breathing. We would only strap up the chest if this was essential to facilitate extrication from difficult access. Major chest trauma cases must be carefully observed as a flail, multiple rib fractures or lung injury can easily become a time critical problem. Deterioration will usually present with a considerable increase in respiratory rate, difficulty in breathing, pain or a significant fall in oxygen saturation. Figure 4.1: Chest flail segments: multiple ribs broken in more than one place move independently of the rest of the rib cage and can seriously compromise breathing. Assessing respiratory complications Chapter 4: R: Respiratory Management Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com

62 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The next step in our assessment is to get your hands on and ‘feel’ the chest. Before putting your hands on the chest, ask the casualty whether they are happy for you to help them and if they have any pain in the chest. If they do, starting away from the pain, gently but thoroughly, feel over all four areas of the chest wall including the front, both sides and the back for any pain, abnormal sensations, movements (e.g. ribs moving inwards when the casualty breathes in) or wounds. Imagine the chest as a ‘box’ that has a front, two sides, a top and back. Ideally the chest should be fully exposed, but in public we should at least try to preserve the dignity of the casualty. This can be performed by exposing selected areas in turn, working around the chest, but ensure that all areas, including the back and sides are assessed. It is rarely necessary to remove a lady’s bra, unless you suspect or can see an underlying injury. A key area that often gets missed and must always be checked, especially in tactical incidents or assaults are the armpits, which must be fully explored (see figure 4.2). Figure 4.2 : Exposure of the chest to look and feel for injuries in the four areas Remember to always feel up and down the back of the chest and look for blood on your gloves In penetrating trauma, wherever possible log roll the casualty and search the back directly. If this is not possible, at the very least get your hands up and down the sides at the back, looking for tenderness or blood on your gloves. Examine the chest for equal movement on both sides; remember that the chest effectively has four sides (front, back and two sides). Carefully feel all over the chest and up into the armpits for wounds, areas of boggy swelling, or a crisp, crunchy sensation (like the crushing of fresh snow) which suggest serious chest trauma. If any of these characteristics are present, the casualty may quickly become time critical, so regular reassessment is again crucial. Gently place your hands on the front left and right sides of the chest, ask the casualty to take a big breath, in and out, as best they can and watch that the rise and fall corresponds with breathing: • Is it equal? • Does the movement look ‘right?’ Serious problems will usually very obvious and although the cause may be not as obvious, it will clearly look abnormal. Feel Chapter 4: R: Respiratory Management

63 Signs and symptoms of respiratory concerns include: • Extremely fast breathing (>20 breaths/min) • Extremely slow breathing (<8 breaths/min) • Grossly unequal chest movement when comparing both sides • Badly deformed chest • Open or “sucking” chest wounds. BTACC responders use a more comprehensive assessment method: As a simple aid or reminder for examining the chest in BTACC, we use the acronym ‘R U IN SHAPE.’ This can be used even by those who cannot use stethoscopes or perform percussion. R – Respiratory rate U – Unequal chest movement IN – Injuries, e.g. wounds, pain S – Search the chest H – Hands to feel all areas A – Ausculate or listen (with stethoscope if trained P – Percuss over chest E – Everywhere (all four sides of the chest – area not already checked) Managing respiratory problems A high respiratory rate usually indicates a significant problem. Fast breathing (> 20 breaths/min) may simply be due to pain or anxiety, but it may also indicate a more serious concern such as chest injury, major haemorrhaging, or head injury. Supplemental oxygen will not improve the casualty who is in pain or anxious, but is essential for those suffering major trauma (see Chapter 3). Providers should use a pulse oximeter to assess the effectiveness of oxygen therapy and titrate it in response to keep saturations >94%. (Remember: Oximetry is unreliable in smoke inhalation/CO poisoning) Another simple but highly effective measure in chest trauma is to simply sit the casualty up. This will often greatly help the casualty with the breathing compared to having them strapped to a flat board or scoop. This may be a balance of risks between spinal immobilisation and breathing and much like airway, breathing must take priority if they are struggling, so gently sit them up. Finally, reassurance is often under-estimated and an effective way to manage chest trauma victims who are scared when they cannot breathe. Encourage them to take slow steady breaths rather than big breaths, which may be impossible. If necessary, and if they have pain, suggest that they support their chest or ribs to minimise pain. Penthrox is ideal for managing moderate to severe pain in chest trauma. Remember: Entonox cannot be used safely in chest trauma and is contraindicated. These may be the only therapies available to the BTACC/ RTACC provider facing a case of serious chest trauma, but these alone could be life saving. Any trauma patient breathing at less than eight breaths/min requires ventilation support with a bag-valve-mask device. This is increasingly reported for a short period after major blows to the head and is called sudden impact brain apnoea. Simply supporting their breathing for a short period can be life-saving. Extremely slow breathing (< 8 breaths/min) may also indicate a serious problem such as a drug overdose, e.g. Fentanyl or heroin. If the casualty has a decreased level of consciousness or is unresponsive, the responders should support the casualty’s breathing by using a bag-valve mask with supplemental oxygen attached (see Chapter 3). Responders should aim to raise the casualty’s respiratory rate to normal levels (12–14 breaths/min). For example, if the casualty is breathing at a rate of six breaths/min, the rescuers should provide 6–8 breaths/min. Signs and symptoms of respiratory problems - ‘Time critical’ Chapter 4: R: Respiratory Management r chest or ribs to minimise pain. Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com

64 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Penetrating chest injury, although less common in the UK than blunt trauma, is sadly increasingly common in many parts of the modern world especially with stabbings, terrorism and active shooter incidents. The chest cavity has two sides, which are separate sealed chambers, with a lung in each side (like two balloons). Inside the chest is normally at slightly below atmospheric pressure to keep the lungs inflated. However, if a hole is created in the chest wall, air will move in from outside and can collapse the lung on that side. The other lung should remain unaffected, unless the hole also enters that side of the chest too. If fit and well, the casualty can survive, with one collapsed lung, although they will experience some breathlessness, especially if they exert themselves. However, if the casualty has any chest disease or limited respiratory reserves, then they will not do so well and may quickly become short of oxygen and very distressed with a high respiratory rate. Sucking chest wounds Sometimes air can be heard going in and out of the hole in the chest. If the hole allows air in but not out, this is called a ‘sucking chest wound’ (see figure 4.3) and the risk is that air will get in and accumulate, unable to get out. This can lead to a build of pressure in the chest, which is called a ‘Tension’ pneumothorax and can be life threatening. When spontaneously breathing this is usually slow to develop. If we are supporting the breathing with ventilation, e.g. BVM, I-gel etc then this “tension” can occur far more quickly and we should be aware of that risk with holes in the chest when ventilating. The main aim of BTACC care is to cover or seal the hole, ideally with a specialist dressing, with a ‘one way’ non-return valve that will allow air to pass out of the chest but not go back in. This should avoid any risk of tension pneumothorax and will also help the collapsed lung to re-expand Such dressings are called CHEST SEALS and there are many different types. Some of the early ones will not stick well if there is moisture, sweat or blood on the chest. The Ashermann type can also get blocked with blood and clot. The modern versions are e.g. Bolin, Russell or SAM seals. Some seals do not have valves and simply stop air entering but does not allow it to leave. A chest seal sticks directly over the hole (see figure 4.4) Figure 4-3: Typical open chest wound which may be ‘sucking’ and should be chest sealed. (This hole may be into either the chest or abdomen It doesn’t matter, just seal it). Figure 4.4: Use of chest seal. a) Assess the chest wall and identify any open wounds (front, sides or back). b) Open the chest seal dressing pack. c) Dry the area around the hole with the gauze swab in the pack to give the dressing the best chance to stick to the skin around the wound. Dressing chest wounds - Penetrating trauma Chapter 4: R: Respiratory Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 65 Chest seals with valves act as one-way air valves, allowing air to leave the chest cavity without getting sucked back in. These dressings can help prevent more serious complications and minimise lung collapse. In traditional tactical medicine, an improvised three-sided dressing, was the first aid measure of choice. However, these have a poor record for effectiveness as they take time to create, often don’t stick well or don’t act as an effective valve. If you don’t have a proper chest seal dressing, then we would recommend that you simply seal the hole with wide adhesive tape, e.g. gaffer tape, an adhesive dressing or even a gloved hand. Chest seals should be applied to any wound or ‘hole’ in the torso, as in penetrating upper abdominal wounds it may also involve the chest cavity, e.g. an long knife wound to the stomach. Chest seals will not stick to the chest wall effectively unless the chest is thoroughly dried before application. Many manufacturers include a single gauze swab to dry the chest before application. Regularly check that the dressing is still adherent. Manufacturers have worked hard to produce effective adhesive dressings and the modern versions stick far more effectively. In some situations, more than one wound may exist. Multiple seals dressings should be placed on the casualty’s wounds. If the casualty has a very large wound, single chest seals or dressings may not provide adequate coverage. In this case, air trapping and tension in the chest is unlikely, so providers should simply attempt to control any bleeding with dressings and keep the area free from contamination by foreign debris. Cling-film can be used for this purpose. Figure 4.4: Use of chest seal. e) Ensure a good seal of the dressing. If it does not fully cover the wound or is not big enough, a sheet of cling-film or a damp saline soaked swab can be used (If the wound is large it is unlikely to be sucking and trapping air, but the lung will still be collapsed inside). d) Peel off backing to expose the adhesive side of chest seal and apply over the wound. Dressing chest wounds Chapter 4: R: Respiratory Management

66 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com If there are multiple wounds or you have no seal then apply an improvised three sided dressing: 1. Place a square of non-porous material (such as plastic dressing packaging) over the wound 2. Tape the dressing on the top and both sides using adhesive tape 3. Leave the bottom of the dressing free, to act as a one-way flap valve and allow any blood to drain out of the chest. Positioning chest trauma - Bad side up or down? A famous trauma myth is that chest trauma cases should be managed ‘Bad side down’ - This was proposed to avoid blood spilling from the upper bad lung into the lower healthy lung, but this is wrong for several reasons: • Contamination from the bad lung to the good one is very unlikely to be an issue • It is painful to lie on the injured side • We cannot monitor the wound if the casualty lies on it • Physiologically, the blood volume in the lungs follow gravity and needs to be in the best working lung, it should therefore be the undamaged one lower-most, with the injured lung upper-most should be on the top side. Therefore, always manage chest trauma cases either sat up or ‘Bad side UP’. Dressing chest wounds Chapter 4: R: Respiratory Management Figure 4.5: Improvised 3 sided dressing in place over a chest wound on the back (arrow indicates the ‘open’ edge) - poor alternative compared to a chest seal.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 67 Ventilating a casualty with a bag-valve-mask is considered a core skill by many responders, but it is one that is often performed badly and ineffectively. It is very easy to simply squeeze the bag, thinking that you are doing a good job, but without actually having any positive effect on the casualty. This is a key part of the reasoning behind ‘hands-only’ CPR, as time wasted providing poor ventilation to the patient, could be better used performing high quality chest compressions. This is discussed further in the cardiac arrest chapter. Use of a Bag-Valve Mask Firstly, it is important to select the correct sized face mask for a good seal between the face and the mask. The mask should sit with the top narrow part over the bridge of the nose and the bottom wider part between the lip border and chin (see figure 4.6). Secondly, it is important to achieve an adequate seal. 1. Form a ‘C’ shape with the index finger and thumb of your dominant hand. 2. Place this around the mask connector and press it down onto the face (thumb over nose and finger over lower edge of mask (chin). 3. Place your other three fingers behind the ‘angle’ of jaw and pull jaw into mask and to open the airway by pulling the jaw forward. 4. The challenge is to press down the mask creating a seal, whilst keeping the airway open. 5. If you achieve this then you can ventilate by squeezing the bag with the other hand. This can be relatively easy or it can be extremely difficult, even for experienced airway experts. Providing supplemental ventilation Chapter 4: R: Respiratory Management Figure 4.6: Applying a non-breathing face mask (left) and checking that the reservoir bag inflates right).

68 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com With training and practice/regular use, even a single responder can ventilate a casualty using a bag-valve-mask device; however, the two person technique is a far more efficient way of providing supplemental ventilation +/- oxygen to the casualty in less experienced hands. (see figure 4.7). To use a bag-valve mask with two responders 1. Choose the correct size of mask to cover the nose and mouth. 2. Position the mask on the patient’s face and ensure an adequate seal. 3. Place the thumbs on either side of BVM connector on the mask and with the fingers open either side like making a ‘butterfly’. 4. With the fingers feel for the angle of the jaw on each side and slide the fingers behind to pull the jaw forward (plus if necessary and safe, a gentle head tilt if required). 5. Press down with the thumbs and pull up with the fingers to seal the mask on the face whilst keeping the airway open. 6. The second responder then squeezes the bag, for approximately one second and both responders watch for a visible chest rise. 7. Release the bag and watch the chest fall. 8. Allow the bag to re-inflate slowly and completely. 9. Repeat at 12-15 breaths per minute in an adult. Ensure that you do not squeeze the bag too hard. Normal chest rise and fall should be observed and used as a guide of how much to squeeze. When two responders use the BVM, one hand holds the mask onto the casualty’s face and the other hand will squeeze the bag, making sure it is squeezed only enough to make the chest rise in a normal fashion. By looking at the amount of chest movement the ventilation volume (squeeze of the bag) can be adjusted so that even a large adult bag can be safely used on small adults and children if a suitable BVM is not available. Using the bag-mask device requires proper training and practice, for those who do not use it frequently it should be a two person technique. BTACC recommends that if working alone, use the pocket mask to support ventilation or do ‘hands-only’ CPR. Providing supplemental ventilation Chapter 4: R: Respiratory Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 69 Figure 4.7: Two person use of a bag valve and mask Chapter 4: R: Respiratory Management Providing supplemental ventilation

70 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The look, listen, and feel approach is used to assess respiratory complications and should be repeated as part of reassessment. • Look around all four sides of the chest for any wounds, bruising, or flail segments. Think of it as a box • Listen to the casualty’s ability to speak and any wheezing or sucking sounds from the chest • Feel for any wounds, pain, broken ribs, or signs of chest trauma • The following conditions are all considered time critical: extremely high or low respiratory rates, difficulty breathing, inability to complete full sentences, low oxygen saturation rates, penetrating chest wounds, fractures to the first or second ribs and gross chest deformity • Open or “sucking” chest wounds may indicate lung collapse and should be dressed with a chest seal or three-sided dressing • If a chest wound is too large for a single dressing, aim to control bleeding and keep the area clean. A casualty suffering major trauma with any of the following is considered time critical: • Respiratory rate > 20 breaths/min • Respiratory rate < 8 breaths/min • Difficulty breathing • Unable to complete full sentences • Oxygen saturation less than 91% on air, 94% on oxygen (or 88% with known underlying chest disease) • Penetrating chest wound • Fractures to first and second ribs • Gross deformity to chest wall • Manage chest trauma sat up or bad side up. Vital vocabulary Chest seal: Specialised circular, adhesive dressing used to cover open or sucking chest wounds. Pneumothorax: Collapsed lung. Respiratory rate: Number of breaths per minute. Three-sided dressing: Type of square dressing traditionally 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. There are now much better alternatives. Summary: Chapter 4: R: Respiratory Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 71 1. Which of the following is NOT a step in respiratory assessment? A Look for equal chest movement B Listen for “noisy” breathing C Assess for reduced conscious level D Feel for painful broken ribs ANSWERS 1: C 2. Respiration should be considered time critical if it is: A Less than 12 breaths/min B Less than 20 breaths/min C More than 12 breaths/min D More than 20 breaths/min ANSWERS 2: D 3. Which of the following conditions is NOT time critical? A Ability to talk normally without gasping B Oxygen saturation less than 90% on air C Difficulty breathing and unable to speak D Grossly unequal chest movement ANSWERS 3: A Revision: Chapter 4: R: Respiratory Management

72 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 4. Which of the following should be applied to a sucking chest wound? A Chest seal B A chest tube most be inserted C Four-sided dressing D No dressing should be applied ANSWERS 4: A 5. If a wound is too large to be covered, even with multiple dressings, you should A Bandage around the chest B Put the casualty head down C Control bleeding with dressings and keep the area clean with cling-film D Wrap clothing or blankets around the wound ANSWERS 5: C Revision: Chapter 4: R: Respiratory Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 73 M.A.R.C.H algorithm – RESPIRATORY Chapter 4: R: Respiratory Management 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 RESPIRATORY SUPPORT • Oxygen 15L/min • Chest seal (wounds) • RR <8/min - BVM - Pocket mask • Bad side upper most • Consider sitting up MASSIVE HAEMORRHAGE AIRWAY PROBLEM? • Unconscious • Airway at Risk • Obstructed • Cx spine: if 2 persons • Sats <92% or less on air H RESPIRATORY PROBLEM? • RR >20/min • Difficulty in breathing • RR <8/min • Sats <91% air / <94% 02 • Open Wounds • Unequal Movement C

74 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Understanding circulatory concerns We have already discussed the measures to control massive external haemorrhage and taking steps to control any life-threatening external bleeding. If the bleeding is not controlled or cannot be controlled, (e.g. if is ‘internal bleeding’ - inside the body), the casualty may gradually go into a state of shock. This can take hours or as little as a few minutes in major bleeding. Shock is failure of the circulation in which the organs in the body, (e.g. brain, kidneys etc) do not receive the essential oxygen and substrates they need to survive. Initially the skin is affected and we turn pale and cold to touch, as blood is diverted from the skin, but eventually the essential organs such as the heart, brain, lungs and kidneys get insufficient blood supply. The total blood volume of an average adult is approximately five litres. As blood loss reaches 1000 ml, the casualty may already start to show signs of shock. The effects of significant blood loss on a healthy casualty can vary massively (see table 5.1). The actual amount of blood lost may be difficult to estimate based on blood on the floor or their appearance alone; therefore efforts should be made to assess the casualty’s consciousness, capillary refill time, and pulse rate to determine the extent of blood loss. Chapter 5: C: Circulatory Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 75 Table 5.1 – Effects that significant blood loss can have on a healthy casualty Amount of Blood Loss (in ml) Signs/Symptoms <500 ml Little serious effect, light-headedness, feeling a little faint 1000–1500 ml Shock, fast pulse rate, fainting, anxiety, restlessness, agitation, drowsy, going quite 2000–2500 ml Extremely fast pulse rate, breathlessness, confusion, reduced consciousness > 3000 ml Coma and ultimately death Remember that massive blood loss can occur internally with minimal, if any, external signs. Do not expect to see the abdomen or parts of the body swelling as significant or fatal. Volumes of blood can be lost with long bone fractures, (e.g. thigh bone/femur) and into the major body cavities such as the chest, abdomen and pelvis without such signs externally. When these injuries are suspected, efforts should be made to: • Handle the casualty gently (minimal log rolling especially) • Immobilise fractures in the injured area to prevent further blood loss • Keep the casualty warm • Facilitate rapid transport to hospital. Signs and symptoms of shock As we saw from the above table, there are many signs of shock and blood loss including: • Changes in mental status • Confusion, restlessness, or anxiety • Cold, clammy, sweaty, pale skin • Rapid breathing (as shock progresses, breathing may become more rapid and shallow). • Rapid, weak pulse or loss of pulse • Increased capillary refill time • Nausea and vomiting • Weakness or fainting • Thirst • Coma and death. Chapter 5: C: Circulatory Management Signs and symptoms of blood loss:

76 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Assessing circulatory problems The indicators that BTACC use to rapidly assess the circulation are consciousness, capillary refill time, presence of pulses and pulse rate. Individually, they may not provide sufficient information, but if they are used in combination we obtain a more reliable simple assessment of the circulation status. Consciousness Consciousness is a useful indicator of the severity of shock. If an adult casualty is conscious and fully oriented, talking and making sense, he or she is not in a significant state of shock. However, if the casualty appears confused or agitated, this may be an indication of shock, especially if there is no other obvious cause. Casualties in this state, if due to shock, should be considered potentially time critical and in need of close observation and reassessment. Severe confusion, drowsiness and ultimately unconsciousness may indicate severe shock and should always be considered time critical. This explains the commonly used term – ‘always worry about the quiet ones’ or casualties who start to go quiet. Continue to regularly monitor for change at all times as shock may develop or get worse if bleeding continues. Capillary Refill Time Capillary refill time is the time required to restore the colour to the skin. This is due to return of blood to the small capillary blood vessels after it has been squeezed out of the skin. Since many factors can affect capillary refill time, (e.g. being cold, poor circulation as well as shock), this indicator alone is a not a reliable assessment tool. Capillary refill time should be considered in conjunction with other methods of assessing circulation, such as pulse rate and level of consciousness. To check a person’s capillary refill time: • Press your thumb on the patient’s nail bed or forehead for five seconds. (If the environment is very cold, use the skin over the sternum or breastbone – compare with yourself) • Release your pressure and watch how long it takes the colour to return. After releasing your thumb the colour should return to the area within two seconds, indicating appropriate blood circulation and volume. A prolonged capillary refill time is anything over two seconds and indicates a possible state of shock (see table 5.2). If it is three to four seconds or more, this is very prolonged and further suggests serious shock. Table 5.2 – Capillary Refill Time State of Capillary Refill Time Time Until Normal Colour Returns Normal <2 seconds Prolonged (potentially time critical) 2–4 seconds Significantly delayed (time critical) >4 seconds It may be difficult to assess capillary refill time in situations with poor lighting, in cold environments, and on casualties with dark skin or severe burns. Chapter 5: C: Circulatory Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 77 The pulses (pressure waves down an artery as the blood pumps from the heart) are felt most easily where an artery runs superficially over a bone, e.g. radial pulse at the wrist, but they may be felt at many different locations on the body. The most common pulse points used in trauma and resuscitation are the radial (wrist) (see figure 5.3) and carotid (neck) (see figure 5.4). In children, the brachial pulse (inside of the elbow) should be used (see figure 5.5) (see chapter 9.2). To determine the pulse rate in beats per minute (if a pulse oximeter is not available or recording) find the patient’s pulse with your fingers: • Count the number of beats for 15 seconds • Then multiply this by four. In a normal adult, the resting pulse rate is 60–100 beats per minute. If the casualty appears unwell and the pulse rate is faster than 110 beats per minute or there is no detectable pulse and the casualty is clearly unwell, this indicates a time critical situation. Signs and Symptoms of potential Circulatory problems include: • Pallor (pale skin) • Cold, clammy skin • Increased pulse rate • Prolonged capillary refill time • Loss of a radial pulse • Confusion or coma. Figure 5.3: Radial pulse: Feel the radial pulse if the casualty is conscious or you have successfully found a carotid pulse. Figure 5.4: Feeling for the Carotid pulse on the right: Feel the carotid pulse if the casualty is unconscious or there is no radial pulse. Figure 5.5: Locating the Brachial pulse: Here it is located under the fingers of the casualty carers left hand. This is often useful and easier to find in children. If no radial pulse is palpable then immediately feel for a carotid pulse. If the carotid pulse is absent or you are unsure and the casualty is unconscious, with no signs of life or normal breathing, then immediately commence chest compressions and life support (CPR). If in doubt, commence CPR in the unconscious/unresponsive casualty. Pulses and pulse rate No Radial | Brachial Feel for carotid No Carotid / No signs of life Life Support CPR Chapter 5: C: Circulatory Management

78 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The BTACC techniques do not include the use of intravenous fluid replacement therapy (IV drips), but concentrates on the fundamental principles of ‘circulation preservation’ (focusing on preventing further blood loss): • Rapidly identifying any ongoing bleeding, signs of worsening shock • Using external haemorrhage control • Gentle handling • Splinting of fractures & pelvis • Scoop-and-run rapid evacuation (transport to hospital as quickly as possible) for time critical casualties. These actions are all simple, but potentially life-saving, measures which can minimise serious blood loss and considerable pain. Circulation preservation Circulation preservation includes several key steps. The first step is to ensure that massive external haemorrhage has been controlled. As we now consider the C’ stage in the algorithm, providers should recheck the casualty for any further external bleeding and if necessary, use the DiD-iT technique of direct pressure, direct pressure, and tourniquet application to control bleeding. (See chapter 2) C – Is now time for bandaging When controlling external major haemorrhage in ‘M’ we DO NOT BANDAGE as this takes too long and is fiddly and difficult, when working under pressure and when your hands are wet or shaking with adrenaline. Once we have managed the massive haemorrhage (I-DID-IT) we can then consider bandaging to cover the wound and to control any ongoing oozing or lesser bleeding. Ideally we use an elastic combat dressing, with an absorbent pad attached, for this purpose. These allows us to maintain firm pressure, uniformly over the wound without ongoing manual direct pressure. Gentle handling is particularly important when massive internal haemorrhaging is suspected, as rough handling and movement may dislodge blood clots which have plugged or reduced the bleeding, e.g. pelvic bleeds. As bleeding into the pelvic cavity can be life-threatening, early application of a pelvic binder, whenever a pelvic injury is suspected, is a “Circulation” measure to reduce blood loss from movement in the fractured pelvis. Splinting: As well as splinting the pelvis, we should also aim to splint the fractures, especially of the long bones such as a femoral fracture. This should be viewed as an essential part of reducing haemorrhage. (See chapter 6) Elevation of legs BTACC does not recommend elevation of the legs in major trauma unless pelvic and spinal injuries have been excluded. In such casualties, if there is no suspected head injury once the casualty is on a scoop long board a slight head down tilt can be used (raise leg-end of the board by 10 - 15cm, e.g. a pillow under the end of the board) if they are feeling very faint. However, this is rarely effective in major trauma and may just delay rapid transfer to a hospital and is more of a first aid measure. Managing circulatory problems Chapter 5: C: Circulatory Management

79 Scoop-and-run evacuation For BTACC providers, Scoop-and-run, early and rapid evacuation is the currently recommended alternative to the old school ‘stay and play’ approach. We should only stay on scene if we are still performing any essential action (usually life-saving) or if the patient transport has not arrived. On rare occasions, if a casualty is time critical and deteriorating and a hospital is close by if the ambulance is significantly delayed, then a decision could be made to transport the patient in a suitable alternative vehicle, e.g. Police car or fire appliance. This should always be discussed with those on scene and a senior officer. Advice could also be obtained from the major trauma centre, Trauma Team Leader via the hospital Red phone. The aim of providers should be to rapidly collect the casualty and transfer him or her to a suitable hospital or equivalent as quickly as possible (see figure 5.6). Offering unnecessary advanced medical skills at the scene may delay transfer to hospital significantly and could compromise the casualty, if not appropriate. Under certain circumstances and with the correct team and equipment complex life saving procedures may be required before transfer. However, these skills are beyond the realms of BTACC providers. Figure 5.6: Rescuers prepare the casualty for a rapid evacuation in the ambulance. Whilst aiming for a rapid transfer, it is still very important to keep all movements smooth and controlled with gentle handling to avoid increasing bleeding or pain. The casualty must be continually reassessed for any signs of ongoing blood loss or worsening shock. To miss a casualty who is deteriorating from worsening shock would be a catastrophe, so with a seriously ill or injured casualty we must stay vigilant. Signs of worsening shock include: • Deteriorating conscious level • Increasing pallor • Cold, clammy skin • Increasing breathing rate • Increasing pulse rate • Loss of palpable pulses • Poor or no signal on the pulse oximeter. Paramedics will usually be given a clot promoting drug called TXA (Tranexamic acid) to such patients and the medical teams will now even give blood on scene, rather than the traditional saline drips. Identifying signs of worsening shock Chapter 5: C: Circulatory Management Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com

80 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Vital vocabulary Capillary refill time: The time taken for the circulation to return to the capillary blood vessels in the skin after it has been squeezed out by the rescuer. Shock: Failure of the cardiovascular system in which the body is not getting the essential oxygen and substrates it needs to survive. Pulse: The wave of pressure created by the heart as it contracts and forces blood into the major arteries and around the body. • If bleeding is not adequately controlled, the casualty may go into shock. • Signs and symptoms of shock include: changes in mental status; confusion or agitation; cold, clammy, sweaty, pale skin; rapid breathing; rapid, weak pulse; increased capillary refill time; nausea and vomiting; weakness or fainting and thirst • The extent of blood loss is difficult to determine based on appearance alone • The human body contains about five litres of blood. The body compensates well for small amounts of blood loss (under 1000 ml) but large amounts may lead to shock • To assess the volume of blood lost, responders should examine the casualty’s state of consciousness, capillary refill time, and pulse rate • Unconsciousness or severe confusion may indicate severe shock and should be considered time critical • To check a person’s capillary refill time, press your thumb on the casualty’s nailbed or forehead and squeeze for five seconds. If it takes more than 2 seconds for colour to return, this may indicate shock • The radial (wrist) pulse should be used for conscious casualties. The carotid (neck) pulse should be used for unconscious casualties. The brachial pulse (inside the elbow) should be used for infants and children • To determine the pulse rate either use the pulse oximeter reading or find the patient’s pulse with your fingers and count the number of beats for 15 seconds, then multiply by four • In a normal adult, the resting pulse rate is 60–100 beats per minute. More than 110 beats per minute or less than 40 beats per minute indicates a time critical situation • The BTACC method does not include the use of intravenous fluid replacement therapy (IV drips) and instead concentrates on circulation preservation using assessment • DiD-iT, gentle handling of the casualty, and immobilising the injured area • Providers should examine casualties for signs of worsening shock • Rapid, scoop-and-run evacuation is also critical in managing circulatory concerns. Summary: Chapter 5: C: Circulatory Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 81 Revision: Chapter 5: C: Circulatory Management 2. If circulation is not preserved, then the patient may: A Develop a very slow pulse rate. B Be stabilised with intravenous fluids. C Develope features of shock such as confusion. D A blood transfusion is a better management option for pre-hospital. ANSWERS 2: C 1. Why is estimating the volume of blood loss difficult? A It is easy to estimate volume if you simply look at the casualty and the scene. B Bigger people don’t contain any more blood volume. C The scene, source, duration and rate of the blood loss are all major factors. D A casualty who is very cold will always lose less volume. ANSWERS 1: C 3. Which of the following assessment tools can be used to assess circulation? A The casualty’s ability to speak in full sentences. B Capillary pulses. C Presence of heart sounds. D Conscious level. ANSWERS 3: D

82 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 5. Which pulse should be examined first for conscious, adult patients? A Carotid pulse B Radial pulse C Brachial pulse D There is no need to check the pulse rate of a conscious patient. ANSWERS 5: B 4. Which of the following capillary refill times indicates circulation of a normal volume and status? A More than 3 seconds B 2 seconds or less C More than 4 seconds D Less than 3 seconds ANSWERS 4: B Revision: Chapter 5: C: Circulatory Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 83 M.A.R.C.H algorithm – circulation Chapter 5: C: Circulatory Management 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 MASSIVE HAEMORRHAGE AIRWAY PROBLEM? • Unconscious • Airway at Risk • Obstructed • Cx spine: if 2 persons • Sats <92% or less on air H 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

84 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Chapter 6: H: Head Trauma and Other Serious Injuries Understanding other trauma concerns The last step in the M.A.R.C.H algorithm addresses head trauma and other serious injuries, including spinal injuries, fractures, abdominal injuries, burns, smoke inhalation, and carbon monoxide poisoning. When appropriate, responders should perform a full-body ‘head to toe’ and ‘front, back and sides’ examination of the casualty to determine the presence of any trauma or injuries. Always try to maintain a high level of respect for the casualty’s dignity in performing this assessment and take the necessary precautions to prevent heat loss during the examination.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 85 Head trauma is a common cause of death or long-term disability. The initial “primary injury” has already occurred, but responders aim to prevent or limit further damage or ‘secondary injury’ as a result of problems such as an obstructed airway, lack of oxygen, inadequate breathing, low blood pressure/shock, or falling level of consciousness. Signs and Symptoms of Head Trauma Signs and symptoms of head trauma include: • Reduced level of consciousness • Wounds or obvious deformity to the head • Watery fluid coming out of the ears or nose • Enlarged pupil in one eye (usually a serious sign) • Combativeness or other abnormal behaviour • Seizures • Low respiratory rate (< 8 breaths per minute). It is essential to detect any changes in a casualty’s level of consciousness, as this can indicate the severity of any injury to the brain (see table 6.1). Change over time or a trend tells us far more than just an isolated assessment. By using the AVPU scale, a responder can ascertain the extent of injury and any improvement or deterioration in the casualty’s condition. For casualties who are ‘A’ or ‘V.’ Attempt to keep the casualty talking to continually reassess consciousness. All casualties that are ‘P’ or ‘U’ should be considered time critical. Table 6.1 – AVPU Assessment Table Assessment Response commands A Alert V Responds to verbal P Responds to pain Time Critical U Unresponsive Time Critical Head trauma Chapter 6: H: Head Trauma and Other Serious Injuries

86 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com For time critical casualties, rescuers should provide effective supportive measures such as providing supplemental oxygen, maintaining an open airway, ensuring adequate respiration, preserving circulation, and arranging for rapid transfer to hospital. There is little more that rescuers can do to manage traumatic brain injuries, but any delays increase the risk of a poor outcome. Current UK standards aim to have all head trauma casualties in hospital for a CT scan within one hour from the time of injury and, if required, in a specialised neurological unit within four hours. If a casualty is suffering from concussion, they will be conscious but may be impaired, confused, or dizzy. Mild head injuries typically do not cause any long-term damage to the brain but may be unnerving for the casualty or those with him, especially if memory of the incident is lost. Responders should assess the casualty using the AVPU system and, if alert, permit a responsible adult or relative to monitor the casualty noting that if the casualty develops a headache, nausea, vomiting or blurred vision, he or she should be taken directly to hospital. Any sports players with concussion should cease playing until reviewed by a medical professional. If the level of consciousness is falling, call an ambulance. Consider all casualties with head injury to have a neck injury until they can be clinically cleared or assessed and examined in hospital. Head trauma Chapter 6: H: Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 87 A spinal injury can have catastrophic consequences, including long term paralysis of limbs or even the acute inability to breathe effectively. However, if effectively managed after the primary or initial injury, much like brain injuries, the risks of any further damage can be minimised. The spinal cord extends from the base of the brain to the lower back and is protected by the vertebral column of bones which comprises of 33 individual bones called vertebra (see figure 6.3). These extend from the base of the skull at the neck through the chest and back to the base of the spine. Injuries to the spine may involve fractures to any of these vertebra or tears to their supporting ligaments, that hold them together in a ‘stack’. Such a fracture does not always mean that there is an injury to the spinal cord or paralysis. The cord runs up and down the back within a bony tunnel created by all of the vertebrae and there is a small amount of space around the cord in the tunnel, which allows for some bony movement or bleeding without compression of the cord. The management of spinal injury aims to: • Identify or exclude spinal injury and to ‘clear’ the spine • Avoid causing secondary spinal injuries and making things worse. To identify spinal injury, first consider the mechanism of injury of the incident—ascertain what has happened to the casualty (e.g. ejection from a vehicle, fall from height etc) and for any clues at the scene, that may suggest spinal injury (e.g. cracked windscreen). • Listen to the casualty regarding pain, pins and needles funny sensation or an inability to move, these may all be signs of spinal or spinal cord injury. Injuries to the spine are more common in the following situations: • Rapid deceleration (e.g. fall from height, road traffic collision) • Direct blows to the head, neck, or back • Injuries close to the spine (e.g. penetrating stab wound to neck) • Extreme twisting or traction injuries to the head, neck, or back • Injuries resulting in unconsciousness. Figure 6.3: Three views of the human spine. Note that it is not straight, but actually has several natural curves. As a result, neither the scoop, long-board nor the KED are the ideal ‘spine protectors’ as they are hard, flat and uncomfortable. As such, they should be seen more as an extrication tool, a spinal splint or short-term transport devices. Spinal injury Chapter 6: H: Head Trauma and Other Serious Injuries

88 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com To manage spinal injuries, the primary focus of rescuers is to prevent further injury. This is especially important, in the situation described in the section above, when the back is ‘broken’ or fractured, but the spinal cord still appears undamaged and intact (that is, the casualty has no abnormal sensations or weakness). Early recognition of the injury and careful handling could mean the difference between full recovery and lifelong paralysis. Spinal injuries can only be managed effectively with two or more rescuers. A single rescuer can do little alone to manage a spinal injury, other than to hold the head, reassure the casualty and to tell them not to move. This is less problematic now that we increasingly appreciate that conscious casualties will often protect their spines far more effectively than we can. This means that the single rescuer is better focused on haemorrhage control, airway, respiration and circulation. If two or more rescuers are present and spinal injury is suspected, the cervical spine should be manually immobilised immediately after the airway is secured (see Chapter 2). All casualties with signs or symptoms of spinal injury should be considered time critical. A spinal injury can have catastrophic consequences including paralysis of limbs or even the inability to breathe effectively. Remember that being smooth and gentle, avoiding rotation or bending the spine is key. However, it is important to remember that as long as you are gentle your handling actions will be trivial compared to the initial injury or impact. Signs and Symptoms of Spinal Injury Signs and symptoms of spinal injury include: • Sharp, severe neck or back pain • Limited mobility of the neck • Feelings of “pins and needles” • Numbness or weakness of the arms or legs • Deformity of the back • Abnormal posturing • Unconsciousness • Paralysis or weakness • Loss of bladder or bowel control • Persistent penile erection • Unexplained signs of shock. The spine should not be immobilised if any of the following conditions are present: • Immobilisation of the spine would obstruct or prevent airway management • The patient forcibly refuses to be immobilised • The trauma is only very minor or isolated (e.g. a limb injury, stabs, gunshots) • A clinician has effectively “cleared” the cervical spine. If you suspect or identify a spinal injury at any level, immobilise the entire spine. Always consider pelvic injury if any mid or lower spinal injury is suspected. If you are unsure about the presence of a spinal injury, be cautious and fully immobilise the entire spine. Spinal injury Chapter 6: H: Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 89 There is now considerable debate about spinal immobilisation and the traditional approach of collar blocks and scoop/board is not considered as ‘gold standard’ any more as a vac-mat is considered better, but they are still used by most providers as simple and familiar. This is likely to change in the next few years with more frequent ‘clearance’ of spines, avoiding immobilisation and use of devices such as vac-mats. The current view is that if it is necessary to immobilise the spine, the following equipment is required: • Adjustable cervical collar (the current best practice opinion still supports the use of collars at present although this may soon change) • Scoop/Longboard with spider straps • Bilateral head blocks with chin and forehead tapes • Vac-mat if available. If collars and blocks are not available then SAM splints, fluid bags, sand bags, or folded cardboard may be used as improvised alternatives. To immobilise the spine, first gently move the spine into a neutral position by straightening the neck, if it is not already in its normal forward-facing position. However, if this adjustment results in pain or numbness or the neck does not move easily to accommodate a cervical collar, then immobilise the spine in its current position without the collar (see figure 6.4, 6.5, 6.6). Spinal injury Chapter 6: H: Head Trauma and Other Serious Injuries Figure 6.4: Manually immobilising a cervical spine, taking care not to cover the casualty’s ears Figure 6.6: Manual immobilisation in a car (take care to avoid the eyes or covering the ears wherever possible) Figure 6.5: Manually immobilises the neck supporting the head in a neutral in-line position

90 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Helmet removal For motorcyclists wearing helmets, if it inhibits exposure of the patient or hinders the provider’s efforts at airway stabilisation the helmet should be removed in a controlled and deliberate fashion. At least two providers are necessary—one to hold the helmet and perform the actual removal, and the second person to maintain manual in-line stabilisation of the patient’s head and neck, from below the helmet, during the procedure. • Support the head from below the helmet with one hand front of neck and under the jaw and the other slid around behind extending around under the back of neck to support head –almost like a collar (Person 1 – P1) • Undo or cut the helmet strap (Person 2 – P2) • Deflate any inflatable padding – emergency red release button inside visor (P2) (see figure 6.7) • Tilt helmet backwards over the nose (P2) • Pull sides of helmet outwards to pass over the ears and then gently rock forward and backwards off the head (P2) • Before finally removing, remember that a gap will then be present between the head and the floor and it must be held firmly by (P1) • A firm support can then be slid under the head, avoiding any ‘chin-chest’ lifting of the head whilst still supporting the head with in-line stabilisation by (P1). The helmet should be retained, and any dents or abrasion to its surface should be noted. Until proven otherwise, always assume the presence of a cervical spine injury. The cervical spine should then be manually immobilised until the hard collar and straps and blocks are in place. Figure 6.7: Deflate any inflatable padding – emergency red release button inside visor Spinal injury Chapter 6: H: Head Trauma and Other Serious Injuries Inflate Deflate

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 91 The Cervical Spine (neck and spine protection) As mentioned above hard collars are currently under serious review by the medical world. However, currently for BTACC/ BTACC providers they are still recommended for cervical spines that have not been cleared and in unconscious or obtunded (under influence of alcohol or drugs) casualties. Avoiding immobilisation and Pre-hospital ‘Clearance’ of the cervical spine and extrication. The casualty who is fully conscious will protect their own spine to a significant degree. This does not mean that there is no injury and x-rays may still be required but immobilisation can often be avoided in the following situations: Clearing the cervical spine and extrication: • If the casualty is keen to self-extricate and able, let them • If they are out of the vehicle or up and walking around, they do not need immobilising. A hard collar must be sized according to the manufacturer’s recommendations and then adjusted to fit before application (see figure 6.8). Figure 6.8: A, B, C: sizing and application of a hard collar in an RTC victim. Spinal injury Chapter 6: H: Head Trauma and Other Serious Injuries

92 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Longboards are still the extrication device of choice and for short-term (<20mins) immobilisation and transport. Ideally they are removed from the board to avoid the risk of pressure sores developing, although for a time-critical unstable patient, with a short transfer to hospital, do not delay and simply leave them on the board. Casualties lying on the floor can be moved on to a longboard using a log-roll technique or more frequently these days, picked up with the assistance of an orthopaedic (scoop) stretcher or similar device. Scoop stretchers have largely replaced longboards on UK ambulances, but they are not suitable for extrication and they still represent another hard board and are preferred by paramedics. (Transfer time should still be limited on such a board). Log-rolling is easy to accomplish, but it usually requires a team of four responders for safety and effectiveness. Because there is often insufficient space for four rescuers to work, it is not always possible to perform this manoeuvre “correctly.” Therefore the principles of movement (rather than specific rules) are stressed here. The procedure for the four-person log roll includes: 1. All rescuers get into position to roll the patient 2. One rescuer (usually holding the head) gives the command and the other rescuers simultaneously roll the patient onto his or her uninjured side 3. The fourth person checks the back for wounds and deformity and then slides the longboard toward the patient 4. Once a rescuer gives the command, the other rescuers roll the patient onto the longboard 5. Centre the patient on the longboard with a ‘v’ manoeuvre if necessary 6. Secure the patient before moving the longboard. In any patient-movement technique, and especially if spinal injury is suspected, everyone must understand who is directing the manoeuvre. The rescuer holding the patient’s head (Rescuer One) should always give the commands so that all rescuers can better coordinate their actions. The specific wording of the command is not important, as long as every team member understands what the command is. Each member of the team must understand his or her specific position and function. Figure 6.8 D, E: fastening the collar & re-applying oxygen with head still supported manually. Spinal injury Chapter 6: H: Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 93 All patient-movement commands have two parts A question and the order for movement: • Rescuer One says, “The command will be ‘Roll!’” when everyone appears ready to roll the patient • Rescuer One asks “Is anyone not ready?” (followed by a short pause to allow for response from any team member) • Rescuer One will then command - “Ready, brace, roll!”. Always try to move the casualty as one unit and keep their head in a neutral position at all times. Do not allow the head to rotate, move backward (extend), or move forward (flex). Scooping off the floor or a long-board • Prepare and brief the team as for log-rolling • Break the scoop into two halves • Ideally remove all bulky clothing that may foul scoop • Align one half of scoop with casualty and adjust it’s size • Lead by person holding head • Nominate person to insert scoop, rest of team on other side • Minimal lift/log roll to insert scoop half • Adjust other half and swap team over • Lower then minimal lift other way for other half • Clip board together • Secure casualty to board • Secure head in blocks. Sometimes this is simply stated as, “Keep the nose in line with the belly button at all times.” Once the casualty is immobilised, immediate evacuation and transfer should be initiated. En route, the casualty should be continually assessed and monitored, and reassurance given due to the restrictive nature of the longboard immobilisation equipment. Always fully immobilise the body on the long-board/scoop BEFORE strapping the casualty’s head into head blocks on the board. Spinal injury Chapter 6: H: Head Trauma and Other Serious Injuries

94 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Fractures Fractures (broken bones) are painful, often unpleasant to look at, but they are rarely fatal unless they damage adjacent blood vessels, such as the thigh bone (femur) and the large femoral artery that spirals around it or the pelvis and the huge network of veins and arteries that run all over the inside of the pelvis to supply all the organs and the legs with blood. If the bones break the skin, this is described as an open fracture and is likely to produce more external bleeding and a considerably greater risk of infection. These need hospital urgently and are usually ‘fixed’ in some way within a few hours of hospitalisation. Fractures that damage adjacent blood vessels and nerves may create a time critical situation or could lead to a long-term disability. They may also indicate the severity of trauma and potential injury, especially with rib fractures which may puncture the lungs or with pelvic fractures which, as described above, may involve massive blood loss. Dislocations and other soft-tissue injuries may be as painful as fractures, and a few are ‘limb threatening’ – in other words they risk loss of the limb because the dislocation effects or cuts off the blood supply. However, they are less likely to be time critical in terms of life threatening. The features, signs and symptoms of fractures can also be seen in dislocation, and the prehospital management is effectively the same. Signs and Symptoms of Fractures Signs and symptoms of fractures include: • Pain at the site of injury • Deformity • Bruising • Swelling • Inability or unwillingness to move the injured body part. Possibly: • Loss of pulses in the affected limb • Crepitus or grating sensation if bone ends move against each other • Fracture blisters on the skim • Nausea and/or vomiting. Management of fractures In simple basic trauma terms, the whole management of most fractures is immobilisation by splinting. At more advanced levels, with access to effective pain relief, we can also gently align and reduce fractures. Splinting limits movement of the injury, reduces pain, helps control bleeding, and decreases the risk of damage to the nearby nerves and vessels. Many different materials can be used as splints. Commercially available splints offer the best support and come in different types and sizes. If a commercial splint is unavailable, improvised splints such as pieces of wood, the good leg and even folded cardboard can be used with good results. All that a splint does is to minimise further movement of the fracture. Chapter 6: H: Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 95 Management of fractures One simple yet effective, commonly available commercial splint is the SAM splint— flexible aluminium sheets covered by foam which can be moulded to fit any shape limb or injury (see figure 6.9). Other rigid splints exist made from firm materials and they are all applied to the sides and back of a limb, creating a gutter for the injured limb to be secured against, with a soft bandage. A more expensive but very effective alternative is the vacuum splints, which come in all shapes and sizes and mould to the injured limb as the air is sucked out of them, forming a stiff, rigid splint. However, they are bulky to carry and require a pump or suction to make then work. (see figure 6.11). Finally, a simple alternative for upper limb injuries is a board arm sling. (see figure 6.10). Figure 6.9: Multiple use of a malleable SAM splint and a crepe bandage Fractures Chapter 6: H: Head Trauma and Other Serious Injuries Figure 6.10: Board arm sling With a long bone fracture, (e.g. thigh or lower leg), the simplest technique is to pad generously between the legs and then fasten them together at multiple levels, using the good leg effectively as a splint. Alternatively use a large flexible SAM splint bandaged to support and immobilise the fracture or a gutter/box splint.

96 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The largest vac-splits are full mattresses. Once the air is drawn out, they conform to the spine extremely well, provide a high degree of immobilisation and probably represent the current ‘gold standard’ for spinal immobilisation. They allow us to immobilise the whole spine in this manner and is useful if normal alignment is not possible or there is serious deformity of the back. However, they are bulky, heavy and can be torn or punctured. As such they are not as effective or widely used in the UK. While certain fractures require specialised splinting techniques (outlined below), splinting usually follows the same general principles: 1. Ideally, do not move the casualty before splinting, unless there is an immediate danger to the casualty or the responder 2. If movement is required, manually immobilise and support the injury 3. Remove clothing from the injured limb to inspect for open wounds, deformity, swelling, bruising, and to assess capillary refill 4. Note and record the pulse, capillary refill time, and sensation in the injured limb below the site of injury or fracture, both before and after splinting 5. Cover all open wounds with a non-adhesive, absorbent dressing before applying the splint 6. Immobilise the joint above and the joint below the injury site 7. Pad all rigid splints 8. When applying the splint, use your hands to support the injury site and minimise movement of the limb until splinting is completed 9. Splint the limb in the position in which it is found, unless it is easy to align or necessary for extrication 10. When in doubt, splint – especially the pelvis 11. Recheck distal circulation below the site of injury. Avoid turning or rolling casualties with fractures onto the side of the injury if at all possible. Figure 6.12: Simple use of a triangular bandage to form a sling for injured arm immobilisation. Splinting should not delay transfer to hospital by more than a few minutes and can sometimes be done en route. Fractures Chapter 6: H: Head Trauma and Other Serious Injuries Figure 6.11: Use of a Vac-splint to immobilise a neck that cannot be moved into a neutral position for application of a hard collar.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 97 Any degree of immobilisation will greatly reduce the pain of the injury and also the amount of bleeding from an unstable fracture. Rib fractures For rib fractures, responders should be careful to handle the casualty gently and continually reassess for developing respiratory compromise, as there will be pain and potentially underlying ling injury. If the casualty is experiencing difficulty breathing, unless there are real concerns about spinal injury, responders should sit then up and provide supplemental oxygen. Lying them flat on a board could result in serious compromise and a lack of oxygen or inability to breathe. Strapping the chest is no longer recommended as it may actually restrict breathing, as does the KED extrication device, favoured by some ambulance providers for vehicle extrication. That said, some casualties may find relief in holding the ribs themselves, as if hugging themselves, manually splinting their injury, especially if they cough. Pelvic fractures Pelvic fractures require special treatment, as they are injuries that often involve severe and potentially lifethreatening blood loss as the broken bones can easily lacerate the large blood vessel networks that run directly adjacent to the pelvic bones. The other risk factor is the potential for concealed bleeding and developing life-threatening shock with little, if any, external sign. In view of the potential catastrophic consequences of missing a pelvic injury, if suspected from the kinematics or pain/deformity, then the pelvis should be immobilised as early as possible with a pelvic splint. Movement of the pelvic bones can greatly increase bleeding and disrupt any clot that may be forming. Therefore, we must not firmly press on or ‘spring’ the pelvis, as is still often described in trauma courses, as this may tear vessels or disrupt blood clots and be life threatening. To stabilise the pelvis, apply a broadly folded triangular bandage or pelvic/frac strap around the hips and fasten firmly, but not overly tight (see figure 6.13). The strap is passed behind the knees or lower back and then moved into position with a side to side ‘sawing action.’ Try not to lift or move the pelvis or spine during this process. The correct position is at the level of the hips (top of the femurs/thigh bones), which is about a hand’s-breadth below the bony top of the pelvis felt at the waist. Apply an additional strap around the feet and ankles to keep them together (figure of ‘8’ strapping is ideal) and stop them splaying outwards, putting rotational force on the pelvis. Do not “spring” or manually assess for pelvic instability or movement, as this can produce life threatening bleeding. Fractures Chapter 6: H: Head Trauma and Other Serious Injuries Figure 6.13: Positioning of a pelvic or frac-strap for suspected pelvic fracture

98 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The abdomen lies between the chest and the pelvis and contains the intestines, stomach, liver, kidneys, pancreas, and the spleen (see figure 6.14). Injuries to the abdomen can have serious consequences such as major bleeding and perforation of the bowels. To recognise an abdominal injury, consider the kinematics of the situation (e.g. stabbing or blunt abdominal trauma) and look for any signs such as wounds or external bruising. Signs of internal bleeding may not be initially obvious as things such as abdominal distension are quite a late sign and can be unreliable. Internal bleeding is far more likely to be detected by developing signs of shock and blood loss with still no obvious signs of external bleeding. The kinematics of the situation may be the best indicator to alert rescuers as to the possibility of internal bleeding and they can then check for signs of shock. Abdominal injury Chapter 6: H: Head Trauma and Other Serious Injuries Figure 6.14: Organs in the abdomen. liver PANCREAS LARGE INTESTINE SMALL INTESTINE APPENDIX GALL BLADDER ESOPHAGUS Stomach