RTACC

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 97 Chapter 6: H - Head Trauma and Other Serious Injuries Best Motor Response CRITERION RATING SCORE Obey 2-part request OBEYS COMMANDS 6 Brings hand above clavicle to stimulus on head neck LOCALISING 5 Bends arm at elbow rapidly but features not predominantly abnormal NORMAL FLEXION 4 Bends arm at elbow, features clearly predominantly abnormal ABNORMAL FLEXION 3 Extends arm at elbow EXTENSION 2 No movement in arms / legs, no interfering factor NONE 1 Paralysed or other limiting factor NON TESTABLE NT Verbal Response CRITERION RATING SCORE Correctly gives name, place and date ORIENTATED 5 Not orientated but communication coherently CONFUSED 4 Intelligible single words WORDS 3 Only moans / groans SOUNDS 2 No audible response, no interfering factor NONE 1 Factor interferring with communication NON TESTABLE NT Eye Opening CRITERION RATING SCORE Open before stimulus SPONTANEOUS 4 After spoken or shouted request TO SOUND 3 After finger tip stimulus TO PRESSURE 2 No opening at any time, no interfering factor NONE 1 Closed by local factor NON TESTABLE NT SITES FOR PHYSICAL STIMULATION FEATURES OF FLEXION RESPONSES Modified with permission from Van Der Naalt 2004 Ned Tijdschr Geneeskd Abnormal Flexion Slow Sterotyped Arm across chest Forearm rotates. Thumb clenched Leg extends Normal Flexion Rapid Variable Arm away from body Finger tip pressure Trapezius Pinch Supraorbital notch OBSERVE Eye opening, content of speech and movements of right and left sides. STIMULATE Sound: spoken or shouted request. Physical: Pressure on finger tip, trapezius or supraorbital notch. RATE Assign according to highest response observed. CHECK For factors Interfering with communication, ability to respond and other injuries. Figure 6.2: Glasgow COMA Scale.

98 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com A spinal injury can have catastrophic consequences, including long term paralysis of limbs or even the acute inability to breathe 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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 99 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

100 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com There is now considerable debate about spinal immobilisation and the traditional approach of collar blocks and scoop/board is not considered as ‘gold standard’ any more as a vac-mat is considered better, but they are still used by most providers as simple and familiar. This is likely to change in the next few years with more frequent ‘clearance’ of spines, avoiding immobilisation and use of devices such as vac-mats. The current view is that if it is necessary to immobilise the spine, the following equipment is required: • Adjustable cervical collar (the current national guidance still supports the use of collars at present although this may soon change) • Scoop/Longboard with spider straps • Bilateral head blocks with chin and forehead tapes • Vac-mat if available. If blocks are not available then SAM splints, 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). 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) Spinal injury Chapter 6: H - Head Trauma and Other Serious Injuries Figure 6.5: Manually immobilising the neck supporting the head in a neutral in-line position

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 101 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 on the front of the neck under the jaw, and the other slid behind extending 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

102 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 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/ RTACC 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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 103 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. (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. Log rolling should be used as little as possible to minimise any increased risk of bleeding. 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

104 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com ALL PATIENT-MOVEMENT COMMANDS HAVE TWO PARTS A question and the order for movement: • Rescuer One says, “The command will be ‘Roll!” when everyone appears ready to roll the patient • Rescuer One asks “Is anyone not ready?” (followed by a short pause to allow for response from any team member) • Rescuer One will then command - “Ready, brace, roll!”. Always try to move the casualty as one unit and keep their head in a neutral position at all times. Do not allow the head to rotate, move backward (extend), or move forward (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 the scoop • Align one half of scoop with casualty and adjust its size • Lead by person holding head • Nominate person to insert scoop, rest of team on other side • Minimal lift/log roll to insert scoop half • Adjust other half and swap team over • Lower then minimal lift other way for other half • Clip scoop together • Secure casualty to scoop • Secure head in blocks. Sometimes this is simply stated as, “Keep the nose in line with the belly button at all times.” Once the 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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 105 In RTACC we use a simple process to clinically clear the spine for extrication. This is based on a combination of the Canadian rules, NEXUS guidelines, the Faculty of pre-hospital care and ATACC consensus guidelines. Spinal injury Chapter 6: H - Head Trauma and Other Serious Injuries If there is severe pain in the neck or back or they have any strange sensations, e.g pins and needles or other serious injury, e.g broken legs then they require full extrication/ immobilisation. (See special circumstances section 8.3) INDICATIONS TO FULLY IMMOBILISE CHECK LIST FOR IMMOBILISATION YES NO Q.1 Is clearance required? (i.e unable to self-extricate or get up and walk) Q.2 Are they over 65yrs Q.3 Is this a serious mechanism of injury, e.g. roll over RTC, fall downstairs etc? Q.4 Is there any neck or back pain? Q.5 Is there any abnormal sensation e.g. pins and needles, weakness or numbness? Q.6 Is there any tenderness when gently pressing down neck and then back? Q.7 Is there pain or limitation rotating the head to right and left? If the answer to all of these questions is NO, the spine does NOT need to be immobilised If any answer is YES then spinal immobilisation should be seriously considered (especially if multiple YES answers) If there is any doubt, immobilise fully or await decision of paramedics or doctor. The presence of any distracting injury is still often included in the clearance process, but this has been demonstrated as unnecessary as even severe traumatic injuries will not mask pain from spinal injury.

106 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 affects 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 pre-hospital 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 skin • Nausea and/or vomiting. MANAGEMENT OF FRACTURES In simple basic trauma terms, the whole management of most fractures is immobilisation by splinting. At more advanced levels, with access to 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 107 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 broad 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.

108 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 109 The ideal pre-hospital immobilisation device for a long bone is a traction splint such as a Kendrick traction device or a CT6, if they are carried by your service (see figure 6.13). These lightweight and highly effective devices will not only immobilise the limb, but also hold the leg out to its correct length and reduce the risk of impaired blood supply beyond the fracture. If major fractures of the lower limbs are present, always consider the need for pelvic strapping and spinal immobilisation as well. After application check for foot pulses, and capillary refill in the toes. If they are now absent, then consider releasing the traction and see if it improves. Figure 6.13: Applying a Kendrick traction splint for the lower leg A) Attaching the hip strap B) Adjusting the pole to length C) Inserting pole in hip strap socket D) Attaching ankle strap (well beyond foot) E) Attach Traffic light straps (RYG) F) Traction to foot and then pull straps tight Fractures – Traction splints Chapter 6: H - Head Trauma and Other Serious Injuries

110 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Any degree of immobilisation will greatly reduce the pain of the injury and also the amount of bleeding from an unstable fracture. RIB FRACTURES For rib fractures, 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. As a result we always consider the possibility of pelvic or long-bone fractures when assessing ‘C’ for circulation. Movement of the pelvic bones can greatly increase bleeding and disrupt any clot that may be forming. Therefore, we must not 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 6.14). 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 6.14: Positioning of a pelvic or frac-strap for suspected pelvic fracture

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 111 A crush injury is a form of blunt trauma involving compression of any part of the body to an extent and duration that causes damage to the body’s tissues. After the immediate injures caused by the crush, such as wounds, bleeding and fractures, the longer the period of crush, the greater the damage resulting from muscle damage and lack of blood supply to the area, and the greater the likelihood that long-term complications or even death will result. Crush injuries of the trunk are often immediately fatal as a result of damage to internal organs or asphyxia (inability to breathe). Crush injuries of the torso and legs may also include structures which can rapidly lead to time critical injuries such as pelvic or long bone fractures, with the associated major bleeding. (see Chapter 6). To diagnose a crush injury, consider the mechanisms and forces involved in the situation. Degrees of crush injury are not uncommonly found in road traffic collision entrapments, (e.g. where the dashboard encroaches on the legs) or in building or trench collapses. (see figure 6.15). After the initial crush injuries, the more prolonged crush until rescue occurs, can result in a build-up of toxins in the trapped limb. Sudden release of the limb may release a large volume of cold blood and toxins which can potentially result in cardiac arrest and death. This is a hugely complex issue and even National expert guidance from the Faculty of Pre-hospital care simply suggests that ideally we should aim to release our casualty as quickly as possible, to prevent further injury. However, in prolonged crush (eg > 30 mins), involving lots of muscles, such as the thighs and buttocks, there may be a large build-up of lactic acid, toxins and a risk of death on release, as stagnant blood and toxins ‘wash-out’ back to the heart and other organs. Anyone trapped for more than 30 minutes with a crushed limb is considered time critical. In view of this, the BTACC/RTACC recommendation goes a step further than the FPHC guidance: • Wherever possible, simply extricate the casualty as quickly as possible in less than 30 mins • In prolonged crush of large muscle areas, such as the thighs, legs or buttocks (not just below knee) responders should aim to control or delay this washout, if possible, by applying an arterial tourniquet, above the crush in the affected limb or limbs, prior to release There is no hard evidence that this will prevent and life-threatening complication, but it is very unlikely to cause harm and will prevent major bleeding on release and allow some control of the outflow of blood and toxins from the limbs. The tourniquet should be applied tightly as if being applied for massive haemorrhage control just above the crushed area. (see figure 6.16). Record the estimated time of crush, the site and time of application of the tourniquets and the time of release, if removed. Once the casualty is released, then the paramedics/doctors will organise a controlled release of the tourniquets on scene or in hospital, with full critical care monitoring and support. As this is such a complex and serious condition, rescuers managing a prolonged crush >30mins should leave the tourniquets on until medical support arrives. If this support is significantly delayed then, have full resuscitation equipment to hand, including the defibrillator and release one leg at a time, closely monitor the casualty and if they feel faint or unwell, then immediately re-apply the tourniquet. After 5 minutes, if all is well then release the other leg too. (This is discussed further in the RTACC Medical Rescue special module) Crush injury Figure 6.15: Crush injury to lower legs. Figure 6.16: Bilateral arterial tourniquets applied before release of Chapter 6: H - Head Trauma and Other Serious Injuries

112 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Suspension trauma, or harness induced pathology, is a fiercely debated topic. It is certainly not as common as was thought in the original HSE Seddon report a number of years ago. However, it would seem that in certain circumstances with certain harnesses, after a prolonged suspension there is a real risk of this potentially serious or fatal condition. The greatest risk would seem to occur when a casualty is suspended in a pelvic harness for prolonged periods (more than 20-30 minutes) motionless - not moving their legs or ‘pushing off’ and working the large muscles, which push blood back to the heart. In such cases, blood pools in the legs and they can faint, but as they remain upright in the harness, then the situation can progressively get worse. This is very rare situation even after a fall arrest, unless the casualty is actually unconscious. The 2009 guidelines from the UK Health and Safety Executive (HSE) recommend treating a casualty by: 1. Encouraging the casualty to ‘push-off’ surrounding structures to keep his leg muscles working, which pumps the blood back to the heart 2. Rescuing the casualty as rapidly as possible (especially if unconscious) 3. Treating the casualty as any other trauma victim, once rescued. (Previous HSE guidelines recommended keeping casualties sitting up after rescue, but this has been dismissed as ineffective). These new guidelines do not address the issue of prolonged unconscious suspension for periods greater than 30 minutes, where a picture similar to the sudden release of crush can occur due to the position of the casualty and potential restriction of circulation of some harnesses, especially as the legs swell. Following research conducted in Cork University in consideration with the pathological process involved and the gaps in the FPHC consensus statement, BTACC/RTACC advises managing suspension trauma with the steps outlined next: 1. Suspended for less than 30 minutes or conscious and pushing off – simply get them down. 2. Suspended for more than 30 minutes unconscious: a. Lower the casualty to just above ground level as quickly as possible b. Apply tourniquets to the lower limbs as high on the leg as possible c. Document the time and placement of the tourniquets d. Then swiftly lower the casualty to the ground and move to a safe horizontal surface e. Assess and treat according to the M.A.R.C.H algorithm f. Await expert medical help. Release of the tourniquets should be performed under medically controlled conditions, fully monitored, ideally in hospital, in the shortest possible time. If this is not possible then with full resuscitation equipment available, including oxygen, BVM and AED, release the tourniquets one at a time and monitor the casualty closely. If they lose their pulse, feel unwell or faint then immediately re-apply the tourniquet. If all is well after 5 minutes, then release the second tourniquet in the same way. Figure 6.17 A technical rescue requiring decisions about speed of extrication. Suspension trauma Chapter 6: H - Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 113 The abdomen lies between the chest and the pelvis and contains the intestines, stomach, liver, kidneys, pancreas, and the spleen (see figure 6.18). Injuries to the abdomen can have serious consequences such as major bleeding and perforation of the bowels. To recognise an abdominal injury, consider the kinematics of the situation (e.g. stabbing or blunt abdominal trauma) and look for any signs such as wounds or external bruising. Signs of internal bleeding may not be initially obvious as things such as abdominal distension are quite a late sign and can be unreliable. Internal bleeding is far more likely to be detected by developing signs of shock and blood loss with still no obvious signs of external bleeding. The kinematics of the situation may be the best indicator to alert rescuers as to the possibility of internal bleeding and they can then check for signs of shock. Figure 6.18: Organs in the abdomen. LIVER PANCREAS LARGE INTESTINE SMALL INTESTINE APPENDIX GALL BLADDER ESOPHAGUS Abdominal injury Chapter 6: H - Head Trauma and Other Serious Injuries STOMACH

114 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com To examine a casualty for abdominal injury: 1. Try and lie the casualty flat if possible 2. Explain what you are going to do to the casualty 3. Expose and visually inspect the abdomen 4. Ask the casualty if they have any pain anywhere 5. Look around the sides of the abdomen 6. Feel along the back on each side of the abdomen, checking for wounds or bleeding 7. If the patient is conscious, starting away from any painful area, apply gentle pressure with the flat of your hand in each of the four quadrants of the abdomen (see figure 6.19) asking the casualty if this causes pain or discomfort, looking for any complaint of pain or grimacing on the casualty’s face. If there is no significant discomfort, then repeat the examination a second time, pressing a little more firmly, keeping your fingers flat on the abdominal wall. SIGNS AND SYMPTOMS OF ABDOMINAL INJURY Signs and symptoms of abdominal injury include: • Abdominal wounds • Bruising on the abdomen • Abdominal pain • Broken lower ribs • Blood in vomitus • Bleeding from the anus or urinary tract • Distension (bloating of the stomach). Little can be done to care for abdominal injuries on scene, but recognition is very important, as massive internal haemorrhaging can lead to shock. Rapid transfer to hospital is essential. Any efforts to treat abdominal injury should not delay transfer. When abdominal wounds are present and time permits, efforts can be made to control external haemorrhaging with simple pressure dressings, chest seals, or—for larger wounds—cling-film. However, there is also likely to be similar amounts, or even more, internal bleeding, so rapid transport to hospital is the priority, especially if there are features of shock. If any abdominal contents have eviscerated (spilled out of the wounds), they can be gently covered with cling-film or saline-soaked swabs. DO NOT try and push them back into the abdomen. Gently handle or move any casualty with a possible internal injury or bleeding to minimise the bleeding and discomfort. Consider a pelvic strap before any movement, if necessary. Abdominal injury Chapter 6: H - Head Trauma and Other Serious Injuries Figure 6.19: 4 Quadrants of the abdomen to examine LEFT UPPER QUADRANT LEFT LOWER QUADRANT RIGHT UPPER QUADRANT RIGHT LOWER QUADRANT

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 115 Figure 6.20: Diagram to describe depth of skin burns SUPERFICIAL SUPERFICIAL DERMAL DEEP DERMAL FULL THICKNESS EPIDERMIS DERMIS SUBCUTANEOUS Burns can vary from minor redness to a life-threatening situation, depending on the depth and location of the burn (see figure 6.20). Superficial burns: (first-degree burns) are the most minor type of burn and are characterised by reddened and painful skin, but without blistering, e.g. sunburn or a minor scald. The injury is confined to the outermost layers of skin, and the casualty experiences minor to moderate pain. A superficial burn usually heals in about a week, with or without treatment. Partial-thickness burns, dermal (second-degree burns) are somewhat deeper, do not damage the deepest layers of the skin, but are the most painful. Blistering is typically present, although they may not form for several hours in some cases. There may be some fluid loss and usually moderate to severe excruciating pain because the nerve endings in the skin are fully exposed to contact and the air. Partial-thickness burns require medical treatment and usually heal within two to three weeks and may result in some form of scarring. Full-thickness burns (third-degree burns) damage all layers of the skin. In some cases, the damage is deep enough to injure and destroy underlying muscles and other tissues. There is often less pain than expected because the nerve endings have actually been destroyed. However, there is typically some marginal or associated partial thickness burn too, which will produce severe pain. Without the protection provided by the skin, patients with extensive full-thickness burns lose large quantities of body fluids and are susceptible to shock and infection. All full thickness burns require hospital review. Burns All burn patients should receive high flow oxygen to meet the body’s increased metabolic demand for oxygen, avoid confusion, agitation, and combat the effects of any carbon monoxide poisoning. Chapter 6: H - Head Trauma and Other Serious Injuries

116 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com It is not always possible or necessary to determine the exact degree or depth of a burn. Burns should be always considered time critical if they: • Cover more than 10% of an adult’s body surface area or more than 5% of the body surface area of a child (under 16 years) – remember that the casualty’s hand (palm & fingers) = approx 1% of skin area • Affect the airway • Are found in a paediatric or elderly casualty (extremes of age) • Are found in a casualty with other serious medical or trauma conditions • Involve the face, hands, feet, genitalia, perineum or major joints • Are located above the shoulders • Are circumferential ( i.e. go all the way around a limb or body part) • Are electrical or chemical burns • Involve fumes or smoke inhalation. All major or time critical burns patients should receive high flow oxygen (15 L/min) to meet the body’s increased metabolic demand for oxygen, avoid confusion, agitation, and combat the effects of any carbon monoxide poisoning. FOR TIME CRITICAL BURN PATIENTS, RAPID TRANSPORT IS ESSENTIAL. Burns are also categorised by the source of the injury: • Thermal • Chemical • Electrical. The signs, symptoms, and treatment of each type vary, as outlined in the following sections. More accurate assessment of burn area: Traditionally burns have been assessed using simple charts such as the Lund and Browder and the ‘Rule of Nines’ but an accurate and far simpler version now exists with the ‘Mersey Burns’ application produced by one of the UK’s leading Burns and Plastics units at Whiston Hospital in Merseyside. This offers a very simply method to record and size the burn based on the size, weight and age of the casualty. Burns Remember to cool the burn effectively for at least 10 minutes, maximum of 20 minutes but avoid significant hypothermia if the burn is very extensive. Chapter 6: H - Head Trauma and Other Serious Injuries Recommendation: Mersey Burns App St Helens & Knowsley Teaching Hospitals NHS Trust

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 117 Thermal burns are the result of direct contact with flames or thermal energy (heat) on the skin or tissue. In all types of thermal burns, treatment should aim to limit the damage caused by the thermal energy, which may still be present when you reach the casualty, who may even still be on fire. EXTINGUISHING THE FIRE Your safety is clearly paramount and if the fire service are not present, then use appropriate fire extinguishers (see guidance in appendix) ensuring that you protect yourself at all times and avoid being in enclosed spaces with fire. MANAGING THE BURN This involves actively cooling the injured area to dissipate the thermal energy which, can remain and cause further damage, even after the direct heat source has been removed. • Place the injured area under clean, cool running water as soon as possible for at least 10 minutes, maximum of 20 minutes. • Only dress the burn once it has cooled completely (see figure 6.21). Immersion in cold water is not as effective as running water, which continues to remove heat energy from the burn. However, if the only water available is in a static container or vessel, then it is better than no cooling. Water does not have to be sterile, but ideally it should be clean. However, if all that you have is tap water, a garden hose or water from the fire engine tank, use it, as the active cooling is the priority and any infection risk is very much a secondary issue, as most burns get infected at some point. DRESSING THE BURN • Cover the burns with ‘burn-film’ (or ordinary cling-firm if nothing else is available) laid on in sheets • Face shield can be used for facial burns • Hands and feet – burn bags or freezer bags • Gel dressings are not ideal as they have a limited heat absorption and are not as effective as running water. The gel can be hard to remove from the raw burn at a later stage in hospital. Burn film keeps the area clean, reduces fluid loss, and significantly reduces pain by covering the exposed nerve endings. Never wrap or wind film around a limb. Always lay strips or sheets on lengthways, as when the limb starts to swell, the dressing will not be tight, constricting the limb. Hands and feet are best managed with clear plastic bags or freezer bags and if possible, with a few millilitres of sterile eyewash/saline added to the bag and then loosely taped around the wrist or ankle. This creates a humidified environment and allows ongoing inspection of the burn, through the bag in hospital. Figure 6.21: Burns are covered with burn-film and plastic bags containing a few millilitres of saline eyewash for the hands and feet. Thermal burns Chapter 6: H - Head Trauma and Other Serious Injuries

118 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Chemical burns result from contact with a caustic or corrosive substance or a substance that reacts with moisture on the skin to generate heat. Every effort should be made to identify the chemicals involved to determine the most appropriate form of treatment, as certain chemicals, such as sodium phosphorous may react negatively with water producing more heat. All chemical powders should be brushed off the patient’s clothing or skin, carefully avoiding coming into contact with this substance yourself. Dry decontamination (ideally by the individual themselves) is now the favoured approach. Removing clothing and brushing the agent off with paper towel is recommended, but if it’s burning, irrigate as soon as possible. After you have removed as much of the dry chemical as possible, irrigate the burned area with clean, cold running water. The water washes off remaining chemical residue and residual thermal energy. Flush the affected area for at least 30 minutes. Once it has been decontaminated effectively, cover the area with a burn-film dressing (if there is obvious residual chemical on the skin, avoid dressings) and provide rapid transport to hospital. Diphoterine – This is an emergency agent used on many chemical sites/labs for the immediate management of chemical burns. Some studies have indicated that it may reduce the injury from burns. However, hospital burns units would still recommend the use of cold running water, for at least 10 minutes, especially for more major burns. Diphoterine can be used, but for smaller burns or for immediate management. It is rarely in sufficient volume, especially for larger burns and we should switch to running water when it runs out. See Clinical Update: A.7 Corrosive Attack Phosphorus burns – water was traditionally avoided as its action can generate significant heat. When a sufficient volume of water is used this effect is minimised and it is therefore a safe and effective option. Electrical burns Electrical burns result from direct contact with a live electric energy source. Even small electrical burns, if sufficient to burn the skin (often looking like cigarette burns) can cause a large amount of tissue damage and a great deal of pain. With electrical burns, there is an added risk of cardiac arrest, which requires immediate basic life support and defibrillation (see chapter 7). Before treating an electrical burn, always ensure that the scene is safe and that you are adequately protected from the electrical source. Before you touch or treat a person who has suffered an electrical burn, be certain that the casualty is not still in contact with the electrical power source which caused the burn. If the casualty is still in contact with the power source, anyone who touches him or her may also be electrocuted. If the casualty is touching a live power source, your first act must be to unplug, disconnect, or turn off the power. If you are unable to do this alone, call for assistance and stand clear until help arrives. After the power has been disconnected, examine the casualty carefully, assessing airway, respiration, and circulation before treating visible, external burns. If there is obvious thermal injury (e.g. flames or blistering), the area may be cooled with water only when there is no risk of contact with electricity. However, cooling is less effective in these burns and the wounds should be rapidly dressed with burn-film before immediate transfer to hospital. Even small electrical wounds can hide major tissue injury, or result in cardiac injury. All electrical burn casualties should be referred to hospital. Chemical burns Chapter 6: H - Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 119 Anyone exposed to fire, smoke, or hot gases is at risk of inhalation injury to the lungs and upper airway. In these incidents, the airway can become dangerously swollen and the lungs can become congested with soot and water which is released as a reaction to the damage of the delicate lining of the lungs. Casualties can die from this injury a day or even weeks later, with no external sign of a burn. SIGNS AND SYMPTOMS OF INHALATION INJURY Signs and symptoms include: • Airway injury: redness or soot around or inside the nose/mouth • Coughing: especially with sooty sputum • Wheezing • Difficulty breathing • Presences of fire, smoke, hot gases or steam at the scene. To treat casualties with inhalation injuries, first move them to a safe distance away from the scene and then assess them in a sitting position, to help them breathe, unless they have a reduced level of consciousness level. If so, it may be safer to lay them down in the recovery position until an ambulance arrives. Administer oxygen through a non-rebreathing mask at 15 L/min. Remember that the pulse oximeter is not reliable in such cases and will potentially read higher than the true value. If the airway starts to swell (lips, tongue, throat, face) or the burn is above the shoulders then consider: • Inserting one or even two fingers into the nasal airway, before the swelling gets too severe, could be life-saving later • Any signs of swelling and the casualty is at significant risk and is clearly time critical. All smoke inhalations should receive 100% oxygen - irrespective of there oxygen saturation on pulse oximeter. If a casualty is asthmatic, they may well benefit from using their blue-grey ‘Ventolin’ inhaler, if their chest is tight or they are coughing a lot. Encourage them to take two puffs of the inhaler, which they can repeat a second time five minutes later if required. Carbon monoxide, cyanide and inhaled poisoning CARBON MONOXIDE Carbon monoxide is a highly toxic, colourless, odourless and invisible gas that binds to the haemoglobin in blood and prevents the normal carriage of oxygen. • High levels of carbon monoxide can result in coma and death within minutes • Victims may exhibit flu-like symptoms and reduced levels of consciousness • Typically they still appear ‘pink’ as the carboxy-haemoglobin in the blood is cherry red. Following a significant level of exposure to fire or carbon monoxide (e.g. house fire or faulty gas appliance) the ‘poisoned’ blood is very red, the casualty does not appear blue or short of oxygen and even the normal pulse oximeter will be fooled and give a very high saturation reading. In view of this the pulse oximeter should only be relied upon for heart/pulse rate readings and not used to assess the oxygen status of these patients as the reading will be falsely elevated. Smoke inhalation Chapter 6: H - Head Trauma and Other Serious Injuries Do not rely on oxygen saturation readings from a pulse oximeter in smoke inhalation victims.

120 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The UK Ambulance HART teams and hospitals have a more complex type of oximeter called a Co-oximeter, which will tell the difference between normal and abnormal blood and can indicate the need for oxygen therapy and hospitalisation. Carbon monoxide is released from partial combustion of substances in fires or in faulty household heating appliances. Carbon monoxide poisoning may result from the following scenarios: • Defective domestic gas/oil appliances such as boilers (most common after the onset of inclement weather when these appliances are first turned on are a period of disuse) • Even short exposure to fires or smoke in a closed environment • Prolonged exposure to fire in any environment • Fuel-driven engines in a confined space • Contaminated compressed gas cylinders (e.g. divers). SIGNS AND SYMPTOMS OF CARBON MONOXIDE POISONING • Reduced level of consciousness or coma • Headache • Fatigue and lethargy • Flu like symptoms • Dizziness • Poor coordination and/or balance • Blurry or double vision • Abnormal, involuntary eye movement (nystagmus) • Ringing in the ears • Shortness of breath • Chest pain • Diarrhoea (especially in children). As you can see, many of these features are nonspecific and vague, which can lead to delayed diagnosis, even when people have sought medical help or guidance for their symptoms but have not linked them to a faulty appliance. A very important prevention message and public education programme has been established by a number of UK Charities, following some tragic deaths in family homes, holiday homes and student accommodation. Always enter any property where there is such a risk with extreme caution, especially after a fire or casualties have been found. This may require breathing apparatus as even a few breaths of carbon monoxide at high level can render you unconscious. TREATMENT OF CARBON MONOXIDE POISONING To treat casualties with carbon monoxide poisoning, responders should: • Administer supplemental high flow oxygen (15L/min) to displace the carbon monoxide from the haemoglobin • Severe cases (including casualties with a history of reduced conscious level or neurological symptoms and pregnant or paediatric casualties) may later require referral to a medical hyperbaric unit • Unconscious casualties need rapid assessment and either airway management with oxygen or if there are no signs of life, then immediate basic life support, with high flow oxygen and ventilation (30:2). CYANIDE AND OTHER TOXINS House fires, where many synthetic furnishings and materials are burned in an enclosed space, may also release dangerous levels of other toxic gases such as cyanide compounds which can be fatal even at very low levels. In France and other parts of the world, every house fire victim is treated for potential cyanide toxicity at the scene. In the UK this practice is rare, even in emergency departments. OTHER HIDDEN DANGERS AND SITUATIONS Tunnels, sewers, silos, or hoppers may also involve dangerous gases or toxins at very high levels, e.g. methane and carbon dioxide which greatly reduce oxygen levels. Gas analysers and breathing apparatus are essential for safe working or rescue in these environments. Carbon monoxide, cyanide and inhaled poisoning Chapter 6: H - Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 121 CHEMICAL SUICIDE In recent years there has sadly been a growing trend from the internet for young adults and teenagers to commit chemical suicide alone or even in groups. They typically use cyanide, which is rapidly fatal and can be produced with a simple blend of some household chemicals based on instructions that they find online. There is a typical pattern to these suicides and they usually seal themselves in a locked room, and clearly mark the door outside to protect relatives and the emergency services. It is essential that rescuers DO NOT ever enter such a room without suitable chemical protection, especially as cyanide compounds can be: • Absorbed through the skin • Exhaled by casualties. If we do manage to rescue the casualties they will then require resuscitation during a full decontamination process, which is very challenging and unlikely to be successful. FARM WORKERS Few appreciate the very real risks of inhaled or skin poisoning and sudden death on farms. There are several key areas of risk including: • Slurry pits • Grain stores and silos • Organophosphate Fertiliser and pesticides, e.g. sheep dip. Slurry pits are often adjacent or underneath cow sheds or shippons and very high levels of methane and carbon dioxide can accumulate in these tanks, which can be released in very high levels when they are agitated. A few breaths of this colourless gas will render the casualty unconscious and rapidly lead to death because of the low levels of oxygen. Grain silos carry similar risks from high levels of carbon dioxide, which can rapidly incapacitate a worker or rescuer, rapidly resulting in death. Working or rescuing casualties in any of these situations requires breathing apparatus and ideally gas analysis before entering the scene. Resuscitation to such casualty is unlikely to be successful, unless they have only just collapsed within a few minutes. ORGANOPHOSPHATES Many chemicals on farms are based on organophosphates such as fertilisers and pesticides. A typical poisoning could involve excessive skin exposure or ingestion, e.g. falling into a sheep dip or spillage. These agents are closely related to chemical weapons such as Tabun and Sarin and result in: • Excessive salivation • Muscle weakness (can worsen to paralysis in extreme cases) • Difficulty breathing • Constricted pupils • Slow pulse rate. This can be a life-threatening emergency and rapid decontamination is essential, ideally dry or wet if necessary with copious amounts of water (always consider where the water is running off to, based on the nature of the chemical) If breathing is difficult, then supporting the breathing with a bag valve mask or pocket mask can be life-saving until help arrives. HART paramedics will carry atropine autojet antidotes for chemical terrorism which will help, but hospital will usually be required for management of the paralysis, that will re-occur despite the atropine. Any casualties brought from a fire or enclosed environment with a reduced level of consciousness should be given high-flow oxygen, assumed to have CO or Cyanide poisoning and be rapidly transported to hospital. Carbon monoxide, cyanide and inhaled poisoning Chapter 6: H - Head Trauma and Other Serious Injuries

122 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com • The final step in the MARCH algorithm addresses head trauma and other serious injuries, including spinal injuries, bone fractures, abdominal injuries, and burns • Treatment of head injuries in the field focuses on preventing further damage • The AVPU scale is used to assess casualty responsiveness • Head trauma casualties must be rapidly transported to hospital • All casualties with signs or symptoms of spinal injury should be considered time critical • While there are certain situations in which the spine should not be immobilised, responders should fully immobilise the spine if there is any doubt • Longboards can be used for extrication and immobilisation. A casualty should either be placed on the longboard by logrolling or with an orthopaedic (scoop) stretcher • Fractures should be immobilised by splinting which limits movement, 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. Splints can be improvised from rigid materials, but commercially available products offer more robust immobilisation • Splints should be applied when there is a doubt about their necessity • For rib fractures, responders should be careful to handle the casualty gently and continually reassess for developing respiratory concerns • Pelvic fractures require immobilisation, since these injuries often involve severe blood loss • Examine casualties carefully for signs of abdominal injury and provide rapid transport to hospital if abdominal injury is suspected • If treating abdominal injuries will not delay transport, wounds should be dressed appropriately • Burns are categorised by depth (superficial, partial-thickness, and full- thickness) and by source (thermal, chemical, electrical) • Thermal burns are the result of direct contact of flames or thermal energy (heat). They should be cooled under running water, dressed in burn-film wrap, and, if time critical, rapidly transported to hospital • Chemical burns result from contact with a caustic or corrosive substance or a substance that reacts with moisture on the skin to generate heat. Chemical burns should be identified, cleaned, washed, and dressed. Casualties should be rapidly transported to hospital • Electrical burns result from direct contact with a live electric source. Safe approach is essential when treating electrical burns. Wounds should be dressed with burn-film before rapid transfer to hospital. All electrical burn casualties should receive supplemental oxygen • When appropriate, pain management drugs such as Entonox and Fentanyl may be used to help stabilise casualties. Summary: Chapter 6: H - Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 123 AVPU scale: A scale to measure a casualty’s level of consciousness. The letters stand for alert, verbal, pain, and unresponsive. Cervical collar: A neck support that partially stabilises the neck following injury. Full-thickness burns: Burns that extend through the skin and into or beyond the underlying tissues; the most series class of burn. Logrolling: A technique used to move a patient onto a longboard. Partial-thickness burns: Burns in which the outer layers of skin are burned; these burns are characterised by blister formation. Splinting: A means of immobilising an injured part by using a rigid or soft support. Superficial burns: Burns in which only the superficial part of the skin has been injured; for example, a sunburn. Revision: 1. Which of the following scales should be used to assess patient response to stimuli? A ABC B MARCH C AVPU D DiD-iT ANSWERS 1: C 2. True or False? Any casualty who has suffered a serious head injury and has an oxygen saturation of 90% should NOT be given supplemental oxygen. A TRUE B FALSE ANSWERS 2: B Vital vocabulary Chapter 6: H - Head Trauma and Other Serious Injuries

124 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 3. When should a rescuer working alone attempt to immobilise the spine in a casualty with suspected spinal injury? A Immediately after securing the airway. B When no other time critical injury needs managing. C Before moving the casualty, under any circumstances. D A single rescuer should never attempt to immobilise the spine. ANSWERS 3: B 4. In the event of a suspected pelvic fracture, rescuers should: A Strap the pelvis, legs, and ankles together and then evacuate the casualty on a longboard or scoop. B Use a traction splint. C Elevate the legs. D “Spring” the pelvis. ANSWERS 4: A 5. Which of the following criteria relating to burns indicates a time critical situation? A The burn has caused blistering on the thigh. B The burn is very painful. C The casualty has sunburn and cannot wear a shirt. D The burn is found on the neck. ANSWERS 5: D Revision: Chapter 6: H - Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 125 M.A.R.C.H ALGORITHM Chapter 6: H - Head Trauma and Other Serious Injuries B.L.S. PROTOCOL NOT BREATHING (10secs) NO SIGNS OF LIFE (10secs) Re-assess again! SAFE APPROACH TIME CRITICAL HAEMORRHAGE CONTROL D.D.T Wound Packing / Haemostatics / Tourniquets Not more than 60 secs if single rescuer AIRWAY MANEOUVRES • Jaw Thrust/Chin LIft • Oxygen 15L/min - Target Sats > 94% on 02 • Suction • NP/OP • i-Gel RESPIRATORY SUPPORT • Oxygen 15L/min • Chest seal (wounds) • RR <8/min - BVM - Pocket mask • Bad side upper most • Consider sitting up CIRCULATORY SUPPORT • Re-assess D.D.T/Bandage CONSIDER: • ‘Scoop and Run’ • Pelvic Strap • Gentle handling • Traction Splints • Head to Toe survey • Elevate Legs INJURY SUPPORT HEAD INJURY (Consider Medical Causes) • Keep patient talking • Monitor Airway/breathing SPINAL INJURY AND FRACTURES • Immobilise/Splint • Pain: Penthrox BURN INJURY • Active Cooling • Cling-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 • Abnormal Pupil Reaction • Pain or numbness • GCS <12/15 • 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

126 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Chapter 7: Resuscitation and Basic Life Support No signs of life In this chapter we will focus on cardiac resuscitation, which has many different names such as BLS, CPR, ALS, chest compressions etc. ‘You can help someone in Arrest’ even with minimal training. Basic Life Support (BLS) and use of AED will also be covered as a shortend refresher in the First Aid & Medical Emergencies Section (see chapter 11).

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 127 CARDIAC ARREST The key to saving someone in cardiac arrest is to identify it quickly, to call for medical help and then to start chest compressions. In the UK the average survival from cardiac arrest out of hospital is around 10%, but in some parts of the world it can be as high as 60% or more. The key to this success is not fancy medical care or advanced paramedic skills, but is actually down to bystander and first responder efforts. The reasons why are demonstrated clearly in (figure 7.1) which shows how survival falls by about 10% every minute without chest compressions and as such within 6 minutes of the arrest occurring the chances of survival falls to 40%. However, even an untrained bystander who attempts to do chest compressions, can significantly improve this situation and at 6 mins improve survival by over 20%. We also now know that for the best chances of overall survival with a good outcome bystander chest compressions can be as important as any of the advanced resuscitation that takes place later. Simply by ‘having a go’ the bystander gives the paramedics the best chance to save a patient. The bottom line is clear – get hands on the chest early and start your compressions hard and fast. So consider a typical scenario. Here is a 69yr old man who is playing golf with his friends when he suddenly complains of feeling short of breath, with some tightness in his chest. Seconds later he collapses on the floor, initially clutching his left arm, but then he becomes unresponsive. He will not answer any of your questions and even with a firm but gentle shake he does not respond and he is looking blue around his lips. NO SIGNS OF LIFE • Quickly recheck, ask him loud and clear ‘Are you alright?’ • Look at his chest and feel with your hand over the mouth – is he breathing? GASPING IS NOT BREATHING When we saying breathing, we mean breathing normally. In other words, gasping or very slow breaths are not ‘normal’ breathing. If in doubt then assume that it is not normal. No signs of life Chapter 7: Resuscitation and Life Support 0 20 40 60 80 100 1min 2min 3min 4min 5min 6min Percentage Survival By-stander CPR No By-stander CPR Figure 7.1: The effects of By-stander CPR on Survival

128 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com HELP ME One of the most important factors in any successful resuscitation is early recognition and that is why we simplified the process of identifying a cardiac arrests - a casualty unresponsive and not breathing normally. • As soon as you suspect a cardiac arrest then call for help • Shout the people around you and then call for an ambulance. CONFIRM CARDIAC ARREST • Open the Airway and feel for breathing on your hand stroke face for 10 seconds (No more) • Feel for a major pulse (Neck, Groin) for 10 seconds (No more) • If there is no breathing or pulse or you are in any doubt then assume Cardiac Arrest. If there are people around then get them to make the 999 call and to state ‘CARDIAC ARREST’ and the exact location. Remember all the things that we discussed about the call for help in the earlier chapter. No signs of life Chapter 7: Resuscitation and Life Support

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 129 Immediately get the casualty onto a firm flat surface in a safe environment. Do not spend more than a few seconds on this as every second counts and ‘hands on the chest’ are what is needed. In other words any interruption or delay to starting chest compressions reduces the chances of survival. If you know where there is an AED (defibrillator) then send someone to get it. If you have a smartphone, it may be worth considering the GoodSAM app which will not only allow you to call the emergency services or other providers but also will tell you where the nearest AED is located and also where you are when you check. Get the casualty onto a firm surface Chapter 7: Resuscitation and Life Support Recommendation: GoodSAM App Available on App Store and Android

130 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Place hands over the mid-lower part of the sternum (breast-bone). Do not delay the chest compressions trying to be too exact, but ensure that you are not compressing the soft abdomen If a person is in cardiac arrest, responders should attempt to maintain or restore circulation through cardiopulmonary resuscitation (CPR). CPR is comprised of two components: chest compressions and ventilations. CHEST COMPRESSIONS Early Chest compressions are the most crucial part and should be started as soon as possible to give the patient the best chance for survival and keep the patient alive until more advanced medical care can be administered. ADULT CPR commences with compressions only. To perform chest compressions, kneel beside the patient’s chest facing the patient (see figure 7.2). Place the heel of one hand in the centre of the patient’s chest. Place the heel of the other hand on top of the hand on the chest, interlocking your fingers. After you have both hands in the proper position, compress the chest of an adult 5 to 6 cm straight down. For compressions to be effective, stay close to the casualty’s side and lean forward so that your arms are directly over the casualty. Keep your back straight and your elbows locked so you can apply the force of your whole body to each compression, not just your arm muscles. Between compressions, lift the heel of your hand off the patient’s chest allowing the chest to completely recoil. Compressions must be rhythmic and continuous. This takes practice and feedback devices such as the Zoll defib pads really help. Each compression cycle consists of one downward push followed by a rest so that the heart can refill with blood. Compressions should be at the rate of 100 – 120 compressions per minute. Cardiopulmonary Resuscitation (CPR) Chapter 7: Resuscitation and Life Support Figure 7.2: Performing Chest Compressions 1. Kneel beside the casualty’s chest. 2. Place the heel of one hand in the centre of the casualty’s chest. 3. Place the heel of the other hand on top interlocking your fingers. 4. Compress the chest of an adult 5 to 6cm straight down. Then allow chest to completely recoil.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 131 It may come as a surprise to hear, but for those who are not involved in resuscitation on a very frequent basis, (e.g. monthly) they are likely to have more success with adult cardiac resuscitations by doing chest compressions only. The reasons for this are simple, as we now know that good compressions are the key element of CPR and to interrupt to deliver breaths/ventilations, can actually reduce the chances of survival. This clearly demonstrates that the key focus must be the compressions and even if capable of doing ventilations, they are less of a focus and must be completed without any delay to resuming compressions. The simple diagram below demonstrates why continuous compressions are so important, as they maintain the blood flow or ‘perfusion’ to the brain and organs of the body, but when we stop compressions, the perfusion drops to near zero immediately. When compressions are resumed, it can take up to 18 compressions, to restore the perfusion again, so we should only do ventilations if they are essential and will count. There are a few exceptions where we would always recommend compressions and ventilations. These exceptions are cardiac arrests where there is a lack of oxygen involved e.g: • Drowning • Hanging • Carbon monoxide poisoning • Children (under 18 years) • Greater than 10-15 mins downtime (cardiac arrest). However, if ventilations are difficult or you cannot do them for whatever reason, carry out compression only ‘hands-only’ CPR. If you are doing compression-only (hands-only) CPR but you have oxygen available, then there is theoretically some benefit in delivering the oxygen during the compressions, as some will flow down an open airway and reach the lungs. Theoretically, this may increase the chances of a good outcome. This should not delay or interrupt the compressions, but if multiple rescuers are present then consider: • Starting compressions and during airway procedures below • Inserting nasal (x2 if possible) and oral airway • Applying oxygen 15 L/min via mask (alternatively insert I-gel) • Holding the airway open and maintain during compressions • Performing continuous compressions and following the AED instructions when it arrives. Why ‘Hands-only’ CPR? Chapter 7: Resuscitation and Life Support

132 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com If attending frequent cardiac arrests and skilled in ventilation this allows the rescuer to ‘breathe’ for the casualty, which may improve the outcome in Cardiac Arrest and will improve the likely outcome in Children drowning and Hypoxic (lack of oxygen) Arrests. To perform ventilation, use a pocket mask or a bag-valve mask (see figure 7.3). For the pocket mask, ensure that the airway is clear and open (jaw thrust, chin lift) then seal the mask onto the face. Use of the pocket mask for ventilation. Keep the casualty’s airway open by using the head tilt–chin lift manoeuvre (or the jaw-thrust manoeuvre for patients with suspected head or neck injuries) and then take a deep breath and blow steadily into the mask for about half a second. Use rapid but gentle, sustained breathing and just enough to make the casualty’s chest rise. Remove your mouth from the mask and allow the lungs to deflate and the chest to fall. If using a Bag valve mask (BVM) squeeze the bag ONLY ENOUGH TO SEE THE CHEST RISE NORMALLY. This allows you to use a large adult bag on small adults or even children. Use of a pocket mask with oxygen attached. The rate of breaths should be 10 to 12 breaths per minute for an adult. If a pocket mask or bag-valve mask is not available and you are unwilling or unable to perform mouth-to-mouth ventilation, continue with chest compressions only at a rate of 120 per minute. (Equivalent to 30: 2). Person Bag-valve-mask (BVM). If the ventilations do not make the casualty’s chest rise and fall, as seen with normal breathing, make sure that the airway opening technique you are using (e.g., head- tilt–chin-lift or jaw-thrust manoeuvre) is being appropriately applied. Check for, and remove any visible obstruction, in the casualty’s mouth, but do not delay further compressions worrying about ventilations – remember that effective life support is far more about chest compressions than ventilations. Provide only two ventilations before returning rapidly to chest compressions, and keep repeating these checks until normal chest rise is seen with ventilation. Ventilations or ‘Rescue breathing’ - Experienced resuscitator If not used to providing ‘ventilations’ on a regular basis, then clinical evidence shows that “hands only” CPR will give better results. Figure 7.3: Performing Ventilations Chapter 7: Resuscitation and Life Support

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 133 Although one-rescuer CPR can keep the casualty alive, two-rescuer CPR is preferable because it is less exhausting for the rescuers, and if necessary one person can deliver chest compressions while the other performs ventilation. One, two or more rescuer CPR, delivers 30 chest compressions for every 2 ventilations. Continue this process without stopping unless the casualty starts to breathe properly or more advanced health care professionals arrive. In two-rescuer CPR, the first rescuer should provide 30 chest compressions and then pause just long enough for the second rescuer to provide two ventilations. To avoid rescuer fatigue—which may result in less effective chest compressions—the two rescuers should switch roles after every five cycles of CPR (about every 2 minutes). Two rescuers should be able to switch roles quickly, interrupting CPR for the minimum amount of time. The aim is that under no circumstances, should CPR be interrupted other than to analyse on the AED - especially for longer than 10 seconds. One or two-rescuer CPR is now the same in adults (no difference in compression: ventilation ratio) Chapter 7: Resuscitation and Life Support Automatic External Defibrillator (AED) In Europe, nearly 700,000 individuals die of cardiac arrest each year. Up to 70% of adult patients who suffer a non-traumatic cardiac arrest are in a state of ventricular fibrillation (VF)—a condition in which the heart muscles are ‘quivering’ or ‘fibrillating’ and not effectively pumping blood. It is in this condition that we are most likely to reverse and save them. This irregular heart electrical rhythm can be defibrillated, reorganised or ‘shocked’ into effective heartbeats with the use of an automated external defibrillator which creates a DC electric shock. (AED) (see figure 7.4). Automated external defibrillators (AEDs) are machines which can accurately identify ventricular fibrillation and advise responders to deliver a shock to defibrillate the heart rhythm. Figure 7.4: An Automated or Advisory External Defibrillator (AED)

134 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Once the AED is brought to the scene, quickly attach the adhesive electrode pads to the casualty. Nearly all AEDs provide accurate and simple voice and screen commands. Follow these and ensure that no one is touching the casualty whilst the AED is analysing the rhythm. PAD PLACEMENT When sticking the pads to the chest, ensure that the chest is dry and not too hairy (safe hair-removal devices can be kept with the AED). Do not delay defibrillation awaiting a razor. Place one pad just to the right of the sternum, below the collar bone and the other pad on the left side of the chest, just below the nipple (for males) or underneath the breast tissue (for females). If the pads are slightly misplaced, avoid removing and reapplying them, as they may not adhere as well. (see figure 7.5) Additionally, responders should check for the 8 P’s which require special attention before administering attaching pads or delivering shocks: • Piercings • Pacemakers • Pendants • Playtex (bras) • Patches (GTN/ nitrate patches) • Perspiration • Paediatric casualty (requiring special pads) • Personnel in contact with patient Foreign objects listed above should be avoided or removed, without delaying the shock or ongoing CPR. Special paediatric pads may be required for children (see Chapter 9). No one should be contacting the casualty when a shock is administered. FEEDBACK DEFIBRILLATOR PADS The latest generation defibrillator pads, such as those produced by Zoll, provide real time feedback to those that our doing chest compressions about the quality of the compressions in terms of: • Rate • Depth • Release Automatic External Defibrillator (AED) Rescuers may refer to the AED pad packaging for correct placement. Chapter 7: Resuscitation and Life Support Figure 7.5: PAD Placement

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 135 FUNCTION OF THE AED/DEFIBRILLATOR The AED will assess the casualty’s status every two minutes and advise when to deliver a shock. (see figure 7.6) When a shock is advised, use the following steps: 1. Stop CPR 2. Disconnect any supplementary oxygen and move bag-valve mask at least 1.5 m away from the casualty 3. Ensure that no one is touching the casualty 4. Shout “Stand clear!” we recommend that the shock is delivered by the chest compressor to ensure their hands are not on it 5. Press the “shock” button on the AED. (Fully-automatic AEDs will deliver the shock automatically) 6. Stand back while the AED delivers a shock 7. Immediately recommence CPR for two minutes until the AED reassesses the casualty’s need for further shocks. Repeat this sequence until the casualty starts to breathe normally. If no further shocks are indicated, continue CPR until the patient regains spontaneous breathing, or more qualified help arrives. If spontaneous breathing is present, check for a pulse (carotid or femoral). Figure 7.6: Analysing a rhythm using an AED AEDs vary in their operation so learn how to use your specific AED. Practice until you can perform the procedure quickly and safely. Ensure you always follow the most recent Resuscitation Council guidelines. Many AEDs are only equipped with adult sized pads which are suitable to down to eight years of age. For smaller children, if no paediatric pads are available then the adult ones can be used over one year of age, placed on the front and back if necessary. Automatic External Defibrillator (AED) Care should always be taken when using AEDs in certain environments, particularly those that are wet or near water sources. An AED can be safely used in children down to 1 year of age. Chapter 7: Resuscitation and Life Support

136 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com RETURN OF SPONTANEOUS CIRCULATION – ROSC When the casualty starts to breathe or show signs of life put them in the recovery position and observe them. Leave the AED pads attached unless they are shivering or having a seizure and continue to monitor them until help arrives. Whilst it is rare for someone to just wake up immediately intact, this can occur if the arrest has been very short or after a period of recovery. Reassure them and keep them comfortable and warm until the ambulance arrives. TRAUMATIC CARDIAC ARREST In Traumatic cardiac arrests, e.g. at a road traffic collision, VF is rare and CPR and defibrillation are unlikely to be successful. The mortality from blunt traumatic cardiac arrest is close to 100%, but most providers will still wish to try some aspect of resuscitation/CPR, as the cause of the incident may have been the cardiac arrest, although they should be aware their efforts are likely to be futile with 1-2% survival or less. However, penetrating cardiac arrests, e.g. from a stabbing, may be amenable to aggressive surgical control, but this is far beyond the scope of all but the most advanced trauma-medical teams and most will die of blood loss or other effects such as bleeding around the heart. Summary: • When a casualty shows no signs of life, he or she is likely to be in cardiac arrest and should be considered time critical • In cardiac arrest, the heart stops contracting which can lead to organ and brain damage • Chest compressions should be performed on all casualties suffering a cardiac arrest • Chest compressions are delivered by placing one hand in the centre of the casualty’s chest, and placing the other hand on top of the fist, interlocking the fingers. Push down 4-6 cm and allow full recoil • Chest compressions should be given at a rate of 100 - 120 compressions per minute • 30 chest compressions should be given followed by two ventilations. This should continue until the casualty starts breathing normally, more qualified help arrives, or you become exhausted • Hands only CPR is often just as effective, if not more so, for in-experienced resuscitators. Therefore, do not struggle with ventilation and focus on chest compressions and defibrillation • An AED will deliver a shock that stops the heart quivering or fibrillating, allowing it to start again in a suitable rhythm • If an AED is available, it should be applied to the casualty using adhesive pads and the voice prompts followed • Traumatic cardiac arrest casualties rarely survive their injuries. Automatic External Defibrillator (AED) Chapter 7: Resuscitation and Life Support

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 137 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. Basic Life Support (BLS): CPR to treat a casualty who has no signs of life until a defibrillator is available 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. 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. Hands Only CPR: Resuscitation for those responders who do not do regular ventilations. Outcome is often just as good if not better in in-experienced hands. Ventilations Artificial: Means of breathing for a casualty. Ventricular Fibrillation (V-fib or VF): An uncoordinated muscular quivering of the heart; the most common abnormal rhythm causing no-traumatic cardiac arrest. Revision: 1. Which of the following would indicate that CPR is needed? A Rapid pulse B Dilated pupils C Absent breathing D Shortness of breath. ANSWERS 1: C Vital vocabulary Chapter 7: Resuscitation and Life Support

138 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 2. Which of the following is NOT a key component of basic life support? A Leg elevation B Chest compressions C Ventilations in drowning cases D Automatic external defibrillation ANSWERS 2: A 3. What is the appropriate depth of chest compressions for an adult casualty? A 1 to 2cm B 2 to 4cm C 4 to 6cm D 5 to 7cm ANSWERS 3: C 4. When performing adult CPR, what is the ratio of chest compressions to ventilations A Always do hands only CPR B 15 to 2 C 30 to 2 D 50 to 2 ANSWERS 4: C Revision: Chapter 7: Resuscitation and Life Support

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 139 5. When should rescuers deliver a shock using an AED? A When the device tells you that a shock is advised B When the device indicates that the pulse rate is below 30 beats per minute C Only when the cardiac arrest was witnessed D Only after two cycles of CPR, if no signs of life are present. ANSWERS 5: A Revision: Chapter 7: Resuscitation and Life Support

140 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com M.A.R.C.H ALGORITHM B.L.S. PROTOCOL NOT BREATHING (10secs) NO SIGNS OF LIFE (10secs) Re-assess again! SAFE APPROACH TIME CRITICAL HAEMORRHAGE CONTROL D.D.T Wound Packing / Haemostatics / Tourniquets Not more than 60 secs if single rescuer AIRWAY MANEOUVRES • Jaw Thrust/Chin LIft • Oxygen 15L/min - Target Sats > 94% on 02 • Suction • NP/OP • i-Gel RESPIRATORY SUPPORT • Oxygen 15L/min • Chest seal (wounds) • RR <8/min - BVM - Pocket mask • Bad side upper most • Consider sitting up CIRCULATORY SUPPORT • Re-assess D.D.T/Bandage CONSIDER: • ‘Scoop and Run’ • Pelvic Strap • Gentle handling • Traction Splints • Head to Toe survey • Elevate Legs INJURY SUPPORT HEAD INJURY (Consider Medical Causes) • Keep patient talking • Monitor Airway/breathing SPINAL INJURY AND FRACTURES • Immobilise/Splint • Pain: Penthrox BURN INJURY • Active Cooling • Cling-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 • Abnormal Pupil Reaction • Pain or numbness • GCS <12/15 • 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 Chapter 7: Resuscitation and Life Support

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 141 RTACC AED – Life support protocol (Based on UK/ERC Guidelines 2015) ASSESSMENT CHECK PATIENT NO RESPONSE CHECK PULSE AND BREATHING (max. 10 secs) • ABNORMAL BREATHING • NO MAJOR PULSE COMMENCE Hands Only CPR 100-120/min continuous OR 30:2 (See adjacent note) AED AVAILABLE • APPLY PADS • TRY NOT TO INTERRUPT COMPRESSIONS ANALYSE RHYTHM SHOCK ADVISED IMMEDIATELY RESUME CPR FOR 2 MINS 1 SHOCK DELIVERED NO SHOCK ADVISED RESUME CPR FOR 2 MINS RETURN TO CONSCIOUSNESS SIGNS OF WAKING UP e.g. MOVING, BREATHING NORMALLY CALL FOR HELP Ring 999/112 (+ GoodSAM App if able) COMPRESSIONS DEFIBRILLATION ASAP Provide ventilations (30:2) in: • Paediatrics • Drowning • Hypoxic Arrests • Experienced Responder Chapter 7: Resuscitation and Life Support

142 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com RTACC Special Modules

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 143 These chapters are additional material that can be included in any dedicated RTACC course as core modules. Table of Contents: Part 2: RTACC Trauma Modules Chapter 8 - Special Circumstances 8.1 - Extrication Module 8.1 A - Extrication - Environment 8.1 B - Extrication - Samurai Laser 8.2 - Water Rescue Module 8.2 A - Drowning and non fatal drowning 8.2 B - Diving accidents & tunnel workers 8.3 - Major incident and Triage Module 8.4 - Medical Rescue Module 8.4 A - Crush 8.4 B - Suspension Trauma 8.4 C - Machinery Entrapment Chapter 9 - Special Patients Module 9.1 - Pregnancy 9.2 - Children 9.3 - Elderly Chapter 10 - Pain Management Module 10.1 - Pain Assessment & Management 10.2 - Penthrox® Administrator Part 3: First Aid & Medical Chapter 11 - First Aid & Medical Emergencies – B.U.R.P.S Safety Calling for Help Immediate Assessment – B.U.R.P.S Bleeding – B.U.R.P.S Major Bleeding – B.U.R.P.S Unconscious / Very Drowsy – B.U.R.P.S No Signs of Life Respiratory Distress – B.U.R.P.S Pain or Numbness – B.U.R.P.S Skin – Appearance & Temperature – B.U.R.P.S Part 4: RTACC Medical Modules Chapter 12 - Medical Devices Module Appendices Appendix A: Clinical Updates 2018 Appendix B: RTACC Algorithm Appendix C: RTACC Trauma kit

144 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Chapter 8: Special Circumstances Module Preparing for special circumstances For most trauma situations, the RTACC methods presented in previous chapters will be sufficient to make an adequate assessment and provide appropriate treatment. However, in certain special circumstances such as: • Extrication • Water Rescue • Major incident and Triage. • Medical Rescue.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 145 Any casualty who cannot self-extricate or be released immediately and evacuated from the scene of injury should be considered to be in a state of entrapment. Entrapment may be the result of a physical entrapment (e.g. a car dashboard crushing the casualty’s legs), an environmental entrapment (e.g. a tactical firearms situation) or a medical entrapment, due to the injuries of the casualty. As such, the speed of extrication is governed by the clinical state of the casualty and the nature of the environment. In some situations, things may be so unstable that some measured compromises must be made to preserve life. When managing a case of entrapment, the responder must determine the necessary speed of extrication (see table 8.4) based on all the factors including kinematics of the situation, environment and especially the patient assessment. In pure medical terms this can be considered as a simple decision, using a flow chart based on the patient’s stability (see figure 8.5). However, some ‘time critical’ conditions do not necessitate or allow immediate extrication. For example, it may be necessary to spend time making the situation safe BEFORE extricating the casualty, e.g. if still taking incoming gunfire in open ground or within a building which is still on fire. Use The ATACC Group, ‘S.A.M.U.R.A.I L.A.S.E.R’ (see figure 8.6) as a guide to determine the method, speed and route of extrication required. This tool is devised to improve communications between the Medics and Rescuers - ‘Medical Rescue’ Table 8.4 – Speed of Extrication SPEED OF EXTRICATION CASUALTY SITUATION RECOMMENDED TIME FOR CASUALTY EXTRICATION URGENT STABLE 20 MINUTES or LESS RAPID STABLE BUT AT RISK / DETERIORATING - ‘TIME CRITICAL’ 5 MINUTES or LESS IMMEDIATE UNSTABLE ‘TIME CRITICAL’ PROBLEM WHICH IS IMMEDIATELY LIFE THREATENING 1 MINUTE or LESS 8.1 Extrication Chapter 8: Special Circumstances

146 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com SUDDEN DETERIORATION IS THIS PATIENT TIME CRITICAL? CAN THE PROBLEM BE MANAGED IN SITU? ‘IMMEDIATE’ EXTRICATION < 1 MINUTE STILL DETERIORATING NO YES YES NO YES YES NO NO ‘RAPID’ EXTRICATION < 5 MINUTES CAN THE SITUATION BE STABILISED? IS THE ENVIRONMENT SAFE? ‘URGENT’ EXTRICATION 20 MINUTES OR LESS Figure 8.5: Extrication in non-RTC entrapment – casualty and environment Extrication / 8.1A – Environment Chapter 8: Special Circumstances