RTACC

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 147 Figure 8.6: Samurai Laser Extrication / 8.1B – ‘Samurai Laser’ Chapter 8: Special Circumstances All Road Traffic Casualties should be classed as an ‘urgent’ and ideally extricated within 20 minutes. SAMURAILASER The METHOD considers the option of inviting the casualty to self-extricate with or without assistance. If they are unable then the casualty will need manually extricating. Self extrication does NOT exclude spinal injury but does suggest ‘self-protection’. S SELF A ASSISTED M MANUAL The SPEED of extrication is usually defined by the stability of the casualty but may also be defined by environmental or other hazards. Most normal ‘ A’ plan extrications should aim to be under 20 minutes. We also have rapid for the deteriorating casualty and Immediate for the arrested casualty or car on fire type situation. U URGENT R RAPID A I IMMEDIATE The ROUTE of extrication is defined by the potential for spinal injury and the need to minimise rotation. However, we also have an emergency option if things go rapid or immediate and finally we always consider the option to re-locate the vehicle where benefits of moving the car vs risks to the casualty are considered. L LINEAR A ANGLED S SIDE E EMERGENCY R RELOCATE SPEED ROUTE METHOD

148 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com In treating casualties of drowning or non-fatal drowning, RTACC focuses on managing cardiac arrest, unconsciousness and hypothermia. Drowning is the third commonest cause of accidental death after falls and road traffic collisions. According to the Lancet journal, drowning accounts for over 300,000 deaths a year globally, 90% of which occur in developed countries. Approximately 56,000 of these deaths are in children less than 5 years old. Many of these will be in bathtubs, as well as swimming pools and lakes. In the UK there are 350 deaths per year, typically in the 20-30 years age group. In warmer weather there is typically a rise in deaths as a result of persons swimming in lakes and reservoirs. Other risk factors include alcohol, low socioeconomic status, epilepsy and it is more common in males. In the UK the Emergency services review the ‘rescue’ at 30 mins and 60 minutes from the time that they arrive on scene (see figure 8.7). In certain situations such as children in extreme cold weather and icy water, the rescue may be extended to 90 minutes. However, the water in the UK is unlikely to be cold enough to prolong survival or protect the brain, as reported in other countries with colder climates. Drowning is a process, with immersion (in water, airway above the surface), submersion (in water, airway below the surface) and finally aspiration where water enters the lungs. The casualty will attempt to hold their breath, but either the will to breathe or cold shock (very rapid shallow breathing from sudden exposure to cold water) will result in water being aspirated into the mouth and upper airways. This will irritate the larynx and cause spasm of the vocal cords. 8.2 Water Rescue Chapter 8: Special Circumstances

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 149 In cases of drowning, the casualty will have had this closure of their larynx (vocal cords) to stop water entry and as a result they will have been starved of oxygen and ultimately had a cardiac arrest. Water aspiration into the lungs is late and relatively uncommon and we do not work to expel that mechanically. Submersion for less than 10 minutes has a very good chance of survival. If a rescue is conducted successfully then the process of drowning is interrupted. Rescue must be conducted safely and is beyond the remit of this text. However, there is rarely any need for ‘in-water resuscitation’ in most cases and rapid extrication is the favoured option. Few drowning victims (0.5%) will have a neck injury, but this must be considered based on the mechanism e.g. diving into shallow water increases the risk, but resuscitation has to be the priority. In anyone who shows no signs of life following rescue; providers should assume that they are in cardiac arrest and require immediate life support. In cases of near drowning, casualties may be unconscious but still have signs of life (e.g., breathing and pulses present), but they are likely to be very cold and suffering from hypothermia. These casualties should be kept warm and given 100% oxygen (especially if they are shivering). If immersed for more than a minute or two or they had a period of reduced conscious level, then they will require review by healthcare professionals or rapid transfer to hospital, as their condition may deteriorate later. When casualties require active resuscitation (CPR): As Hypoxia (lack of oxygen) has caused the cardiac arrest initially we give 5 rescue breaths, ideally with supplementary high flow oxygen 15L/min, via a face mask or I-gel with a bag valve mask. This may be difficult and associated with water or foam coming out of the mouth and nose. Make sure that you have suction available and be prepared to remove the I-gel if necessary for effective suction, but do not delay the start of chest compressions. If there is no response we then continue resuscitation with 30:2 compressions and ventilations, as this arrest is due to hypoxia. If you are unable or unwilling to give rescue breaths then simply perform chest compression only CPR, although this is likely to be less effective in a drowning victim. We continue resuscitation until medical help arrives or the casualty shows signs of spontaneous breathing and circulation. In which case we place them in the recovery position, keep them warm and monitor them visually and with our pulse oximeter for further signs of deterioration. Continue supplemental oxygen by I-gel or mask. Casualties from non-fatal drowning incidents are likely to have a degree of hypothermia. Whilst theoretically this may offer some protection of essential organs such as the brain, in reality it is only really true for children and cases of drowning in icy cold water, where the body temperature is dropped very quickly. In general terms remove them from the exposed environment, remove wet clothing and apply warm blankets or clothing. Foil blankets will limit further heat loss but will not warm the casualty. Consider using body heat to maintain or gently increase their temperature. Any victim who has been submerged for more than 90 minutes should be presumed dead. Chapter 8: Special Circumstances It is important to clear the airway with suction or positioning, but rescuers should not attempt to push fluid out of the lungs in the resuscitation of victims of drowning. Water Rescue / 8.2A – Drowning and non fatal drowning

150 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com UK RISK ASSESSMENT FOR SUBMERSION RESCUE YES GO YES NO NO NO ON GO VERY COLD WATER? YOUNG OR SMALL? DRA – GO/NO GO INCIDENT REVIEW 0 minutes 90 minutes 30 minutes 60 minutes Information Gather Body size Water temperature Time last seen Start Clock Person submerged? YES NO Figure 8.7 - Nation Operation Guidance on Water Rescue and Flooding. Chapter 8: Special Circumstances Water Rescue / 8.2A – Drowning and non fatal drowning

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 151 Water Rescue / 8.2B – Diving accidents and tunnel workers Chapter 8: Special Circumstances Divers are at risk from a number of problems including drowning, gas embolism (gas bubbles in the blood), and decompression illness. The risks of medical complications increase with greater dive duration, dive depth, and speed of ascent. If a diver ascends too quickly, large air bubbles are created in the blood which may block the blood supply to major organs and produce stroke-like symptoms (e.g., weakness, paralysis, unconsciousness, severe difficulty in breathing). Small gas bubbles may also develop in the tissues and joints, resulting in significant pain and inflammation known as decompression illness or “the bends.” The presence of any of the following signs and symptoms following a dive may indicate decompression illness: • Red/purple skin rash (commonly on the trunk) • Pains in the muscles or joints (commonly in the shoulders, neck, knees) • Paralysis or weakness of limbs • Areas of altered sensation on the body • Loss of bladder and bowel function • Impaired coordination • Any other unexpected symptoms in the nervous system • Missed decompression stops • Accidental rapid ascent to surface. Casualties exhibiting any of these symptoms require urgent rescue, supplemental oxygen, resuscitation, emergency review and probable recompression in a hyperbaric chamber. Divers should be removed from the water and should not be permitted to return until they have been examined by a medical professional. Never attempt to return a diver to the water to help symptoms or attempt ‘in water’ recompression. The ambulance service and coast guard should be informed, as the casualty may require immediate direct transfer to an appropriate hyperbaric medical facility. This will often require a helicopter transfer, so consider identifying a possible landing site nearby. There are no specific problems with helicopter transport and this is highly unlikely to worsen the condition. With the low altitudes involved, the change in atmospheric pressure is very small compared to the pressure at depth underwater. If the casualty is fully conscious, he or she should be encouraged to drink fluids, staying well hydrated, as dehydration will worsen the condition. They may take simple pain killers such as Ibuprofen or paracetamol to provide some relief until they can undergo recompression in a chamber. Entonox must NEVER be given for pain related to diving accidents although Penthrox is an effective safe alternative. Once re-pressurised, pain and symptoms will usually rapidly disappear, unless there has been a long delay reaching treatment. All diving accidents should be treated as Time Critical. Casualties of diving accidents should be given high-flow oxygen (15 L/min). Do not reduce the flow, even if pulse oximeter indicates 100% saturation. If in doubt contact an emergency recompression unit on their 24hr Hotline +44 (0) 151 648 8000

152 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Despite the common misconception a major incident does not have to involve hundreds of casualties. What it actually means is that the number of casualties ‘overwhelms’ the available resources. For example, if you are a solo medic, attending to three seriously injured colleagues may totally overwhelm your capabilities and is in effect a major incident. Alternatively, a hospital emergency department may suddenly receive 50 casualties simultaneously from a serious incident such as a bomb blast and the department is immediately totally overwhelmed. Whilst both represent a major Incident, the second would more commonly also be described as a Major Civilian Disaster as the numbers are so large and the impact on the community and healthcare provision is so much greater. In such situations we must provide effective care to as many casualties as we possibly can. This requires some form of prioritisation to avoid wasting time concentrating on a small number of individuals, whilst others are left unaided. Major incidents occur on a regular basis. In 2017, England witnessed five terrorism-related major incidents, resulting in approximately 40 fatalities and 400 injured. Triage is a key principle in the effective management of a major incident and involves prioritising patients on the basis of their clinical acuity. In response to the London 7/7 bombings, the UK’s National Ambulance Resilience Unit (NARU) introduced the NARU sieve. Combining elements of civilian practice (the traditional MIMMS Triage Sieve) and the existing DMS Military Sieve, the NARU sieve now includes an assessment of conscious level and catastrophic haemorrhage. Unfortunately, a number of military and civilian trauma registry studies have shown that the Military Sieve (essentially analogous to the NARU sieve) also lacks the accuracy to adequately identify those needing a life-saving intervention. This system of prioritisation of the injured is called ‘Triage’ and there are many different ways of doing this from a simple sieve through to some of the complex sort processes which consider a large number of parameters in reaching a final conclusion. Other triage systems from around the world such as SALT and START are considered to be too complicated and inaccurate for BTACC/RTACC use. Traditionally in the UK the NARU sieve has been used across the emergency services, however during a recent study this was proven to under-triage by approx 30%. For BTACC/RTACC we adopt the simplest and most evidence based of sieves, namely (MPTT-24). Developed by J Vassallo (see figure 8.8) which is a highly effective tool when used properly but there are certain basic rules: • The individual performing the triage does not treat any casualties until all of the process is completed • The individual must keep moving and work through all of the casualties • A typical triage assessment should take less than a minute • Triage is just a ‘snapshot’ of the current position and must be repeated. The casualties are classified according to their injuries into a number of groups as described below: A number of triage systems and categorisations exist based upon a colour coding, Priority 1-3 or delayed, urgent or immediate. The simple coding defines the priority for evacuation: When dealing with an overwhelming number of casualties we must adopt an affective system that does ‘the most for the most’ but ideally manages everyone injured. 8.3 – Major incident and Triage GREEN – PRIORITY 3 (P3) – Delayed AMBER/YELLOW – PRIORITY 2 (P2) – URGENT RED – PRIORITY 1 (P1) – IMMEDIATE Chapter 8: Special Circumstances

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 153 The triage process is repeated to ensure that the casualty carers remain up to date with the status of the injured. Obviously come casualties will get worse but others may actually get better and be less dependent upon medical care. In addition, as more resources arrive we can provide trauma care for more people and those with fewer injuries. The actual categorisation or ‘sieving’ of the casualties is based upon a number of key parameters that are easy and quick to assess, e.g. ability to walk, breathing, pulses or capillary refill time. Once a casualty has been assessed they must be marked and recorded. Many methods have been used including a simple marker pen to write on the forehead, triage cards and even coloured pegs or bands. Chapter 8: Special Circumstances Figure 8.8 - MPTT-24 P3 18 P2 11 YES P1 CATASTROPHIC HAEMORRHAGE? NO P1 RESPIRATORY RATE 12-23 Apply Tourniquet/Haemostatic dressing Place in recovery position NO WALKING? YES P3 NO BREATHING? NO DEAD DEAD 3 HEART RATE <100 YES P2 P1 8 RESPONDS TO VOICE? NO P1 NO YES YES YES 8.3 – Major incident and Triage

154 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The term ‘Medical Rescue’ is something that ATACC has promoted for over 20 years and it describes a joined-up approach of linking rescue with the medical management for the advantage of the casualty. This has been touched on in other approaches, such as casualty centred rescue, enhanced first aid for rescuers and A plans and B plans, based on the medical condition of the casualty. In this chapter we will tackle some very complex and medically challenging conditions, where the rescue is a key part of the medical management. This seamless approach to medical and rescue care is something that ATACC advocates in all pre-hospital cases, as if the two elements are intimately linked then the whole process will be faster and safer, through the joined-up approach to care. The three areas that we will cover in this RTACC special module are crush injury, suspension trauma and machinery entrapment. These can present huge challenges to those confronted with such incidents and much of the current National guidance fall short of offering solutions to some of these situations. In the chapter we take the current best practice recommendations, plus the experience of the ATACC Faculty to offer viable and practical solutions to give the casualty the best chance of survival, through our simple, practical measures, applied on scene. 8.4 – Medical Rescue Chapter 8: Special Circumstances If the body is crushed, then several things can occur which can be split into early and late: EARLY - CRUSH INJURY • Crush of the chest can result in an inability to breathe, rib fractures, lung injuries, internal bleeding and ultimately death from asphyxia • If limbs are involved then there is initially damage to the soft tissue of skin and muscle, with potential bleeding, de-gloving (Muscles and skin are stripped off their attachments to underlying structures and bones) and fractures of the bones. LATE - CRUSH SYNDROME • If large groups of muscle are trapped for prolonged periods then on release there is the potential for collapse and even sudden death • Large areas of crushed and injured muscle can result in kidney failure days later in hospital, needing urgent medical attention or dialysis. We will now look at these elements and how they can be managed during a rescue to improve the outcome for the casualty Medical Rescue / 8.4A – Crush

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 155 Medical Rescue / 8.4A – Crush 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 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. The immediate effects of crush are injuries, such as wounds, bleeding and fractures. This bleeding can be life threatening and should always be considered as it may often be concealed with inside the body in crush of the pelvis, abdomen or chest. However, it can also be concealed if limbs are crush inside machines or other objects that limit our view of the injury. For example, if the legs are trapped underneath the dashboard at a road traffic collision, if may be very difficult to assess for major bleeding and the first that may raise our awareness, may be blood appearing on the floor of the car or even coming from under the car. Any hint of major bleeding should be managed according to our ‘I DID IT’ approach, however in most cases director compression will be impossible, when the limb is trapped. Indirect pressure at the groin or upper arm may be possible and will allow some control, but this is often difficult and impractical to maintain during a rescue. For this reason the best option is a tourniquet applied above the crush, as soon as you suspect bleeding or prior to release. 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 may 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). As such, on release apply pelvic binders and splints early to minimise further blood loss. Chapter 8: Special Circumstances

156 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Medical Rescue / 8.4A – Crush Pain is frequently a major issue in crush injury, especially if fractures are involved. Good pain relief is a crucial part of crush injury management and Penthrox or Entonox given early can be a great stop gap until injectable pain killers can be given by the paramedics. If there is crush injury to the chest or abdomen, then Penthrox is the safer alternative and Entonox is contra-indicated. Wounds due the crush injury can rarely be managed before release of the body part, but there may be little to see externally other than discolouration and bruising, or the skin may be broken with varying degrees of wound and tissue loss. These should simply be managed with clean ambulance dressings. The crush injury phase is rarely fatal, unless involving the torso. This often creates a false sense of security, as the casualty may well be talking normally and appear completely stable in terms of observations and monitoring. This sense of calm and the typical complexity of the release from the vehicle or the machinery etc can result in a serious drop in the pace of the rescue and time can slip away, putting the casualty at greater risk of problems after release. The problems that are occurring, result from large amount of muscle tissue being trapped, crushed or having it’s blood supply restricted by the crush. This restriction of blood flow creates several problems: • The initial crush may simply prevent the flow of blood in the veins out of the area affected, this produces a congested, increasingly swollen limb, which is often blue tinged in colour • As the limb starts to swell, it may then start to be further compressed by the entrapment, building up the pressure in the leg and restricting the in-flow of blood in the arteries. Eventually the circulation to the leg may become totally cut-off and the limb will appear white, with no capillary refill and the tissues will start to be starved of oxygen • If the crush is sufficient, then the whole blood to the leg may be cut-off immediately from the point of injury without any swelling. When there is no effective circulation to the limbs the tissues are dying: • Toxins such as lactic acid will start to build up • Damaged muscles will release potassium, calcium and myoglobin • Blood will become cold in the trapped limb • Blood will be trapped in the limb and unable to return to the heart. For small muscle groups such as the arms or lower leg, then this is not a huge problem in most cases and the limb can simply be released without serious adverse effect. However, if the large muscle groups of the lower limbs, such as the quadriceps, hamstrings and buttocks are involved, then the risk problem is much worse as a lot more toxin and damage muscle will occur. In addition to the amount of muscle involved, we must also consider time. As the longer the tissues are trapped the more toxins will be built up. These toxins can have immediate effects on release, but also later effects in the hospital as they can result in kidney failure. • Entrapment of upper limbs or legs below knee rarely creates problems due to build-up of toxins on release • Where large amounts of muscle are trapped then the rescue becomes time critical. How long someone needs to be trapped for and how much muscle needs to be involved, to produce serious problems is a total unknown and will vary between individuals and the types and extent of entrapments. What is clear is that deaths do occur following uncontrolled release of casualties. In view of this, the International First Aid community, recommends that anyone crushed for more than 15 minutes, should be rescued only when paramedics or medical support arrives. Chapter 8: Special Circumstances

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 157 Medical Rescue / 8.4A – Crush Sudden release of the limb may release of a large volume of cold blood, lactic acid and toxins which can potentially result in, volume overload on the heart, abnormal heart rhythms, even cardiac arrest and death. This is a hugely complex issue and even National expert guidance from the Faculty of Pre-hospital care (FPHC) simply suggests that we should aim to release the casualty as quickly as possible, to prevent further injury. This feels a little like crossing your fingers and hoping for the best! So what do we recommend in RTACC: • Firstly 15 minutes seems overly conservative and a little short. Under 30 minutes, then we would suggest that problems are unlikely to occur and we would recommend that you simply extricate them as quickly as possible and then visually monitor them as suggested by the FPHC. 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 toxins and a risk of death on release, due to the ‘wash-out’ back to the heart and other organs. Therefore, anyone trapped for more than 30 minutes with a crushed limb is considered time critical and we need to provide some control of this process to allow the body to cope with the toxins. Once they have been released, if the casualty has a cardiac arrest, then they will be practically impossible to resuscitate, as the heart has been poisoned. (We call this ‘Rescue Cardioplegia’ – as it occurs on rescue or release and the cardioplegia refers to a fluid cocktail that is used in heart surgery to stop the heart beating). 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 (>30 mins) of large muscle areas, such as the thighs, legs or buttocks, then responders should aim to control or delay this washout, 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. Some leading Ambulance Service protocols are now starting to adopt this approach around the world eg Queensland Ambulance Service, Australia. Chapter 8: Special Circumstances

158 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The tourniquet should be applied tightly, as if being applied for massive haemorrhage control just above the crushed area. As this is such a complex and serious condition, rescuers managing a prolonged crush >30mins should leave the tourniquets on until medical support arrives. Once the casualty is released, then the paramedics/ doctors will organise the controlled release of the tourniquets on scene or in hospital, where full critical care monitoring and support are available. If this support is significantly delayed then, we would recommend the ATACC ‘Staged release protocol’ is adopted. (See figure 8.9) Ensure that you have full resuscitation equipment to hand, including the defibrillator. We will then go through a series of controlled release steps, allowing washout of the toxins and a return to normal physiology as the body ‘deals’ with them. Medical Rescue / 8.4A – Crush Chapter 8: Special Circumstances 3 MINS 3 MINS TOURNIQUET RELEASED + Re-inflated 30 seconds later TOURNIQUET RELEASED TOURNIQUET RELEASED + Re-inflated 30 seconds later Figure 8.9: Staged Release Protocol When releasing the tourniquet, do not release it slowly – release fully and quickly then re-apply after the 30 seconds Closely monitor the casualty throughout the 30 seconds and if they feel faint or unwell, then immediately re-apply the tourniquet. Repeat this process three times then after 5 minutes, if all is well then release the other leg in a similar fashion too. Record the estimated time of crush, the site and time of application of the tourniquets and the time of release, if removed. After release, once they are stable then dress the wounds and apply splints as required.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 159 Medical Rescue / 8.4A – Crush Chapter 8: Special Circumstances CRUSH SYNDROME The casualty may now appear fine and wish to simply go home. They may appear to have escaped, with no fractures or bleeding but just some bruising in the large muscle areas. Unfortunately, this individual is in the ‘eye of the storm’ (See figure 8.10/11) and has the potential to further life-threatening complications later, typically from kidney failure. This occurs from the release of a substance called ‘myoglobin’ and other toxins from the damaged skeletal muscles. The more damage, the more muscles involved and the longer the time crushed, then the higher the risk. A similar picture is seen if someone lies on the floor all night, unconscious or unable to get up, such as someone intoxicated or an elderly person after a fall. They get pressure area marks on their skin and the underlying muscles get damaged. The myoglobin is filtered out of the blood by the kidneys, but they can quickly become blocked with the substance and kidney failure can quickly develop, which can be fatal. Crush Syndrome CRUSH EMBOLISM/ ARRHYTHMIA RESCUE CARDIOPLEGIA Figure 8.10: Eye of the storm - Vortex CALM THE EYE OF THE STORM

160 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Crush Syndrome CRUSH EMBOLISM/ ARRHYTHMIA RESCUE CARDIOPLEGIA CALM THE EYE OF THE STORM Most of the research for Crush Syndrome has come from earthquake zones of the world, where casualties are often trapped for days, before release and most of them will have some degree of kidney failure as a result of the muscle damage. A medical fluid protocol exists for any prolonged crush > 30 minutes, which aims to keep the casualty well hydrated and producing lots of alkaline urine to best protect their kidneys. However, the worst cases will still require dialysis, which maybe lifelong. We are certainly aware of cases of trapped truck drivers developing kidney failure after 40 minutes of entrapment. IN SUMMARY Crush has early and late phases and can be fatal in either. Always be concerned about anyone trapped for a prolonged period, involving large muscle groups. MANAGEMENT <30 mins – release them as quickly as possible, but consider a tourniquet before release if your suspect major bleeding from the limb. >30 mins – trapped by arm or lower leg then simply release as above. >30 mins – involving large muscle groups, then apply tourniquets to the entrapped limbs just prior to release. Leave them in situ until specialist medical help arrives. If the help is delayed or your location is remote, then remove the tourniquets with the staged release protocol. CHRONIC KIDNEY INJURY RHABDOMYOLYSIS Medical Rescue / 8.4A – Crush Chapter 8: Special Circumstances Figure 8.11: Eye of the storm - Vortex

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 161 Medical Rescue / 8.4B - Suspension Trauma Suspension trauma, or harness induced pathology, is a fiercely debated topic. This was first described by NASA scientists and some French cave explorers, who had experience unconsciousness and even cardiac arrest whilst suspended, motionless for as little as 10 minutes. Research has been limited, by the simple fact that it is deemed too dangerous. However, real cases in rescues and incidents are very rare or largely un-reported. In industry, an extensive report was written for the Health and Safety Executive in 2002 by Mr Paul Seddon – this generated considerable concerns about the risks of suspension trauma to anyone working at height in a harness. The problem appeared to relate to pooling of blood, in the lower half of the body, when suspended in an upright or semi-upright position on a line or on a fall arrest device. IN this position, it stated that consciousness can be rapidly lost, as blood enters the legs, but cannot return as a result of gravity and the tight leg loops of the harness. At the time, the report recommended a swift rescue, then sitting the casualty up against a wall, with their knees bent, to avoid washout of toxins in the stagnant blood from the legs. SUSPENSION TRAUMA STAKEHOLDER GROUP Many medical experts questioned the realities of this suspected problem and as such, a large body of the Medical and Rescue community, including ATACC Faculty, gathered for a stakeholder workshop at the HSE Laboratory in Buxton, in April 2008. The meeting reached a number of conclusions, but left some serious questions unanswered and many left the meeting frustrated, at the limited guidance provided. Suspension trauma or harness induced pathology, is certainly not as common as was thought in the original HSE Seddon report. However, it would seem that in certain circumstances, with certain type of harness, 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. The leg muscles, especially in the calves, would normally create a ‘muscle pump’ effect which drives blood back from the legs to the heart. When this effect is lost, then blood pools in the legs, resulting in a faint, but if the still remains upright in their harness, then the situation can progressively get worse, restricting blood flow back to the heart and starving the blood supply to the brain. This is very rare situation even after a fall arrest, unless the casualty is actually unconscious. Modern fall arrest systems suspend the casualty in a semi-horizontal position and line workers are told to push off surrounding structures with their legs or to use leg loops, to work the muscles of the legs, to drive the blood back up to the heart. The management guidelines from the HSE where release in 2008 and are summarised below. The 2008 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. In addition, the previous HSE guidelines which recommended keeping casualties sitting up after rescue, has been dismissed as ineffective. Chapter 8: Special Circumstances

162 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Medical Rescue / 8.4B - Suspension Trauma GAPS IN THE NEW HSE GUIDANCE These new guidelines do not address the issue of prolonged, unconscious suspension, especially for prolonged periods, especially 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, particularly when the legs swell. Simply getting get the casualty down, leaves us once again ‘hoping’ that all will be well and does not feel like a robust strategy for the most high-risk cases. Once they deteriorate, it may well be too late to resuscitate them, much like severe crush injury. Following research conducted in Cork University, considering the pathological processes involved and the gaps in the FPHC consensus statement, BTACC/RTACC advises managing suspension trauma with the steps outlined below: 1. Suspended for less than 30 minutes or conscious and pushing off – simply get them down as quickly and safely as possible 2. Suspended for more than 30 minutes and or unconscious then: a. Lower the casualty to just above ground level as quickly as possible – keep harness under load b. Apply tourniquets to the lower limbs as high on the leg as possible c. Record 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 using the Crush ‘staged release protocol’ 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 of finally releasing the first leg, then release the second tourniquet in the same way. Chapter 8: Special Circumstances

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 163 Medical Rescue / 8.4C - Machinery Entrapment Machinery entrapment is another are of ‘medical rescue’ and even the most complex incidents can be managed effectively by considering a simple approach developed by the ATACC faculty. Extremities, limbs and even the whole body can be drawn into machines and for the larger industrial machines, the human body offers very little resistance to the workings and as such the first priority must be to switch off the machine (STOP), ideally at the emergency stop button, which is usually close by, easy to spot and rapid. Ensure that the machine is fully shut-down and that there is no tension or torque left in the machine, that may produce movement or danger to the rescuers or the casualty. The site engineer will always be one of the most useful people at incidents such as this, where specialist machinery is involved. By the time that the emergency services arrive, this will usually have been done and we will then need to assess the status of the casualty with a simple M.A.R.C.H assessment. They will typically be in considerable pain and there may be major bleeding evident. Controlling any major bleeding is the next step, so we apply a tourniquet to the limb, above the entrapment. This will be painful, as they are tight and the injury will still be very painful, especially if involving fractures or open wounds. Analgesia is our next priority and of RTACC providers, the ideal agent is Penthrox, as it is easy to administer, rapid and highly effective. Chapter 8: Special Circumstances

164 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Medical Rescue / 8.4C - Machinery Entrapment If the entrapment is due to a shoe or boot, then we may simply be able to slip the leg out of the boot or shoe but ensure that all there is no movement in the machinery as we release or cut the footwear. Other clothing may also be the cause of the entrapment, and simply by cutting away the clothing, we may find an uninjured limb, simply pulled into the machine by clothing. To release a limb, in a machine we need to now look at the mechanism, as many machines with rollers have pre-tensioners that can be release to sperate the rollers. Once again, the local engineer can be invaluable, but ensure that they are turning the adjuster the right way, to avoid further injury of the casualty. We now need to consider the options for release. Some machines can be dismantled quickly and easily, whereas others are impossible to dismantle because of the sheer size, whilst others may be cast-metal and the hand or limb is trapped by the mechanism inside. This makes release through stripping the machine down, impossible and considerable time can be waster trying. Simply transporting the machine to hospital does not help either, as few operating theatres or emergency departments have the necessary tools and cutting equipment to facilitate a release. In these cases, a doctor is typically needed on scene, to discuss options, which may include simply amputating the mangled body part, but this is rarely necessary. Another alternative, which is highly effective is to simply Reverse the machine by hand and the trapped body part will usually then be easily released. We have summarised this approach in our ‘S.T.A.R.R’ methodology to make it easy to remember the priorities and the options. (See figure 8.12) Chapter 8: Special Circumstances

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 165 Medical Rescue / 8.4C - Machinery Entrapment STEP 1. Stop STEP 2. Tourniquet STEP 3. Analgesia STEP 4. Release Figure 8.12: S.T.A.R.R Method STEP 5. Reverse Chapter 8: Special Circumstances

166 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Medical Rescue / 8.4C - Machinery Entrapment AMPUTATION The last resort is amputation and with modern space creation and extrication tools, this is rarely required, but there are three situations where it must be seriously considered: - Situation is too dangerous to delay extrication - Casualty is too unstable and will not survive a prolonged extrication - If the limb is so badly damaged that it will need amputating (this will typically involve a doctor on scene, or through video/radio comms link). In the UK several years ago, a tragic death occurred in the floods in Hull, when a man was trapped up to his neck in fast flowing, dirty flood water, by his leg which was caught in a metal railing. All attempts to free him failed and surgical amputation was considered but deemed impossible in view of the conditions. He eventually dies after 5 hrs from hypothermia and many of the rescuers were also seriously affected by the incident, as they held him in their arms to keep him above water. At the inquest, the Coroner, said that this must never happen again, so ATACC Faculty sought a solution. We tested the hydraulic cutting equipment used by the Fire Service, on animal legs and then on human cadaveric legs. The tools will not only work underwater (not the electric ones) and they cut the limbs quickly and remarkably cleanly, with little detrimental effect. This work has been published, together with a further study looking at other tools that can be used in various situations, such as the reciprocating saw. It is worth considering in advance of such incidents, who would actually operate the tools and perform the procedure? This is where a truly cross-trained medical rescue team comes into it’s own. Once again, amputation is rarely necessary, but in some situations it can be life-saving, so consider all the possible options to complete the procedure and discuss it with the medics on scene too, as they will help with the decision and also provide the necessary pain relief or anaesthetic. Chapter 8: Special Circumstances

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 167 1. If a limb has been crushed for more than 30 minutes, following release A Blood flow will start after another 30 minutes B Blood flow will never be restored C Toxins and cold blood will wash out of the muscles D The limb will typically need immediate amputation ANSWERS 1: C 2. For a casualty to be more at risk from suspension trauma, he or she would likely: A Be unconscious B Be thrashing around on the rope C Have been lowered to the ground too quickly D Have been stuck inverted ANSWERS 2: A 3. Which of the following situations would be considered entrapment? A A casualty with a gunshot wound in an exposed area receiving incoming fire B A casualty suffering burns from a live electrical source. C A casualty with a complete traumatic amputation D An agitated pedestrian suffering from memory loss after a road traffic collision ANSWERS 3: A Revision: Chapter 8: Special Circumstances

168 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 4. For an ‘Immediate’ extrication, the casualty must ideally be evacuated within: A 1 minute B 10 minutes C 5 minutes D 3 minutes ANSWERS 4: A 5. If a casualty is considered time critical, this always necessitates immediate extrication A Always B If the injury can be stabilised then immediate extrication is not essential C The injuries must not influence the speed of the extrication D Await medical support before extrication ANSWERS 5: B Revision: Chapter 8: Special Circumstances

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 169 Chapter 9: Special Patients Module Preparing for special patients While caring for these casualties can be a traumatic experience for responders, the situation demands the same basic process and methods of resuscitation as for normal adult casualties, with a few notable differences as outlined on the next page. Responding to emergencies involving: • Pregnancy • Children • Elderly

170 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com CARING FOR PREGNANT WOMEN For pregnant casualties, rescuers should strive to manage the mothers’ injuries first, as managing her will best protect the unborn child. Rescuers should enquire how far along the pregnancy is (A normal pregnancy is 38-40 weeks). Have there have been any problems so far or with previous pregnancies? In pregnant casualties, any of the following conditions should be treated as time critical: • Complaints of abdominal or pelvic pain • Sensations of tightening (contractions) • Bleeding or fluid loss from the vagina. • Open abdominal wounds or impalement Some pregnant women may feel uncomfortable, light-headed, or dizzy lying on their backs, as the weight of the baby may restrict blood flow back to the heart in this position. These casualties may prefer to lie on one side and should be permitted to do so during transport. When immobilised on a longboard or scoop, it was traditionally tilted between 15-30 degrees, usually to the left, but it is now recommended that we simply displace (gently push) the pregnant uterus towards the left side, even during a cardiac arrest. All pregnant trauma patients should be given high flow oxygen. Entonox may be provided if the casualty is in pain if there is no chest trauma or reduced conscious level. Penthrox is not licenced in the UK for labour pain, but can be used safely for trauma in pregnancy. Pregnant casualties may be more comfortable if they are transported with uterine displacement. 9.2 Children CARING FOR CHILDREN There is always debate over the issue of caring for children using adult protocols and methods, but basically, whilst the ‘normal’ values for some paediatric observations vary with age, the essential management principles are exactly the same. Maintain the airway, stop bleeding, keep them warm and get them to hospital quickly. As such, for children above the age of two years, they are effectively ‘small adults’. The BTACC algorithm can therefore be used for children but if the modified BTACC Paediatric Algorithm is available (see end of chapter) then it will be useful as it includes parameter ranges relevant to various age groups of children. Children get many of their behavioural cues from their parents. Be sure to be calm and communicate with the child’s parents about the treatment you are providing. 9.1 Pregnant Chapter 9: Special Patients Module

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 171 M: MASSIVE HAEMORRHAGE CONTROL Children’s bodies have a smaller volume of blood than adults (see table 9.1), so even a small amount of blood loss can be very serious or even life threatening. TABLE 9.1 – Blood Loss in Children AGE (IN YEARS) AVERAGE BLOOD VOLUME LIFE THREATENING BLOOD LOSS (30%) 1 800 ml 260 ml 5 1500 ml 500 ml 10 2400 ml 800 ml The DiD-iT method (application of direct pressure, more direct pressure, and tourniquet) can be used to control haemorrhaging in children, but thumb or finger pressure will often be all that is required. A: AIRWAY MANAGEMENT Though the principles of airway management are the same, children have some anatomical differences from adults which make their airway slightly more difficult to manage. • Firstly, a child’s airway is smaller in relation to the rest of the body. Therefore, secretions or swelling from illnesses or trauma can more easily block the child’s airway • Secondly, because a child’s tongue is proportionally larger than an adult’s (relative to overall body size), the tongue can more easily block the airway in unresponsive children • Thirdly, because a child’s upper airway anatomy is more flexible than that of an adult, you must remember to avoid overextending the neck of an infant or child when attempting to open the airway. Keep the child’s neck in a neutral or slight sniffing position to avoid overextending • Finally, the trachea (windpipe) and airways of the lung are very narrow and even a millimetre change in diameter, from swelling for example, will therefore have a very large effect on air flow and resistance to breathing. Children can compensate as the demands on their respiratory system change, largely by breathing faster, but they can quickly get tired and progress into respiratory distress or failure. Therefore, it is important to perform a complete and thorough patient assessment and to monitor the child’s vital signs, reassessing at least every five minutes when caring for seriously ill or injured paediatric patients. Children go ‘blue’ from lack of oxygen very quickly as they have a relatively higher rate of oxygen consumption compared to adults. All children with significant traumatic injures should therefore receive oxygen. This will do no harm even to young babies if administered pre-hospital. 9.2 Children Chapter 9: Special Patients Module

172 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com TABLE 9.2 – Normal Respiratory Rates in Children AGE (IN YEARS) RESPIRATORY RATE (BREATHS/MIN) TIME CRITICAL BABY (infant) 25–40 <18 or >40 TODDLE TO PRE-SCHOOL 20–30 <15 or >30 SCHOOL-AGE 15–20 <12 or >20 TEENAGER 12 – 15 <8 or >20 A: AIRWAY MANAGEMENT When delivering supplemental oxygen to children, use a paediatric non-rebreathing mask (the one with the reservoir bag) or the paediatric face mask on the bag valve mask. If a child will not tolerate the mask, then gently waft the oxygen across his or her face. The pulse oximeter will still work very effectively even on very small fingers and the results will be accurate, if it gives a steady reading. R: RESPIRATORY MANAGEMENT Breathing rates in children are faster than in adults. Table 9.2 presents the normal estimate breathing (respiratory) rates for children. Excessively fast or slow rates for a specific age group indicate a time critical situation and require immediate intervention and transfer. If we look at children, especially young children as they are breathing and follow the ‘R U IN SHAPE’ process, it may be very obvious that the child has respiratory distress. There may be flaring of the nostrils, recession or drawing in of the chest between the ribs and also use of the muscles all around the upper chest and neck to help with breathing. The steps for determining responsiveness, checking / maintaining the airway, and checking supporting a child’s breathing are essentially the same as for an adult casualty (Chapter 4), but you should keep the following differences in mind: 1. The optimal airway position depends on the child’s age—neutral position for infants, with a gradual introduction of a slight sniffing position for older children. 2. The rate of ventilation is slightly faster for children. Give 1 ventilation every 3 to 5 seconds (about 12 to 20 ventilations per minute) instead of the adult rate of 1 ventilation every 5 to 6 seconds (10 to 12 ventilations per minute). For infants, give 1 breath every 2 seconds (30 breaths per minute). When resuscitating a child using a bag-valve mask, use a paediatric mask. The bag can be a larger volume or even an adult type, as long as the two persons performing the technique both monitor the chest movement carefully to ensure that chest rise is adequate but not overinflated or over-expanded. This usually means a tiny amount of squeeze and movement of the adult bag. 9.2 Children Chapter 9: Special Patients Module

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 173 C: CIRCULATORY MANAGEMENT The easiest pulse to feel in young children is the brachial on the inside of the arm just above the elbow. Felt in the groove between the biceps and triceps muscle on the inside of the upper arm. Pulse rates in children are generally faster than those in adults. Table 9.3 presents the typical normal pulse rates for children. Excessively fast or slow rates for a specific age group indicate a time critical situation and require immediate intervention and transfer. Blood volume in children is considerably less and can be no more than a few hundred millilitres in the very young. As such it is even more crucial that we go to considerable lengths to preserve circulation and minimise bleeding in children and transport them rapidly to hospital. TABLE 9.3 – Normal Pulse Rates in Children AGE PULSE RATE (BREATHS/MIN) TIME CRITICAL BABY (infant) 100–150 <70 or >150 TODDLE TO PRE-SCHOOL 90–140 <70 or >140 SCHOOL-AGE 70–110 <60 or >120 TEENAGER 60–100 <50 or >120 H: HEAD TRAUMA AND OTHER SERIOUS INJURIES Head injuries may be difficult to assess in children as they may not cooperate with responders’ assessment attempts. The AVPU scale may still be used, but it is not as reliable since younger children may not respond in the same manner as adults. Drowsiness, lack of activity, interest, or responsiveness in children can signal serious illness or injury. Bone fractures in children are usually obvious because of bruising, deformity, and pain. However, due to a higher degree of tissue and bone flexibility, children may have serious underlying or internal injuries, despite not having any fractures. Cases of children being run over by motor cars, without any serious injury, remarkably do occur, but all obviously need hospital assessment. Treat child casualties from incidents with possible bony fractures with close monitoring and immobilisation around the possible injury site to reduce pain. All children with burns (other than small superficial burns and minor sunburn) should be considered time critical. Small burns are those less than 1% of the child’s body surface area. A good way to estimate this is to consider the child’s outstretched palm with fingers as roughly 1%. This will tend to over-estimate the burn area but if ever there is any doubt, the child should be taken to hospital. When cooling burns, be careful not to cool the child excessively. Because children have a greater surface area relative to the mass of their body, they lose relatively more heat than adults do and have limited abilities to compensate for changes in temperature. If burns are cooled for too long, the child may be come hypothermic. However, it is still important to cool the burn properly to prevent further damage (5-10mins). 9.2 Children Chapter 9: Special Patients Module

174 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com While it is important to cool the burn, no unnecessary delay should occur in transferring the child to hospital and avoid causing hypothermia. CHOKING IN CHILDREN The same algorithm can be used in children down to the age of one year of age. Below this age (Infants) the abdominal thrusts are replaced with chest thrusts/ compressions. Small children can be placed across the lap for back blows and infants can be cradled in the arms. One other difference for children is that if the child is unconscious, commence paediatric life support which starts with five rescue breaths before chest compression starts. Abdominal thrusts should not be used in choking infants (children under one year of age) – chest compressions are used instead. H: HEAD TRAUMA AND OTHER SERIOUS INJURIES Great care should be taken in cooling burns that extend over 10% of the child’s body surface area. Once a burn has been cooled, the application of burn-film in strips, creates a good dressing that allows the area to be kept clean, continually seen and also can be cooled again if required without having to be removed. Blankets should be offered to the child to avoid excessive cooling and hypothermia once the cling-film has been applied. 9.2 Children Chapter 9: Special Patients Module

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 175 BASIC LIFE SUPPORT (SEE RESUSCITATION CHAPTER) Children require basic life support if: • There are no signs of life, e.g. normal breathing • If they are collapsed unconscious with a heart rate of less than 60 beats per minute. As children are more likely to have a hypoxic (lack of oxygen) cause for a cardiac arrest when compared to heart disease in adults, they require modifications for life support: • Commence life support with five rapid rescue breaths (one second for each breath in then let them exhale spontaneously) • In children a bag valve mask can be used. There are many different sizes which can be confusing, but it is more important to simply squeeze the bag, just enough to see the chest rise and fall and no more • Alternatively, a pocket mask is simpler and easier to use for many and may be preferred, but remember that an adult’s lungs are much larger than most children, so blow gently until the chest rises • When only one rescuer is present, provide one minute of BLS BEFORE going for help • In children, a resuscitation ratio of 15 compressions to two breaths (15:2) is recommended, but the adult ratio of 30:2 is also satisfactory if responders are confused about what to do • When more than one rescuer is present, immediately start life support whilst sending the other individual for appropriate help. Compressions should be: • Applied to lower half of the chest • Compress the chest 1/3 of it’s depth • At a rate of 100-120/min (basically two per second). For young children use one hand for compressions and for toddlers and infants use two fingers. DO NOT GIVE UP! • In general, the principles of RTACC apply equally to pregnant women and children, with some modifications • When caring for a pregnant casualty, complaints of abdominal or pelvic pain, tightening sensations, or blood of fluid coming from the vagina are all time critical concerns • The RTACC method does not apply to infants (children under one year of age) • The overall volume of blood in children is lower than that of adults, so even a small amount of blood loss should be a cause of concern for responders • When applying direct pressure to control massive haemorrhaging, thumb or finger pressure may be sufficient • A child’s airway differs from that of an adult. These differences can complicate airway care • A paediatric face mask should be used whenever it is necessary to provide oxygen or rescue breaths • It may be difficult to assess head trauma in children, as they often do not understand or comply with assessment attempts • Bone fractures in children are usually obvious because of bruising, deformity, and pain • There are a few notable differences regarding the performance of CPR on children such as hand placement and compression pressure • AEDs can be used on children, but paediatric pads should be used when available. 9.2 Children Chapter 9: Special Patients Module

176 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com SIZE BABY TODDLER SCHOOL TEEN HR/MIN >150 >140 >120 >120 Chapter 9: Special Patients Module M.A.R.C.H ALGORITHM – FOR CHILDREN B.L.S. PROTOCOL NOT BREATHING NO SIGNS OF LIFE Re-assess again! SAFE APPROACH TIME CRITICAL HAEMORRHAGE CONTROL D.D.T Not more than 60 secs if single rescuer AIRWAY MANEOUVRES • Jaw Thrust • Oxygen 15L/min • Chin Lift - Sats > 95% • NP/OP • Cx spine caution RESPIRATORY SUPPORT • RR <8/min - BVM - Pocket mask • Oxygen 15L/min • Chest seal (wounds) CIRCULATORY SUPPORT • Re-assess D.D.T CONSIDER: • ‘Scoop and Run’ • Pelvic Strap • Gentle handling • Traction Splints • Elevate Legs INJURY SUPPORT HEAD INJURY • Keep child talking / engaged SPINAL INJURY AND FRACTURES • Immobilise BURN INJURY • 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 <95% HEAD & OTHER INJURIES • Unconscious • GCS <12/15 • AVPU • Pain or numbness • Drowsy / Listless • Burns • Crying • Fever • Others CIRCULATION PROBLEM? • Unconscious • Radial Pulse absent • CRT > 3secs • Radial Pulse >110/min SIZE BABY TODDLER SCHOOL TEEN RESP/MIN >40 >30 >20 >20 RESPIRATORY PROBLEM? • RR >20/min • Difficulty in breathing • RR <8/min • Sats <91% air / <94% 02

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 177 The world’s population is changing as you can see from this diagram. Not only is it significantly growing, but it is also growing older. (see figure 9.4) The numbers under 15yrs (Green) is now fairly constant, but all other ages are steadily increasing, especially from 60 years onwards, including the over 80 years age group. This is reflected in our own Fire & Rescue casualty data which shows that: • 67% are over 50 years • 40% are over 80 years • 10 % are over 90 years. In the 90s the average age of trauma victims was 36yrs and the largest single age group was the 0-24yrs (40%) involved in road traffic collisions. Some 20 years later in the 21st century, the average age group is 59yrs with the largest group being the >65yrs with only 30% of them involved in RTCs, but 40% have had a ‘low fall’ and 86% get CT scanned for major trauma. 9.3 Elderly Chapter 9: Special Patients Module World Population Source: UN 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 8 8 8 9 9 10 11 13 16 19 21 34 37 38 35 33 30 27 25 24 22 21 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000 6,000,000 7,000,000 8,000,000 9,000,000 10,000,000 Above 60 Percentage Below 15 80 + 75 –79 70 –74 65 –69 60 –64 15 –59 0 –14 Age Figure 9.4: WORLD POPULATION Source:UN

178 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com FALLS This simple infographic from the USA, demonstrates the scale of the problem for the elderly. As you can see, those of 80+ years on average fall once every year. Up to 50% of these falls go unreported as the majority are in the home. 9.3 Elderly Chapter 9: Special Patients Module TRIPS T TABLETS OR MEDICATION R RESTRICTED OR REDUCED VISION I IMMOBILITY, WEAKNESS OR POOR BALANCE P PAST MEDICAL HISTORY S SAFETY HAZARDS Figure 9.5: TRIPS ACRONYM They have an increased rate of falls for several reasons: T – Tablets and medication that may reduce awareness, create dizziness on standing or balance problems, as well as increasing the risks after a fall such a Warfarin and bleeding. R – Restricted or reduce vision. I – Immobility, weakness or poor balance. P – Past medical History e.g. Parkinson’s, previous stroke, cardiac disease. S – Safety hazards e.g. rugs, carpets, steps and stairs. Falls Age 65+ 1 out of 3 people fall each year Age 72+ Fall every two years Age 80+ Fall every year

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 179 The elderly are often very stoic and many will suffer in silence or they are used to pain and discomfort from managing their day to day problems such as arthritis. So we need to look out for non verbal cues and take care not dismiss things that they say. Many will try to dismiss their injury, or their trauma as minor or trivial, as it would have been years ago. PAIN Pain is under treated in the elderly and not just from trauma but also ‘elder abuse’ & maltreatment is under reported, so always consider welfare and safeguarding issues. ASSAULTS Assaults are sadly not uncommon in the elderly and leave them injured & vulnerable these victims have a 5 times higher mortality from the injuries than a younger population with similar injuries. The elderly account for 20-30% of pedestrians hit by motor vehicles as they are more at risk with their reduced senses and slower reaction. They are also far more at risk from injury from the most minor trauma. OSTEOPOROSIS A gradual weakening of the bones (see figure 9.6) from 50yrs on wards, primarily in females, which greatly increases the risk of all fractures, especially hips after a fall and necks after RTCs. Patients >65years with rheumatoid arthritis are also at much higher risk from neck injuries in RTCs and we should have a low threshold to immobilize them for extrication. 9.3 Elderly Chapter 9: Special Patients Module Figure 9.6: Bone deterioration over time

180 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 10 COMMON CHRONIC CONDITIONS FOR ADULTS 65+ Figure 9.7 illustrates that in over 65 years up to 80% have 1 chronic condition and 68% have 2 or more. High blood pressure, cholesterol and arthritis are the commonest but there are a number of others. Many of them also like a tipple and this can increase their risks of falls, bleeding and getting cold very quickly. 9.3 Elderly Chapter 9: Special Patients Module 80% have at least 1 chronic condition 68% have 2 or more chronic conditions 11% Chronic Obsturctive Pulmonary Disease 14% Heart Failure 14% Depression 11% Alzheimer’s Disease and Dementia 29% Ischemic 27% Diabetes Heart Disease (Coronary Heart Disease) 47% High 31% Arthritis Cholesterol Quick Facts 58% Hypertension (High Blood Pressure) 18% Chronic Kidney Disease The elderly are very mobile with over 1 million drivers over the age of 80 years on UK roads and 121 over 100 years. They are not necessarily more dangerous as drivers, but they are far more vulnerable than younger age groups The under 30’s represent the age group in the most RTCs, but this may reflect the fact that >70years do far fewer miles. They are however far more susceptible to injuries, even at low speeds, especially as they are often poorly placed for the safe use of SRS protection in the car. Mobility scooters are very popular with many elderly people, but remember that they can result in some falls and injuries at 15-20 mph or more, which can be very serious in this age group. Being able to travel some distance can often put the injured in some remote isolate locations where there is little help and they will get cold and features of hypothermia very quickly. However, even lying on the floor at home for half an hour or more can result in pressure sores, muscle damage and hypothermia, depending upon the surface, the clothing and the temperature of the environment. Always assume the worst until they clearly demonstrate that they are uninjured and their normal self. Figure 9.7: Common Chronic Conditions.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 181 WHAT’S THEIR NORMAL? Clearly not all elderly people are the same Important to get some history about their health Look around for clues if they cannot tell you, such as medication, med-alert bracelets, inhalers, breathing machines such as this CPAP machine or home oxygen. Encourage them to use any medication that they feel will help them, until the ambulance arrives. Many will be on lots of tablets and there are many sorters and simple devices to help identify what medicines are due throughout the day. Have a look if they have missed tablets today or may be taken too many. WARFARIN Warfarin is one of a number of different types of blood thinning medication, taken by an increasing number of elderly patients, which will significantly increase the risk of major life threatening bleeding in trauma and any patient that mentions that they are taking such anti-coagulants should raise serious concern, even after minor injury, especially if there is evidence of traumatic injury, wounds, head or chest injuries. Other medications such as some blood pressure tablets can mask the normal signs of shock, so we must always have a high index of suspicion and a low threshold for hospital referral. CONFUSION Confusion is not always due to dementia, it could also indicate other problems such as: • Sepsis • Medication problems • Low blood sugar • Hypothermia • Stroke. As some simple questions, including: • ‘Have you eaten today?’ – if they are fully conscious but confused then offer them a sweet drink (2 sugars) in case they have a low blood sugar • If they feel very hot then consider sepsis and inform ambulance control • If they are very cold then gently warm them up with warm blankets and/or body heat if not in a heated environment. 9.3 Elderly Chapter 9: Special Patients Module

182 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com FRACTURES Suspect fractures when there is: • Pain • Swelling • Deformity • Unable to use limb. In falls in the elderly the classic injury is a fractured neck of femur which will give severe hip pain and they will be unable to stand on the leg in the majority of circumstances. The affected leg is usually shorter and rotated outwards or inwards compared to the normal leg. Rib, shoulder, collar bone and wrist fractures are also common even after minor falls. STROKE FAST is an acronym for the easy to recognise features of a developing stroke: F – FACE: look for facial weakness, suggested by one side of the face drooping, or an unequal smile, or dropped eyelid or inability to puff out the cheeks equally. A – ARMS: ask the patient to raise both arms at the same time and look for any differences, can they keep them up there normally for them. S – SPEECH: is the speech slurred or abnormal? This will often be noticed by the family and can be quite subtle or very obvious and can include an inability to speak or express what they want to say. T – TIME: this stresses the fact that time is of the essence in terms of identifying the problem and getting the patient to hospital immediately. A key part of making the diagnosis is to compare both sides of the body. If any are abnormal then this is a stroke until proved otherwise. HEART ATTACK Heart attack and cardiac problems are not always as obvious in the elderly. They may simply feel dreadful, short of breath or dizzy and light headed. These symptoms always warrant further investigation as well as chest pain and sudden onset of back pain. AWARENESS Look at the patient, the scene and be suspicious as the signs of a problem may be very subtle. If necessary arrange to call back and do a welfare check wherever possible. Be gentle with everything that you do, as skin, muscles and bones are all easily damaged and pain can result from even small movements in arthritis and other conditions. At all times, respect their privacy and dignity as they are still entitled to make choices in their life with any necessary support. Some may have advanced directives in place which define what treatment that we can offer. If in doubt, listen to the patient (if they have capacity it is their choice), the family or the carers, but if still unsure in an emergency then do what feels right, appropriate and in the patients best interest. 9.3 Elderly Chapter 9: Special Patients Module

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 183 1. Considering Childrens’ Airways: A The tongue is relatively large. B All children have blocked nasal passages. C Jaw thrust and head tilt will not work. D We cannot use airway devices. ANSWERS 1: A 2. Because children have less overall blood volume than adults, which of the following is true? A Children suffering from trauma require CPR more often than adults. B Blood pressure in children is higher than in adults. C A small amount of blood loss in children can be significant. D Blood transfusions are always necessary to treat massive haemorrhaging. ANSWERS 2: C 3. In care of the pregnant casualty. A Oxygen should not be used. B Occasional abdominal contractions can be ignored. C You always need to tilt the casualty to the right. D Penthrox can be used for trauma in pregnancy. ANSWERS 3: D Revision: Chapter 9: Special Patients Module

184 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 4. The quick test for a potential stroke in a casualty: A Assess the hearing. B Is called F.A.S.T. C Requires a blood sugar test. D Assesses the respiratory rate. ANSWERS 4: B 5. The normal respiratory rate in children compared to adults is: A Higher. B Lower. C Not a useful sign. D Easier to assess. ANSWERS 2: A Revision: Chapter 9: Special Patients Module 6. Falls in the elderly: A Rarely happens at home. B Can be assessed with the T.R.I.P.S. acronym C Are less serious when the blood is thinned with drugs e.g. Warfarin. D Can never be blamed on poor eyesight.. ANSWERS 2: B

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 185 Chapter 10: Pain Management Module Pain assessment and management Pain is one of the most distressing feelings for any casualty and one that they can often remember. Pain can also confuse the signs that we use to identify shock as an injured person will have an increased breathing and pulse rate from the distress of the pain. Do not simply assume that it is as a result of the pain, always consider shock first. Where casualties have serious injuries such as wounds or fractures, effective pain management will certainly help stabilise or calm them and even reduce bleeding.

186 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com There are many ways of providing pain relief, though they may have serious side effects or be difficult to administer. In view of this BTACC/RTACC providers have always had very limited access to pain relief for casualties and traditionally this has been limited to: • Reassurance • Splinting/immobilisation • Entonox (possibly) • Encouraging casualty to use own pain killers. Even if we have access to pain killers there are other issues and problems too, as you will see below. Typically oral pain relieving medicines (e.g., paracetamol, ibuprofen or aspirin) take too long to be absorbed into the casualty’s body and need the full cooperation of the casualty to take them. Therefore they are not effective in most emergency settings. Medications injected under the skin (subcutaneous) or into a muscle (intramuscular) or vein (intravenous) are absorbed more quickly, but this form of administration requires a higher level of medical training and is therefore not suitable for all responders. Injections under the skin or into muscle can also be very unpredictable in terms of onset and effect, especially in shocked casualties. BTACC doesn’t use pain killing drugs, but continues to focus on pain management by emphasising stabilisation, immobilisation, and rapid transfer to hospital. However, in some areas local arrangements may allow ‘responders’ to use selected pain relief agents such as Paracetamol, Entonox gas (nitrous oxide and oxygen mixture), Penthrox or even Fentanyl. Different agents are compared in the (see table 10.1). Entonox is easy to administer and has a rapid onset. The gas has been used very effectively in the UK for many years and if the casualty cooperates and inhales several large breaths of the gas, the analgesic quickly takes effect and has been described as being as good as morphine. When the casualty becomes drowsy or stops inhaling the gas, the effects quickly cease. Entonox is usually delivered through a demand valve, which requires the casualty to hold the mask or mouthpiece themselves and then to take a breath, rather than a continuous flow of gas, as used in anaesthesia. This further improves the safety when using this agent as if they casualty cannot self-administer or hold the device then they will not get any Entonox. Casualties may experience drowsiness, dizziness, or light-headedness with Entonox gas, and they should be warned about these possible side effects before the drug is administered. Entonox should never be used in patients with suspected major chest trauma, diving or compressed gas breathing accidents or casualties with a reduced conscious level. 10.1 – Pain assessment and management Chapter 10: Pain Management 1-2 Simple ‘over the counter’ pain killers >3 usually means medical attention 4-5 Usually means hospital THE WONG-BAKER™ PAIN SCORE

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 187 Penthrox is fairly new to the UK as an analgesic agent. The active drug called methoxyflurane and was first used as an anaesthetic, at significantly higher doses back in the 60s and 70s. Although used for millions of anaesthetics worldwide, it fell out of favour as the wake up was very slow and there was a low but real incidence of kidney damage associated with high doses. As newer agents were produced it was withdrawn in the UK, but its use continued in Australia and Asia at a much lower dose, were it still worked very effectively as a potent pain killer. This use continued for over 30 years and over 5 million patients, without serious adverse effects and in view of this, it has now being licenced again in the UK from 2016. The UK licence currently approved by the MHRA is for: • Adult patients • Major trauma • Moderate to severe pain (Pain score >4/10) • No contraindication on checklist. When such as patient is identified and the check-list agrees that they are safe with Penthrox, then it can be administered. The agent is delivered through a plastic inhaler or ‘Green whistle’ and within a few breaths (typically 6-10) the patient will get very effective pain relief. As such it is quick to act, potent and wears off rapidly if discontinued. There is no sedative effect and complications are very minor such as wooziness, nausea, feeling drunk. Penthrox can be administered by any trained individual who has access to the product and, unlike Entonox, it can be used safely in major chest trauma and it seems more potent. The user training guide is included in the appendix of the RTACC manual. An alternative is Fentanyl—a strong opioid controlled drug, similar to morphine, which may be administered in the form of a lozenge or lollipop, avoiding the need for intravenous access. With Fentanyl, the pain relief is felt within minutes and lasts for around 30 minutes. A small loop is provided for the casualty’s thumb so that should the casualty become drowsy and drop his or her arm, the lozenge will be pulled out (see figure 10.2). Fentanyl should never be used unsupervised. Fentanyl lozenges take about five minutes to reach full effect and must not be chewed or sucked as the drug is absorbed much better from the lining of the mouth rather than the stomach. If removed from the mouth, the effects wear of in less than a minute or two. As a controlled drug, the use of Fentanyl is limited for many potential users, but has been adopted my organisations such as mountain rescue teams. Since the introduction of Penthrox to the UK, that is far more likely to meet the analgesic needs of non-medical responders, who are unlikely to get easy access to Home Office Controlled drugs like Fentanyl. Penthrox has no such restrictions and does not need to be double locked or managed and regulated in the same manner. It also avoids the main serious side effects of opiods, such as respiratory depression and drowsiness. Figure 10.2. Fentanyl lozenges. These can rapidly and effectively deliver excellent pain relief to help stabilise casualties. 10.1 – Pain assessment and management Chapter 10: Pain Management

188 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Table 10.1 – Comparing different common pain-killers and their uses PAIN AND INDICATION PAIN-KILLER COMMENT MILD PAIN Minor injuries, headaches PARACETAMOL Check if taken any in last 6 hours IBUPROFEN Not if any history of gastro-intestinal bleeding or asthma MODERATE PAIN e.g. sprains, scalds and minor burns CODEINE Not if conscious level reduced CODEINE – PARACETAMOL As for individual drugs combinations VOLTAROL (DICLOFENAC) Not if any history of ulcers, bleeding disorders SEVERE PAIN e.g. Major trauma, fractures, burns, cardiac pain CODEINE (HIGHER DOSES) Not if conscious level reduced May cause sickness May cause respiratory depression TRAMADOL Not in head injuries May cause sickness May cause respiratory depression ENTONOX Inhaled drug: needs specialist equipment and training PENTHROX Inhaled, rapidly acting and very effective. Simple to administer with few side effects FENTANYL LOZENGES / INTRA-NASAL FENTANYL Controlled drug ORAL MORPHINE Controlled drug INTRAVENOUS MORPHINE/FENTANYL Intravenous Controlled drug KETAMINE Specialist Intravenous/ Intra-nasal controlled drug THIS IS NOT A PRESCRIPTIVE DOSAGE CHART BUT MERELY A GUIDE TO DRUG SELECTION All drugs to be administered according to manufacturers guidelines 10.1 – Pain assessment and management Chapter 10: Pain Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 189 Vital vocabulary Crush injury: A form of blunt trauma in which the body is compressed to an extent and duration that causes damage to the body’s tissues. Drowning: Submersion in water that results in suffocation or respiratory impairment. Suspension trauma: An injury in which a casualty is suspended motionless in a harness for a long period of time. Entrapment: A situation in which a casualty cannot be immediately released or evacuated from the scene of injury. • Certain situations such as crush injuries, suspension trauma, and entrapment require specialised knowledge • Crush injuries can be diagnosed based on the kinematics of the situation • The longer that a limb is crushed, the more likelihood that damage and complications will occur • Suspension trauma is rare but can occur when a casualty is suspended motionless in a harness for more than 20 minutes • To treat an unconscious victim of suspension trauma, lower the victim close to the ground, apply tourniquets, then lay the casualty on the ground and treat using the standard BTACC algorithm • Entrapment occurs when a physical or environmental barrier makes it difficult to evacuate a casualty • Rescuers must determine the appropriate speed of extrication for cases of entrapment, based on the casualty’s condition and the kinematics of the situation • For victims of drowning or near drowning, rescuers should focus on resuscitation following cardiac arrest and managing possible hypothermia • When faced with large numbers of casualties we aim to do the most for the most. The best way to achieve this is Triage (assess) every casualty before you start treating individuals • The Triage Sieve is a reliable assessment tool for prioritising who needs to be evacuated or treated first. Summary: Chapter 10: Pain Management

190 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com This is a one to two hour course and includes the following elements: • User course (1-2 hrs) • Clinical studies - Self-assessment • Basic user materials and access to supporting papers. This training course has been commissioned by Galen Ltd Chapter 10: Pain Management 10.2 – Penthrox® administrator Methoxyflurane is now licensed for use as an emergency analgesic for moderate to severe pain, as a result of traumatic injury in fully conscious adults (>18years) This course will explain the history and background of the drug and describe how it can be used safely with good effect and so the risks of serious adverse effects can be minimised. Each combination pack contains1 : • One vial containing 3 mL of methoxyflurane 99.9% • Inhaler • Activated carbon (AC) chamber • Sealable plastic bag This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at www.mhra.gov.uk/yellowcard or for Ireland via the HPRA at www.hpra.ie. They can also be reported to Galen Limited at +44 (0)28 3833 4974 or e-mail [email protected]. The drug has been brought to the UK market by Galen Limited. The training is being provided by medical commercial training company, The ATACC Group, which has been established with members of the International ATACC Faculty. ATACC is the Anaesthesia, Trauma and Critical Care Faculty, which established its highly regarded and Royal College accredited trauma course back in 1998. Since then both the course and the Faculty have grown and evolved into what is now regarded as the leading pre-hospital and in-hospital trauma course available anywhere in the world. The course is famous for its anaesthetic focus and innovative and modern teaching style. Galen have embraced those skills to ensure that the training is relevant and best suited to the modern trauma care market. Introduction

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 191 Methoxyflurane is a clear almost colourless liquid. It is normally stored in darkened glass bottles to protect it from light. Although it does not support combustion, it is flammable at high temperatures (flash point 63 degrees). The liquid releases a vapour with a characteristic sweet or fruity odour which is one reason why it is well tolerated on inhalation by patients. Methoxyflurane is a member of the volatile fluorinated hydrocarbon group like many other anaesthetic agents5, such as sevoflurane and halothane9 It is actually an ether molecule that is substituted with both chloride and fluoride atoms and has the chemical name of 1,1 difluoro, 2,2 dichloro, methyl ether. The two fluorides are the reason for some of the potential complications that have been previously associated with the agent and this will be discussed further below. This is the only volatile anaesthetic agent with significant analgesic properties and these can be demonstrated at significantly lower doses than those required for surgical anaesthesia6 This is what allows the safe use of methoxyflurane as an analgesic with a low risk of serious adverse effects. Back in the 1960’s methoxyflurane was marketed as an anaesthetic agent by a company named Abbot and it was called ‘Penthrane’. It was described as a potent, easily controlled means of providing surgical anaesthesia, analgesia and muscle relaxation. It was delivered as an inhaled anaesthetic vapour, and unlike some predecessors such as chloroform and ether, it was free of the risk of explosion and was rapidly widely adopted internationally. PHARMACOKINETICS AND METABOLISM Following inhalation of the vapour, the absorption of methoxyflurane is rapid and as it is highly lipophilic or lipid soluble, it rapidly leaves the blood and diffuses into the fatty tissues of the body. This effect results in a slow rise in blood levels and onset and recovery of anaesthesia. Once the anaesthetic was discontinued, these tissues act as a reservoir of agent, which can then be slowly released over a prolonged period, which may even extend to several days after a prolonged exposure. This was also associated with a slow wake-up and recovery typically reported as nearly 60 minutes for a 90 minute anaesthetic. Soon after exposure it begins to be metabolised in the liver by several cytochrome P450 (CYP450) isozymes particularly 2E1 and 2A6 History & background 1,1, Difluoro, 2,2 dichloro, methyl ether - Methoxyflurane Chapter 10: Pain Management

192 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com As the methoxyflurane is metabolised it releases a number of elements and compounds including: • Fluoride • Oxalic acid • Difluoromethoxyacetic acid • Dichloroacetic acid 60% of the methoxyflurane and metabolites such as fluorine, fluoride and oxalic acid are released in urine and the remainder is exhaled. These fluoride-based metabolites cause renal damage at high concentrations, considerably higher than with a single analgesic dose. Although it had widespread use in the 60s, over the following 10 years it became clear that it was not entirely without problems2 in terms of side effects. At anaesthetic concentrations it was increasingly found to cause liver and renal failure. Further investigation of this problem demonstrated that, like many others in medicine, it could be predicted. In its lifetime methoxyflurane was used as an anaesthetic over 10 million times and there were approximately 100 cases of clinical nephrotoxicity reported to be associated with its use and 20 methoxyflurane-related deaths due to renal failure29 Long before anaesthetics were discovered, the eminent physician, Paracelsus Von Hohenheim, made the following famous medical statement in 1500s, Dosis Facit Venenum or ‘the dose makes the poison’ This was certainly the case for methoxyflurane, as it is for most medicines, which demonstrated both hepatotoxicity and irreversible, dose-dependent nephrotoxicity in some patients, finally quantified in a study by Cousins and Mazze in 19732 Since the 1970s numerous other similar, but safer and more effective volatile anaesthetic agents, have been developed. Despite most also containing various combinations of halide atoms, they are not associated with the same side effects at anaesthetic doses, but sadly they also do not possess the same analgesic properties as methoxyflurane. When methoxyflurane was popular as an anaesthetic agent, others saw the potential for use as an analgesic and in 1968 Abbott produced a device called the ‘Analgizer’ for delivering Penthrane as a simple form of pain relief. This is not hugely dissimilar from the modern Penthrox inhaler and established the concept of use for pain relief rather than anaesthesia, but it used a volume of 15mls of agent, which is considerably greater than the modern version, which uses only 3mls. Despite its advantages, the risks and potential complications of anaesthesia were considered too great and Abbott withdrew the Analgizer in 1975. Methoxyflurane was withdrawn from the market by the MA holder in 2001 and subsequently removed from the drug register by the FDA in 20053. Since 1975 its use has been continued in Australia and New Zealand as an analgesic4 with very positive benefits and without any significant adverse effects. This substantiates the concerns being dose related and is the basis of the relaunch in the UK. History & background Chapter 10: Pain Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 193 Research has now revealed that the normal 3ml analgesic dose is six times below the anaesthetic safe limit and eight times below the sub-clinical risk of renal failure (where it can only be detected by blood screening). This level still includes a very significant safety margin and it is not until we get to 16 times the basic analgesic dose that we reach a level that will produce true and potentially long-standing renal toxicity. In fact, even if we use the maximum daily dose of 6ml, we remain well within the safe limits defined by dose finding and complication studies. We will discuss this again further later in the training. In 2015 the Australian company, Medical Developments International, obtained a licence for methoxyflurane (Penthrox) in the UK and Ireland. Galen Limited obtained the rights to market and distribute methoxyflurane in the form of Penthrox in the UK and Ireland. This launch will work within clearly defined constraints agreed with the company and the approving body. The product available is called PENTHROX and it will be delivered from a disposable inhaler. Penthrox has been available in UK and Ireland since early 2016. It gives Patient Controlled Analgesia (PCA) in a lightweight, portable, non-invasive, handheld inhaler1 It is generally well tolerated and requires no intravenous access. It can be self-administered under the supervision of a person trained in its administration. Penthrox will be used for the emergency relief of moderate to severe pain in fully conscious adult patients with trauma and associated pain1 Beyond this there are a few other restrictions and limitations which we will discuss further through the course. To identify exactly which patients meet the criteria for administration we will use the simple 0-10 pain scoring system or the Wong-Baker faces scale as it will help to rapidly identify those that will benefit most from Penthrox analgesia. The current recommendation is for adults with pain scores of 4 on 10 or more i.e. moderate to severe pain. Numerous studies have demonstrated the effectiveness of Penthrox as an analgesic, including a recent UK RCT10 which we will discuss later in the course.23, 24 Wong – Baker Faces Pain Rating Scale & the role of Penthrox History & background NO PAIN MODERATE PAIN WORST PAIN 0 1 2 3 4 5 6 7 8 9 10 Chapter 10: Pain Management

194 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com THE PENTHROX INHALER The Penthrox inhaler is easy to set up and use, with minimal patient instruction required to self-administer the agent safely. It is fast and effective and typically provides significant analgesic effect within 6 – 10 inhalations1 The device is single patient use and entirely disposable. There is no servicing, calibration or maintenance. After use place it into the disposal bag, seal and then discard in the appropriate waste bin. The Penthrox Inhaler comes in a small pack that can easily fit into the medicines cabinet, your trauma pack or jacket pocket. Inside the pack there is the green plastic inhaler device, with the Activated Carbon Chamber, a cotton ribbon wrist strap, the 3ml liquid of Penthrox agent in a dark coloured bottle, a plastic disposal bag and the Patient Information Leaflet. A single dose of methoxyflurane is 3 mL (one bottle)1 and this amount of Penthrox will provide 25 - 30 minutes of analgesia if used continuously1 or up to 1 hour with intermittent use. If after this period further analgesia is required a second dose (3mls) can be administered. However, the maximum dose in one episode should not exceed 6 mL (two bottles of methoxyflurane). Used intermittently, this could provide up to a maximum of two hours of analgesia. There are no plans to release additional individual bottles of methoxyflurane (refill packs) in the UK. (They are available in other countries and may be remembered by any HCPs who used Penthrox in Australia). WHEN TO CONSIDER USING PENTHROX Penthrox can be considered for any conscious, adult patient with moderate to severe pain from traumatic injuries such as these: • Chest Injuries • Fractures • Abdominal trauma • Dislocations • Burn Injuries • Lacerations. The contents of the Penthrox Inhaler Pack History & background Chapter 10: Pain Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 195 Self assessment: TRUE or FALSE questions: Self test 1 True False Penthrox must never be used for severe burns Penthrox has a slow onset of action Penthrox dose must not exceed 6 mls in a single episode Penthrox is suitable for mild pain (1 to 3/10) Methoxyflurane will not cause dose-dependent renal failure ANSWERS 1: F, F, T, F, F Self test 2 True False Methoxyflurane is largely exhaled rather than metabolised Methoxyflurane was removed from the drug register by the FDA in 2005 One of the metabolites of methoxyflurane is fluoride Methoxyflurane is the only volatile anaesthetic with strong analgesic effects at low doses Methoxyflurane analgesia is not typically well tolerated ANSWERS 2: F, T, T, T, F Chapter 10: Pain Management

196 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Methoxyflurane effectiveness as an analgesic agent The main alternatives for pain relief in the pre-hospital or emergency department include non-invasive oral, intranasal or inhaled drugs, and invasive or intravenous drugs such as paracetamol, tramadol and the opioid-based drugs. All of these agents have advantages and disadvantages. THE METHOXYFLURANE STOP! TRIAL There have been many studies looking at the ability of methoxyflurane to provide analgesia and to look at its safety profile, but evidence from randomised controlled trials has been scarce until the STOP! trial10. This was a UK-based trial published in the EMJ in 2014. Six sites were selected to conduct a randomised, double blind, placebo-controlled study with 300 patients. There were 149 patients treated in the methoxyflurane group and 149 patients treated in the control group, all with acute pain and the study looked at change in pain intensity on a visual analogue score (VAS) as its primary endpoint. The results were recorded at baseline, 5,10, 15 and 20 minutes after starting the drug. The test dose was 3ml methoxyflurane against 5ml saline placebo (with a drop of methoxyflurane on the inhaler to ensure both active and placebo had a similar smell). Over 80% of the methoxyflurane group described significant pain relief within 10 breaths and it reduced the pain significantly more than the placebo. Now you may question the value of a saline placebo, but remember that even up to 40% of the effect of morphine has been described as placebo based in the past, although in future an active agent comparator will give us even more information about equivalent effects. However, there is no doubt that methoxyflurane provides significant pain relief. Shown below is a summary graph comparing the VAS pain scores for the placebo in grey and the methoxyflurane in green, after each five minute period. As you can see, even within 5 minutes there is a clear drop in pain score, which falls further at 10 minutes and is sustained with further improvement effect up to 20 minutes The median time to pain relief was four minutes, which compares very favourably with 11 minutes for intranasal fentanyl and 16 minutes for oromucosal fentanyl and five minutes with IV morphine23, 24 Throughout the study, the methoxyflurane was described as effective and well tolerated, with no significant safety concerns and any adverse events were mild and transient. Chapter 10: Pain Management