RTACC

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 47 Figure 3.7 Inserting a Nasal Airway STEP 1: Size and then lubricate the airway with gel. STEP 2: Introduce airway into the best nostril, which appears clear and large enough for the airway. (Commonly the right one because of the angle on the airway tip). STEP 4: Nasal airway fully inserted. The airway stays in place and the safety cuff avoids the need for safety pins to stop the airway slipping further into the nose. If the casualty coughs or gags excessively, pull the airway out slightly and also check the mouth for any bleeding from the back of the nose. If there is bleeding, suck it out of the mouth, but leave the airway in place if it is working well. STEP 3: Gently advance the airway along the floor of the nose. This should not require anything more than finger and thumb pressure. The lining of the nose is delicate and has some thin bones called turbinates which can produce a slight crunching feeling. If the airway passes with minimal pressure then proceed. DO NOT FORCE THE AIRWAY – Just steady gentle pressure. To insert a nasal airway, use the following steps: 1. Ensure you have selected the appropriate size; measure the distance from the tip of the nose to the bottom attachment of the ear. The diameter of the tube is often compared to that of the casualty’s little finger in training manuals, but simply looking at the nostril is probably a far more reliable indicator. If a nostril is obviously obstructed then choose the other side. 2. Lubricate the airway with a water-soluble gel and place the airway in the largest nostril. The cut bevel on the nasal airway lends itself to insertion in the right nostril, but it can go into either. The curvature of the device will follow the curve of the floor of the nose, and on the right with the bevel facing the septum. 3. Place the tip of the bevel to the septum and insert it gently along the nasal floor, parallel to the mouth. (Remember that the bevel is usually cut for the right nostril but can be used in either). Do not insert the airway upwards towards the brain, but rather directed towards the back of the head. 4. When completely inserted, the safety flange should rest against the nostril to stop it slipping further into the nose and down the throat. The older designs used a safety pin for this purpose, but this is a sharp which is best avoided with the newer designs. Do not force the airway, just use finger and thumb and gentle pressure. If you feel any resistance, withdraw it a few centimetres and try again. If it will still not advance, remove the airway and try to insert it in the other nostril. Airway adjuncts Chapter 3: A - Airway Management

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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 49 Figure 3.9: Traditional inverted method of inserting oral airways. Step 1: Insert the correct size airway upside down along the rough of the mouth over the tongue. Step 2: At the back of the mouth, rotate the airway and drop into place behind the tongue. This method is not preferred by RTACC as although it avoids pushing the tongue backwards it requires reasonable mouth opening (~2cm) and can be awkward. Choking treatment Choking occurs when a foreign body lodges and partially, or even worse, totally obstructs the airway, resulting in an inability to breathe effectively despite good respiratory effort. The first step in managing a conscious person who may be choking, with a blocked airway, is to simply ask, “Are you choking?” or something similar. If the casualty can answer your question, at least some air is moving in and out allowing them to speak and the airway would seem to be only partially blocked. Encourage them to lean forward and cough in an attempt to clear the obstruction. Until the object has gone, there is still concern as it could progress to complete obstruction at any time. This still warrants very urgent action as this is a time critical situation. If the patient is unable to speak or cough, the airway is probably totally blocked. This is a life-threatening emergency and needs immediate action. Airway adjuncts Chapter 3: A - Airway Management

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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 51 If the five abdominal thrusts do not relieve the airway obstruction, responders should continue to provide an alternating sequence of five back blows and five abdominal thrusts. The ERC/UK Resuscitation Council guidelines for choking treatment are outlined in (see figure 3.12). If these efforts do not relieve the airway obstruction and the casualty becomes unconscious, responders should carefully lay the casualty on the ground and immediately call for help, 999/112 and begin CPR (see Chapter 7). Figure 3.11: Providing Abdominal Thrusts and then checking the mouth Choking Chapter 3: A - Airway Management

52 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The same algorithm can be used in children down to the age of one year of age. Below this age (infants) the abdominal thrusts are replaced with chest thrusts/compressions. Small children can be placed across the lap for back blows and infants can be cradled in the arms (head down along the forearm). Another key difference for children is if the child becomes unconscious, we then commence paediatric life support which starts with five rescue breaths before chest compression starts. Details of paediatric life support are found in Chapter 9. In cases of choking abdominal thrusts should not be used in infants (children under 1 year of age) – chest compressions are used instead. Figure 3.12: Adult choking algorithm (based on UK and European Resus Council guidelines) Assess the severity of the choking Conscious Five back blows Five abdominal thrusts Repeat until choking relieved or unconscious Mild Choking able to speak or cough Encourage to cough Severe Choking unable to cough Unconscious: Start CPR Choking in children Chapter 3: A - Airway Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 53 Under normal circumstances, a person’s body can operate efficiently using the amount of oxygen found in normal room air. However, in some situations, such as in major blood loss from a traumatic injury, (as the oxygen is carried by red blood cells) insufficient oxygen may be delivered to the cells of the body, which can result in shock, death, or serious long term disability. This can also occur if the breathing is compromised and oxygen does not reach the blood from the lungs. Administering supplemental oxygen to a casualty should increase the amount of oxygen delivered to the cells of the body and often makes a positive difference to the casualty’s outcome. Room air contains 21% oxygen, whereas an oxygen cylinder contains pure oxygen (100%). In some situations and medical conditions, oxygen can theoretically worsen the condition of a casualty, e.g. COPD and therefore it is important to assess the patient’s oxygen status, and their general health before giving oxygen. However, all casualties with major traumatic injuries are likely to require supplemental oxygen through a reservoir mask or nasal prongs (cannulae) at a flow rate sufficient to maintain oxygen saturations of 94% or more. If they have COPD then >88% may be sufficient. A pulse oximeter should be available, to check the oxygen saturation and compare the levels before and after oxygen therapy, to assess the response. If the casualty improves, you may consider reducing the oxygen flow rate. Aim for a target saturation of between 94–98% in the average adult casualty, but if unsure or their condition is unstable e.g. • Head injury • Features of shock • Difficulty in breathing, e.g. asthma, then the higher flow rate should be used. The British Thoracic Society guidelines were initially produced for medical conditions. However, the latest version is far wider reaching, identifying that high levels of oxygen administration are not benign or without risk to some. We now deliver oxygen to maintain saturations as described above: aim for 94-98% in most patients. In RTACC managing serious illness or injury we are more likely to risk harm by withholding oxygen, rather than administering it. See section on COPD for exception. Oxygen should be used to treat hypoxaemia (low oxygen levels in the blood) and not simply breathlessness. (see figure 3.13). A pulse oximeter is very simple to use. A sensor probe is clipped on to the casualty’s finger and a LED is shone through the finger, giving the findings on the screen. Most commonly the pulse and oxygen saturation will be recorded, but newer models may also provide other information as well such as a pulse waveform. Figure 3.13: Apply the pulse oximeter early, almost like your ‘hand-shake’, to assess the oxygen status and pulse of the casualty. Supplementary oxygen Chapter 3: A - Airway Management Ventilation using a pocket mask provides 16–18% oxygen. Bag-valve mask ventilation with room air 21% oxygen. Oxygen cylinder delivered at 15 L/min through a non-rebreathing mask with a reservoir bag provides 60–80% oxygen. Bag-valve masks, with oxygen 15L/min and reservoir provides 100% oxygen (need to check manufacturer/type as some don’t provide spontaneous breathing)

54 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com There are times when we may wish to limit the amount of oxygen that we give to our casualties. We do this by reducing the flow on the oxygen cylinder from 15 L/min in steps: 15 to 10, 6 or 2 L/min. COPD & CHRONIC CHEST DISEASE PATIENTS RTACC responders should be aware that there are a small percentage of patients with severe chronic obstructive pulmonary disease (COPD) or chronic chest disease who can deteriorate or become drowsy if given oxygen. This is called ‘Hypoxic drive’ and high levels of oxygen will depress their breathing (see figure 3.14). They are far less common than some healthcare training suggests. Many of these patients are aware of their condition and will inform responders. Our target oxygen saturation in these patients with COPD is 88-92%. If the casualty does not mention COPD or warnings about too much oxygen, then continue as normal but if any of these occur: • They become drowsy • Find breathing more difficult • Respiratory rate drops below 12/min. Then reduce the flow of oxygen on the cylinder flowmeter from 15 L/min to 6 L/min the oxygen and continue to monitor the casualty with a target oxygen saturation >88%. If they continue to deteriorate in any of the above ways then try discontinuing the oxygen for a minute or two, but if the conditions still worsens ( Oxygen saturation less than 88%), then resume oxygen therapy at 6 L/min. Be aware that far more patients die from a lack of oxygen than oxygen toxicity. If you are unsure and the patient has low oxygen saturations (<92%) then administer oxygen at 15 L/min and monitor the casualty. CARDIAC PATIENTS Cardiac patients potentially having a heart attack are another group to whom we no longer administer excessive amounts of oxygen. In patients with severe chest pain and those with a suspected heart attack we simply aim to keep the oxygen saturation >94% by adjusting the flow of oxygen, usually between 4 and 15 L/min. To avoid confusion in RTACC, we simply aim for an oxygen saturation >94%. In cardiac arrest we always deliver 100% oxygen at 15 L/min in all patients. This can be reduced after they are successfully resuscitated based on their oxygen saturations and any other health conditions. Supplementary oxygen – Adjusting oxygen flow Chapter 3: A - Airway Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 55 Figure 3.14: Safe administration of Oxygen guideline Supplementary oxygen – Adjusting oxygen flow Chapter 3: A - Airway Management *Reassess patients every 2 min SEVERE COPD/CHEST DISEASE Sats <88% ALL OTHER PATIENTS Sats <92% If Drowsy & RR falling <12 Sats <88% NOTE: Continually monitor the patient visually when administering Oxygen, however formally reassess oxygen sats and clinical condition every 2 mins at least and adjust the Oxygen flow accordingly (L/min). APPLY NON RE-BREATHING MASK If Drowsy & RR falling <12 Sats <88% EXCHANGE PRONGS FOR NON RE-BREATHING MASK If Drowsy & RR falling <12 Sats <88% If Sats >94% If Sats fall below 94% Try stopping Oxygen If getting worse or sats still falling 15 L/min and support breathing with BVM Check pulse oximeter Sats on air APPLY NASAL PRONGS

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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 57 When we use a pulse oximeter, the oxygen saturation is considered ‘Time critical’ if <91% on air or < 94% on oxygen. A casualty who is not breathing will require support for their breathing or ‘ventilating’ with either a pocket mask or a bag- valve mask (see figure 3.16). Bag-valve masks require a responder to squeeze the bag to push air through a one-way valve, into the mask, held firmly to seal it on the face and then into the casualty’s airway and lungs - the chest will visibly rise. After each ‘ventilation’ the bag is released and the casualty passively exhales - the chest will visibly fall. The “used” air empties back into the mask and escapes through holes before the one-way valve, to avoid it being blown back into the patient with the next ‘ventilation’. (This is discussed in more detail below) Bag-valve masks are single-use and should be disposed of after use. Paraquat overdose is quoted as a key contraindication for oxygen therapy. In confirmed cases of paraquat overdose, avoid oxygen unless the casualty has sustained a major injury or is in extremis (e.g. has a respiratory rate more than 30/min, oxygen sats <91%, unconscious, in arrest or time critical). In such cases, oxygen should be given, as in any resuscitation. Figure 3.16: Using a pocket mask with oxygen mask Oxygen equipment NASAL PRONGS/CANNULAE Nasal prongs/cannulae are very well tolerated way of delivering up to 60% oxygen in adults and children. They are very useful when the casualty will not tolerate a face mask or if they are using Penthrox for analgesia and requires supplementary Oxygen to keep their saturation above 94% The oxygen is delivered in Litres/min from as little as 1-2L.min up to 15L/min from a cylinder. Chapter 3: A - Airway Management

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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 59 I-Gel These notes have been adapted for RTACC from the Intersurgical User Guide INTRODUCTION The I-gel offers a simple and easy to use airway adjunct for unconscious casualties. Originally developed for anaesthetic use, the I-gel has rapidly become the emergency airway of choice in many situations where unconscious casualties are encountered, e.g. serious head injuries or cardiac arrests. Familiarisation and training in the use of the device takes no more than a few hours and even in inexperienced hands it is likely to offer a superior airway to the alternatives of nasal and oral airways and face masks and can be inserted in seconds. Unlike the other airway devices it also stays in place without constant attention and does not require the inflation of any cuffs as it is simply advanced into place and immediately provides an effective airway. BACKGROUND The I-gel supraglottic airway management device, is made of a medical grade thermoplastic elastomer, which is soft, gel-like and transparent. This device has been developed after extensive literature searches related to airway devices dating back as far as the 5th century. The I-gel is a truly anatomical device, achieving a mirrored impression of the pharyngeal, laryngeal without causing compression or displacement trauma to the tissues and structures in the vicinity. The I-gel has evolved as a device that accurately positions itself over the larynx, providing a reliable seal and therefore no cuff inflation is necessary. This has several potential advantages, including easier insertion, minimal risk of tissue compression and stability after insertion (i.e. no position change with cuff inflation). The I-gel is designed as a latex free, sterile, single patient use device. The tube section is firmer than the soft bowl of the device. The firmness of the tube section and its natural oropharyngeal curvature allows the device to be smoothly inserted by grasping the proximal end of the I-gel which helps glide the leading edge against the hard palate into the pharynx. It is not necessary to insert fingers into the mouth of the patient to achieve full insertion. The smooth under surface of the device allows it to easily slide posteriorly along the hard palate, pharynx and into correct position. An integrated gastric channel can provide an early indication of regurgitation, facilitates venting of gas from the stomach and allows for the passing of a nasogastric tube to empty the stomach contents. SOFT NON-INFLATABLE CUFF The novel soft non-inflatable cuff fits snugly over the laryngeal inlet. The tip lies in the proximal opening of the oesophagus, isolating the oesophageal opening from the laryngeal inlet. Chapter 3: A - Airway Management

60 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com GASTRIC CHANNEL The gastric channel runs through the device from its proximal opening at the side of the distal tip of the non-inflatable cuff. Since the distal tip of the device fits snugly and anatomically correctly into the upper oesophageal opening, the distal opening of the gastric channel allows for the passing of a nasogastric tube to empty the stomach contents (not an RTACC skill at present) and can facilitate the active venting of gas from the stomach. The gastric channel can also provide an early indication of regurgitation. moving out of the upper oesophagus. The I-gel’s shape follows the mouth and throat curvature of the patient. It is anatomically widened and concaved to eliminate the possibility of it turning over when in position, thereby reducing the risk of malposition. It also provides vertical strength to aid insertion. USES The I-gel has been primarily developed for maintain the airway during general anaesthesia. However, whilst it has not been formally evaluated in prehospital and other domains, there is increasing evidence and recommendations that it is ideal for these situations providing a simple and easy to use, but highly effective emergency airway device, as an alternative to the endotracheal tube. At least one study has actually described improved outcomes in cardiac arrest if used instead of intubation in the first 15 mins post arrest. CONTRA-INDICATIONS • Not trained in the use of the device • Patient is conscious or awake • Trismus, limited mouth opening, throat/mouth abscess, trauma or mass • Do not use excessive force to insert the device • Casualty will not tolerate as too ‘awake’ which may lead to coughing, bucking, excessive salivation and retching • Do not reuse or attempt to reprocess the I-gel • Casualty is vomiting • Use with caution in patients with an increased risk of a full stomach e.g. hiatus hernia, sepsis, morbid obesity, pregnancy, unless in an emergency • Care should be taken with patients who have poor broken or loose teeth. PATIENT SELECTION In RTACC the I-gel is currently only used for adult resuscitation and airway maintenance. It is suitable for casualties who: • Are unconscious • Have a relaxed and floppy lower jaw. I-gel must be lubricated according to the instructions for use. The patient should always be in the ‘sniffing the morning air’ position prior to insertion with the assistant helping to open the patient’s mouth, unless head/neck movements are considered inadvisable or are contraindicated. • The leading edge of the I-gel’s tip must follow the curvature of the patient’s hard palate upon insertion. I-Gel Chapter 3: A - Airway Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 61 SIZE SELECTION At present we are only recommending that RTACC providers use the I-gel in adults. However, it can easily be extended for use in children if they are frequently attended by the providers and there is an identified need. PRE-USE CHECKS • Inspect the packaging and ensure it is not damaged prior to opening • Inspect the device carefully, check the airway is patent and confirm there are no foreign bodies or a BOLUS of lubricant obstructing the distal opening of the airway or gastric channel • Carefully inspect inside the bowl of the device, ensuring surfaces are smooth and intact and also that the gastric channel is patent • Discard the device if the airway tube or the body of the device look abnormal or deformed. PRE-INSERTION PREPARATION - ADULT I-GEL. Sizes 3, 4 and 5. • Always wear gloves • Open the I-gel package, and on a flat surface take out the protective cradle containing the device • Place a small bolus of a water-based lubricant, such as K-Y Jelly, onto the middle of the smooth surface of the cradle in preparation for lubrication. Do not use silicone based lubricants • Grasp the I-gel along the integral bite block and lubricate the back, sides and front of the cuff with a thin layer of lubricant • Check that lubricant remains in the bowl of the cuff or elsewhere on the device. Avoid touching the cuff of the device with your hands • If not used immediately, place the I-gel back into the cradle in preparation for insertion • Remove dentures or removable plates from the mouth before attempting insertion of the device • NB. The I-gel must always be separated from the cradle prior to insertion. The cradle is not an introducer and must never be inserted into the patient’s mouth. PRE-INSERTION PREPARATION - PAEDIATRIC I-GEL. Sizes 1, 1.5, 2 and 2.5 • Always wear gloves • Open the i-gel package, and take out the cage pack containing the device. Place a small bolus of a water based lubricant, such as K-Y Jelly, onto the smooth inner surface ready for use. Do not use silicone based lubricants • Grasp the I-gel along the integral bite block and lubricate the back, sides and front of the cuff with a thin layer of lubricant. Ensure after lubrication has been completed, that none remain in the bowl of the cuff or elsewhere on the device • Avoid touching the cuff of the device with your hands • Place the I-gel back into the cage pack if not used immediately. Currently size 3 and size 4 will be recommended as part of the RTACC trauma kit I-GEL SIZE PATIENT SIZE PATIENT WEIGHT (KG) 1 Neonate 2-5 1.5 Infant 5-12 2 Small paediatric 10-25 2.5 Large paediatric 25-35 3 Small adult 30-60 4 Medium adult 50-90 5 Large adult 90+ THE GREEN AREA DEFINES THE MOST COMMON ADULT SIZES I-Gel Chapter 3: A - Airway Management

62 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com INSERTION OF THE I-GEL A proficient user can achieve insertion of the I-gel in less than five seconds. • Grasp the lubricated I-gel firmly along the integral bite block. Position the device so that the I-gel cuff outlet is facing towards the chin of the patient • The patient should be in the ‘sniffing the morning air’ position with head extended and neck flexed. The chin should be gently pressed down before proceeding to insert the I-gel • Introduce the leading soft tip into the mouth of the patient in a direction towards the hard palate • Glide the device downwards and backwards along the hard palate with a continuous but gentle push until a definitive resistance is felt. WARNING: Do not apply excessive force on the device during insertion. • It is not necessary to insert fingers or thumbs into the patient’s mouth during insertion • If there is early resistance during insertion a ‘jaw thrust’ is recommended • At this point the tip of the airway should be located into the upper oesophageal opening and the cuff should be located against the laryngeal framework. The incisors should be resting on the integral bite-block. WARNING: In order to avoid the possibility of the device moving up out of position prior to being secured in place, it is essential that as soon as insertion has been successfully completed, the I-gel is held in the correct position until and whilst the device is secured. • Sometimes a feel of ‘give-way’ is felt before the end point resistance is met, due to the passage of the I-gel through the narrow part at the back of the throat • Once resistance is met and the teeth are located on the integral bite block, do not repeatedly push I-gel down or apply excessive force during insertion • A horizontal line (Adult sizes 3, 4 and 5 only) at the middle of the integral bite-block represents the correct position of the teeth. If the teeth are located lower than the distal tip of the bite block, it is likely the device has been incompletely inserted. CHECKING CORRECT POSITION • Once inserted and secured, remove the face mask from the Bag valve mask and connect the BVM directly onto the I-gel • Gently squeeze the bag. The rise and fall of the chest should be seen • If the chest does not rise and fall or the casualty is struggling to breathe, suspect that the I-gel is misplaced, remove it and try again • NO more than three attempts to site the I-gel should be made and if these fail, return to face mask with airway adjuncts, e.g. nasal and oral airways. REMOVAL OF THE I-GEL • If at any stage the casualty starts to gag, cough or wake up with the I-gel in place, immediately remove the securing tape of straps and prepare to pull it out gently and smoothly. On occasions the casualty may bite on the I-gel, but at some point they will cough it out if sufficiently awake that they don’t need it any more. Source: Inter-surgical I-gel user guide, www.i-gel.com I-Gel Chapter 3: A - Airway Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 63 • Loss of the airway can result in death within minutes if it is not properly managed • The airway should be regularly assessed in all casualties, as conditions may change rapidly • A partially obstructed airway restricts the flow of air and can result in a harsh, high pitched noise known as stridor • A totally obstructed airway allows no sounds of breathing effort to be heard • The look, listen, and feel approach is used to assess airway problems • Look for chest rise and any obvious signs of facial or airway trauma • Listen for breathing effort • Feel for breath • Various positions may be used to try and relieve airway obstruction including the recovery position, sitting position, or prone position. • The tongue may be blocking the airway in unresponsive, unconscious casualties. The jaw-thrust should be used in this situation to open the airway. Alternatively, if there is no potential for spinal injury, the head tilt-chin-lift manoeuvre may be used. • Nasal or oral mechanical airway devices can be inserted into the mouth or nose to assist breathing. • Choking occurs when a foreign body lodges and obstructs the airway, resulting in an inability to breathe effectively • For a conscious choking casualty, provide up to five back slaps. If these fail to dislodge the obstruction, provide up to five abdominal thrusts. Alternate between back slaps and abdominal thrusts until the obstruction is dislodges or the casualty becomes unconscious • For an unconscious casualty who has been choking, inspect the airway (look into the mouth); provide 30 chest compressions and two ventilations. Continue this cycle, checking the airway before delivering the breaths each time • All major trauma patients should receive supplemental oxygen at a rate of 15 L/min • A hypoxaemic casualty requires high concentration oxygen until the oxygen saturation reaches 94–98%. • Oxygen equipment includes an oxygen cylinder, pressure regulator, flow meter, and a range of face masks or bag-valve masks • Always take appropriate safety precautions when working with or around supplemental oxygen to avoid combustion or damaging the cylinder • If a casualty is not breathing, he or she should be given ventilated breaths with a bag-valve-mask device • If more than one responder is present, the spine should be immobilised whilst securing the airway, before proceeding to the next step in the MARCH assessment process. Summary: Chapter 3: A - Airway Management

64 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Apnoea: Condition where the casualty is not breathing. Bag-valve mask: A device used to deliver supplemental oxygen to a casualty who is not breathing. Oxygen is squeezed from the bag, through a one way valve and into the mask applied to a casualty’s face. Head tilt–chin lift manoeuvre: Opening the airway by tilting the head backward and lifting the chin forward, bringing the entire lower jaw with it. Hypoxaemia: Low levels of oxygen in the blood. Jaw-thrust manoeuvre: Opening the airway by bringing the jaw forward without extending the neck. I-Gel: Type of Supraglottic airway for unconscious casualties. Nasal airway: An airway adjunct that is inserted into the nostril of a casualty who is not able to maintain a natural airway; also called a nasopharyngeal airway. Oral airway: An airway adjunct that is inserted into the mouth to keep the tongue from blocking the upper airway; also called an oropharyngeal airway. Pulse oximeter: A machine consisting of a monitor and a sensor probe that measures the oxygen saturation in the blood. Recovery position: A side-lying position that helps an unconscious patient maintain an open airway. Stridor: Harsh, unmistakable noise that indicates airway obstruction. Revision: 1. A casualty with an airway problem should be assessed A Only during the initial MARCH assessment B Regularly, based on the severity of the casualty’s condition C Every 10 minutes. D Every 2 minutes by your watch ANSWERS 1: B 2. Which of the following is NOT a sign of potential airway obstruction following trauma? A Swollen lips B Loss of facial hair following a fire C Confusion & memory loss D Blood in the mouth ANSWERS 2: C Vital vocabulary Chapter 3: A - Airway Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 65 3. The ability to talk is a sign that the casualty’s airway is: A Clear B Not at risk C Totally obstructed D Is not going to swell ANSWERS 3: A 4. To treat an unconscious adult who is choking, a responder should first: A Attempt five back blows followed by five abdominal thrusts B Attempt one abdominal thrust followed by five back blows C Encourage the casualty to cough D Commence CPR ANSWERS 4: D 5. Oxygen should be provided to a casualty suffering major trauma at a rate of: A 2000 psi B 20 breaths/min C 15 L/min D Delivery is based on the cylinder size ANSWERS 5: C Revision: Chapter 3: A - Airway Management

66 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com M.A.R.C.H ALGORITHM – AIRWAY MANAGEMENT Chapter 3: A - Airway Management B.L.S. PROTOCOL NOT BREATHING (10secs) NO SIGNS OF LIFE (10secs) Re-assess again! SAFE APPROACH TIME CRITICAL AIRWAY MANEOUVRES • Jaw Thrust/Chin LIft • Oxygen 15L/min - Target Sats > 94% on 02 • Suction • NP/OP • i-Gel MASSIVE HAEMORRHAGE AIRWAY PROBLEM? • Unconscious • Airway at Risk • Obstructed • Cx spine: if 2 persons • Sats <92% or less on air H R C HAEMORRHAGE CONTROL D.D.T Wound Packing / Haemostatics / Tourniquets Not more than 60 secs if single rescuer

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 67 Understanding respiratory problems Many trauma patients have respiratory or breathing problems, as a result of direct blunt or penetrating chest injuries as well as also other less obvious causes, e.g. head injuries, shock or a medical cause such as asthma. In casualties with serious chest trauma, the distress or difficulty in breathing can be very obvious, but in lesser trauma there may be few, if any, signs initially, but they may slowly develop and progressively get worse. Where there are injuries to the upper chest, the first and second ribs are very strong and offer protection to the structures of the neck and upper chest. If these ribs are fractured, it strongly suggests a major impact and likely underlying serious trauma with possible internal injuries. Such cases should be managed with a high index of suspicion and requires careful and regular reassessment. Wounds, especially penetrating wounds, (e.g. stabbings or gunshots) in the neck or around the collar bone can indicate serious internal injury to many of the important structures inside. This can make them challenging to manage in the field due to the presence of large blood vessels, nerves, and the trachea. When lacerated or torn by injury, many of these structures can retract into the chest or up the neck, increasing the risk of death. However, spinal injuries in penetrating trauma of the neck are far less common and should not delay rapid management of bleeding and airway issues. Chapter 4: R: Respiratory Management

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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 69 Chapter 4: R - Respiratory Management Listening to the breathing, even without equipment such as a stethoscope, can provide valuable information about a casualty’s respiration. Firstly, listening for air movement serves as a valuable method to verify that the casualty is breathing, as discussed in the airway chapter. Similar to when assessing the airway, assessing the casualty’s ability to speak quickly gives us a lot of useful and reliable information. If the casualty is able to speak comfortably in full sentences they are unlikely to have a significant chest injury. In addition, you may hear some of the following additional sounds: • Wheeze: Caused by narrowed airways deep inside the lungs. Can be caused by smoke inhalation and burns, or medical conditions such as asthma and severe allergic reaction • Sucking or bubbling: May be due to air entering a sucking chest wound • Crackling or gurgling: Indicative of fluid (or infection) within the lungs, such as a casualty with non fatal drowning. Listen Figure 4.2 : Exposure of the chest to look and feel for injuries in the four areas Remember to always feel up and down the back of the chest and look for blood on your gloves The next step in our assessment is to get your hands on and ‘feel’ the chest. Before putting your hands on the chest, ask the casualty whether they are happy for you to help them and if they have any pain in the chest. If they do, start away from the pain, gently but thoroughly, feel over all four areas of the chest wall including the front, both sides and the back for any pain, abnormal sensations, movements (e.g. ribs moving inwards when the casualty breathes in) or wounds. Imagine the chest as a ‘box’ that has a front, two sides, a top (above collar bones and neck area) and back. Ideally the chest should be fully exposed, but in public we should at least try to preserve the dignity of the casualty. This can be performed by exposing selected areas in turn, working around the chest, but ensure that all areas, including the back and sides are assessed. It is rarely necessary to remove a lady’s bra, unless you suspect or can see an underlying injury. A key area that often gets missed and must always be checked, especially in tactical incidents or assaults are the armpits, which must be fully explored (see figure 4.2) – these are vulnerable areas even when wearing body armour. Feel

70 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Chapter 4: R - Respiratory Management Managing respiratory problems A high respiratory rate usually indicates a significant problem. Fast breathing (> 20 breaths/min) may simply be due to pain or anxiety, but it may also indicate a more serious concern such as chest injury, major haemorrhaging, or head injury. OXYGEN THERAPY Supplemental oxygen will not improve the casualty who is in pain or anxious, but is essential for those suffering major trauma (see Chapter 3). Providers should use a pulse oximeter to assess the effectiveness of oxygen therapy and titrate it in response to keep saturations >94%. (Remember: Oximetry is unreliable in smoke inhalation/CO poisoning). SITTING UP Another simple but highly effective measure in chest trauma is to simply sit the casualty up. This will often greatly help the casualty with the breathing compared to having them strapped to a flat board or scoop. This may be a balance of risks between spinal immobilisation and breathing and much like airway, breathing must take priority if they are struggling, so gently sit them up. Signs and symptoms of respiratory concerns include: • Extremely fast breathing (>20 breaths/min) • Extremely slow breathing (<8 breaths/min) • Grossly unequal chest movement when comparing both sides • Badly deformed chest • Open or “sucking” chest wounds. RTACC responders can use a more comprehensive assessment method: As a simple aid or reminder for examining the chest we use the acronym ‘R U IN SHAPE.’ This can be used even by those who cannot use stethoscopes or perform percussion. R – Respiratory rate U – Unequal chest movement IN – Injuries, e.g. wounds, pain S – Search the chest H – Hands to feel all areas A – Ausculate or listen (with stethoscope if trained) P – Percuss over chest E – Everywhere (all four sides of the chest – area not already checked) Signs and symptoms of respiratory problems - ‘Time critical’ Unlike blunt trauma, in penetrating trauma, wherever possible we log roll the casualty and search the back directly. If this is not possible, at the very least get your hands up and down the sides at the back, looking for tenderness or blood on your gloves. Examine the chest for equal movement on both sides; remember that the chest effectively has four sides (front, back and two sides). Carefully feel all over the chest and up into the armpits for wounds, areas of boggy swelling, or a crisp, crunchy sensation (like walking on fresh snow) which suggest serious chest trauma and a leak or hole in the lung. If any of these characteristics are present, the casualty may quickly become time critical, so regular reassessment is again crucial. Gently place your hands on the front left and right sides of the chest, ask the casualty to take a big breath, in and out, as best they can and watch that the rise and fall corresponds with breathing: • Is it equal? • Does the movement look ‘right?’ Serious problems will usually very obvious and although the cause may be not as obvious, it will clearly look unequal or abnormal. Feel

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 71 Chapter 4: R - Respiratory Management Penetrating chest injury, although less common in the UK than blunt trauma, is sadly increasingly common in many parts of the modern world especially with stabbings, terrorism and active shooter incidents. The chest cavity has two sides, which are separate sealed chambers, with a lung in each side (like two balloons). Inside the chest is normally at slightly below atmospheric pressure to keep the lungs inflated. However, if a hole is created in the chest wall, air will move in from outside and can collapse the lung on that side. The other lung should remain unaffected, unless the hole also enters that side of the chest too. If fit and well, the casualty can survive with one collapsed lung, although they will experience some breathlessness, especially if they exert themselves. However, if the casualty has any chest disease or limited respiratory reserves, then they will not do so well and may quickly become short of oxygen and very distressed with a high respiratory rate. SUCKING CHEST WOUNDS Sometimes air can be heard going in and out of the hole in the chest. If the hole allows air in but not out, this is called a ‘sucking chest wound’ (see figure 4.3) and the risk is that air will get in and accumulate, unable to get out. This can lead to a build of pressure in the chest, which is called a ‘Tension’ pneumothorax and can be life threatening. When spontaneously breathing this is usually slow to develop. If we are supporting the breathing with ventilation, e.g. BVM, I-gel etc then this “tension” can occur far more quickly and we should be aware of that risk with holes in the chest when ventilating. Dressing chest wounds - Penetrating trauma REASSURANCE Finally, reassurance is often under-estimated and an effective way to manage chest trauma victims who are scared when they cannot breathe. Encourage them to take slow steady breaths rather than big breaths, which may be impossible. If necessary, and if they have pain, suggest that they support their chest or ribs to minimise pain. PAIN RELIEF Penthrox is ideal for managing moderate to severe pain in chest trauma. Remember: Entonox cannot be used safely in chest trauma and is contraindicated. These may be the only therapies available to the BTACC/ RTACC provider facing a case of serious chest trauma, but these alone could be life saving. Any trauma patient breathing at less than eight breaths/min requires ventilation support with a bag-valve-mask device. This is increasingly reported for a short period after major blows to the head and is called sudden impact brain apnoea. Simply supporting their breathing for a short period can be life-saving. Extremely slow breathing (< 8 breaths/min) may also indicate a serious problem such as a drug overdose, e.g. Fentanyl or heroin. If the casualty has a decreased level of consciousness or is unresponsive, the responders should support the casualty’s breathing by using a bag-valve mask with supplemental oxygen attached (see Chapter 3). Responders should aim to raise the casualty’s respiratory rate to normal levels (12–14 breaths/min). For example, if the casualty is breathing at a rate of six breaths/min, the rescuers should provide 6–8 breaths/min. Managing respiratory problems Figure 4-3: Typical open chest wound which may be ‘sucking’ and should be chest sealed. (This hole may be into either the chest or abdomen It doesn’t matter, just seal it).

72 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Chapter 4: R - Respiratory Management d) Peel off backing to expose the adhesive side of chest seal and apply over the wound. Figure 4.4: Use of chest seal. a) Assess the chest wall and identify any open wounds (front, sides or back). b) Open the chest seal dressing pack. c) Dry the area around the hole with the gauze swab in the pack to give the dressing the best chance to stick to the skin around the wound. The main aim of RTACC care is to cover or seal the hole, ideally with a specialist dressing, with a ‘one way’ non-return valve that will allow air to pass out of the chest but not go back in. This should avoid any risk of tension pneumothorax and will also help the collapsed lung to re-expand. Such dressings are called CHEST SEALS and there are many different types. Some of the early ones will not stick well if there is moisture, sweat or blood on the chest. The Asherman type can also get blocked with blood and clot. The modern versions are Bolin, Russell or SAM seals. Some seals do not have valves and simply stop air entering but does not allow it to leave. A chest seal sticks directly over the hole (see figure 4.4) Dressing chest wounds - Penetrating trauma

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 73 Chest seals with valves act as one-way air valves, allowing air to leave the chest cavity without getting sucked back in. These dressings can help prevent more serious complications and minimise lung collapse. In traditional tactical medicine, an improvised three-sided dressing, was the first aid measure of choice. However, these have a poor record for effectiveness as they take time to create, often don’t stick well or don’t act as an effective valve. If you don’t have a proper chest seal dressing, then we would recommend that you simply seal the hole with wide adhesive tape, e.g. gaffer tape, an adhesive dressing or even a gloved hand. Chest seals should be applied to any wound or ‘hole’ in the torso, as in penetrating upper abdominal wounds it may also involve the chest cavity, e.g. an long knife wound to the stomach. Chest seals will not stick to the chest wall effectively unless the chest is thoroughly dried before application. Many manufacturers include a single gauze swab to dry the chest before application. Regularly check that the dressing is still adherent. Manufacturers have worked hard to produce effective adhesive dressings and the modern versions stick far more effectively. In some situations, more than one wound may exist. Multiple seal dressings should be placed to cover all the casualty’s wounds. If the casualty has a very large wound, single chest seals or dressings may not provide adequate coverage. In this case, air trapping and tension in the chest is unlikely, so providers should simply attempt to control any bleeding with dressings and keep the area free from contamination by foreign debris. Cling-film can be used for this purpose. If there are multiple wounds or you have no seal then apply an improvised three sided dressing: 1. Place a square of non-porous material (such as plastic dressing packaging) over the wound 2. Tape the dressing on the top and both sides using adhesive tape 3. Leave the bottom of the dressing free, to act as a one-way flap valve and allow any blood to drain out of the chest. Chapter 4: R - Respiratory Management Figure 4.5: Improvised 3 sided dressing in place over a chest wound on the back (arrow indicates the ‘open’ edge) - poor alternative compared to a chest seal. e) Ensure a good seal of the dressing. If it does not fully cover the wound or is not big enough, a sheet of cling-film or a damp saline soaked swab can be used (If the wound is large it is unlikely to be sucking and trapping air, but the lung will still be collapsed inside). Figure 4.4: Use of chest seal. Dressing chest wounds - Penetrating trauma

74 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Chapter 4: R - Respiratory Management Providing supplemental ventilation Ventilating a casualty with a bag-valve-mask is considered a core skill by many responders, but it is one that is often performed badly and ineffectively. It is very easy to simply squeeze the bag, thinking that you are doing a good job, but without actually having any positive effect on the casualty. This is a key part of the reasoning behind ‘hands-only’ CPR, as time wasted providing poor ventilation to the patient, could be better used performing high quality chest compressions. This is discussed further in the ‘cardiac arrest’ chapter. USE OF A BAG-VALVE MASK Firstly, it is important to select the correct sized face mask for a good seal between the face and the mask. The mask should sit with the top narrow part over the bridge of the nose and the bottom wider part between the lip border and chin (see figure 4.6). Secondly, it is important to achieve an adequate seal. 1. Form a ‘C’ shape with the index finger and thumb of your dominant hand. 2. Place this around the mask connector and press it down onto the face (thumb over nose and finger over lower edge of mask (chin). 3. Place your other three fingers behind the ‘angle’ of jaw and pull jaw into mask and to open the airway by pulling the jaw forward. 4. The challenge is to press down the mask creating a seal, whilst keeping the airway open. 5. If you achieve this then you can ventilate by squeezing the bag with the other hand. This can be relatively easy or it can be extremely difficult, even for experienced airway experts. Figure 4.6: Applying a non-breathing face mask (left) and checking that the reservoir bag inflates right. POSITIONING CHEST TRAUMA - BAD SIDE UP OR DOWN? A famous trauma myth is that chest trauma cases should be managed ‘Bad side down’ - This was proposed to avoid blood spilling from the upper bad lung into the lower healthy lung, but this is wrong for a number of reasons: • Contamination from the bad lung to the good one is very unlikely to be an issue • It is painful to lie on the injured side • We cannot monitor the wound if the casualty lies on it • Physiologically, the blood volume in the lungs follow gravity and needs to be in the best working lung, it should therefore be the undamaged one lower-most, with the injured lung upper-most should be on the top side. Therefore, always manage chest trauma cases either sat up or ‘Bad side UP’. Dressing chest wounds - Penetrating trauma

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 75 With training and practice/regular use, even a single responder can ventilate a casualty using a bag-valve-mask device; however, the two person technique is a far more efficient way of providing supplemental ventilation +/- oxygen to the casualty in less experienced hands. (see figure 4.7). TO USE A BAG-VALVE MASK WITH TWO RESPONDERS 1. Choose the correct size of mask to cover the nose and mouth. 2. Position the mask on the patient’s face and ensure an adequate seal. 3. Place the thumbs on either side of BVM connector on the mask and with the fingers open either side like making a ‘butterfly’. 4. With the fingers feel for the angle of the jaw on each side and slide the fingers behind to pull the jaw forward (plus if necessary and safe, a gentle head tilt if required). 5. Press down with the thumbs and pull up with the fingers to seal the mask on the face whilst keeping the airway open. 6. The second responder then squeezes the bag, for approximately one second and both responders watch for a visible chest rise. 7. Release the bag and watch the chest fall. 8. Allow the bag to re-inflate slowly and completely. 9. Repeat at 12-15 breaths per minute in an adult. Ensure that you do not squeeze the bag too hard. Normal chest rise and fall should be observed and used as a guide of how much to squeeze. By looking at the amount of chest movement the ventilation volume (squeeze of the bag) can be adjusted so that even a large adult bag can be safely used on small adults and children if a suitable BVM is not available. Using the bag-mask device requires proper training and practice, for those who do not use it frequently it should be a two person technique. RTACC recommends that if working alone, use the pocket mask to support ventilation or do ‘hands-only’ CPR. Providing supplemental ventilation Chapter 4: R - Respiratory Management

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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 77 Air can enter the chest cavity abnormally from: • A hole in the chest wall and possibly the lung too from something that penetrates from outside e.g knife or broken rib. • A hole in the lung from inside (usually from blast injuries or high pressure inhalation). Remember that the lungs are like two balloons inside the chest cavity and there are two sides to the chest, that are isolated unless breached by a penetrating object. If this air enters the chest cavity from outside or from a hole in the lung, but is then trapped in the cavity, and unable to escape, pressure will start to build in the chest and the lung will be squashed down, like a collapsed balloon. If this air trapped in the chest cavity continues to increase, then pressure continues to build up. When breathing is spontaneous, this happens slowly in most cases, but if ventilated with a BVM or through an I-gel then this can happen much more quickly. Eventually the pressure can reach such a high level that it squashes the veins in the chest and pushes the heart to the opposite side of the chest which restricts the output of the heart. This can result in a life-threatening drop in blood pressure and severe difficulty breathing. This is called a ‘Tension pneumothorax’ and is a life-threatening condition – this is high pressure inside the chest that needs to be released as quickly as possible and is a ‘Time critical’ situation. This is an advanced level skill beyond RTACC. For paramedics and doctors, this is done with a needle inserted into the chest or by opening up a hole in the chest, to decompress the chest cavity, allowing the heart to function and the lung to re-inflate. Therefore, if ventilating a casualty or supporting their breathing then be aware that this may accelerate the process and look for signs of deterioration including: • Falling oxygen saturations • Increasingly unequal movement of chest • Abnormal side of chest looking bigger or over-inflated • Increasing respiratory rate if spontaneously breathing • Worsening signs of shock • Cardiac arrest. If this deterioration occurs when you have sealed a hole with a chest seal: • If the seal has a valve, then make sure that the valve is not blocked, e.g. with blood, and rapidly attempt to clear it or remove/replace it. • If it cannot be cleared or you have simply sealed the hole with a normal dressing, then peel back the edge of the dressing to expose the hole and listen for a sudden release of air as the tension escapes. Whether this works or not, this is now a time critical emergency and requires immediate advanced medical treatment and hospital. Tension pneumothorax Chapter 4: R - Respiratory Management

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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 79 1. Which of the following is NOT a step in respiratory assessment? A Look for equal chest movement B Listen for “noisy” breathing C Assess for reduced conscious level D Feel for painful broken ribs ANSWERS 1: C 2. Respiration should be considered time critical if it is: A Less than 12 breaths/min B Less than 20 breaths/min C More than 12 breaths/min D More than 20 breaths/min ANSWERS 2: D 3. Which of the following conditions is NOT time critical? A Ability to talk normally without gasping B Oxygen saturation less than 90% on air C Difficulty breathing and unable to speak D Grossly unequal chest movement ANSWERS 3: A Revision: Chapter 4: R - Respiratory Management

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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 81 M.A.R.C.H ALGORITHM – RESPIRATORY Chapter 4: R - Respiratory Management B.L.S. PROTOCOL NOT BREATHING (10secs) NO SIGNS OF LIFE (10secs) Re-assess again! SAFE APPROACH TIME CRITICAL AIRWAY MANEOUVRES • Jaw Thrust/Chin LIft • Oxygen 15L/min - Target Sats > 94% on 02 • Suction • NP/OP • i-Gel RESPIRATORY SUPPORT • Oxygen 15L/min • Chest seal (wounds) • RR <8/min - BVM - Pocket mask • Bad side upper most • Consider sitting up MASSIVE HAEMORRHAGE AIRWAY PROBLEM? • Unconscious • Airway at Risk • Obstructed • Cx spine: if 2 persons • Sats <92% or less on air H RESPIRATORY PROBLEM? • RR >20/min • Difficulty in breathing • RR <8/min • Sats <91% air / <94% 02 • Open Wounds • Unequal Movement C HAEMORRHAGE CONTROL D.D.T Wound Packing / Haemostatics / Tourniquets Not more than 60 secs if single rescuer

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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 83 Table 5.1 – Effects that significant blood loss can have on a healthy casualty AMOUNT OF BLOOD LOSS (IN ML) SIGNS/SYMPTOMS <500 ml Little serious effect, light-headedness, feeling a little faint 1000–1500 ml Shock, fast pulse rate, fainting, anxiety, restlessness, agitation, drowsy, going quiet 2000–2500 ml Extremely fast pulse rate, breathlessness, confusion, reduced consciousness > 3000 ml Coma and ultimately death Remember that massive blood loss can occur internally with minimal, if any external signs. Do not expect to see the abdomen or parts of the body swelling as significant or fatal volumes of blood can be lost with long bone fractures, (e.g. thigh bone/femur) and into the major body cavities such as the chest, abdomen and pelvis without such signs externally. When these injuries are suspected, efforts should be made to: • Handle the casualty gently (minimal log rolling especially) • Immobilise fractures in the injured area to prevent further blood loss • Keep the casualty warm • Facilitate rapid transport to hospital. Signs and symptoms of shock As we saw from the above table, there are many signs of shock and blood loss including: • Changes in mental status • Confusion, restlessness, or anxiety • Cold, clammy, sweaty, pale skin • Rapid breathing (as shock progresses, breathing may become more rapid and shallow). • Rapid, weak pulse or loss of pulse • Increased capillary refill time • Nausea and vomiting • Weakness or fainting • Thirst • Coma and death. Chapter 5: C - Circulatory Management Signs and symptoms of blood loss:

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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 85 The pulses (pressure waves down an artery as the blood pumps from the heart) are felt most easily where an artery runs superficially over a bone, e.g. radial pulse at the wrist, but they may be felt at many different locations on the body. The most common pulse points used in trauma and resuscitation are the radial (wrist) (see figure 5.3) and carotid (neck) (see figure 5.4). In children, the brachial pulse (inside of the elbow) should be used (see figure 5.5) (see chapter 9.2). To determine the pulse rate in beats per minute (if a pulse oximeter is not available or recording) find the patient’s pulse with your fingers: • Count the number of beats for 15 seconds • Then multiply this by four. In a normal adult, the resting pulse rate is 60–100 beats per minute. If the casualty appears unwell and the pulse rate is faster than 110 beats per minute or there is no detectable pulse and the casualty is clearly unwell, this indicates a time critical situation. Signs and Symptoms of potential Circulatory problems include: • Pallor (pale skin) • Cold, clammy skin • Increased pulse rate • Prolonged capillary refill time • Loss of a radial pulse • Confusion or coma. Figure 5.3: Radial pulse: Feel the radial pulse if the casualty is conscious or you have successfully found a carotid pulse. Figure 5.4: Feeling for the Carotid pulse on the right: Feel the carotid pulse if the casualty is unconscious or there is no radial pulse. Figure 5.5: Locating the Brachial pulse: Here it is located under the fingers of the casualty carers left hand. This is often useful and easier to find in children. If no radial pulse is palpable then immediately feel for a carotid pulse. If the carotid pulse is absent or you are unsure and the casualty is unconscious, with no signs of life or normal breathing, then immediately commence chest compressions and life support (CPR). If in doubt, commence CPR in the unconscious/unresponsive casualty. Pulses and pulse rate No Radial | Brachial Feel for carotid No Carotid / No signs of life Life Support CPR Chapter 5: C - Circulatory Management

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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 87 Scoop-and-run evacuation For RTACC providers, Scoop-and-run, early and rapid evacuation is the currently recommended alternative to the old school ‘stay and play’ approach. We should only stay on scene if we are still performing any essential action (usually life-saving) or if the patient transport has not arrived. On rare occasions, if a casualty is time critical and deteriorating and a hospital is close by if the ambulance is significantly delayed, then a decision could be made to transport the patient in a suitable alternative vehicle, e.g. Police car or fire appliance. This should always be discussed with those on scene and a senior officer. Advice could also be obtained from the major trauma centre Trauma Team Leader, via the hospital Red phone. The aim of providers should be to rapidly collect the casualty and transfer him or her to a suitable hospital or equivalent as quickly as possible (see figure 5.6). Offering unnecessary advanced medical skills at the scene may delay transfer to hospital significantly and could compromise the casualty, if not appropriate. Under certain circumstances and with the correct team and equipment complex life saving procedures may be required before transfer. However, these skills are beyond the realms of RTACC providers. Figure 5.6: Rescuers prepare the casualty for a rapid evacuation in the ambulance. Whilst aiming for a rapid transfer, it is still very important to keep all movements smooth and controlled with gentle handling to avoid increasing bleeding or pain. The casualty must be continually reassessed for any signs of ongoing blood loss or worsening shock. To miss a casualty who is deteriorating from worsening shock would be a catastrophe, so with a seriously ill or injured casualty we must stay vigilant. Signs of worsening shock include: • Deteriorating conscious level • Increasing pallor • Cold, clammy skin • Increasing breathing rate • Increasing pulse rate • Loss of palpable pulses • Poor or no signal on the pulse oximeter. Paramedics will usually give a clot promoting drug called TXA (Tranexamic acid) to such patients, and some medical teams will now even give blood on scene, rather than the traditional saline drips. Identifying signs of worsening shock Chapter 5: C - Circulatory Management

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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 89 2. If circulation is not preserved, then the patient may: A Develop a very slow pulse rate. B Be stabilised with intravenous fluids. C Develope features of shock such as confusion. D A blood transfusion is a better management option for pre-hospital. ANSWERS 2: C 1. Why is estimating the volume of blood loss difficult? A It is easy to estimate volume if you simply look at the casualty and the scene. B Bigger people don’t contain any more blood volume. C The scene, source, duration and rate of the blood loss are all major factors. D A casualty who is very cold will always lose less volume. ANSWERS 1: C 3. Which of the following assessment tools can be used to assess circulation? A The casualty’s ability to speak in full sentences. B Capillary pulses. C Presence of heart sounds. D Conscious level. ANSWERS 3: D Revision: Chapter 5: C - Circulatory Management

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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 91 M.A.R.C.H ALGORITHM – CIRCULATION Chapter 5: C - Circulatory Management B.L.S. PROTOCOL NOT BREATHING (10secs) NO SIGNS OF LIFE (10secs) Re-assess again! SAFE APPROACH TIME CRITICAL AIRWAY MANEOUVRES • Jaw Thrust/Chin LIft • Oxygen 15L/min - Target Sats > 94% on 02 • Suction • NP/OP • i-Gel RESPIRATORY SUPPORT • Oxygen 15L/min • Chest seal (wounds) • RR <8/min - BVM - Pocket mask • Bad side upper most • Consider sitting up CIRCULATORY SUPPORT • Re-assess D.D.T/Bandage CONSIDER: • ‘Scoop and Run’ • Pelvic Strap • Gentle handling • Traction Splints • Head to Toe survey • Elevate Legs MASSIVE HAEMORRHAGE AIRWAY PROBLEM? • Unconscious • Airway at Risk • Obstructed • Cx spine: if 2 persons • Sats <92% or less on air H RESPIRATORY PROBLEM? • RR >20/min • Difficulty in breathing • RR <8/min • Sats <91% air / <94% 02 • Open Wounds • Unequal Movement CIRCULATION PROBLEM? • Unconscious • Radial Pulse absent • CRT > 3secs • Radial Pulse >110/min HAEMORRHAGE CONTROL D.D.T Wound Packing / Haemostatics / Tourniquets Not more than 60 secs if single rescuer

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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 93 Head trauma is a common cause of death or long-term disability. The initial “primary injury” has already occurred, but responders aim to prevent or limit further damage or ‘secondary injury’ as a result of problems such as an obstructed airway, lack of oxygen, inadequate breathing, low blood pressure/shock, or falling level of consciousness. SIGNS AND SYMPTOMS OF HEAD TRAUMA Signs and symptoms of head trauma include: • Reduced level of consciousness • Wounds or obvious deformity to the head • Watery fluid coming out of the ears or nose • Enlarged pupil in one eye (usually a serious sign) • Combativeness or other abnormal behaviour • Seizures • Low respiratory rate (< 8 breaths per minute). It is essential to detect any changes in a casualty’s level of consciousness, as this can indicate the severity of any injury to the brain (see table 6.1). Change over time or a trend tells us far more than just an isolated assessment. By using the AVPU scale, a responder can ascertain the extent of injury and any improvement or deterioration in the casualty’s condition. For casualties who are ‘A’ or ‘V.’ Attempt to keep the casualty talking to continually reassess consciousness. All casualties that are ‘P’ or ‘U’ should be considered time critical. Table 6.1 – AVPU Assessment Table ASSESSMENT RESPONSE / COMMANDS A ALERT V RESPONSE TO VOICE P RESPONDS TO PAIN TIME CRITICAL U UNRESPONSIVE TIME CRITICAL Head trauma Chapter 6: H - Head Trauma and Other Serious Injuries

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

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 95 In this section we will consider some of the RTACC level skills that can be used to assess and reassess patients with head injury or reduced level of consciousness. This will include supplemental examination techniques and also some clinical management. NEUROLOGICAL ASSESSMENTS These tests need to be: • Simple to perform • Reproducible, even by different people • Repeatable to follow trends and identify change • Sensitive. In our RTACC extended management we are going to consider two additional ways to assess neurological function: • Glasgow Coma Scale • Pupil response. PUPIL RESPONSE The normal pupils (the black area in the centre of the eye) respond to light conditions. In bright light they shrink to 2-4mm but in low light or darkness they will fully dilate upto 8mm. This reaction is very rapid although it does slow in the elderly. Both pupils should be the same size, although some long standing conditions can alter the shape and size of one pupil (ask the patient if you see a difference). Interestingly when one pupil ‘reacts’ to changing light conditions, then the other eye does reflexly too, so they should always be the same size. Therefore when we test each eye, we assess the response to light twice, first looking at the one with the light shining in and then a second time looking at the other eye. If they are not equal, then there is some disruption of the light detection or the light response pathways in the head. Procedure for testing pupils: • If possible reduce the ambient light • Look and compare the pupils, they should be mid sized and equal • Record the size as ‘pin-point’, ‘mid-size’ or ‘dilated’ • If conscious then ask the casualty to look at a distant object • Using a pen torch or focussed low intensity light source move the light from the cheek and onto one the first eye for 3-4 seconds • Watch the pupil, which should constrict immediately • Move the light off the first eye, back onto the cheek (pupil should enlarge again) • Shine the first eye again, but this time watch the second eye which should react the same as the first eye did • Repeat this process shining the light into the second eye. This examination should take less than a minute to complete and can be repeated if conscious level changes or as part of your repeated assessment (e.g. every 15 mins). If the casualty is unconscious then we will need to gently lift the eyelids with your fingers, resting your hand on the forehead. Shine the light with your other hand. Pupils can be individually abnormal or both abnormal here are some common changes with some causes: • Both pupils dilated, and unresponsive - drugs, serious head injury, death • Both pupils dilated but react to light - fear, excitement • Both pupils pin-point small - opiod overdose (check breathing rate), very bright light • SIngle pupil enlarged and not responding - potential brain injury, Time-critical. Extended management of head injuries: Chapter 6: H - Head Trauma and Other Serious Injuries

96 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com GLASGOW COMA SCALE. This scale has now been in clinical use around the world for over 40 years and is based on simple tests of eye opening, speech and movement (motor) response. For each of these we look at various levels of stimulus and the associated response. (see figure 6.2). This is scored against a simple chart and the sum of the scores out of a potential total of 15. • A score of 15/15 is fully conscious • A score of 3/15 is totally unresponsive (it is not possible to score lower than 3/15). Figure 6.2 demonstrates each part of the scale and how the latest recommendations describe the process of: • Check • Observe • Stimulate • Rate. Once the test is completed and the score is obtained, it gives us a ‘snapshot’ indication of the current status of the patient. This can then be reassessed and compared accurately at any later stage to look for deterioration or improvement. A GCS less than 12/15 will typically require some close airway monitoring and if less than 8/15 they require urgent advanced airway management to protect their lungs from regurgitated stomach contents as the natural protective gag reflex will be impaired. Extended management of head injuries: Chapter 6: H - Head Trauma and Other Serious Injuries Pen Tourch Equal pinpoint pupils Normal mid sized equal pupils Equally enlarged pupils Unequal pupils