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Related Subjects: |Initial Trauma Assessment and Management |Thoracic Trauma Assessment and Management |Flail Chest Rib fractures |Resuscitative Thoracotomy |Haemorrhage control |Traumatic Head/Brain Injury |Traumatic Cardiac Arrest |Abdominal trauma |Tranexamic Acid |Silver Trauma |Cauda Equina

Introduction

• Pre-hospital care is a rapidly developing and complex speciality.
• Safety is of paramount concern and we include discussion and detail on this topic.

Arrival at the scene

• Position your vehicle to protect the scene from other traffic and to provide a visual warning of the presence of an incident (with the use of appropriate beacons/lights where available).
• Ensure a safe exit from your vehicle with due regard to other traffic
• Safety / hazards: Personal safety, Scene safety – identify any obvious hazards, Patient’s safety
• Personal safety and protection from hazards at the scene is of paramount importance and takes precedence over other concerns.
• The scene should not be approached until you, as the rescuer, are safe from actual and potential hazards. Medical personnel who attend these types of incidents frequently will have their own personal kit and equipment.
• Personal protective equipment should include:
  • Fire retardant, high visibility overalls
  • Boots (with reinforced toecaps)
  • Gloves, Helmet and Eye protection
• Having ensured your own personal safety, thought should be given to the safety of the scene (for the rescuer) and that of the patient(s) involved.
• Liaison with the fire service may be required to render the scene safe for the ongoing rescue; until this is achieved there may be limited or no patient contact.
• ‘Reading the wreckage’ and identifying the mechanism of the incident can help to predict the likely pattern of injury sustained by the patient(s). Treatment should be based on expected injury until a particular injury can be confidently excluded.
• Early communication means that resources are more likely to arrive on scene rapidly and to facilitate a rapid rescue. It is important to liaise with the emergency services on scene.
• Triage: Where you encounter multiple casualties, it is important to attempt to prioritise the order in which you plan to assess and treat the various patients. The process in referred to as ‘triage’
• Access to patient usually straightforward, but in a small proportion of cases may be severely limited. Early discussion with the fire service is important to establish a plan for rapid access and subsequent extrication

Primary survey

• Massive haemorrhage control M
• Airway with cervical spine control A
• Respiration (Breathing) R
• Circulation C
• Head injury (Disability) H
• M/A/R/C/H is intended as both an assessment and intervention framework – problems are managed as they are identified.
• Massive Haemorrhage Control: If there is no massive haemorrhage then proceed with A/R/C/H or A/B/C/D as appropriate. If massive haemorrhage exists then apply the following principles
  • Direct pressure
  • Elevation
  • Indirect pressure
  • Wound packing
  • Tourniquet
  • Haemostatic agents
• Major haemorrhage caused by trauma may cause death very rapidly and control of haemorrhage should take precedence over other interventions.
• This is particularly relevant to penetrating injuries, such as gunshot wounds to the extremities. The above steps should be followed in order. If they fail, a tourniquet can be applied proximal to the site of bleeding and tightened to control blood flow. This can be a life-saving intervention.
• Massive haemorrhage from the chest and/or abdomen requires rapid transfer to hospital.

Airway with cervical spine control

• Manual immobilisation of the spine | Jaw thrust | Simple adjuncts / supraglottic adjuncts |Intubation |Surgical airway
• Basic airway manoeuvres such as a jaw thrust may be life-saving. Avoid a chin lift in view of the high risk of cervical spine injury. The cervical spine should be immobilised as soon as access is possible. This should be the sole responsibility of a selected individual. It is done either manually, in the initial phase, and then using a cervical collar and immobilisation using sandbags and tape.
• Simple airway manoeuvres and adjuncts (oral and nasal airways) are often successful in managing the airway. Supraglottic airways (laryngeal mask airway and similar devices) require the patient’s conscious level to be very depressed for successful insertion. They are useful for those without the appropriate skills for endotracheal intubation.
• Patients who can be intubated without drugs have a very poor outcome and it is beyond the scope of this article to discuss roadside drug-assisted intubation.
• The surgical airway (trans-cricoid approach) is another useful and life-saving procedure when the airway cannot be maintained by other means. With training it is (relatively) easy to perform with a scalpel, forceps and a cuffed size 6 endotracheal tube. There are many kits available for this purpose and most employ the Seldinger approach (i.e introduction of the cricothyroidotomy tube over a guidewire). The Melker Cricothyrotomy Set by Cook Medical is an example of such a device (www.cookmedical.com/cc/dataSheet.do?id=4016).

Breathing

• Oxygen | Control of ventilation |Seal open / sucking chest wounds |Chest decompression
• High flow oxygen should be provided at the earliest opportunity, provided it is safe to do so (wait for the fire service to extinguish any fires). Ventilation can be assisted with a bag-valvemask to provide adequate oxygenation and control of carbon dioxide. Open chest wounds
• You assess the patient: Airway No response, noisy breathing.
• Respiration Respiratory rate 22/minute, decreased air entry on the right, normal percussion both sides, trachea central, SaO2 90% on air.

Circulation

• Intravenous and intraosseous access
• Limited fluid resuscitation
• Access to urgent surgery
• Venous access is often difficult, but transfer should not be delayed by attempts to gain intravenous access.
• Intraosseous access may be appropriate for both paediatric and adult patients where intravenous access is difficult. Rapid transfer for surgery is paramount for those patients with uncontrollable bleeding, particularly bleeding into a body cavity.
• The choice of fluid is a matter of ongoing debate. Isotonic sodium chloride in 250ml aliquots titrated to the presence (or absence) of a radial pulse is the preferred option.
• In patients with a penetrating chest injury, the presence a carotid pulse is a suitable endpoint. In patients with head injuries higher blood pressures may be targeted to maintain cerebral perfusion. Frequent reassessment is crucial.

Head Injury

• Spinal care
• Reversal of hypoxia / hypotension
• Control of agitation
• Prevention of aspiration
• Safe transport
• Access to urgent surgery
• All trauma patients should be assumed to have a spinal injury and treated as such, until this can be confidently excluded.
• There are rare exceptions, when a patient who would otherwise die if spinal care was commenced or continued. Full spinal immobilisation should be employed including a collar, spinal board and blocks. Tape should be used to secure the head to the blocks. This should be done as soon as physically possible and prior to moving the patient to a site of definitive care.
• Care of the head injured, agitated or unresponsive patient is challenging. Adherence to simple principles can improve outcome. Rapid reversal of hypoxia, correction of hypotension, airway protection and rapid transport to a neurosurgical centre are paramount.