NOTE

All the medical procedures and drug administration mentioned in this text should be done only under a senior doctor’s consultancy.

 

 

·         Primary survey

·         When you take the call on the ambulance think if there is a positive injury mechanism.

·         Assign each EMT member role. For example on 3 EMT members, 1 can immobilize the head and handle the airway, 1 can be a team leader and 1 can bring the nessecary equipment.

·         Don’t forget the necessary precautions (gloves, mask etc).

·         You reach the scene: 

·         Safety comes first! (e.g. on fire call the fire brigade; on a gun fight call the police; on a car accident wait until the police patrol closes the road; if electric wires on the road call Power Company). Other dangers are body fluids, blood, passing vehicles, gas (petrol) on the road, guns, cold etc. Be careful not to slip on blood.

·         Assess the ambient temperature. Consider hypothermia in case the patient was too long on cold. Also a cold skin may not be because of shock, but because of low ambient temperature!

·         Assemble the necessary medical equipment.

·          Assess the situation. 

·         How many are the victims? TRIAGE!

·         What happened (e.g. car accident)? Kinematics (e.g. what injuries would you suspect on a car collision with frontal direction). Did the patients have their belt fasten? Is there a positive injury mechanism.

·         Patient’s age. Do you need any back up? How will you transfer the patients and where?

·         Primary survey.

·        ‘TREAT FIRST WHAT KILLS FIRST’!

·        ‘TREAT AS YOU GO’!  

·         A (airway and C – spine immobilization): First immobilize with your hands the patient’s head. Do it before you ask him/her ‘are you Ok’ (otherwise the patient will turn to look you!). Keep the manual immobilization until the patient is completely tied up on a long board. After the patient’s head manual immobilization, check ABCDs in the position you found the patient (e.g. supine, prone, sitting, semi prone etc).

 

Whichever position the patient is found (prone or supine) immobilize manually the head (before you ask ‘are you OK?’) and then check ABCDs. Next, if the patient is prone, align the patient’s limbs, log roll (don’t forget to look the back!), place on a long board and recheck ABCDs. The initial ABCD assessment before log rolling the patient has also legal consequences e.g. a patient may be found paralyzed on the initial assessment before we turn him/ her with log roll.

 

Be careful the cervical collar should not be too tight, but so much as to enable the patient open the mouth (e.g. to vomit).

 

·         Start from A. Check for airway’s patency. A patient that talks has a patent airway. A threatened airway may be indicated by snoring or blood thru the mouth or stridor. Open the airway with jaw thrust (or chin lift if not suspected cervical trauma), perform suction and place an oropharengeal airway (if no gag reflex).

·         B (breathing). Check RR (respiratory rate) and breathing effort and depth. Is breathing shallow and laboured? Check for equal bilateral chest expansion (if no, exclude e.g. flail chest). Ausculate the chest (bases, apexes & axillae) and check for equal breath sounds. Percuss the chest. Any tympany? Check oxygen saturation (SpO2).

·         Give oxygen! In case of apnoea or if RR (respiratory rate) is > 30 or < 10, or GCS is <_8, perform BMV (bag mask ventilation) or intubate.

·         C (Circulation): check radial pulse. If absent, check femoral pulse. If absent, check carotid pulse. Is pulse fast & thready? Also, is it regular or irregular?

 

Check the BP. Check for obvious external hemorrhage. Stop it by direct pressure and elevation (if not fracture), or with arterial root pressure points. Tourniquet should be avoided, but on uncontrolled bleeding on amputation, place it 10 cm above the stump and frequently release it. Avoid also blind vessel clamping. Pressure with single finger on gauze may stop bleeding! Don’t remove gauzes, but from a packet of gauzes on the wound remove the first ones and add more. 

 

Obtain vascular (IV/IO) access (2 wide IV lines – grey or orange). On hypovolemia give 500 ml NS (normal saline) or RL (Ringers - Lactated) and reassess (we may give e.g. 1 – 2 Lt fluids) and also consider early to transfuse blood (if not type available give Group O Rh negative). Fluids should be warm (39 degrees C). On hypovolaemic children give 20 ml/kg fluids. On no response, repeat 20 ml/kg and if shock still remains give 15 ml/kg packed red blood cells PRC to 10 ml/kg crystalloids or give 10 ml/kg whole warmed blood. On hypovolaemic newborns give10 ml/kg fluids over 5 – 10 min.

 

Connect on monitor if available. You can also take a 12 lead ECG if indicated (e.g. blunt heart trauma/ contusion).

 

Check capillary refill time (normally is < 2 sec on 5 sec finger’s pulp pressure, alternatively check the forehead between the eye brows, on black check the thenar eminence, on babies check the sternum), check skin’s color (pale? mottled? Cyanosis?) and temperature (are extremities pale, cold& clammy?). About skin temperature, exclude cold weather (especially if the patient was for a long time on cold that may cause cold skin). Also exclude hypothermia.

 

In case of a pelvis fracture, immobilize it with a sheet, or PAST (if available). Immobilize limb fracture. Give fluids (NS normal saline, or RL Ringer’s Lactated, preferably warmed on 39 degrees C) in the ambulance. Keep the SBP (systolic BP) 80 –  90 mmHg with fluids. Don’t use D5W (5% dextrose).

·         D (Disability): GCS (Glasgow Comma Scale), pupils (size and reaction to light) and abnormal postures (stereotypical flexion or extension). Intubate if GCS <_8. Use paralytic drugs if GCS > 3. In case you haven’t got light a use the laryngoscope’s light!

·         E (Exposure/ Environment): Εxpose the patient (remove clothes) and check the skin for wounds, rash etc. Log Roll the patient and check the back. Next, prevent hypothermia (which will complicate coagulation) with blankets. E, in hospital,  is also to call Expert!

·         Reassess the patient every 5 min and when the patient deteriorates.

·         If the patient is critical ill, immobilize on a long board (during log roll don’t forget to see the back e.g. for injury) and transfer immediately to the nearest most appropriate hospital. Reassess frequently the patient.

·         If the patient isn’t critical ill, perform secondary survey (examine from head to toes), deal with isolated not threatening for life injuries and fractures. Reassess. Then transfer.

 

Also, take history: AMPLE (Allergy, Medications, Past medical History, Last meal, Events/ Environment).

 

Spinal immobilization may be omitted on a penetrating trauma without neurological signs. However, if unsure, immobilize!

·        Contact with the receiving hospital! Appraise them.

·        Don’t forget a thorough documentation of the event on the patient’s medical files.

 

 

 

 

 

·        On a blunt trauma (e.g. fall from stairs) in case the LOC (level of consciousness) is decreased and GCS is < 15, immobilize the patient on a long board. If LOC is not altered, but the patient has spinal pain or tenderness or exhibits a neurological deficit or complaint then also immobilize. If not, but there is a positive injury mechanism, misleading/ trap injuries or difficulty on communication with the patient or the patient is under alcohol or illicit drugs influence or there is a wound that distracts you, then immobilize the patient. If not, don’t immobilize. If unsure, immobilize! 

·         Laryngeal mask. Initially we inflate the cuff to check if it inflates. We hold it like a pencil. We put normal saline on the tube. We enter it in the patient’s mouth until we feel it stops. We inflate he cuff with tube size x 10 – 10 e.g. fore size 4 we inflate with 4 x 10 – 10 = 30ml. Then, we ausculate the axillae and the stomach and check the tube for water vapor. Next, we secure the tube with a tape. For men we use size 4 – 5 (usually 5) and for women (and small men) size 3 – 4 (usually 4).

·         We removed dust with a brush and not by washing.

·         On electrocussion we perform heart monitoring (and also check potassium levels).

·         Patients with hypothermia and temperature < 32 degrees C will not have rigor. If T (temperature) is < 28 degrees C there is possibility for VF (ventricular fibrillation). VF may also occur by non gentle manipulations on the patient! However, rapid reheat on a stable hypothermic is also dangerous.

·         When you want to open the airway (e.g. with jaw thrust) you can kneel and stabilize the patient’s head between your knees!

·         On jaw thrust we place the thumbs on the patient’s zygomatics or below the patient’s mouth. We elevate the jaw to an up and front direction.

·         We place the oropharengeal airway by 180 degrees rotation or with a tongue depressor, without rotation. On children we use the tongue depressor without rotation.

·         During BMV (bag mask ventilation) with your lower fingers you can simultaneously perform jaw thrust (in case you haven’t placed an oropharengeal airway). During BMV it is essential to keep the mask tight. Circle the mask with your thumb and index forming the letter ‘C’. The rest fingers (middle, ring and little finger) stabilize the jaw and have the shape of the ‘reversed letter E’.

·         During jaw thrust or chin lift, another rescuer immobilizes the head!

·         On chin lift the jaw is moved to a frontal and (little bit) to a down direction.

·         The oropharengeal airway’s proper length is estimated by fitting to the distance between the mouth’s angle (incisors) and the angle of the mandible.

·         The nasopharyngeal airway’s proper length is estimated by fitting to the distance between the tip of the nose and the tragus of the ear. Alternatively, the proper size fits to the patient’s little finger. Contraindicated on cribiform or nasal or facial injury, or if you suspect basal skull injury and also on apnea. Don’t forget to put gel! Enter it with rotating movements.

·         Prolonged suction will end to hypoxia!

·         Remove a dislocated artificial denture, but keep a not dislocated because it will help keeping the airway during BMV (bag mask ventilation).

·         Orotracheal intubation. Use paralytics if GCS <3. Initially, assemble the equipment (ET endotracheal tube, suction, laryngoscope, capnographer – CO2 detector capnographer or esophageal detector, gel, syringe and Magill’s forceps). Check that the cuff inflates properly and check also the light of the laryngoscope. Pro – oxygenate with 100% oxygen for 2 – 3min. Remove the C (cervical) – spine colar and ask another rescuer to immobilize the head or you can kneel and immobilize the head with your knees and simultaneously intubate or sit and have the patient’s head between your legs!

 

Grab the laryngoscope with the left hand and enter the ET (endotracheal) tube with the right hand. Enter the laryngoscope in the RIGHT angle of the mouth, follow the tongue and elevate it without touching the epiglottis (otherwise we will have vagotony with bradycardia). Visualize the vocal cords and then enter the ET tube with your right hand. The insertion depth is about 24 cm on men and 22 cm on women.

 

Inflate the cuff with 5 – 8ml air. The intubation lasts max 30 sec or the time you hold your breath! Ausculate the axillae (for equal bilateral breath sounds) and the stomach (for bubbles) and check ET tube for water vapors. Secure the ET e.g. with a tape. Place a capnographer (CO2 detector) (or oesophagal CO2 detector device, however the most safe method to ascertain the right placement of the tube is the CXR chest X’ Ray). Use curved blade (size 3 or 4).

 

On children < 8 years old don’t use ET (endotracheal tube) with cuff, but an uncuffed ET. Straight blade is used on infants (< 1 years old) and neonates. On children premedicate with atropine (to prevent with bradycardia) and, in case of head trauma, with lidocaine. The size of ET tube on adults is 8 – 9 mmID on men and 7 – 8 mmID on women. In case you have another rescuer, you can perform Sellick’s maneuver during intubation, in order to prevent aspiration. However, if aspiration occurs, release the Sellick maneuver; otherwise you may cause oesophagal perforation. In that case perform suction. 

 

In case the patient is on a sitting position (e.g. in the car) and there is not a need for emergency evacuation, you can perform intubation, however another rescuer needs to immobilize manually the head and also during intubation you must hold the ET (endotracheal) tube and laryngoscope with the opposite hands i.e. with your right hand hold the laryngoscope and with the left the ET.

·         Percutaneous (endo) tracheal intubation PTV/ needle cricothyroidotomy. A rescuer immobilizes the head. With your 1 hand immobilize the larynx and with the other hand you enter on the cricoids cartilage a wide (14 G) IV catheter connected with a syringe which contains normal saline.

 

You continuously withdraw the planger of the syringe and when you aspirate air you are in the trachea. Then you enter 1cm inside. You remove the syringe and then you remove the needle, and the plastic part of the catheter remains in. You connect with an oxygen tube and then connect the tube with a 3 way. Connect the 3 way via an oxygen tube to an oxygen supply. Periodically you open and close the 3 way in order the inspiration to expiration ratio to be 1 :  4.

 

In case you do not wave a 3 way, you can make a hole on the oxygen tube and periodically obstruct it with your thumb to the above ratio. The PTV is effective only for 45 min, so seek soon a permanent airway e.g. tracheotomy.

·         Before Log Roll perform ABCDs. On a supine patient that needs Log Roll the first thing is 1 rescuer to immobilize the head and another rescuer to align the patient’s limbs. A 3^rd rescuer brings the long board opposite from the side that the patient’s head is turned (if it looks laterally). The rescuer that immobilizes the head gives the order (‘1,2 ,3’) for the log – roll. The rescuer that holds the long board initially supports it with his/her knees and during the log roll slowly he/she removes them. When the patient is on a lateral position a rescuer looks quickly the back!

 

The 2 rescuers that hold the patient with a specific way:  the 1 rescuer has the upper hand holding the patient’s arm and the lower hand holding the patient’s pelvis. The other rescuer has the upper hand holding the patient’s forearm (crossed to the other rescuer’s arm) and the other hand holding the patient’s tibia (during log roll the rescuer holds the tip of both sides of the patient’s trousers or has the patients legs tied with a tape in order both legs to move as 1 during log roll).

 

When the patient is supine on the long board, in case the patient is not on a proper place, but has slipped down, we can drag the patient up. This is performed by 2 rescuers. A 3^rd immobilizes the head. The 1^st rescuer holds the patient’s axillae and the 2^nd holds the patient’s pelvis. The 2 rescuers are below the patient. With an order, the 2 rescuers drag the patient up, in order to put the patient on  a proper place on the long board.

·         We tie the patient on the long board with a specific way. One belt goes below the knees, 1 above the knees, 1 on the pelvis, 2 belts cross the chest. Also we pass a tape thru the cervical collar’s ‘jaw’ (avoid touching with the tape the patient’s jaw). We tie the belts on their other side in the holes of the long board’s handles. We also place a cervical collar.

 

First we place the chest belt, next the pelvis, next we immobilize the cervix (collar, sides, and tape on the cervical collar’s ‘jaw’) and last we place the leg belt. We tie the belts not very hard, but in that way that our finger passes below. The patient’s upper extremities are outside the belts (in order not to obstruct the IV lines). They may be tied (not hard) with gauze and we may place IV lines. Besides the patient’s head we prefer shoft material (e.g. with gauze or towels) and not sand bags or normal saline fluid containers.

 

We also put sheet between the patient’s legs and on the outer aspect of both legs. We also may use a towel below the patient’s head in order to keep the head on line. Finally, we stop the cervical immobilization only when the pelvis and the thorax have immobilized.

·         If the patient is prone, we initially immobilize the head (before we talk to the patient) and next we take the ABCDs. To log roll the patient, we place the long board and turn the patient opposite to the side he/she looks (has the head turned). The long board is placed just in front of the 2 rescuer’s (that hold the patient and are kneeled) bodies and they stabilize it with their knees. During log roll, they remove slowly their knees.

·         The cervical collar’s size is estimated by the distance (with our hand) between the patient’s jaw angle and the upper limit of the trapezoid (trapezius) muscle.

·         In case the patient is on an erect position (stands up), 3 rescues immobilize the patient on a long board. The 1^st rescuer immobilizes the head (before anyone talks to the patient) and another rescuer approaches with the long board vertically to the floor and places it on the patient’s body and simultaneously takes the head’s immobilization. Then the other 2 rescuers stand on each side of the patient (i.e. the one is on the left and the other on the right) and with their one hand hold the long board (from its handle) above the patients shoulder and with the other hand hold the long board by passing their hand below the patient’s axilla. The 3^rd rescuer immobilizes the patient’s head.

 

In case we have 2 rescuers, they stay on the patient’s side and immobilize with their 1 hand the patient’s head (by holding it with their palms on the side of the head) and with their other hand hold the long board (from one of its handles) by passing their hand below the patient’s axilla.

·         On a child that needs immobilization on a long board we place a folded sheet below its back in order to come below its back and keep its spinal cord to a neutral aligned position, because children (and especially babies) have larger head.

·         In case the patient’s head is on an abnormal position we try to align it. However, if the patient has pain or muscle spasm or exhibits neurological signs, such as numbness, we leave the head on its previous position that did not appear neurological signs and we immobilize it e.g. with a sheet or a towel.

·         On a baby that we found on a baby’s seat inside a crashed car, we initially immobilize its head manually (we approach the baby from the font and not the back, in order not to frighten it). We don’t put collar on babies, but a towel around its head (without suffocating it).

·         We hold the baby’s seat and remove it out from the car and place it besides the long board (in which we have placed a folded towel in order to come below the baby’s back an keep its spine at neutral aligned position, because babies have big head). Then 3 rescuers transfer the baby from its seat to the long board, holding the 1^st one the baby from its axillae, the 2^nd one from its pelvis and the 3^rd one immobilizing its head.

·         A patient is found on a sitting position, touching a wall with his/her back. Initially a rescuer (before he/she talks to the patient) immobilizes manually the patient’s head. Another rescuer assesses ABCDs. Next, 2 rescuers stabilize the patient holding with their one hand the patient’s chest and with the other the patients back, and carefully they move the patient to the long board. The head immobilization is kept until the patient is completely tied on the long board.

·         In case the patient has a fracture at his/her arm, we palpate the radial pulse and ask if the patient has numbness/ paresthesia at his fractured extremity. We also check the capillary refill time on the finger of the fractured extremity. When the patient is immobilized and tied on the long board, we perform traction of the extremity and immobilization on a splinter. We recheck pulse and check for sensory deficits (such as numbness) and capillary refill time. In case after traction we lose pulse and we have sensory deficits (e.g. numbness or paresthesia), we return the extremity to the previous position that pulse and sensation was OK.

·         Helmet removal: the 1^st rescuer comes above the patients head, holds with both hands the helmet at its side (with his/her fingers holding the lower part of the helmet) and brings it on a neutral position. Then, the 2^nd rescuer unties the helmet’s strap (or cuts it) and opens the helmet’s screen. Then the 1^st rescuer lifts the helmet until he/she sees the patient’s nose. Then he/she lifts carefully the helmet in order to release the nose and with lateral movements he/she releases the whole helmet. The 2^nd rescuer, in the above procedure of removal, with his/her 1 hand holds and immobilizes the patient’s jaw and with the other holds the patient’s cervix and occipit.

·         On a patient that is trapped inside a car after a car accident we perform emergency evacuation in case the patient is critical ill (according to ABCDs, e.g. on shock), or there is danger (e.g. from a fire), or other patients in more serious medical condition need to be reached first and the patient is an obstacle on reaching them.

·         On a car accident, in case a patient needs emergency evacuation, we don’t put oxygen, neither we administer fluids. However, we may place oropharengeal airway and cervical collar. 

·         The golden period from trauma scene to the OR (operation room) is 1 h. That means that the ambulance has to stay on the scene maximum 10 min.

·         Ideally an ambulance arrives on a trauma scene in 10 min, stays there for max 10min, and transfers the patient in hospital in 10 min. There the patient is resuscitated, stabilized and in max 30 min (or sooner) and reaches the OR door in 1 hour from the trauma.

·         A break of the car’s screen like a star indicates head/cervical/spinal injury.

·         A bended steering wheel indicates heart/lungs/ big vessels and abdominal injuries. 

·         A frontal car collision with an up and front direction of the driver indicates head, spinal, chest, pelvis and abdomen injury. The down and frontal direction of the driver indicates pelvis, hip (dislocation) and lower limbs fractures. 

·         On a posterior car collision suspect cervical injury (from a low head pillow/ supporter or a second collision to a stable object).

·         A lateral car collision indicates neck, shoulder etc. injury.

·         A motorbike collision to a car may cause bilateral femoral fractures, or knocking down on the front part of the car or leg trapping on the car’s side.

·         On knee/lower extremity injuries exclude poplietal artery rupture. 

·         A pedestrian may be knocked down by a car. On an adult the injuries are usually laterally (because the adults react and try to avoid the car). On a child the collision is frontal with pelvis, abdomen and chest injuries and also the kid may be fall to the road and run over by the same or another car.

·         On a penetrating trauma with knife that is left intact into the body, stabilize the knife with elastic tapes in order not to be moved during transferring to hospital.

·         Hypothermia complicates coagulation. Prevent it! Therapeutic hypothermia is used only after arrest on patients with coma, however is not used on trauma.

·         Children may have severe lung contusion without rib fractures. So, rib fractures on children indicate severe injuries (e.g. lung contusion).

·         On the elderly, the injury may be a consequence of an acute medical condition e.g. an old person may suffer from a MI (heart attack) and cause a car accident.

·         Flail chest means > 2 ribs fracture with have as a consequence opposite movement of chest on breathing.

·         An arrhythmia may pre – existed or may be caused by heart contusion or be ought to an ACS (acute coronary syndrome). The last 2 may coexist and also may cause both increased Troponins and ECG ischemic changes.

·         Cover a bowel or other splachnic organ with warm (normal saline on 39 degrees C) wet gauzes.

·         A pregnant with abruption placenta may have blood per vaginum.

·         On head trauma exclude and treat hyper/ hypoglycemia, increased ICP (intracranial pressure), hypotension and hypo/ hypercapnia.

·         Basal skull fracture may be exhibited with leakage of CSF thru nose or ear, blood from the ear and later (e.g. after a few hours) raccoon eyes and Battle sign. CSF leakage can be suspected if the leaking fluid from the nose or ear makes a halo on a shine paper.

·         Increased ICP (intracranial pressure) may manifest with decreasing GCS score >_2 degrees, non reactive pupils, pupil dilation (anisokoria), hemiplegia, hemiparesis and Cushing triad (increased BP, decreased HR and irregular breathing). It may result to herniation.

·         Treatment of increased ICP and impending herniation is with bed elevation (max 30 degrees, don’t do it in hypotension), mannitol and perhaps Lasix (don’t give any of them on hypotension, but treat first hypotension e.g. with fluids and perhaps with operation), sedation, paralysis with barbirutates (not on hypotension), and controlled mild hyperventilation (Keep Pa CO2 35 – 45mmHg). On head trauma on RSI use lidocaine on premedication and as anesthetic use etomidate (if not hypotension). 

·         On trauma and especially on fractures and burns remove jewerely and rings from patient’s hand.

·         On burns place gauzes. However, wet gauzes may cause hypothermia on burns> 10% BSA.

·         Burns usually don’t cause shock early. Exclude first hypovolemia from internal or external injuries.

·         On suspected inhalation burns intubate early.

·         For estimating BSA% on burns remember the rule of 9%. On adults the head is 9%, the upper extremity 9%, the lower extremity 18%, the frontal trunk (chest, abdomen) is 18%, the posterior trunk (back) is 18% and the genitals are 1%. On children the head is 18% and the lower extremity is 13,5%. Also the patients palm is 1%. 

·         Don’t forget tetanus immunization on all trauma patients, burns, frostbites, lacerations, animal or human bites, stings and electrocution.

 

APPENDIX: SIGNS OF HYPOVOLAEMIC SHOCK

Signs of hypovolaemic shock (haemorrhage - external or internal blood loss; or severe dehydration e.g. on severe diarrhea or vomiting) include: tachycardia (if not on β' blockers or pacemaker!), fast thready pulse, narrowed pulse pressure (Systolic BP - diastolic BP), weak peripheral pulses, tachypnea, decreased level of concioussness (LOC), decreased urine output (adults < 0.5 ml/kg/h, children 1ml/kg/h, infants 2 ml/kg/h), decreased capillary refill time (>2 sec), hypotension (late, with > 30% volume loss on adults and > 40% on children), cool pale skin, diaphoresis (not on dehydration); also decreased skin turgor (unreliable on the elderly) and dry mucus membranes (e.g. dry tongue) on dehydration.

NOTE

Some information in this text is empirical and its reliability can't be ascertained. It is suggested to search official medical articles, books and guidelines in order to ascertain the medical information of this text.

All the medical procedures and drug administration mentioned in this text should be done only under a senior doctor's consultancy.

 

BIBLIOGRAPHY FOR EMERGENCY & ACUTE MEDICINE

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7) Thomas J., Monaghan T., Oxford Handbook of Clinical Examination and Practical Skills, Oxford Medical Publications, 2008.

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Physicians, 4th edition (revised), 2006.

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16) ACLS (Advanced Cardiac Life Support), American College of Emergency Physicians, Study Guide, 2^nd edition, Jones and Bartlett Publishers, 2007.