extended like a trombone. 4. The casualty \200\231s foot is strapped to the foot plate. 5. The pump is used to increa se the pressure within the closed \200\230U \200\231 of the splint which extends, applying traction to the limb. Enough pressure is applied to make the casualty comfortable (approxi mately 10% of body weight). 6. The supports are positioned under the leg at mid thigh and mid calf and the knee support is secured. IMMOBILIZATION AND EXTRICATION1 691 7. The splint stand is lowered and the locking nuts are secured to keep the splint to length. 8. The pressure is released by depressing the air release valve. Trac 3 splint The Trac3 and hare splints (see Fig. 13.2a) are effectively the same and shar e a method of application. Method of application 1. The splint is adjusted for length against the uninjured leg. The s traps are opened and correctly positioned at intervals down the leg. The correct ankle hitc h is selected. 2. The hitch is placed under the ankle , the straps are folded across the front of the ankl e, and the rings are brought together under the foot. 3. Manual traction is commenced with one hand and the leg supported whilst the splint is put in place. (An effective method is t o log roll the patient away from the injured leg, place the splint, and roll the patient ba ck onto the splint). The top padded ring must fit under the ischial tuberosity. 4. The top strap is done up, avoiding the external genitalia. 5. The traction hook is put t hrough the rings and traction taken up (whilst maintaining manual traction). 6. The foot stand is raised and the Velcro straps are positioned and tightened. The Sager splint (Fig. 13.2c) The Sager splint is light and can be used to splint one or bo th femurs. It does not extend significantly beyond the end of the patient \200\231s foot. T he Sager splint is the authors \200\231 splint of choice for pre-hospital use. Method of application 1. The cushioned \200\230seat \200\231 of the splint is placed betwe en the patient \200\231s legs, against the perineum and symphysis pubis. Care should be tak en not to trap the external genitalia. The top strap is fastened around the thigh. 2. The splint is extended until the ankle hitch lies at the normal heel position. 3. The ankle harness is applied behind the heel and wrapped around the malleoli and the cushions adjusted to fit the leg. 4. Traction is applied until the patient is comfortable (approximately 10% of body weight). 5. The thigh strap is tightened and lower straps secured. 6. An identical method is used if both legs are being splinted. CHAPTER 13 Patient rescue and transportation 692 (a) (b) (c) Fig. 13.2 Types of traction splint: (a). Donway; (b). Trac 3; (c). Sager. Figs. 13.2a,b rep rinted with permission from Greaves I and Porter K (1997). Pre-hospital medicine \200\224th e principles and practice of immediate care. Edward Arnold. Fig. 13.2c reprinted with permi ssion from Greaves I et al. (2005). Emergency care: a textbook for paramedics, 2nd edn. W.B . Saunders Co. Ltd. IMMOBILIZATION AND EXTRICATION1 693 Contraindications to traction splintage - Injuries at the ankle - Dislocation of the knee - Fractures around the knee (apply without traction) - Dislocation of the hip - Fracture of the pelvis. Pneumatic antishock garment (PASG) Also known as the military antishock trouser (MAST) suit , this is an inflatable garment that covers the legs and abdomen and can be inflated to a p ressure of 100mmHg. It can be used to: - Splint fractures of the pelvis and lower limbs - F acilitate inter-hospital transfer of patients with intra-abdominal bleeding Provide some degree of tamponade for patients with ruptured abdominal aortic aneurysms. It is no longer recommended for use in the treatment of hypovolaemic shock because of the c atastrophic deterioration that can occur when the splint is deflated. If it is used to faci litate remote transfer, adequate fluid replacement must proceed at the same time. Specific contraindications for its use include: - Cardiac failure - Pulmonary oedema - Significant c hest injuries - Diaphragmatic rupture - Advanced pregnancy. The PASG is difficult and time consuming to apply and its application will delay transfer to hospital. It is therefore con traindicated in all but the most prolonged transfers. Methods of extrication Extrication devices A number of extrication devices are in use in th e UK, all of which are fairly similar in design and use. They include the: - Kendrick extri cation device (KED) - Russell extrication device (RED) - ED 2000 - Telford extrication devi ce (TED). These have been introduced to replace the short spinal board. They provide support and stab ilization particularly to the upper spine. Whilst maintaining inline manual stabilization a nd with the patient wearing a cervical collar, the splint is inserted behind the patient by moving the whole patient slightly forward in the sitting position or by retracting the sea t. The patient is secured to the device by a series of straps around the trunk and by strap s that go around the legs to secure the splint in the groins. Finally, the cervical spine i s immobilized using the supporting neck side pieces of the splint. These are secured in pla ce by two velcro straps, one across the forehead, the other across the cervical collar. The splint is provided with lifting handles to facilitate easy and safe movement. CHAPTER 13 Patient rescue and transportation 694 Scoop stretcher The scoop stretcher provides a means of lifting a patient from a horizon- t al position onto a trolley cot. It can be split in half longitudinally and is applied from both sides of the patient. It has a supporting head cushion and the bottom part of each com ponent must be extended to fit the patient before application. The two parts of the stretch er are placed one on each side of the patient (ensuring that the narrower foot end is at th e patient \200\231s feet), then the two components are locked first at the top end and then at the feet. It may be necessary to lift the pelvis slightly to facili- tate distal lockin g of the splint and to ensure that the buttocks are not pinched between the two sides of th e stretcher. The patient can be moved in the position they are found, an airway protected p osition, or supine position. The scoop stretcher can be used as a means of transpor- tation for short journey times or as a means of lifting a patient onto a vacuum mattress or troll ey cot. Spinal boards Spinal boards are used to facilitate extrication. They provide a stable secur e base to which the patient is strapped for full spinal immobilization. Although not design ed as a transportation device, in UK ambulance practice, spinal boards are commonly used on top of the trolley cot to transfer the patient to hospital. There is a risk of the patient developing pressure sores on the board, especially in those patients with neurological inj uries. If the transportation time is likely to be more than 20 minutes, consideration shoul d be given to scooping the patient off the spinal board and onto a vacuum mattress. In hospital, the patient should be removed from the board at the earliest opportunity. In p atients with significant trauma, this is normally undertaken at the completion of the prima ry survey. In non-urgent cases, for example where the board is used as a precautionary meas ure and where there will be delay in the A&E until the patient is seen by a member of the m edical staff, the patient should be log rolled off the board after the first set of stable clinical observations. The patient is then secured on the hospital trolley using sandbags a nd tape. Extrication using a long spine board In road traffic collisions, whilst inline stabilizatio n is maintained and the whole spine supported, the patient can be carefully maneuvered onto the board in order to carry out a controlled extrication. The most common approach is to insert the spinal board horizontally through the open door o f the vehicle, placing the end of the board on the seat adjacent to the patient \200\231s t high. The patient can then be turned and gently laid backwards onto the board which can the n be removed. If the roof has been removed, the board can be inserted behind the patient wh o can then be laid back against it and moved along the board in a controlled fashion. If the patient is lying supine, they can be loaded onto the spinal board using a supervised log rolling technique. Alternatively, a scoop stretcher can be used to lift the patient on to the spinal board. All rescuers should be familiar with the technique of log rolling and the use of the scoop stretcher, spinal board, and extrication techniques. IMMOBILIZATION AND EXTRICATION1 695 Vacuum splints/mattresses Vacuum splints/mattresses provide rigid support and can conform t o a deformed limb or to the body itself. The splints or mattress consist of a strong, tough , plastic material skin which contains polystyrene beads. Removal of the air from between t he beads in the skin makes the splint rigid. The whole body vacuum mattress is a good immob ilization device but is unsuitable for lifting. Vacuum immobilization devices can be used for: Limb trauma (upper and lower) - Spinal injuries - Inter-hospital transfer of patients with multiple injuries. Stretchers The scoop stretcher (described above) is most commonly used and is standard equi pment on UK ambulances. Other forms of stretcher for specific rescue situations are: The Neil Robertson stretcher - The Paraguard stretcher. The Neil Robertson stretcher is a canvas stretcher with wooden slats sewn into the canvas and straps to secure the splint in place. The stretcher is then reinforced by poles which have carrying handles. The Paraguar d stretcher is a similar device which is capable of bending around obstacles to facilitat e extrication. CHAPTER 13 Patient rescue and transportation 696 Transportation in pre-hospital care Pre-hospital care practitioners are not only responsibl e for the safe pack- aging and transportation of patients, but must ensure their own arriva l at an incident scene in a safe and timely manner. Medical transportation The immediate care doctor most commonly uses their own private vehic le adapted to the response role: - A green rotating beacon can be used when proceeding to an emergency/accident (Road Traffic Act 1976). The doctor must be familiar with the legal r equirements of this Act. In some areas, doctors acting as agents of the ambulance service have special arrangements with the police to use blue flashing lights and audible devices. Appropriate car markings approved by the BASICS Equipment Committee are designed for ease of identification of the doctor and for safety. All doctors who take responsibility for providing a rapid response should undergo specific driver trai ning through the police or ambulance services. BASICS have their own specific driving cours es and advanced driving techniques form part of the courses run by the Royal Society for th e Prevention of Accidents (RoSPA) Patient transfer vehicles Historically, ambulance designs have paralleled those of light ch assis vehicles with a coach built body. Gissane and Rothwell from the Birming- ham Accident Hospital (UK) were the first to produce a prototype design with the capability to lower th e floor of the ambulance to the ground. A road ambulance may not be the ideal method of transportation, particu- larly for time-cri tical injuries or illnesses with a long traveling time to hospital. Access may be difficult in rural and remote areas. The use, therefore, of off-road four-wheel drive vehicles or he licopters may be more appropriate. Mode of transportation The pre-hospital care practitioner should be familiar with: The limitations of the vehicle being used - The effects of the mode of transportation on th e patient - The effects of the mode of transportation on the medical equipment being used during transit The effect of the mode of transportation in limiting possible medical interventions The importance of correct patient packaging, handling, and loading. transportation IN PRE-HOSPITAL CARE1 697 Limitations of the vehicle UK frontline ambulances conventionally have a single trolley cot which can be secured to the side or centrally, the latter giving increased patient access. Further developments have resulted in the addition of extra equipment and redesign of the cabin layout. The ergonomics of ambulances are not ideal. Deceleration forces in braking potentially incr ease intracranial pressure. Ideally, therefore, the patient should be loaded and transporte d feet first, which is not possible in rear loading vehicles. Vertical forces in passing ov er road humps and bumps are also a problem and the patient would be best positioned over th e area of the wheel base. Most vehicles are designed so that the suspension functions best at 30 miles an hour and there is, therefore, no justification for slow transfer (for exampl e, of spinal injury patients). Helicopters have their own limitations: Limited to flying in daylight hours (civilian helicopters) - Unable to fly during adverse w eather conditions - Constrained by strict safety regulations governed by the helicopter operator and the Civil Aviation Authority Unsuitable for the transfer of certain groups of patients (for example, heavily pregnant females and psychiatrically unstable patients) - Prone to mechanical probl ems and require regular servicing. Effects of the mode of transportation on the patient The problems of deceleration and patie nt positioning have been previously discussed in relation to land vehicles. Some patients d evelop motion sickness in transit or become claustrophobic, particularly in smaller helicop ters. Fear of flying (or crashing!) may also prevent aeromedical evacuation of some casualt ies. A prophylactic antiemetic should be given to those patients who admit to travel sickne ss. There are potential problems flying patients in non-pressurized aircraft. However, all heli copters in the UK fly at an altitude which will not mark- edly affect pressure either withi n air-filled equipment (such as the cuff of an endotracheal tube) or potential sites of inj ury (pneumothoraces, hollow abdominal viscera). There is no need, therefore, to fill ET tub e cuffs with water, although, where relevant, the placement of thora- costomy tubes before take off should be considered since this interven- tion is likely to be difficult or imposs ible in flight. Effects of the mode of transportation on the medical equipment being used during transporta tion Equipment carried on frontline ambulances, including helicopters, is approved by the a ppropriate authorities for safe patient use during trans- port. Motion and vibration may ef fect ECG monitoring which is suscepti- ble to picking up electromagnetic radiation. Pulse o ximeters may also be affected by vibration. Although defibrillators are approved for in-fli ght use, most helicopter services would elect to commence appropriate life support measures in the event of patient collapse and to land the helicopter prior to defibrillation. CHAPTER 13 Patient rescue and transportation 698 In the case of inter-hospital transfer of intensive care unit patients, there may be proble ms with incompatibility of equipment and the avail- ability of sockets for syringe drivers. It is essential that there is regular liaison between the ambulance service and hospital s taff to determine a standard of equipment which will facilitate safe inter-hospital transpo rtation. Effects of the mode of transportation in limiting possible medical interventions A time-cri tical emergency will dictate on-scene times (in non- entrapment) and also the urgency with which hospital should be reached. When using land-based transportation, a quick ABC assessm ent and appropriate interventions can be performed, followed by loading onto a spinal board . Monitoring and intravenous access can be established en route to hospital. Liaison betwee n ambulance crew personnel should ensure that the vehicle is going steadily in a straight l ine when cannula- tion is attempted. In the event of a cardiorespiratory arrest, the ambu- lance should stop safely and both crew members should undertake resuscitation. The relatively confined space of a helicopter and the associated noise makes further assess ment (for example, listening to the chest) difficult and puts a reliance on monitoring. The patient should have an adequate ABC assessment and any necessary interventions should be u ndertaken prior to loading. Intravenous cannulae should be secure. Following pack- aging it should, however, be possible to make an ABCD reassessment. An in-flight emergency may best be managed by landing the helicopter. Awareness of importance of correct patient packaging, handling, and loading Patient handlin g, loading, and package should be standard practice and compliant with normal manual handli ng techniques. Patients should be secured on a spinal board, if indicated, and then on to a n ambulance trolley cot with access for ABC assessment and monitoring and to any cannulae i nserted for administration of drugs and fluids. Care in transit should include: Routine reassessment and monitoring of the patient including a non-invasive blood pressure, pulse rate, respiratory rate, pulse oximetry, and ECG monitoring. Completion of appropriate documentation. In the case of seriously injured patients, this is often undertaken after handover of the patient in the emergency d epartment. Aeromedical evacuation In many respects, ambulance helicopters are simply ambulances that f ly. They do, however, have the ability to fly direct from A to B, therefore reducing transf er time both to the scene and from the scene to the hospital. Air ambulances therefore have a major role in reducing morbid- ity and mortality in time-critical medical or trauma emer gencies (for example, cardiac arrests and major trauma). transportation IN PRE-HOSPITAL CARE1 699 Indications for air ambulance use include: 999 calls greater than 15 miles or 10 minutes traveling for the nearest land base Difficult access to or egress from the scene - Difficult road terrain including speed bumps . (Particular examples include river banks, large golf courses outside football complexes). - Weather conditions which allow flying but make land access difficult (flooding, heavy snowfall). Other potential advantages are: Preservation of an essential land-based resource \200\230freed up \200\231 by a helicopter undertaking a long distance transfer Provision of a quicker response to rural and remote incidence - Proven benefit in severe tr auma in remote and rural areas - Transportation of the patient to a hospital that best suit s their clinical needs Provision of care to lesser emergencies where there are time delays due to difficult access (for example, a patient out in the hills with a fractured ankle) Delivery of a doctor or medical team and equipment direct to the scene. The helicopter is an underused resource for medical emergencies and could assist in achieving compliance with national service frameworks, for example, coronary heart disease. Helicopters do not have an appreciable effect on ORCON performance. Disadvantages of air ambulances Include: Daylight hours \200\231 flying only - Inability to fly in adverse weather conditions - Requ irement for a landing site adjacent to the A & E department - Need to ensure the patient is appropriately packaged prior to loading - Limited room for procedures to be undertaken in flight. Aircrew London HEMS provides a continuously medically manned service. The Lincolnshire Air Ambulance and the Warwickshire Air Ambulance have doctors as part of the regular air crew. The other services usually have two well trained paramedics as the basis of their response. Aircraft pilots are specifically tasked with the safe flying of the aircraft and are not i nvolved in any medical care. Regulations In the UK, the Civil Aviation Authority covers aviation practice and there are clear definitions relating to mission types, crew types, and the use of the aircraft. The p roviders of a helicopter service must have an Air Operations Certificate (AOC). The Joint A viation Authority (JAA) has defined two types of crew and two types of mission: - HEMS crew members \200\224these are normally paramedics or doctors who have been specifically trained and are assigned to the HEMS flight to provide medical a ssistance to the patient and assist the pilot during a mission with such roles as navigatio n and air craft radios. CHAPTER 13 Patient rescue and transportation 700 Medical passenger \200\224a medical person, usually a doctor, nurse, or paramedic who is ca rried during a HEMS flight and whose role is directly focused on the patient care. No speci fic training is necessary other than pre-flight briefing. Helicopter air ambulance flight \200\224is a pre-planned flight requiring medical assistance where immediate transportation is not essential, for example, an inter-h ospital transfer between dedicated landing sites. Helicopter emergency medical service (HEMS) flight \200\224a flight by helicopter for the p urpose of emergency medical assistance where immediate and rapid transportation is essentia l for medical personnel, supplies, or ill or injured patients. Safety Safety regulations apply to the flight crew and emergency service person- nel should be briefed on ground safety issues. Important considerations include: - The danger of walk ing into the tail rota. - The dangers of the main rota if the aircraft has landed on uneven ground or the rotas are displaced when it is windy. As a consequence, a helicopter should never be approached unless the pilot has given a clea r signal to do so. - Only trained air crew should be allowed to move equipment and patients in and out of the aircraft when possible. At the scene The pilot has the ultimate decision with regard to the landing site. An ideal landing site, at a minimum, should be twice the diameter of the rotating blades. In the cas e of the Bolkow 105 or Squirrel helicopter, this is about 25 meters in diameter or approxi mately half the size of a tennis court. The ground should be firm and flat, free of debris, and away from any power or telephone lines. The site should be kept clear of people at the time of landing and those near by should be instructed to look away as the downdraft close to landing may blow foreign objects into their eyes. Choice of aircraft The size of the helicopter and its engine performance will determine res trictions such as the number of crew and the amount of equipment that can be carried. Wind speed, atmospheric pressure, and temperature all affect performance. The weight that can be carried varies from day to day; on very hot summer days, performance is reduced and approp riate measures to lighten the load will be necessary. This may involve reducing the number of people carried, the medical equipment, or fuel. Aircraft used in the UK Aerospatiale Dauphin This has a large cabin and can carry two patie nts and two medical crew. It can be a single or twin pilot operation. Access to the patient is complete from head to toe. transportation IN PRE-HOSPITAL CARE1 701 Aerospatiale Squirrel This is a smaller aircraft, usually crewed by a pilot and two medical crew. It is normally used to carry a single patient, although a double fit is possi- ble. Access is to one side of the upper body only, making in-flight proce- dures very difficult. Bolkow 105 This is a twin engine aircraft with a small interior cabin which limits the numb er of patients to one and medical crew to two. The second crew member acts as a navigator. Access to the lower half of the patient is limited in flight. Bolkow 135 Larger than the 105, the 135 has the additional capacity to carry a medical pass enger. Other helicopters These include the search and rescue helicopters of the Royal Navy and Roy al Air Force. The Sea King helicopter is suitable for long-range trans- fers in difficult c onditions and at night. Military helicopters are not subject to CAA rules regarding night f lying. This page intentionally left blank Chapter 14 703 Sporting events and mass gatherings Mass gathering medicine 704 CHAPTER 14 Sporting events and mass gatherings 704 Mass gathering medicine A mass gathering is defined as a collection of 1000 people or more. Legal requirements The number and diversity of casualties depends on: - The nature of the e vent - The venue - The attendees - The climate. For example, politically related marches an d derby football matches are often associated with hostile crowds and violent situations, o ften compounded by the effects of alcohol. Peaceful gatherings (for example, summer fetes) may produce few casualties from the event itself but will produce the usual number of day-t o-day minor and major emergencies. Depending on the nature of the event, the incidence of casualties is variably reported to b e between 0.11 per thousand to 9.0 per thousand. At pop concerts, 1 \200\2232% of the audie nce will seek medical assistance during the event of which approximately 10% will need trea tment on site. Approximately 1% of those needing medical assistance will require referral t o hospital. These figures may be significantly altered by adverse weather conditions, poor facilities, and alcohol abuse. Landmark events in mass gathering medicine in the UK include: The Ibrox Park football disaster, 1972 - The Bradford fire, 1985 - The Hillsborough Stadium disaster, 1989. Following the Wheatley Report into crowd safety after the Ibrox Park incid ent, The Guide to Safety at Sports Grounds (commonly referred to as The Green Guide) was pr oduced in 1973 and has subsequently been revised. This was followed shortly afterwards by t he Safety at Sports Grounds Act 1975 stipulating legislation for safety at certain grounds. Following Lord Justice Taylor \200\231s report into the Hillsborough Stadium disaster in 19 89, the medical arrangements for football league grounds were reviewed in the Gibson Report and, as a consequence, the concept of crowd doctor was developed and an acceptable level o f clinical competence was defined. It is currently recommended that all doctors attend an a ppropriate pre-hospital care course run by the Football Association in conjunction with the Faculty of Pre-hospital Care of the College of Surgeons of Edinburgh and that all such doc tors should be the holder of the Diploma in Immediate Medical Care, again of the Royal Coll ege of Surgeons of Edinburgh. MASS GATHERING MEDICINE1 705 The Gibson Report for football ground events made the following recommendations: - One first aider per 1000 spectators - One or more first aid rooms with a ppropriate equipment - A doctor should be present if the attendance is about 2000 or more - One ambulance with a paramedic crew should be present if the crowd is above 5000 5000 \200\22325,000 attendance \200\224one A&E ambulance (with a paramedic crew) plus one ambulance officer 25,000 \200\22345,000 attendance \200\224one A&E ambulance (with a paramedic crew) plus one ambulance officer, one major incident equipment vehicle and a paramedic crew, and one cont rol unit 45,000 or more attendance \200\224two A&E ambulances (with paramedic crews) plus one ambula nce officer, one major incident equipment vehicle and a paramedic crew, and one control uni t. Contingency planning All stadia should have a contingency plan for emergencies as well as a major incident plan. The suggested recommendations for a contingency plan include the foll owing, which can be adapted to fit most situations: - Fire - Bomb threat, suspect package - Buildings and services Damage to structures - Power cut or failure - Gas leak or chemical incident Safety equipment failure Turnstile counting mechanism - Closed circuit television - Public address system - Electron ic information boards - Stewards \200\231 radio system - Internal telephone systems Crowd control Surging or crushing - Pitch incursion - Late arrivals or delayed start - Lock outs - Disord er inside the ground - Large-scale ticket forgery - Emergency evacuation - Ticketing strate gy in the event of an abandoned fixture - Features/considerations specific to the location. CHAPTER 14 Sporting events and mass gatherings 706 Each stadium should have its own major incident plan which has been agreed by all involved in the major incident response including the planning officers, emergency services, and hea lth and safety organizations. It should be noted that a paramedic, for the purpose of mass gathering medicine, is a person who holds a current certificate of proficiency in ambulance paramedic skills as issued by the Institute of Health Care and Development and who has imm ediate access to appropriate levels of specialist equipment including drug therapy as per t heir normal practice. In addition, a paramedic crew, as a minimum, consists of a paramedic and IHCD trained technician. Any practitioner who is involved in providing support at mass gathering events should be fa miliar with the Guide to Safety at Sports Grounds (Green Guide) (4th edn, 2003) and the Eve nt Safety Guide (1999, reprinted 2002). In addition, the practitioner should be familiar wi th the major incident plan and, most importantly, take part in regular major incident exerc ises. 707 Index addresses, useful 66 \200\2237 adrenaline 92, 309, 310, aminophylline 403 amiodarone 92, 311, 530 amphetamines 463, 403 amputation 284 A Abbreviated Injury Scale 356 advanced life support (AIS) 618 90 \200\223100 amputated parts 284 surgical 284 traumatic 284 anesthesia 380 \200\22394 abdomen, anatomy of 218, see also cardiac arrest Advanced Life Support (ALS) course 8 Advanced Life Support Obstetri cs (ALSO) course 8 219 pelvis 218, 219 peritoneal cavity 218, 219 retroperitoneum 218, 219 abdominal aortic aneury sm benzodiazepine reversal 325 etomidate 380, 381. intravenous agents 380 \200\2233 ketamine 331, 378, 380 \200\2233 propo fol 382 thiopentone 383 see also local anesthesia; muscle relaxants; rapid sequence inducti on (AAA) 154 \200\22367 Advanced Pediatric Life abdominal pain see acute Support (APLS) course 7 abdomen abdominal thrusts (Heim- lich maneuver) 516, abdominal trauma 218 \200\22322 blunt trauma 2 18 \200\22319, 221 evisceration 221 impaling injuries 221 injury, mechanism of Advanced Trauma Life Support (ATLS) approach 7 aggressive behavior 462 \200\22380, 492 \200\223493 air ambulances 698 \200\2239 analgesics 376 \200\2238 administration routes aircraft 700 \200\2231 aircrew 699 \200\223700 limitations 697 medical interventions, effec ts on 698 patient, effects on 697 regulations 699 \200\223700 safety 700 362 \200\2233 218 \200\22319, 220 management 221 patient assessment 220 pelvic fractures 221 penetrating trauma 218 \200\22319, 221 accreditation 12 compound 318 Entonox 340 inhalation 363 intramuscular 363 intraosseous 363 intravenous 363 ketamine 331, 378 nasal 362 obstetric 346, 370 opioids 364 \200\22375 oral 362 paracetamol 345 rectal 362 route of choice 363 subcutaneous 362 sublingual 362 topical (patches) 362 CE inhibitors see angio- tensin converting enzyme (ACE) inhibitors cetabular fractures 254 Achilles tendon ruptures alcohol abuse 140, 483 see also ethanol; methanol ambulance commander 586 \200\2237, 590 ambulance loading officer 590 278 ambulance loading point acromioclavicular 586 \200\2237 dislocations 230 acute abdomen 154 \200\22367 abdominal aortic aneu- ambulance parking officer 590 ambulance parking point anaphylaxis rysm (AAA) 154 \200\22367 586 \200\2237 adrenaline 309, 310 circulation 184 hydrocortisone 329 acute appendicitis 157 acute pancreatitis 159 acute pyelonephritis 162 bowel obstruction 16 4 diagnosis 154, 155, 156 diverticular disease 166 gallbladder disease 158 gynecological ca uses 163 medical causes 167 mesenteric infarction 165 peptic ulcer disease 160 symptoms 155 ureteric colic 161 ambulance response times 56 ambulance safety officer angina 590 \200\2231 clinical features 72 glyceryl trinitrate 328 unstable 114 \200\22315 angiotensin converting ambulance service 56 \200\22357 ambulance dispatch 57 major incidents 590 \200\2231 NHS tru sts 56 organization 56 roles 56 vehicle item checklists enzyme (ACE) inhibitors 408 ankle fractures 265 \200\2236 ankle inversion/eversion 28 \200\2239 266 see also air ambulances; lateral ligament sprain acute medical patient, ABC transportation 265 approach 70 adder bite 409 amil nitrate 464 Maisonneuve fracture 265 INDEX 708 ankle injuries 278 anti-arrhythmics 311, 332 antibiotics 410 anticholinergic drugs 411 anti cholinergic syndrome bone and joint injuries automatic vehicle location system (AVLS) 57 AV nodal re-entrant tachy- cardia (AVNRT) 108 A VPU assessment 187, 194, 224 \200\2237 closed fractures 226 compound fractures 226 dislocations 224, 226 fracture classification 2 24 limb-threatening injuries 413, 403 303, 503, 538 anticholinesterases 386 anticoagulants 412 antiemetics 25, 335, 337, 225 B barbiturates 414 Basic Trauma Life Support management principles 369, 375 225 antifreeze see ethylene mechanism of injury 224 patient assessment 224 \200\2235 splintage 226 \200\2237 glycol antihistamines 317, 319, (BTLS) course 7 batteries, swallowing 415 bends, the 377, 569 \200\22371 benzine penicillin 356, 315 benzodiazepine 331, 378 413 boots 20 bradycardia 102 \200\2237, 314, anxiety disorders 487 aortic dissection 73 appendicitis 154 \200\22367, 658 armed forces 58 , 593 arrhythmias 398 500, 502 \200\2233 1st degree heart block 103 midazolam 336 poisons 403, 416 reversal 325 substance abuse 465 2nd degree heart block peri-arrest 97 \200\2239 104, 105, 106 artificial ventilation 87, 83 chest compressions 84, 3rd degree heart block 107, 107 children 529 Mobitz type 1 104 Mobitz type 2 105, 106 peri-arrest 100 sinus 102, 1 03 brain anatomy 192 brain injuries 200 \200\2231 contusion 200 extradural haematoma beta blockers 417 biological incidents 620, 87 mouth-to-mask 632 \200\2235 resuscitation 84 anthrax 635 biological agents 632 \200\2235 biological threats 633 biological weapons 632 c asualty management 11, mouth-to-mouth resuscitation 83 resuscitation, abandoning 84 aspirin 312 asthma 333 634 \200\2235 dissemination 634 recognition 634 acute exacerbations 200 128 \200\2239 generalized injury 201 intracerebral haematoma bites see venomous bites children 513 \200\22314 classifications 129 hydrocortisone 329 pneumothorax 126 pregnancy 6 58 salbutamol 348 and stings 200 bladder injuries 222 blast injuries 286 \200\2239 intracranial hemorrhage 200 \200\2231 blast injury mechanisms lacerations/penetrations 286 \200\2237 blast wind 287 burns 288 crush injuries 289 fragmentation 287 management 289 primary blast injuries 201 asystole/PEA arrest 94 \200\2236 subarachnoid 4 Hs and 4 Ts 94 ALS algorithm non- hemorrhage 201 subdural haematoma VF/pulseless VT 95 automated external defi- brillator (AED) 95 cardiac tamponade 95 childre n 529 hypo/hyperkalaemia 95 hypocalcaemia 95 hypothermia 95 hypovolaemia 94 hypoxia 94 pote ntially reversible 200 see also head injuries breaking and entering 38 breath, shortness of 76 \200\2237 288 psychological effects 289 secondary injuries 288 shock wave 286, 287 tertiary injuries 288 thermal injury 287 asthma 76 causes of 76 COPD 76 metabolic acidosis 76 \200\2237 pneumonia 77 pneumothorax 77 pulmonary embolism 77 pulmonary oedema 76 blast lung 288 bleach 418 blood glucose causes 97 dextrose 320 poisoned patients 399 unconscious patients 136, tension pneumothorax 95 thromboembolism 95 thrombolysis 94 toxins 95 British Association for Immediate Care (BASICS) 140 driving courses 696 Emergency Medicine Journal (EMJ) 64 blood pressure 500, 606 \200\2237 see also hypertension; atracurium 385 \200\2236 atropine 356, 314, 403, 406, hypotension BM Stix 70, 78, 152, 194 body temperature regulation 560 407, 529 \200\22331 insurance 40 record keeping 46 training 6 \200\2239, 62 automated external defibril- lator (AED) 92, 95 INDEX1 709 British Association for Immediate Care (BASICS) Scotland 6 \200\2239, 62 children 528, 529 \200\22331 defibrillation 82, 90, 92, individual chemicals 630 information gathering 95, 622 drowning, near 567 drugs in 90, 93 electromechanical asso- ciatiaon (EMD) 82 hypothermia fo llowing 90 monitor checks 90 patient assessment 82 patient handover 90 pulmonary embolism information sources 625 organizational manage- ment 622 \200\22330 patient transfer 630 per sonal protective equipment 622 British Red Cross 58, 593 bronchiolitis 512 burn injuries 296 \200\223305 analgesia 305 associated injuries 301 associated medical conditions 301 regional provider services resuscitation 628 \200\2239 scene safety 622, 625 terrorist inci dents 620, blast injuries 288 burn depth 298 \200\223299 burn extent 300, 301, 303 burn site 301 burn wound zones 296 carbon monoxide poisoning 305 chemical burns 296 children 541, 540 contact burns 296 deaths 296 dressings 305 electrical injury 298 erythema 298 explosive burns 296 f lame burns 296 flash burns 298 fluid loss 296 hypothermia 296, 303 immediate care 302 \200 \2234 infection 296 inhalation injuries 301 ionizing radiation burns 132 \200\2233 pulseless electrical activity 621 (PEA) 82 treatment 630 triage 626 \200\2237 chest drain kits 15 chest injuries 208 \200\22317 recovery position 83 safety 82 ventricular fibrillation (VF) 82, 90 \200\223100, 530 see also artificial ventila- tion; asystole/PEA arrest; bradycardia ; tachycardia cardiac tamponade 95 cardiogenic shock 184, 534 cardiological emergencies back examination 212 blast injuries 208 blunt injuries 208 cardiac tamponade 214 chest exam ination 211 clinical signs page 205 diaphragmatic ruptures 216 82 \200\2239 diffusion 211 flail chest 214 fractured ribs 216 fractured sternum 217 massive haemothorax carpal bone fractures 243 casualty clearing officer 588 \200\22390 casualty clearing station 586 \200\2237 214 CBRN incidents 620 \200\22321 presentation, mode of mechanism, of injury 208 open chest wounds 214 pain management 217 patient assessment 211 p enetrating injuries 208 pneumothorax, sim- ple/closed 216 primary survey 213 pulmonary cont usion 216 pulmonary perfusion 210 respiration, and anatomy 298 621 non-accidental injury structured response, need for 620 \200\22321 (NAI) 298 pain 296 pathophysiology 296 patient age 301 patient disposal 305 scalds 296 scene safety 3 02 smoke inhalation 304 see also biological incidents; chemical incidents; nuclear and radiological incidents cerebral odema 192 cerebrovascular accident (CVA) 144 208 \200\2239 butane 478 \200\22380 cervical spine injuries 205, secondary survey 216 \200\22317 stab wounds 209 surface landmarks 208 \200\22310 surgical e mphysema 217 tension pneumothorax 280 \200\2233 airway obstruction 172 \200\22388 children 534 \200\2235 suggested equipment 15 see also im mobilization; C caffeine 403 calcaneum fractures 267 calcium channel blockers 213, 212 \200\22313 spinal injuries trachea 208 ventilation 210 chest pain 72 \200\2235 causes of 73 chest wall pain 72 cholecy stitis 74 gastrointestinal causes of Chemdata 624 chemical burns 296 chemical incidents 620, 419 calcium chloride 406, 407 cannabis 466 carbamazepine 420 carbon monoxide 305, 622 \200\22330 advisory systems 622 \200\2237 clinical management 626 debriefing 630 decontamination 21, 6 28 definition of 622 \200\22330 documentation 630 hazardous materials 73 421 \200\2232