a m u a r t d n a s c i d e a p o h t r O Age >65 \200 Vomiting >2 times \200 Amnesia before impact of >30min. \200 Dangerous m echanism (pedestrian struck by car; car occupant ejected, fall from a height of >1m, or downstairs). The NICE guidelines on head injury adds post-traumatic seizure, coagulopa- thy and focal ne urological deficit as indications for a CT head.388 CT of the cervical spine CT assessment of the cervical spine is quick and ef- fective. Meta-analysis suggests that CT be used as t he \201 rst line investigation in those with a depressed mental status, though not as a m atter of course for less severe injury, in which plain radiography should still be used.389 It also has cost-bene \201 t implications.217 It is indicated if an injury is seen on the plain \201 lm series and if there is inadequate visualization (C7/T1 can be diffi cult t o image in full with plain X-ray.) A similar approach applies for other spinal injuries, bu t remember that MRI will be needed to assess the vital soft tissue structures. CT of the ch est Evidence of traumatic injury on CXR that warrants further imaging: \200 Haemothorax \200 Pneumothorax \200 Widened mediastinum (all diffi cult to spot on a supine \201 lm ) \200 Pneumomediastinum \200 Posterior rib fractures \200 Frac- tures of ribs 1 or 2 \200 Pulmonary contusion. CT of the abdomen and pelvis Usually done together. Indication s may in- clude: \200 Free \202 uid noted on FAST scan (p727), but beware US algorithms for as- sessment in blunt abdominal trauma)223 \200 Suspicion of retroperitoneal haemor- rhage (shock but not cause found) \200 Renal trauma (macroscopic haematuria, microscopic haematuria + shock). CT of the appendicular skeleton Part of pre-operative planning for co mplex injury patterns. \200\207Remember to think of patterns of injury: eg rib fractures w ith bilateral pulmo- nary contusions have a high coincidence of intra-abdominal injury Appropriate use of Emergency Departments From our point of view, the ideal scenario is to h ave a pristine, ever-ready but empty trauma department with the doctors and nurses educatin g themselves (etcetera) in the coff ee room, occasionally being called out by paramedics to save a few lives in a brief display of energy and technical brilliance. This is not how th e public sees our role. If in shock, having just run over a hedge- hog, some people feel th ey need attention now. All Emergency Departments are abused \200\224because it is always do ctors who de \201 ne what abuse is. Thus up to 70% of users have been deemed inappropriate in some studies. This \201 g- ure dwindles towards nothingness if abuse is de \201 ned as those consultations where all 3 parties to the visit, on re \202 ection, concur that it was inappropri- ate: the doctor, the patient family, and the patient \200\231s GP (who may have sent them). Overcrowding and \200\230exit-block \200\231390 This is a major probl em in Emergency De- partments the world over \200\224partly re \202 ecting centrally deter mined reductions in acute bed provision and availability, and partly re \202 ecting access problems for populations seeking prompt help with immediate (and, sometimes, chron- ic) pr oblems. If the inpatient side of a hospital is full, patients will stack up in Emergency De partments, awaiting admission. If overcrowding is cumulative, ambulances may be redirected to other hospitals (adding to delay and danger) and patients with genuine needs may, catast rophically, decide they cannot wait any more hours for help. How to cope with inappropriate attendance \200 Triage by a trained nurse is one way to reduce inappropriate attendance. (In the UK, triage is mandatory.) Is this condition life-threatening, urgent, or semi-urge nt or is delay acceptable? These are the chief categories. If the most urgent patients are seen \201 rst, patients who do not really need to be in the department can wait for ages, and many will begin to drift away. Note that if long waits become essential because of dea ling with life-threatening conditions, this should be explained to patients (under the term s of the UK health charter \200\224and as a matter of common courtesy). 780 a m u a r t d n a s c i d e a p o h t r O Another way to reduce unnecessary spending is to have primary care fa- cilities within the Emergency Department, or, more radically, to have GPs as the casualty offi cers \200\224bec ause they use resources more sparingly and are used to dealing with mismatches between pati ent \200\231s expectations and reality. Is this expectation borne out in practice? In one c areful randomized study of patient-contacts with the Emergency Department in Dublin (N=4684 ), GPs treating people with semi-urgent problems investigated less (by 20%), referred to ot her hospital services less (by 39%), admitted fewer patients (45%) and prescribed more ofte n (43%): there were no diff erences in meas- ures of outcome.391 It is not clear whether th e more economical style of the GPs was to do with being a GP, or because these doctors were older and more experienced than their emergency department counterparts.1 Risk management strategy when overwhelmed by the work to be done: \200 Prioritize the wai ting tasks and then concentrate on the task in hand. \200 At times you may feel you are w orking at a pace that is faster than is com- fortable. This is part of \200\230continuous learning \200\231, and as you get better this un- ease will abate. Look on it as practice f or emergency situations where quick decisions are vital. Working faster need not mean makin g more errors. Have good techniques of clinical decision-making, which you continue to re- \201 ne. Start with something like the system on p532. Keep the goal in mind: What to do for the best for this patient. 1 UK GPs are an established part of the team at the front line seeing patients in Emergency Departments: they join the growing team of emergency nurse practitioners, junior doctors, and consultants (eg in a \200\230meet & greet \200\231 capacity) to tackle the turnover of patients with more minor injuries and ailments. Medical specialists (eg dedicated emergenc y pediatricians) are also increasingly involved. 781 Another busy shift? In the middle of any horrendous Emergency Department shift, you may be forgiven for wondering what on earth is happening outside to prompt such a heave in the num ber of attendances. Rumors circulate that sunshine means that children are out in force at the local playgrounds, or rain means that old ladies will be slipping up on the kerb. Perha ps late on a Friday night you despair at the number of alcohol-related incidents? Similarly , you hear that because the Grand National is on, the shift is going to be a quiet one \200 until the race \201 nishes and people are out spending their winnings (or drowning their losses). Factors that have been suggested to be correlated with an increase in the a m u a r t d n a s c i d e a p o h t r O number of Emergency Department attendances include: \200 Warm, dry and sunny weather cond itions.392 \200 Season, especially winter for the over-65s and the under 1s.393,394 \200 Local music festivals (despite on-site facilities).395 \200 An at-home winning national sports side (sadly, for assault).396 \200 Major natural disasters (eg a hurricane, thoug h with an understandable reduction on the day of the disaster).397 \200 And yes \200 Mond ays.394 Other studies have suggested that attendances may be reduced by major televised sporting events.398,399 It is a complicated mix which depends on where in the world you are work- ing and it is not always clear whether these factors are delaying, precipitating, or causative (though logic may point the \201 nger of causality).1 Ultimately, the aim of such epidemiological studies is to help in emergency department staf fi ng and logistics, and taken with a pinch of salt, one message is clear: \200\207Don \200\231t despair, as all of these factors are well beyond your control! 1 Why not have a look at your own departmental data \200 Bites, stings and foreign bodies Mammal bites All animal bites are contaminated, especially those of human animals: everything that comes out of the human mouth is poison. John Stein beck Cannery Row. Clean well with soap and water, debriding if needed. See p746. \200\207A void suturing unless cosmetically essential. Give antibiotics covering anaerobes unless ver y trivial and not high-risk (risk \200\200 if: \200 , >50yrs, immunosuppressed, wound is t o the hand, face or foot, delayed presentation, penetration of underlying structures, crush wound), eg co-amoxiclav 500/125 tab/8h PO (clindamycin 300mg/6h PO if allergic to penicill in \200\224but beware pseudomembranous colitis).231,400 Bites from monkeys (speci \201 cal ly macaques) require treatment with valaciclovir to pre- vent transmission of Cercopithecin e herpesvirus 1 which in humans leads to a fatal encephalitis. NB: dog bites may lead to cr ush injuries, so x-ray to check no underlying fracture or foreign body, bites from cats may not be as trivial as they look: they carry Pasteurella multocida, streps, and fusibacteria . Is tetanus prophylaxis needed (p730)? Consider rabies if bitten outside UK. (Post- exposu re rabies prophylaxis: phone the UK Central Public Health Lab/Health Protection Agency, 020 8200 6868; after hours, 020 8200 4400.)401 Snake bites Britain \200\231s only poisonous sn ake, the adder, is very rarely lethal. There are about 100 bites per year in the UK402. Aus tralia has 3000 bites per year, with 1 \200\2232 fatalities. The WHO considers envenomatio n to be a neglected tropical disease, with >10000 envenomations occurring in India alone. B ites are usually on the hand or foot403 \201\227: Wrap the entire aff ected limb in a crep e bandage and immobilize it. Identify the species if possible and move the patient to hospi tal. Treat ABCs \200\224respiratory paralysis, hypotension, cardiac arrest and seizures can occur. Check clotting time (many venoms are anticoagulant), renal function, CK, d-dimer, F BC, urine for myoglobinuria. Venom detection kits exist \200\224use if there are clinical s igns (nausea, \200\201LOC, ptosis, weakness, coagulopathy, muscle pain) or abnormal bioche mistry. (Indications for antivenom treatment include abnormal biochemical/clinical signs.) In the UK, give European viper venom antiserum (see BNF) 1 vial IV over 15min. Use the same dose for children. It may be repeated after 1h, if there is no improvement. Have adrenalin e to hand (p237). If the bite is from a foreign snake or spider, the relevant antivenom may be held at pharmacies in London or LiverpoolUK \200\224they are available via the National Poisons Information Service and via www.toxbase.org. \200\207Avoid tourniquets, incisions , and sucking the wound (but a limb bandage may help con \201 ne venom). Lesser weever \201 sh stings (Echiicthys vipera) \200\224eg in barefoot UK bathers. It is not serious, an d may be relieved by immersion of the leg for 5 \200\22320min in water which is as hot as c an be tolerated (eg <45 C). Scorpion venom Signs: BP \200\201 or \200\200, renal failure , LVF. \201\227: Lidocaine SC at the site relieves pain. Antidotes prepared from animal an tisera are eff ective against some species of scorpion.404 Prazosin & L-carnitine 660mg/8h PO may help.405,406 Airgun pellets These are common, and can be hard to remove. Deaths have occurred, eg when a pellet enters brain through the eye. Get 2 radiographic views to posit ion the foreign body. Ultrasound guidance may also help localize the pellet, but be aware t hat only shadow or reverberation artifact may be visible, and not the pellet itself. If it has just penetrated the skin, inject local anesthetic carefully so that you can still palpa te it: if you cannot remove it easily, leave it in situ rather than risk extensive tissue d estruction trying to \201 nd it; give antibiotics. Pellets tracking subcutaneously, or wh ich have penetrated deeply, must be sought. Other foreign bodies \200\207Always do radiogr aphy if there may be glass/metal/ stone in a wound. Tiny shards may be left in situ. Even l arge shards can be hard to \201 nd, needing exploration under GA to remove. Ultrasound ma y be useful. \200\207Always do orbit radiography for a high-velocity metallic foreign body that cannot be seen (eg grinding/hammering injury). 782 a m u a r t d n a s c i d e a p o h t r O 783 Ingestion of a metallic object407 Pathways for metallic foreign body (FB) ingestion managem ent may diff er from hospital to hospital, so check your local guidelines. In general: \200 Do CXR to tell you whether the object has progressed to below the dia- phragm, beyond which it is most likely to be safe. There are very rare re- ports of objects lodging at th e pylorus, resulting in gastric erosion.408 \200 If displaying neck/upper airway symptoms : Do a lateral neck radiograph: with a CXR, this should enable you to diff erentiate GI and respiratory tract location. Foreign bodies can occasionally sit asymptomatically at the va l- leculae (= \200\230little ditches \200\231, which are the recesses between mucosal fold s at the base of the epiglottis), or in the piriform fossae (which are recesses in the uppe r esophagus, either side of the laryngeal inlet). a m u a r t d n a s c i d e a p o h t r O AXR: Recommended in children \200\224many will have a second FB elsewhere. \200 If in upp er \201\223 of esophagus: There is risk of perforation, and the object needs endoscopic re moval. Ensure there are no more foreign bodies before removing the scope. If lower down, re peat radiography after 12 \200\22324h. If the coin is still in the esophagus, remove endosc opically under GA. \200\207Button batteries lodged anyway in the esophagus need urgent rem oval. If below diaphragm: Let it pass. The stool can be screened for passage of the object, eg manually, with x-rays or with a metal detector. The same principles hold for button/tube battery ingestion \200\224reports of heavy metal p oisoning are very rare.409 Surgical removal is warranted for the rare cases of GI obstructi on and maybe for persistence of failure to pass. Fish bones are the chief foreign body to s tick in the upper airway/GI tract. Radio-opacity may be species dependent.410 Lateral neck radiographs are in- sensitive: CT may be needed, followed by endoscopic removal.411 \200 \207Heimlich maneuver and back blows See p795. Bee stings Scrape them out gently with a knife or credit card quickly.412 This technique is better at removing a sting than pinching it out, because bee stingers are barbed ( \201 g 1), whereas wasp stingers are smooth. As a conse- quence, the stinger is left in the skin, still attached to the poison sac and tip of the abdomen, meaning that her \201 rst sting will likely be her last.1 Pheromones released from the expiring bee attract more bees, but you may be able to outrun them if you see them coming. NB: although always fatal to the bee, a single sting almost ne ver kills you (risk <1 in 1,000,000; 4 deaths/yr in UK). Fatalities are more likely if you get >200 stings (but >1000 is survivable). Ice calamine lo- tion help itch. Give antihi stamines for severe swelling/ itch. \200 Anaphylaxis, p237.413 Killer bee stings (Africani zed honeybees: Apis mellifera scutellata) Despite treatment on ITU (antihistamines, cortico steroids, bronchodilators, vasodila- tors, bicarbonate, mannitol, and ventilation), deaths occur 1 \200\2233 days after the attacks (>100 stings), from ARDS, BP \200\200 \200\200, h epatic and subendocardial necrosis, haemolysis, rhabdomyolysis, acute tubular necrosis, and DIC.414 Fig 1. Bee stinger ( \211\21040). Courtesy of Jeff Beck 1 Bees that sting are \200 . The stinger is a vestigial ovipositor that has subsequently b ecome a stinging organ, evolved for defense purposes (against both other bees and larger, t hicker-skinned interferers). Common minor procedures \200\207When in doubt, ask the trauma nurse: she will have seen it all before. \200\234I \200\231ve hammered my \201 nger, doctor \200\235 This usually ca uses a subungual haema- toma \200\224relieved by expressing the blood through a hole trephi ned in the nail, using a 19G needle. No force is needed. Simply twiddle the needle vertical ly on the nail: the cutting edge will make a suitable hole (p747). \200\234I \200\231ve sw allowed a \201 sh bone and it \200\231s stuck \200\235 Always examine the throat and tons ils carefully. Often the bone has only grazed the mucosa. Use a good light, and grip the to ngue with gauze to move it out of the way before removing any visible bones with forceps. I f you fail, refer to ENT (see p567). \200\234My \201 sh hook has barbed my \201 nger \200\235 In \201 ltrate with plain lidocaine and push the hook on through the \201 nger, provided no important structures are in its way. Once the barb is through, cut it off . Re move the hook where it entered. \200\234My tooth has been knocked out \200\235 Try to repl ace permanent teeth. Send deciduous teeth to the tooth fairy. If the former, after the pati ent sucks it clean (do not use water) transportation in milk \200\224or reinsert it, stabil izing with \201 n- ger pressure (or biting). Go to a dentist for splinting. Plaster \200 \230backslabs \200\231 (for undisplaced forearm fractures). \200 Remove anything which im pairs \201 nger circulation (eg rings). \200 Protect yourself and your patient with a p lastic apron. \200 Measure the length for the back slab \200\224from knuckles to just bel ow elbow, so 784 a m u a r t d n a s c i d e a p o h t r O that the \201 ngers and elbow will remain mobile. Cut a piece of plaster-impregnated bandage 5 times longer than the desired length. Fold it into 5-ply. Then see \201 g 1, 1 , OPPOSITE. Cut off one corner so that it does not impinge on the thumb. \200 Cut a wedge off the oth er end with the wedge \200\231s thick end on the same side as the thumb. This aids elbow movement. 2 Roll stockinette over the forearm, to well above the elbow. \200 Wind a roll of wool padd ing over the stockingette (turns must overlap by 50%, so protecting \202 esh from the hard plaster). 3 Immerse the plaster bandage in tepid water and apply it to the dorsum of the arm \200\224without pitting it with your \201 nger tips. 4 Re \202 ect the stockinette down from the elbow and up from the wrist making comfortable top and bottom ends to the plaster. 5 Place a bandage right around the forearm to keep everything in place, secur- ing its end with a strip of wet plaster). 6 Setting takes place over 4min: sooner if warm water is used. \200 Put the arm in a sling for 1 day \200\224after which encourage movement of shoul- der, elbow, and \201 ngers to prevent stiff ness. \200\207Cautions for the patient: 1 Re- turn immediately to A&E if the \201 ngers go blue, swell, or you cannot move them. 2 Do not get the plaster wet. 3 Do n ot lift heavy weights with the hand. Give the patient a plaster care information card. Removing a tight ring from a swollen \201 nger Pass a No.4 silk suture through the ring f rom distal to proximal. Wind the distal end around the \201 nger in a distal direction. T hen unwind from the proximal end distally (should pull the ring over the coil). Lubrication + compression + traction may also make for success and a relieved patient. If not, try usi ng a ring cutter (though not for brass or steel). \200\234I \200\231ve caught my penis in my zip \200\235 Failing copious lubrication with mineral oil, the most elegant method is to cut out the bridge from the slider of the zip with strong wire-cutters as shown in \201 g 2. The zip then falls apart and all that is needed is a new zip. (Beware the bridge \202 ying off at speed: hold gauze by it.) What if the trousers are of immense value? Try t he Savile Row technique: in \201 ltrate the skin with 1% lidocaine (no adrenaline!); caref ully manipulate the prepuce along the side of the slider by an unzipping movement.415 785 a m u a r t d n a s c i d e a p o h t r O Fig 1. Plaster backslab. Fig 2. Solution to the zipped penis problem. \200 Drowning Worldwide, around 400,000 drowning deaths occur yearly: most are chil- dren. 416 Drowning is the 3rd leading cause of unintentional injury death world- wide. In general children under 5 are at greatest risk, New Zealand and Cana- da are exceptional in that ad ult males in these countries drown at higher rates than children. Many drownings in adults are associated with alcohol. Most drownings in children occur in those who are poorly super vised near water. It is quite common for a toddler to bath with a slightly older sibling \200\230in charge \200\231 \200\224 the mother thinking that as the child can sit up, he ca n also save himself from drowning should he topple over. Males are at greater risk of drown ing than females. 786 \200 In communities wealthy enough to have many private swimming pools there are summertime spat es of drownings. An adult is temporarily distracted and leaves the garden, and, on return, \201 nds a corpse in the pool. When such a child is brought to A&E the chief concerns are : 1 Cardiac arrest 2 Hypothermia, OHCM p860 3 Acidaemia 4 Pulmonary oedema. Management focu ses on ABCDE (p725): \200 Immobilize the cervical spine as you open the airway \200\224th ere may have been a m u a r t d n a s c i d e a p o h t r O trauma here through cause or eff ect. Clear vomit from mouth. Give 100% O2 to prevent hypoxia \200\224water in alveoli will dilute surfactant and increase atelectasis. CPAP or PEEP may be required. Expect BP to drop after leaving the water. Transportation with a minimum of rough handling and in the horizontal position (although not always possible in extreme environments). This helps reduce cardiovascular instability.417 \200 If pulseless, start cardiopulmonary res uscitation. \200 Monitor ECG. De \201 brillate if VF (APLS, p239). For the \201 rst sh ock, give 2J/kg body weight ( 20J at 12 months, 40J at 4yrs, 60J at 8yrs, and 80J at 12yrs ). De \201 brillation often fails until core T >30 C. Heroic measures have been tried w ithout clearly aff ecting outcome418 \200\224eg rapid core rewarming (warm- water immersion , warm IV \202 uids at 40 C, breathing heated humidi \201 ed gas,419 peritoneal dialysi s, thoracotomy for heart irrigation, or heart bypass). Do Glasgow Coma Scale, p720; if <6 the prognosis is poor. \200 Monitor core T . Remove w et clothing and examine for signs of other injury. \200 If T <35 C, monitor rectal T often and rewarm using high ambient T . Circu- latory support may be needed to counter re warming vasodilatation. Measur- ing left atrial pressure helps guide IV \202 uid: too muc h will \200\200ICP. \200 Pass a nasogastric tube to relieve gastric dilatation. \200 C heck U&E, blood gasses, and Hb. Get expert advice on the problem of acidosis. \200 In the case of continuing resuscitation without success, it is vital not to halt proceedings unti l full rewarming has been achieved and asystole is noted on ECG. Children and adults have b een reported to make a full recovery.420 \200 Remember to consider that drowning may not have been the only life-threat- ening insult.421 The coroner will need to be informed of de aths. Eff ects of asphyxia and fresh water overload The child usually swallows large amount s of water before \201 nal aspiration. This leads to gastric dilatation, vomiting, and fu rther aspiration.416 ARDS can occur, leading to the major villain, hypoxaemia \200\224hence cerebral oedema and \200\200ICP. To combat these, steroids and antibiotics are sometimes given, but without proof of effi cacy. As the raised intracranial pressure (ICP) is due to cell death (cytotoxic oedema), steroids do not lower ICP (unlike the vasogenic oedema seen with space-occupying le- sions). The diving re \202 ex Children retain this useful adaptat ion to our earlier aquatic way of life. As cold water hits the face, the pulse slows and bl ood is diverted from limbs and muscles to vital areas (brain, kidney). Cold reduces the met a- bolic rate. This is the physiological explanation for remarkable stories of recov- ery f rom prolonged (eg 20min) total immersion. 787 Preventing death by drowning In richer parts of the world, drownings in garden ponds are ge tting commoner, while those in natural freshwater sites are declining. Toddlers have the hi ghest drowning rates \200\224so prevention must target toddlers: \200 Constant supervisio n of infants in baths by adults. Even brief moments a m u a r t d n a s c i d e a p o h t r O away, eg to answer the doorbell, can be disastrous. \200 Isolation fencing that surrounds the pool, separating it from the home.422 \200 Not swimming alone or in remote, unguarde d sites. Training of the public in basic life support. If given promptly, neurological outc omes are better.423 \200 Heat exhaustion/heat injury Heat injury occurs when core body tempera- ture rises eg to >39 C. Basal metabolic rate produces 100kcal/h; radiation from the sun can contribute 3 00kcal/h, and strenuous mus- cular activity 900kcal/h (enough to raise the core temperature by 1 C every 5min). Cool- ing is achieved mainly by evaporation. Above environmental temp eratures of 35 C, 75% of heat loss is by sweating. Convection usually ac- counts for 15% o f heat loss (more if conditions are windy), but if the environment is very hot it can contr ibute to heat gain. Acclimatization to a hot environment (metabolic and cardiovascu- lar ch anges reduce body core temperature and reduce the threshold for sweating), is mainly comple ted by 7 \200\22312 days. Forms in the spectrum of heat illness \200 Oedema: There is swe lling of hands, feet, and ankles in the \201 rst days of ex- posure (worse after long-hau l \202 ights). It settles spontaneously over 28 days. Avoid diuretics. 788 \200 Risk factors \200 Elderly ( \200\201reserves) \200 Obese ( \200\201reserves) \200 Chi ldren ( \200\201sweating) \200 Exercising in the heat \200 military personnel424 \200 athletes425 \200 Acute febrile illness \200 Chronic illness \200 Drugs426 \200 coc aine \200 ecstasy \200 lysergic acid diethylamide \200 tricyclic antidepressants \200 amphetamines \200 phenothiazines a m u a r t d n a Dehydration s c i d e a p o h t r O Heat cramps: Painful large muscle cramps after a lot of sweating. Treat with oral rehydrati on (half teaspoonful salt to each liter of water). Painful rhabdo- myolysis (OHCM, p307) ca n also contribute. Heat tetany: Hyperventilation induced by rapid change in temperature. Treat as for usual hyperventilation. Heat exhaustion/syncope: Weakness, fatigue, light-headedness, nausea, vomiting, cramps, pil o-erection. Core temperature is <40 C. Treat with copi- ous \202 uids eg 1L/h PO; and co oling with moist spray and increased convection (fan). Rarely, IV \202 uids are needed. T he exact etiology is unclear.427 \200 Heat stroke: Acute neurological impairment with cor e temperature \211 40 C. Typically associated with organ dysfunction. There are two types \200\224 \200\230classic \200\231 or non-exertional, and exertional heat stroke. \200\230 Classic \200\231 type \200\224is seen when those who have poor cardiovascular reserve, such as infants or the elderly are subjected to environmental heat stress.428 This form of heat stroke can be the most severe. Tachycardia, tachypnoea, hypotension, irritability, confu- sion, seizures ( hyponatraemia), and coma may occur. Skin may be hot and dry. Mortality: 10%. Complications include persistent neurological damage, congestive cardiac failure, cen trilobular liver necrosis (which can lead to liver failure), acute renal failure (especiall y in those in whom exercise contributes) due to rhabdomyolysis. Haematuria and proteinuria feature early, DIC can oc- cur at 12 \200\22336h. Exertional heat stroke is seen in athlete s/healthy individuals involved in vigorous activity who may not be acclimatized to their en viron- ment. Treatment is through rapid cooling (aim for <38.9o within 30mins of initiating treatment). Evaporative cooling is the safest method \200\224wet the pa- tient with tepid water and fan the skin. Ice packs can be used in axillae and groin. Cooling blankets may be used as can immersion in an ice bath. More invasive methods of cooling have no clear bene \201 t. IV \202 uids and electrolyte replacement may be necessary.429 Prevention of heat illness430 1 Avoid exercise in extreme heat. For those voluntarily undertaking exercise in extreme conditions, acclimatization is vital. 2 Wear loose- \201 tting clothing only. 3 Keep well hydrated \200\224especially if exercis ing; eg 500mL PO prior to exercis- ing and 200mL/15min whilst exercising. As much as 2L/h o ral \202 uid can be required in desert conditions. \200 Electric shock injuries This accounts for 1000 deaths per year in the USA. Lightning strikes kill 150 \200\223300 people per year and seriously injuries 1000 \200\2231500. Util ity workers and those working with electricity lines are the most commonly aff ected. Injur ies within the home are usually due to using improperly earthed appliances or using elec- t rical appliances near water. Factors that increase the severity of injury 431 1 Type of cur rent: Alternating current (AC) is more dangerous than direct cur- rent (DC) of the same mag nitude, causing muscle spasm that may make it impossible for the victim to let go of the so urce. DC usually produces a single large muscular contraction. 789 \200 a m u a r t d n a s c i d e a p o h t r O 2 Energy delivered: This is a product of the applied voltage and subsequent current. Extrem e heating of tissues may occur, causing internal and exter- nal burns and coagulation necro sis. 3 Current pathway: The route that the current takes through the body is also an important f actor. If it passes through the head or chest (eg entry in one arm and exit from the other) , fatal injury is more likely. 4 Resistance encountered: Fluid and electrolyte-rich tissues conduct electric- ity well. Bo ne is the most resistant tissue, whereas skin thickness ( \200\230 resist- ance) is importa nt in limiting the amount of current that passes through the body. Tissues designed to cond uct electricity \200\224heart and nerves \200\224do badly, and they may sustain preferentia l damage when other tissues remain intact. \200\207Check carefully for nerve damage, even if the surface appearances are mild. DC usually causes asystole, and AC causes VF. 5 Contact duration: The briefer the electrocution episode, the better! Treatment of electri c shock \200 Ensure the source of current is turned off before attempting rescue. \200 Use paradoxical triage: resuscitate the apparently \200\230dead \200\231 before attending to the living. Using standard resuscitation techniques, resuscitate long and aggressively \200\224remarkable recoveries have been reported. Assume blunt trauma (stabilize the spine). \200 If there are burns (p732), more \202 ui d replacement is required than for normal thermal burns as electrical burns may penetrate d eeper(start at 7mL/kg/% rather than the standard 4mL/kg/% and adjust to a target urine outp ut of 1 \200\2232mL/kg/hr). \200\207Check for rhabdomyolysis. \200 Treat arrhythmias con ventionally. \200 Occult internal damage can lead to compartment syndrome, most frequentl y in the legs. See p738. TASER injuries432 \200 The TASER is a conducted electricity device used by law enforcement in the US, UK and Australasia. The TASER was invented by Jack Cover, and is an acronym for \200\230Thomas A Swift \200 \231s Electric Ri \202 e \200\231 \200\224named after a \201 ctional character who devel oped an electric ri \202 e. TASERS \201 re barbed copper wires which attach to a subject \200\231s skin or clothing, and discharge upto 50,000 volts of electricity. TASER injuries may be related to barb injuries, electrical injuries or secondary injuries from falling. Barbs should be removed, unless embedded in the orbits or genitalia (pinch the metal part o f the barb and pull directly backwards whilst stabilizing the tissue with the other hand). Patients who have been tasered require an ECG to check for arrhythmia (not shown to persist beyond time of being tasered). Examination for secondary injuries due to muscle contraction should be car- ried out. 790 12 Pre-hospital immediate care Accidents and their prevention 791 Accident statistics (UK) 792 \200 Basic life support Determinism (arti \201 cial respiration) 794 Free will \200 Choking 795 \200 Road crashes Assessment and triage 796 Triage algorithm 797 Equipment 798 \200 First aid treatment 798 \200\230Scoop & run \200\231 or \200\230stay & play \200\231? 799 \200 Recovery position 799 Hazards and extrication 800 1 m Fig 1. If we take a deterministic world view, accidents are in- evitable. But proponents of free will counter that accidents are preventable (see BOX). If we allow ourselves to be ca rried along a road that we feel is laid out for us, then do we relinquish authority to prev ent these accidents? There is a paradox here: it seems both views co-exist and contradict, so which is the real world view? 1 Pre-hospital analgesia 802 Conduct in the \201 eld 803 Communications 804 NATO phonetic a lphabet 805 \200 The major incident 806 Helicopter transportation 808 Trauma scoring 810 B last injury 812 Diving accidents 813 High-altitude medicine 814 Cracks in the teacup 816 Th e helix, the spiral, & penultimate points 816 The last word 816 In German we note that acci- dents don \200\231t just happen: they are built (einen Umfall bauen). Image created by Dr Tom Turmezei. Relevant pages in other chapters Glasgow Coma Scale (p720); ABCDE \200\223 im- mediate app roach to trauma life support (p725); Child Coma Scale (p201); adult basic life support algo rithm (p721); cardiorespiratory arrest (p238 \200\2239 & OHCM endpapers); drowning (p786); burns & smoke inhalation (p732); spinal injury (p766); heat exhaustion (p788); electrocutio n (p789); pneumothorax (OHCM p182); asthma (p164). Sources The best text we have found is P re-hospital Medicine by I Greaves & K Porter, Arnold. For a more concise companion, the sam e authors have also published the Oxford Handbook of Pre-Hospital Care, OUP. EBM and pre-ho spital care: See F Bunn et al Report of WHO Pre-hospital Care Steering Committee. De \201 nition Pre-hospital Immediate Care is the provision of skilled medical help at the scene of an accident or medical emergency, or while in transit to hospital. The Diploma in Immediat e Medical Care (DIMC) is a benchmark for professional standards in this area (nurses, docto rs, and paramedics may apply). 1 History Baron Dominique Larrey, Napoleon \200\231s Surgeon Marshall, may have pro- vided the \201 rst skilled help at the scene with his ambulances volantes ( \200\230 \202 ying am- bulances \200\231), and was the \201 rst to apply the principle of triage \200\224to sort the injured into priorities for treatment (p796 \200 \2237). Note The aim of this chapter is not to provide a full account of the care of any pa tient prior to hospitalization \200\224this is by and large the province of the general pra ctitioner. Rather, our aim here is to highlight those circumstances when doc- tor and param edic can work together eff ectively to save life. 791 \200\207 \200\230Accidents \200\231 are in fact predictable and preventable Road crashes a ff ect 1 in 4 people in their lifetime. Each day 3400 people die and >50,000 people are in jured on the world \200\231s roads. 90% of fatalities are in low- and middle-income countri es, even though they contain <50% of the world \200\231s vehicles. Crash- es are a chief ca use of death in those <45yrs; most deaths in the 15 \200\22319 age group are preventable. I ndia has the worst record (14 fatalities/10,000 vehicles /yr \211\210 106,000 deaths/ yr). 2 In the UK, road deaths have fallen since 1966 despite a >50% \200\200 in numbers of veh icles. There were 2,222 deaths and 27,000 serious injuries in Britain in 2009.4 Car users accounted for almost half of all deaths, cyclists for 5%, motorcy- clists for 22% and ped estrians for 26%. Proven life-savers 3 \200 Booster seats \200 Fencing around water e r a c areas e t a i d e m m Flame-resistant clothes \200 Smoke detectors i l a t i p s o h - e r P Data analysis shows little impact on the rate of decline in fatal accidents in the UK from the seat-belt law (1983). One reason may be risk compensation, ie safety improvements are t ransferred by drivers into increased speed or recklessness, showing that public health expe rts must recognize our complex emotional and cognitive reactions to safety issues. 5 Air bags also give a complex picture. They reduce fatalities, but front seat children witho ut a seat belt and infants in passenger-side rear-facing car seats are at risk of fatal inj ury. Burns, high-frequency hearing loss, corneal and retinal injuries also occur. 6 Age fac tors: babies are rarely killed as their risk exposure is less. Deaths fall in middle age, r ising again before falling in old age. In children, death rates are higher in lower social classes and more deprived socioeconomic areas. 7 Alcohol is involved in 17% of fatal crashe s. 24% of drivers and 33% of pe- destrians killed have blood alcohol levels > the legal lim it of 80mg/100mL (17.4mmol/L). This rises to 50% of drivers and 75% of pedestrians killed between 10PM & 4AM. 4 There is evidence that older drivers compensate for alcohol-impaired performance by driving carefully; young drivers can com- pensate in this way, but may choos e not to do so (peer group pressure or a delight in risk-taking). Chronic marijuana use is also associated with an \200\200 risk of car crash \200\224interestingly, the same study s howed that after controlling for other risk factors, acute use was not. 8 Benzodiazepines, antidepressants, antihistamines, and mobile phone use (the latter illegal in UK since 2003) also contribute to road crashes, and it is important that patients are ad vised not to drive while on these. 9 \200\207If a patient has epilepsy or diabetes with hypoglycaemic attacks (or is otherwise un \201 t to drive, p526) it is his duty to inform the licensing authori- ties, and the do ctor \200\231s duty to request him to do so. Prevention A vital cognitive shift occurs if t he word accident is replaced by preventable occurrence, implying that accidents are predict able \200\224often re- sulting from laziness, haste, ignorance, bad design, false economy, and failure to apply existing knowledge. Safety education can change behavior. 10