Other road users may react to emergency vehicles in a number of ways. Hopefully, they will simply move out of the way in a safe manner. Sudden braking, rapid changes of lane, and ref usal to give way are also possible. When other motorists do co-operate, this should be ackn owl- edged. Escorted convoys pose particular hazards. Other vehicles may give way to one ve hicle before pulling out into the path of those follow- ing, confusion may occur when side roads are not blocked as expected, and the situation may degenerate into a race. Parking at scene The first vehicle on scene should park in the fend off position (Fig. 1.3) . If other vehicles are already present, the new arrival should use the system in Fig. 1.4, or follow the instructions of the police. If the police are in charge of the incident, a ( spare) set of keys should be left in the ignition. Otherwise, the vehicle should be locked. Accidents en route Green lights do not confer any privileges under the Highway Code. It is essential, therefore, that due care is paid to avoiding accidents. When an accident involvi ng a responding car does occur, the driver is obliged to stop and exchange details as in a \200\230conventional \200\231 collision. GETTING THERE: SAFE DRIVING TO THE SCENE1 43 Fig. 1.2 Using road position to maximize visibility on a rural road. Reprinted with permiss ion from Greaves I et al. (2006). Emergency care \200\224a textbook for paramedics, 2nd edn . W.B. Saunders. CHAPTER 1 An approach to pre-hospital care 44 Fig. 1.3 The \200\230fend off \200\231 position. Reprinted with permission from Greaves I et al. (2006). Emergency care \200\224a textbook for paramedics, 2nd edn. W.B. Saunders. GETTING THERE: SAFE DRIVING TO THE SCENE1 45 s e c i l e n o o P C , s c d e m a r a p i r o f 2 k o o b t x e t s e n o C e r i F a \200\224 e r a c y c n e g r e m E . ) 6 0 0 2 ( s e n o C 1 e r i F . l a t e n o i t a v r e s e r I r e d u o h s s e v a e r G m o r f l d r a H l a r t n e C h s a r C s e n o C n o i s s i m r e p h t i w d e t n i r p e R . e n e c s s e n o C e c n a l u b m A t a g n k r a p i . s r e d n u a S e c v r e s - i t l u M i . B W s e n o C r o t c o D . . n d e 4 1 . . g i F d n 2 CHAPTER 1 An approach to pre-hospital care 46 Record keeping Good record keeping is an essential component of pre-hospital care. How- eve r, the lone practitioner cannot be expected to complete records at the same time as assessi ng and managing a critically ill or injured patient. It is inevitable, therefore, that in s ome cases notes will be compiled retrospec- tively, usually after patient handover either t o ambulance personnel or in hospital. This is no reason for inadequate or incomplete record s. Missing clinical data should not be guessed or estimated! Good records should be kept for the following reasons: They may contain information which will otherwise be unavailable once pre-hospital personnel have left the hospital. They will prevent drug errors such as repeat dosing or overdosing (this is particularly important if opiates have been given pre-hospital). They will facilitate audit, service development, and research. - They may offer some protec tion in the event of a subsequent complaint or inquiry. They are legal records in the event of an inquest or criminal case. All the necessary infor mation should be entered on a pre-printed sheet. Unless there is absolutely no alternative, scribbled notes on scraps of paper are inadequate, amateurish, and bring the specialty int o disrepute. Equally, there is little point in every pre-hospital practitioner inventing th eir own record chart. We suggest that practitioners either use the one provided by the loca l ambulance service (with their permission) or the BASICS report form, available from BASIC S (contact details on p.66). This page intentionally left blank CHAPTER 1 An approach to pre-hospital care 48 The emergency services: the police Roles Duties of the police include: - Keeping the peace. - Prevention and investigation of crime. - Protection of property. - Law enforcement (incl uding road traffic). - Major incident management. - Investigation of sudden death, as agent s of the coroner. Organization Each police force is under the operational command of a chief constable (commi ssioner in London). However, police services are required to consult the public they serve and, as a result, are heavily involved in community liaison. A number of authorities and bo dies have responsibil- ity for the strategy and efficiency of each individual force. The Ho me Office is responsible for promoting the general efficiency of the police and has ultimat e responsibility for levels of funding. In addition, it is responsible for the setting of n ational performance targets and approves the appointment of chief and assistant chief const ables. The local police authority consists of local councilors, magistrates, and independent membe rs. It is responsible for the provision of an efficient police service in its area and has ultimate responsibility for expenditure which is delegated to a greater or lesser extent to the chief constable. The police authority sets local policing objectives and targets and, in consultation with the chief constable, is responsible for the preparation and submission to the Home Office of a local policing plan. Civilian staff are employed by the police aut hority but, in general, are placed under the operational control of the chief constable. The chief constable directs and controls the police force. S/he is responsible for the fina ncial management of the force under the control of the police authority and directs police officers and civilian staff other than those managed directly by the police authority. The chief constable is responsible for drawing up the draft policing plan for approval or amend ment by the police authority. The chief constable is responsible for the operational deploy ment of his resources. Rank structure The rank structure of provincial police forces is shown in Fig. 1.5, and of the Metropolitan Police, in Fig. 1.6. The City of London police force uses the same rank st ructure as the Metropolitan Police. Other police forces The Royal Parks Police has responsibility for the London Royal Parks, t he British Transportation Police for railroad tracks and train stations, and the Ministry o f Defense Police for areas of Defense estates. The Special Con- stabulary is a part-time vo lunteer police force which assists the regular constabulary. THE EMERGENCY SERVICES: THE POLICE1 49 245 23 Constable Sergeant Inspector Chief inspector Superintendent Regional police services UK Chief superintendent Assistant chief constable Deputy chief constable Chief constable Fig. 1.5 Police service ranks and rank markings \200\224provincial (outside London). Reprin ted with permission from Greaves I et al. (2006). Emergency care \200\224a hand- book for p aramedics, 2nd edn. W.B. Saunders Ltd. 245 23 Constable Sergeant Inspector Chief inspector Superintendent Metropolitan and City of London police Commander Commissioner Chief superintendent Deputy assistant commissioner Assistant commissioner Deputy commissioner Fig. 1.6 Metropolitan (and City of London) police ranks and rank markings. Reprinted with p ermission from Greaves I et al. (2006). Emergency care \200\224a handbook for paramedics, 2 nd edn. W.B. Saunders Ltd. CHAPTER 1 An approach to pre-hospital care 50 Special duties Criminal investigation The Criminal Investigation Department (CID) deals wit h serious crime such as burglary, sex offenses, and murder. Special departments dealing wit h areas such as child abuse, drug, and computer crime operate under the umbrella of the CID as does the Scenes of Crime Department. Traffic The Traffic Department is responsible for safety on the roads, accident investigati on, and vehicle related crime. Operations (special operations) These include: - Firearms teams - Dog teams - Mounted polic e - Underwater search - Air support (helicopters) - Anti-terrorist operations. Preservation of evidence Pre-hospital clinicians must be aware of the importance of preserv ing evidence. Blundering into a crime scene may alter or destroy evidence and render a subs equent successful prosecution impossible. If it is possi- ble that a crime has taken place, great care should be taken to ensure that evidence is not lost. It is important, therefore , to: - Wear gloves, even if they are not clinically indicated. - Avoid touching any object more than is absolutely necessary. - Avoid opening or closing doors or switching off light s or appliances (unless safety or patient management demands it). Restrict the numbers of medical staff entering the scene. In managing the patient it is vital to: Avoid removal of clothes by cutting through stab or gun holes. - Ensure that articles from different patients are not mixed. - Remove articles (including clothes) from the patient an d hand them to an identified person (preferably a police officer) for bagging and labeling. Nevertheless, it should be remembered that the primary responsibility of all health service s personnel, at all times, is to save and preserve life. Major incidents The role of the police at a major incident is discussed in Chapter 10. This page intentionally left blank CHAPTER 1 An approach to pre-hospital care 52 The emergency services: the fire service Roles - To save life (including accident rescue an d extrication). - To protect property (fire or flooding). - To provide humanitarian support . - To protect the environment (including hazardous material management). Organization Fire Services operate under local authority control via fire authorities. In E ngland and Wales, ultimate responsibility for all fire services lies with the Home Secretar y who exercises this responsibility through the inspectors of the Fire Department. Fire aut horities have absolute discretion in the day-to-day management of their services. In Scotla nd, final responsibility lies with the Secretary of State for Scotland. Each service is headed by a Chief Fire Officer (Firemaster in Scotland) from a headquarters housing senior officers and support staff. Regionally, most services are divided into divi sions each under the control of a divi- sional officer. Every division contains a number of stations each under the control of a station officer. Each station is staffed by four watc hes contain- ing firefighters and under the command of a sub-officer assisted by a lead- in g firefighter. Fire service rank markings are shown in Fig. 1.7. Officers above the rank of sub-officer have white helmets; below sub- officer have yellow. The greater the width of black banding, the more senior the officer. Retained firefighters work part-time in the fire service, providing sup- port to full-time colleagues in urban areas or a primary response service where the call level is insufficien t to justify full-time manning. Road traffic accident management The fire service recognize six phases in the management of a road traffic collision entrapment. These are: - Scene assessment and safety. - Stabiliza tion and initial access. - Glass management. - Space creation. - Full access and immobiliza tion. - Extrication. Scene assessment and safety An overview of the incident scene with an assessment of any haz ards present and a determination of immediate priorities. Stabilization and initial access Stabilization of vehicles and initial approach to trapped casualties. In certain circumstances, hazards may determine the necessity for an imme- diat e snatch rescue of casualties. THE EMERGENCY SERVICES: THE FIRE SERVICE1 53 Firefighter Leading firefighter Sub-officer Station officer Assistant divisional officer Divisional officer Senior divisional officer Assistant chief officer Chief officer Fig. 1.7 Fire service ranks and rank markings. CHAPTER 1 An approach to pre-hospital care 54 Glass management Controlled removal or breakage of windows with protection of trapped casua lties. Space creation and full access Systematic dismantling of the vehicle to achieve access to t he casualties for treatment and extrication. Extrication Controlled extrication of the casualty under the supervision of a para- medic o r doctor whilst maintaining spinal immobilization. Fire service equipment Fire brigade vehicles carry the following equipment: - Personal prot ective equipment - Communications equipment - Basic medical equipment - Extrication equipme nt - Miscellaneous equipment Lighting - Stabilization - Specialist extrication equipment. Major incidents The role of the fire services in the management of major incidents is descr ibed on p.592. This page intentionally left blank CHAPTER 1 An approach to pre-hospital care 56 The emergency services: the ambulance service Roles - Emergency patient transfer. - Routine patient movements. - Provision of medical support at the scene of major incidents. Organiz ation Ambulance services are NHS trusts under the direction of a chief execu- tive. Each tr ust has a trust board, the chairman of which is appointed by the Secretary of State. The bo ard contains executive and non-executive directors. The service headquarters provides finan cial and human resources management. Each ambulance service has a medical director or advis or. In some services, a full time medical director has been appointed. The operations component of each ambulance service includes: Accident and emergency vehicles ( \200\230front-line \200\231 ambulances) - Patient transpo rtation services - Support and technical components Accident and emergency vehicles also un dertake specialist transfers of critically ill patients as well as retrieval missions for s pecial categories of patient such as neonatal intensive care. Emergency ambulance response times are governed by ORCON (Operational Research Consultantcy) standards. These require an ambulance to reach the patient in 50% of cases within 8 minutes, and in 95% of cases, in 1 4 minutes in urban areas and 19 minutes in rural areas. There is no clinical rationale for these figures and they are likely to change. In addition to emergency vehicles, the ambulan ce service also provides the routine transportation for outpatient visits, hospital admissi ons, and discharges and for a variety of other social services agencies. They are also char ged with providing a structured response to major incidents (see pp.592 \200\2233). As well as front-line ambulances and patient transportation vehicles, ambulance service tru sts also provide paramedic response vehicles (cars, four-wheel drive vehicles, motorbikes a nd cycles), support vehicles (including major incident control vehicles), and helicopters ( although air ambulances may also be charitably funded). THE EMERGENCY SERVICES: THE AMBULANCE SERVICE1 57 Ambulance dispatch Modern ambulance dispatch is highly technical. Details from 999 calls en ter a computer aided dispatch (CAD) system which is able to locate the most appropriate veh icle using an automatic vehicle location system (AVLS). In order to reduce response times, vehicles are dispatched as soon as the approximate location of the call is known. Protocol- based dispatch systems allow prioritization of calls and data can be passed directly to amb ulance crew en route to the incident via a pager or vehicle-based data terminal. These disp atch systems also provide first aid instruction for the caller before the ambulance arrives . CHAPTER 1 An approach to pre-hospital care 58 The emergency services: other agencies Her Majesty \200\231s Coastguard Her Majesty \200 \231s Coastguard is part of the Maritime and Coastguard Agency (MCA). It is responsible for co-ordinating search and rescue around Britain \200\231s coast through six Maritime Rescue Co-ordination Centers (MRCC), twelve Maritime Rescue Sub-centers (MRSC), and sector bases. The Royal National Lifeboat institution (RNLI) The RNLI is a charity which provides 24-hou r rescue services around the coast of Great Britain and the Republic of Ireland. It operate s both in-shore and seagoing rescue services. The armed forces Pre-hospital clinicians are unlikely to encounter members of Her Majesty \200\231s Forces unless there has been a major incident, when their assistance under the Military Aid to the Civil Powers (MAC) scheme ma y be requested (see p.593). The voluntary services St John \200\231s Ambulance St John \200 \231s Ambulance was founded in 1877. It provides first aid cover at a wide range of public events and sporting fixtures. Although the majority of volunteers are first-aid trained, St John \200\231s can also provide doctors and registered nurses. Locally, St John \200\231s is divided into divisions, then districts, areas, and counties. Uniform is worn, with a str uctured rank system. A considerable range of often sophisticated equipment and vehicles is available. St John \200\231s Ambulance is a major first aid trainer. British Red Cross The British Red Cross is an arm of the international Red Cross Move- ment founded by Henri Duna nt. It aims to provide care to people in their own communities and after major or traumatic incidents but also provides volunteers for service overseas in both peace and war. Each lo cal branch of the Red Cross is run by trustees who are responsible to the National Council. St Andrew \200\231s Ambulance Service St Andrew \200\231s Ambulance Service in Scotland pr ovides first aid provision at sporting fixtures and public events. Women \200\231s Royal Vo luntary Service (WRVS) Founded just before the Second World War, the WRVS plays a wide rang e of roles in community life from old people \200\231s luncheon clubs to hospital tea bars and meals on wheels. Although the emergency services provided by the WRVS have declined in importance since the war, teams are available and can be provided for a wide range of emerg ency situations from house fires to major incidents. Each area of the UK has a WRVS co-ordi nator for these services. Emergency services provided by the WRVS include refreshments, war m bedding, rest center provision, and support and comfort, not only to victims but also to members of the emergency services. This page intentionally left blank CHAPTER 1 An approach to pre-hospital care 60 The Faculty of Pre-hospital Care The Faculty of Pre-hospital Care of the Royal College of S urgeons of Edinburgh organizes the Diploma in Immediate Medical Care of the Royal College o f Surgeons of Edinburgh (DipIMC.RCSEd) and the Fellowship in Immediate Medical Care of the Royal College of Surgeons of Edinburgh (FIMC.RCSEd.) Details of both these examinations can be obtained from the Examinations Office at the College (see useful addresses, p.66). The Faculty also accredits a wide range of short modular courses such as the First Person o n Scene (FPOS) Course and (jointly with BASICS and BASICS Scotland) Pre-hospital Emergency Care (PHEC), and is actively involved in a wide range of joint educational initiatives with other medical bodies. The provision of expert advice regarding pre-hospital care matters is an important part of the Faculty \200\231s role and it works with a wide variety of agencies from airlines to oi l-rigs. The Faculty has an active Pre-hospital Care Research Center based at the James Cook University Hospital on Teesside. Membership of the Faculty is open to paramedics, doctors, and nurses, as well as other emer gency personel (for contact details, see p.66). Mem- bers receive the Emergency Medicine Jo urnal as part of their subscription. This page intentionally left blank CHAPTER 1 An approach to pre-hospital care 62 BASICS and BASICS Scotland The British Association for Immediate Care (BASICS) and BASICS S cotland are national charities which represent a wide range of individual pre- hospital pro viders and schemes. Both organizations are very heavily involved in educational initiatives and, like the Faculty (see p.60), offer advice regarding the provision of pre-hospital car e through a wide range of bodies and standing committees. Contact details for BASICS, BASIC S Education, and BASICS Scotland are given on p.66. BASICS members receive the Emergency Me dicine Journal as part of their subscription. This page intentionally left blank CHAPTER 1 An approach to pre-hospital care 64 Suggested reading General texts Practical pre-hospital care Ian Greaves, Keith Porter, and Jason Smith (eds) (2006). Elsevier. Pre-hospital care: a textbook for paramedics, (2nd edn). Ian Greaves, Keith Porter, and Tim Hodgetts (eds) (2005). Elsevier. Pre-hospital emergency care secrets. Peter T Pons and Vincent J Markovchick (eds) (1998). H anley and Belfus. Essentials of immediate care (2nd edn). C John Eaton (1999). Churchill Livingstone. More specialized texts Safety at scene Vic Calland (2000). Mosby. Handbook of patient transportation Terry Martin (2001). Greenwich Medical Media. Roadcraft: the police driver \200\231s handbook The Stationery Office (1999). Pre-hospital pediatric life support Advanced Life Support Group (2000). BMJ Books. Major incident medical management and support (2nd edn) Advanced Life Support Group (2002). BMJ Books. Major incident management system Timothy J Hodgetts and Crispin Porter (2002). BMJ Books. Journals Emergency Medicine Journal (BMJ Publications) The EMJ is the \200\230house journa l \200\231 of BASICS, BASICS Scotland, and the Faculty of Pre-Hospital Care. Mainly concern ed with emergency medi- cine, (A&E) it also includes a significant component of pre-hospita l care and publishes most of the important pre-hospital research and practice development. This page intentionally left blank CHAPTER 1 An approach to pre-hospital care 66 Useful addresses Advanced Life Support Group 29 \200\22331 Ellesmere Street, Swinton, Manch ester M27 OLA www.alsg.org 0161 794 1999 British Association for Immediate Care (BASICS) Tu rret House, Turret Lane, Ipswich, Suffolk IP4 1DL www.basics.org.uk 0870 165 4999 BASICS Ed ucation Turret House, Turret Lane, Ipswich, Suffolk IP4 1DL www.basics.org.uk 0870 165 4999 BASICS Scotland Sandpiper House, Aberuthven Enterprise Park, Aberuthven PH3 1EL www.basics -scotland.org 01764 663671 Department of Academic Emergency Medicine, University of Teessid e Academic Center, The James Cook University Hospital, Marton Road, Middlesbrough, Clevelan d TS4 3BW www.teessideem.org.uk 01642 282898 EdExcel IHCD Stewart House, 32 Russell Square, London WC1B 5DN www.edexcel.org.uk 0870 240 9800 Examinations Office, Royal College of Sur geons of Edinburgh Examinations Office, Royal College of Surgeons of Edinburgh, The Adamson Center, 3 Hill Place, Edinburgh EH8 9DS www.rcsed.ac.uk 0131 527 1600 USEFUL ADDRESSES1 67 Faculty of Pre-hospital Care of the Royal College of Surgeons of Edinburgh Faculty of Pre-h ospital Care, Royal College of Surgeons of Edinburgh, Nicolson Street, Edinburgh EH8 9DW ww w.rcsed.ac.uk 0131 527 1732 Faculty of Pre-hospital Care Research Unit Academic Center, The James Cook University Hospital, Marton Road, Middlesbrough, Cleveland TS4 3BW www.teesside em.org.uk 01642 282898 This page intentionally left blank Chapter 2 69 Acute medical and surgical problems Approach to the acute medical patient 70 A symptom-based approach 72 Pre-hospital investiga tions and monitoring 78 Pulse oximetry 80 Cardiological emergencies 82 Advanced life suppor t 90 Bradycardias 102 Tachycardias 108 Myocardial ischaemia 114 Pericarditis 122 Shingles ( Herpes zoster) 124 Acute pulmonary oedema 126 Acute exacerbations of asthma 128 Chronic obs tructive pulmonary disease (COPD) 130 Pulmonary embolism 132 Pneumothorax 134 Hyperventilat ion syndrome 138 The unconscious patient 140 Cerebrovascular events 144 Status epilepticus 146 Meningococcal meningitis and meningococcal septicaemia 148 Poisoning (including drugs a nd alcohol) 150 Hypothermia 150 Diabetic emergencies 152 The acute abdomen 154 Abdominal ao rtic aneurysm (AAA) 154 Acute appendicitis 157 Gallbladder disease 158 Acute pancreatitis 1 59 Peptic ulcer disease 160 Ureteric colic (renal stones) 161 Acute pyelonephritis 162 Gyne cological causes of abdominal pain 163 Bowel obstruction 164 Mesenteric infarction 165 Dive rticular disease 166 Medical causes of abdominal pain 167 CHAPTER 2 Acute medical and surgical problems 70 Approach to the acute medical patient The initial clinical priority in the management of me dical problems in the pre-hospital environment is to ensure that the patient does not suffe r a catastrophic deterioration before they reach definitive care. For this reason, the fami liar ABC approach is as relevant in medical cases as it is in trauma: A Airway Consider C spine immobilization if the patient may have suffered an injury during a collapse. B Breathing Patients whose respiratory effort (rate and volume) is inadequate will require ventilatory support. All patients should receive high-flow oxygen unless it is apparent tha t they are suffering solely from an exacerbation of established chronic obstructive pulmona ry disease. C Circulation An assessment of the pulse and blood pressure (by palpation of pulses if nece ssary) provides evidence of inadequate circulation as a result either of dysrhythmia or car diac failure. D Disability AVPU and pupillary assessment may suggest the presence of an intra- cerebral c atastrophe or a reduced level of consciousness due to a meta- bolic problem or poisoning. E Exposure Limited exposure may reveal signs of complicating injury, a MEDIC ALERT \233\232 bracelet, needle marks, or cutaneous signs of disease. Many patients who present with pre-hospital medical problems will be suffering from an exac erbation of an existing problem. Similarly, a knowl- edge of the previous medical history m ay suggest the current diagnosis. If the diagnosis is not clear, a symptomatic approach mus t be used. DON \200\231T FORGET A BM STIX This page intentionally left blank CHAPTER 2 Acute medical and surgical problems 72 A symptom-based approach Chest pain Ischaemic chest pain Angina (see p.114) Clinical featur es: - Typically crushing \200\230like a weight \200\231 \200\230like a band round my ches t \200\231 - Induced by exercise - Improved by rest - Often a previous history - Responds t o GTN spray - More common in smokers. Myocardial infarction (see p.116) Clinical features: - Similar character to angina - More s evere and/or prolonged than \200\230usual \200\231 angina pain - Onset at rest - Not relie ved by rest/GTN. Associated symptoms: - Shortness of breath - Pallor - Cold clammy skin. Chest wall pain Clinical features: - Usually \200\230sharp \200\231 - Worse with coughing, deep respiration (pleuritic) - Associated with well localized chest tenderness - May follo w minor trauma (may be spontaneous) - NOT normally associated with shortness of breath - Re spiratory examination normal. Pulmonary pain Pneumothorax (see pp.134 \200\2236) - Usually \200\230sharp \200\231 - Sudd en onset - Pleuritic in nature - Not usually associated with chest wall tenderness (unless traumatic) - Associated with shortness of breath - May be previous history of pneumothorax - More common in asthmatics and tall young men - Reduced breath sounds and hyper-resonant p ercussion note on examination. A SYMPTOM-BASED APPROACH1 73 Causes of chest pain (see text) Ischaemic heart disease Angina - Myocardial infarction Chest wall pain Minor trauma - Costochondreitis Pulmonary Pneumothorax - Pneumonia - Pulmonary embolism Gastrointestinal Oesophageal reflux/oesophagitis - Peptic ulceration Aortic dissection - Rarer causes Herpes zoster (shingles) - Cholecystitis - Pancreatitis - Pericarditis CONSIDER PNEUMOTHORAX IN THE DETERIORATING ASTHMATIC CHAPTER 2 Acute medical and surgical problems 74 Pneumonia - Onset usually gradual - Pleuritic - Associated with shortness of breath - Green /brown sputum (worse early morning) - Patient generally unwell Pyrexial - Sweaty - Rigors (in systemic infection) Haemoptysis may be present - Commonly complicates COPD. Pulmonary embolism (see p.132) - Sudden onset - Pleuritic - Associated with shortness of br eath - Haemoptysis (sometimes) - Dizzness, syncope, collapse (rare) - Associated with DVT ( check the calves!) - Increased risk with: Oral contraceptive pill - Immobility \200\224long journeys, illness - Pregnancy and childbi rth - Previous thromboembolic disease - Morbid obesity - Recent surgery May be a family history of DVT or PE. Gastrointestinal causes of chest pain Oesophageal reflux/oesophagitis - Usually retrosterna l - Burning - Worse after food - Associated with particular food types - May be worse in ce rtain positions - Associated with trapped wind - May be a long history - May respond to ant acids. Peptic ulcer pain - Usually epigastric - May be history of aspirin/non-steroidal ingestion - May radiate to the back (beware aortic aneurysm \200\224see p.154). Aortic dissection - Sudden onset central and interscapular/back pain - Pain may be \200 \230tearing \200\231 - Patient may be hypo- or hypertensive - Physical examination may reve al absent pulses, new murmurs, neurological signs, or BP differences between the arms. A SYMPTOM-BASED APPROACH1 75 Herpes zoster \200\224shingles (see p.124) Shingles may present with pain in the clear dist ribution of one of the thoracic nerve roots. When the typical vesicular rash is present, th e diagnosis is obvious, However, the pain may precede the rash. Cholecystitis (see p.158). Pancreatitis (see p.159). Pericarditis (see pp.122 \200\2233). CHAPTER 2 Acute medical and surgical problems 76 Shortness of breath Asthma (see p.128 \200\2239) - Tachypnoea - Reduced peak flow - Signs o f underlying infection or pneumothorax - Declining respiratory effort and exhaustion (more severe and late cases) Cyanosis - Hypoxia - Hypotension (late and severe cases) - Ventilatory failure /confusion o r coma (suggestive of rising PaCO2). Pulmonary oedema (see p.126) - Breathlessness (acute o r acute on chronic) - Cough - Frothy sputum (may be lightly blood stained) - Collapse - Sho ck, sweating, pallor, peripheral coldness. Other symptoms reflect the underlying cause: - Chest pain - Palpitation. COPD (p.130) - Wheeze unresponsive to inhaler therapy - Production of purulent sputum/incre ased sputum production - Increasingly severe breathlessness - Respiratory failure - Increas ed respiratory rate (>25/min suggests a significant exacerbation) - Cyanosis - Use of acces sory muscles - CO2 retention flap, confusion (indicative of hypercapnoea) - Bilateral wides pread wheezes (beware the silent chest) - Peripheral oedema. Causes of shortness of breath Asthma - Pulmonary oedema - COPD - Pneumonia - Pneumothorax - Pulmonary embolism - Hyperven tilation syndrome - Respiratory compensation for a metabolic acidosis A SYMPTOM-BASED APPROACH1 77 Pneumonia - Cough - Tachypnoea - Purulent sputum - Pyrexia/rigors - Pleuritic chest pain - May be underlying lung disease. Pneumothorax (pp.134 \200\2236) - Shortness of breath (usually sudden onset) - Chest pain ( non-specific, often pleuritic) - Acute severe exacerbation of asthma or COPD - May be previ ous history - More common in asthmatics and tall young men - Increasing difficulty in manua lly ventilating a patient or deteriorating hypoxia despite effective ventilation. Pulmonary embolism (see p.132) - Sudden onset - Pleuritic - Associated with shortness of br eath - Haemoptysis (sometimes) - Dizziness, syncope, collapse (rare) - Associated with DVT (check the calves!) - Increased risk with: Oral contraceptive pill - Immobility \200\224long journeys, illness - Pregnancy and childbi rth - Previous thromboembolic disease - Morbid obesity - Recent surgery May be a family history of DVT or PE. Hyperventilation syndrome (see p.138) - Anxiety/panic - Hyperventilation - Per-oral tinglin g - Carpopedal spasm - Tinnitus - Chest tightness. Respiratory compensation for a metabolic acidosis - Difficult to diagnose definitively pre- hospital - May be secondary to: Diabetic ketoacidosis - Tricyclic antidepressant poisoning. CHAPTER 2 Acute medical and surgical problems 78 Pre-hospital investigations and monitoring Pre-hospital investigations are only of value if the results will alter patient management. Most investigations can be undertaken more effe ctively, more comfortably, and more quickly after arrival in hospital. Under no circumstanc es should the transfer of a critically ill or injured patient be delayed. All patients with significant injuries or medical problems should have the following monitoring: - ECG - Pulse oximetry - Non-invasive BP (during transfer) ALL pa tients whose level of conscious is reduced should have a BM stix (blood sugar measurement ). This page intentionally left blank CHAPTER 2 Acute medical and surgical problems 80 Pulse oximetry The pulse oximeter probe contains two light-emitting diodes (producing red a nd infrared light) and a light detector which measures the intensity of the light after it has passed through the tissues. Oxygenated and reduced haemoglobins show different light-ab sorbing properties which affect the relative amounts of light measured by the sensor. Pulse oximetry measures pulse and oxygen saturation; it does not measure PaO2. Applications - Measurement of oxygenation during transportation. - Assessment of limb viabi lity following injury. - Assessment of pulse and saturation in ill patients. Limitations - Does not measure CO2, therefore may provide false reassurance in respiratory failure or inadequacy with rising CO2 levels. May be ineffective in poor tissue perfusion (including due to cold). - Effected by bright a mbient light. - Ineffective through metallic nail varnish. - Does not distinguish met- or c arboxyhaemoglobins and may, therefore, give a falsely high O2 reading in carbon monoxide poisoning. PULSE OXIMETRY1 81 Altitude (x 1000ft) 5 15 10 Sea level 100 90 80 70 b H n o i t a r u t a S % 60 50 40 30 20 10 0 0 10 20 30 40 50 60 70 80 90 100 110 Partial pressure of arterial oxygen (mmHg) Fig. 2.1 Hemoglobin-oxygen dissociation curve. CHAPTER 2 Acute medical and surgical problems 82 Cardiological emergencies Patient assessment The assessment of the patient with a known or suspected cardiac prob- lem is as follows: - Observe Responsiveness - Pallor - Sweating - Dyspnoea (count the respiratory rate!) - Cyanosis - Ju gular venous pressure Listen Noise of airway obstruction - Wheeze - Added sounds (crepitations or rhonchi) - Heart sound s Feel Pulse (volume, rate, and character) - Distal pulses where appropriate - Chest expansion. Cardiac arrest The most common arrhythmias associated with cardiac arrest are ven- tricular fibrillation (VF) and pulseless ventricular tachycardia (pulseless VT). Providing good-qua lity advanced life support is available, there is little if any justification for transport ing patients with one of these rhythms to hospital until cardiac output has been restored. Cardiac arrest may also occur with pulseless electrical activity (PEA) and asystole. Immediate actions in cardiac arrest: Assess response - Assess airway - Assess breathing - Call for help Expose chest - Commence CPR 30 compressions: 2 breaths. As soon as a diagnosis of cardiac arrest is established, professional assistance must be so ught if a defibrillator is not available, even if this means leaving the patient for a shor t period. Safety Safety is vital at a cardiac arrest. Careful attention should be paid to ensuring th at rescuers are not at risk during defibrillation. Defibrillation may take place in the rai n (the patient \200\231s chest should be wiped dry first) but is dangerous if the patient i s lying in a pool of water (for example, at the side of a swimming pool). CARDIOLOGICAL EMERGENCIES1 83 (a) (b) (c) Fig. 2.2 Placing a patient in the recovery position. Reprinted with permission from Greaves I and Porter K (1997). Pre-hospital medicine \200\224the principles and practice of immedi ate care. Edward Arnold (Publishers) Ltd. CHAPTER 2 Acute medical and surgical problems 84 Basic life support Good basic life support is the key to the treatment of cardiac arrest. P rolonged absence of BLS makes a successful outcome extremely unlikely. If a patient has not had BLS for 15 minutes or more after a collapse, and the monitor shows asystole, ALS is no t indicated. The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) recognizes the following as b eing reasons for NOT commencing resusci- tation: - Decapitation - Massive cranial and cereb ral destruction - Hemi-corporectomy - Decomposition - Incineration - Hypostasis - Rigor mor tis - Submersion for more than one hour - Presence of a \200\230Do Not Resuscitate \200 \231 (DNR) order or living will. Artificial ventilation In order to avoid the risk of transmission of infection, not to ment ion for esthetic reasons, mouth-to-mouth resuscitation cannot be recom- mended for use by h ealth-care professionals. Whenever possible, mouth-to-mask ventilation should be used with supplemental oxygen. A resuscitation face shield or pocket mask is an alternative. If mouth-to-mouth is carried out, the nose should be closed by pinching and poorly fitting dentures and foreign bodies removed from the mouth. Well- fitting dentures should be left i n place. Summary of BLS CHECK FOR SAFETY - Check for responsiveness (shake the shoulders* and ask \200\230are you alright? \200\231). If the patient responds, leave them as they are; attempt to gain further information and seek help if necessary. If there is no response, SHOUT FOR HELP. - Use simple maneuvers to open the airway. - If th ey are breathing normally, put them in the recovery position and obtain help, otherwise: Give 30 compressions \200\224DO NOT check the pulse first (for technique, see below). Give 2 rescue breaths (for technique, see below). - Repeat cycle of 30 compressions followe d by 2 rescue breaths**. - Continue until spontaneous breathing recommences or assistance (with a defibrillator) arrives. NOTES Care if there is a possibility of C spine injury. ** Compression only CPR may be used as an alternative in situations where the rescuer is unable or unwilling to provide artificial r espiration. CARDIOLOGICAL EMERGENCIES1 85 UNRESPONSIVE? Shout for help Open airway NOT BREATHING NORMALLY? Call 999 30 chest compressions 2 rescue breaths 30 compressions Fig. 2.3 Adult basic life support algorithm. Reprinted wth permission from Resus- citation Council (UK) (2005). Resuscitation Guidelines. CHAPTER 2 Acute medical and surgical problems 86 Technique of mouth-to-mask ventilation - The airway is cleared and the chin tilted (ideally not if there is a risk of C spine injury, although it may be necessary). Well-fitting fals e teeth are left in situ. The mask is applied over the nose and mouth and the face \200\230lifted \200\231 into it with the hands in the position shown opposite (Fig. 2.4a) Breaths lasting 1 second are given, whilst watching for the chest to rise. - During the \200\230expiration \200\231 phase, the mouth is lifted from the mask which continues to be held in place Irrespective of the number of rescuers, ventilations are delivered at a ratio of 2 breaths to 30 compressions. Technique of chest compressions (see Fig. 2.4b) - The heal of the hand is placed at the mid point between the suprasternal notch and the xiphisternum. The other hand is placed on top of the first and the fingers interlocked. - Keeping the arm s vertical and straight, the chest is compressed one-third of the thickness of the chest.