any gasoline. Identify the time-critical patient \200\224some will die unless rapidly removed from the vehicle, at whatever cost. Read the wreckage \200\224relate the damage of the vehicle to potential injuries: steering wheel deformed = chest injury; dashboard intrusion = patella/femur fracture posterior di slocation of the hip. Bodies are softer than metal: major bodywork distortion = major injur y. The easiest way to enter a car is through the door \200\224try this before removing the windshield or the roof! Remove the wreckage from the casualty, not the casualty from the wreckage; don \200\231t try to maneuver the casualty through too small a hole. Don \200\231t move from one entrapment situation straight into another \200\224if necessary spend a short time stabilizing the patient before moving into the back of the ambulance. 801 Hazchem advice for the control of the chemical 4WE 2513 Hazard symbol and description in a diamond on white square background (rest of label is bla ck lettering on an orange background) e r a c Substance identi \201cation number and name CORROSIVE 8 e t a i d e m m Bromoacetyl bromide SPECIALIST ADVICE 0705 826435 PACE transportation Supplier \200\231s name (optional) Specialist advice and telephone number i l a t i p s o h - e r P Danger labels FLAMMABLE GAS 2.1 EXPLOSIVE EXPLOSIVE EXPLOSIVE 1.1 1.2 1.3 TOXIC GAS 2.3 FLAMMABLE LIQUID 3 OXIDIZING GAS 2.2 NON-FLAMMABLE NON-TOXIC GAS 2.2 SPONTANEOUSLY COMBUSTIBLE 4.2 DANGEROUS WHEN WET 4.3 oxidizing AGENT 5.1 FLAMMABLE SOLID 4.1 ORGANIC PEROXIDE 5.2 INFECTIOUS SUBSTANCE TOXIC 6.1 RADIOACTIVE 7 6.2 RADIOACTIVE I 7 RADIOACTIVE II 7 RADIOACTIVE III 7 CORROSIVE 8 MISCELLANEOUS DANGEROUS GOODS 9 NFPA (National Fire Protection Association) The US NFPA uses a \200\230 \201 re diamond \200\231 for immediate risk identi \201 - ca tion for emergency personnel. A number from 0 to 4 (4 being most dangerous) is placed in ea ch colored sub-dia- mond: BLUE for \200\230health \200\231, RED for \200\230 \202 ammabi lity \200\231, YELLOW for \200\230reactivity \200\231. The WHITE diamond contains further \200\230special \200\231 in- formation, eg COR for corrosive, ALK for alkaline. NFPA 704 h as codes for a large number of dangerous chemicals, eg ben- zene (3 4 0), hydrogen peroxide (2 0 1 COR). 41 4 0 3 Pre-hospital analgesia Why should I give pain relief? There are more than humanitarian reas ons for giving analgesia. Catecholamines released with pain may further reduce peripheral p erfusion and oxygen delivery in hypovolaemic shock, and increase myocardial oxygen demand f ollowing myocardial infarction. When do I give pain relief? Unless all hope of life and res cue has been aban- doned, the priorities of securing an airway and stabilizing the cervical spine, maintaining ventilation, and optimizing the circulation always come before an- alge sia. The eff ects of any drugs must be weighed against their potential side- eff ects (resp iratory depression; sedation). How do I relieve pain? Psychological: Beecher noted in 1944 at Anzio1 that sol- diers were indiff erent to serious injury. This is unlikely in road cra shes; a soldier is released from war horrors by his injuries, but a crash victim is just be ginning his nightmare. Reassurance that \200\234the doctor is here \200\235 is important. Splintage: Simple splints can be improvised from clothing; an uninjured leg can splint the injured one. In \202 atable air splints are not very robust, although are light and easy t o apply. Box splints (fold around the limb) are popular but poorly accommodate a deformed l imb, when a vacuum splint (full of tiny beads) is better. Traction splints should be used f or a fractured femur: they also reduce blood loss, morbidity, and mortality (the Thomas spl int reduced mortality of open fractured femur from 80% to 20% in World War I). Gaseous: Nit rous oxide provides comparable analgesia to 10mg morphine. It is mixed with 50% O2 as Enton ox or Nitronox in blue cylinders with a white top. It separates at \200\2236 C (O2 on top). \200\207Do not use in decompression sickness, p813, pneumothorax (may tension), acu te head injury or bowel obstruction. Opioids: Morphine is the gold standard. Give 0.1mg/kg (5 \200\22310mg) as starting dose, if \201 t/healthy person with signi \201 cant pain, o therwise in small aliquots (1 \200\2232mg) IV. Naloxone must be available at all times. Dos e example: 0.1 \200\2230.2mg IV eg repeated at 2min if needed. Fentanyl is at least as eff ective as morphine and may be easier to titrate given faster onset of action. A typical adu lt dose starts at 25 \200\22350micrograms. 42 NSAIDS: IM NSAIDs (diclofenac 75mg IM, repeat ed once only, at 30min if needed, or ketorolac 10mg IM stat then 10 \200\22330mg/4 \200\223 6h as needed, max 90mg/day, \200\201 to 60mg/day in elderly or if <50kg) has a role in mus culoskeletal pain \200\224and it doesn \200\231t entail monitoring for sedative eff ects; n ot recommended for children. 43 Ketorolac can be given IV over \211 15sec; avoid in: hypov olaemia; labor; asthma. Ketamine: This is a potent, short-acting analgesic at 0.1 \200\2230 .5mg/kg IV. 44 At higher doses it can be used as sole anesthetic agent (2mg/kg IV will prod uce 5 \200\22310min of surgical anesthesia); \200\230emergence delirium \200\231 is common unless a benzodiaz- epine (midazolam 2mg IV) is also given. 45 Sedation: An anxious or ag gressive patient is often in pain or hypoxic. Reas- surance, a clear airway with supplement al oxygen and analgesia is better than sedation, although this is needed rarely: give small aliquots of midazolam (p630, up to 1.5mg in elderly \200\224have \202 umazenil to hand). Local anesthesia: (p632) Peripheral nerve blocks aid release of a trapped limb. Femoral ne rve block is most used and provides complete analgesia (anaesthe- sia) for femoral fracture s (less eff ective for low shaft fracture). Locate the ar- tery in the groin and put 10 \200\22320mL 1% plain lidocaine in a fan shape lateral to the artery. Aspirate frequently t o avoid intravascular injection. Maximum dose <3mg/kg or 0.28mL/kg of 1% (p731). 802 \200 e r a c e t a d e m m i i l a t i p s o h - e r P 1 Anzio, 33 miles south of Rome, was a crucial Allied beachhead in the recapturing the \200\230Eternal City \200\231 (5/6/44). 803 Keeping records In the controlled bustle of activity at a pre- hospital emergency scene, the same focus tha t is applied to care provision also needs to be applied to recording of the care given. Rec ording procedures and drugs is vital for safe, and therefore good, practice (see MINIBOX). On arrival at hospital, a full dose of morphine given on top of an unknown administration i n the \201 eld can be enough to lead to overdose. Essence of keeping records \200 Good practice = safe practice \200 Treat \201 rst, th en make records \200 Use well-known formats e r a c e t a i d e m m Care provision will inevitably have to come \201 rst, but then it is vital to create accu rate records (and dare we say, \200\230undoctored \200\231 in retrospect). Importantly, if using a pre-prepared sheet, use those that are widespread and not your own customized layo ut that may cause confusion from delay in interpretation. Good record keeping is also vital for trauma scoring (p810). i l a t i p s o h - e r P Treading along the \200\230thin blue line \200\231 (UK) Very few would think that in passi ng through a red traffi c light with your green emergency lights \202 ashing (p798) to ge t to an accident scene, or that in smash- ing a front door to get to a trapped victim you w ould be open to legal action: \200\207just remember that you could be. In most circumstances, however, provided that you observe the correct codes (eg a red light means \200\230give way \200\231 and is not a simply thoroughfare in your favor) legal act ion is unlikely. Ultimately a life-saving decision may fall into your hands, so in preparing to make the rig ht the decision, you will get it right. Don \200\231t be put off from these challenges, as they are part of the essence of the specialty. Consider the fol- lowing scenarios: \200 B reaking and entering: Doctors and paramedics cannot legally force entry to a private addres s, but you would be unlikely to face repercussions if doing so in an attempt to save a life . Driving: For example, as long as appropriate sirens/lights are used, you: can exceed the st atutory speed limit by 20mph; can use bus lane; can stop and park on clearways; can treat r ed light as \200\230give way \200\231; cannot ignore one-way signs; cannot cross double wh ite lines; cannot ignore stop signs. Consent: This is too large a topic to cover here completely. Consider that if there is a si tuation where obtaining informed consent may be an issue (eg un- conscious, mental health i ssues, <16yrs old in absence of parent or guardian) life-saving treatment can probably be a dministered without fear of repercus- sion. Further non-life-saving treatment beyond this m ay raise problems. See also OHCM p570. Restraint: Unless restraining an aggressive or violent individual for safety reasons, medic al practitioners have no right to restrain an individual: to do so would constitute assault . Con \201 dentiality: Be aware that the open environment of a pre-hospital setting is more vulnerable to breaches in con \201 dentiality in the form of both verbal and written commu nication. \200\207Check that you have the appropriate clinical indemnity to cover your pra ctice. Communications The radio net A radio user is identi \201 ed by a \200\230call sign \200 \231. Messages are usually passed through a central controller (call sign \200\230control \200\231, or \200\230zero \200\231) without being able to hear other users \200\224 \200 \230two-frequency simplex \200\231; but on some nets all users can hear and talk directly t o each other \200\224 \200\230single-frequency simplex \200\231. Acquiring a \200\230radio voice \200\231 This takes practice: rhythm should be steady; speed is slower than normal s peech; volume \200\224do not shout or whisper; pitch should be raised if the voice is gruff . Remember: \200\230RSVP \200\231. Using a radio Switch on and check battery light (switc h off to change bat- tery). Listen (single-frequency) or look (two-frequency) at the \200 \230channel busy \200\231 light \200\224you do not want to interrupt any message. Wait 1 \200\2232sec after pressing the transmit button before speaking, or the important \201 rs t few words are lost. Release the transmit button after speaking, or you will prevent other s from transmitting. VHF radios have a longer range than UHF. Messaging To initiate say the receiver \200\231s call sign then your own. Say \200\234over \200\235 to indicate when th e receiver should reply. To continue a message always start with your own call sign when yo u speak. To end a transmission say \200\234out \200\235. 804 e r a c e t a d e m m i Example: \200\234Zero from Mike One, message over. \200\235 \200\234Zero, go ahead over. \200\235 \200\234Mike One, moving now to new location out. \200\235 i l a t i p s o h - e r P Remember that anyone can be listening: don \200\231t be a comic ( \200\234Send the rover ov er, over \200\235); don \200\231t swear; address by appointment rather than name. Key words Spell long or diffi cult words using the NATO phonetic alphabet (see OPPOSITE) \200\224you do not want an \200\234empty box \200\235 when you asked for \200\234Entonox \200\235. L ong numbers (drug dose; grid reference) are given whole, then digit by digit (eg 1000 = \200\234one thousand, \201 gures one-zero-zero-zero \200\235). \200\234Roger \200\235 or \200\234OK \200\235 means you have understood: they are pro-words (see BOX 2); \200\234s ay again \200\235 means repeat the mes- sage. ( \200\234Repeat \200\235 is the order for ar tillery to \201 re again and is avoided, at least on military networks!) ETA/ETD are comm on abbreviations for estimated time of arrival/departure. Avoid radio gibberish ( \200\234r oger dodger/ten four/over and out \200\235; \200\234negative \200\235 and \200\234positiv e \200\235 for \200\234yes \200\235 and \200\234no \200\235). Telephone Mobile telephones are useful for pre-hospital communication. How- ever, in major incidents all cells are rap idly utilized (often by the press). In the UK, on application to the Cabinet Offi ce the te lephone may be registered to operate on a number of restricted cells in cases where the sys tem is overloaded \200\224this is ACCess OverLoad Control (ACCOLC). Some UK emergency service ranks Epaulet 2 pips 3 pips Crown Laurel \200\230U \200\231 Laur el \200\230U \200\231 around pip Divisional Offi cer Ambulance Police Inspector Offi cer band 1 Chief Inspector Asst. Divisional Offi cer Offi c er band 2 Superintendent Fire Station Offi cer Asst. Senior Offi cer UK \201 re service helmets Color Yellow Yellow Yellow White White White Black bands Nil 1 thin 2 thin 1 thin 1 thick 1 thick (18mm), 1 thin (12mm) Rank Fire \201 ghter Leading \201 reman Sub-offi cer Station Offi cer Assistant Division al Offi cer Divisional Offi cer 805 NATO phonetic alphabet & number pronunciation for radio use C CHARLIE A ALPHA H HOTEL F FOX TROT M MIKE K KILO P PAPA R ROMEO U UNIFORM V VICTOR W WHISKEY X XRAY ( \200\234ECKS RAY \200\235) 3 THUREE 1 WUN 8 ATE 6 SIX B BRAVO G GOLF L LIMA Q QUEBEC D DELTA ( \200\234DELL TAH \200\235) I INDIA ( \200\234IN DEE AH \200\235) N NOVEMBER ( \200\234NO VEM BER \200\235) S SIERRA ( \200\234SEE AIR RAH \200\235) E ECHO J JULIET O OSCAR T TANGO Y YANKEE Z ZULU 5 FIYIV 0 ZERO e r a c e t a i d e m m 2 TOO 7 SEVEN 4 FOWER 9 NINER . DECIMAL Pro-word examples (in blue) in a dialog between OHCS9 and FY1 OHCS9: \200\234Foxtrot Yanke e Wun, Foxtrot Yankee Wun, this is Oscar Hotel Charlie Sierra Niner. Request rendezvous Too Decimal Fiyiv centimeters south- east of McBurney \200\231s point. Read back for check. Ov er. \200\235 \200\234Oscar Hotel Charlie Sierra Niner, this is Foxtrot Yankee Wun. I read back: Too decimal \201 yiv centimeters south-east of McBurney \200\231s point. Over. \200 \235 i l a t i p s o h - e r P FY1: OHCS9: \200\234Foxtrot Yankee Wun, Foxtrot Yankee Wun, this is Oscar Hotel Charlie Sierra Niner. Correct. Out. Go ahead means \200\234I have got your initial call; pass the rest of your message \200 \235. Roger (or Romeo) means \200\234ok \200\235. Over means \200\234this is the end of m y transmission and I await reply \200\235. Out terminates a dialog. NB: \200\234over and o ut \200\235 is contradictory. Wilco means \200\234I will comply \200\235 and implies Roger (so \200\234Roger wilco \200\235 contains re- dundancy \200\224don \200\231t use). It is wise to precede \200\230wilco \200\231 with the instruction you are going to comply with \200\224in case you have misheard it. Station calling is used when addressing an unidenti \201 ed station which has just hailed the receiver, eg if OHCS9 has received a transmission from an uniden- ti \201 ed station we will reply: \200\234Station calling OHCS9 \200\224 this is OHCS9. Over. \200\235 \200\230This is \200 \200\231 means this transmis- sion is from the station whose designator immediately follows. Say again means \200\234I have not understood your message, please repeat \200\235 (all after x means those words after x all before means all words before x). Emergency radio messages (using an example at sea) \200 Mayday is the international distr ess call for when death is at hand (from the French phrase M \200\231aidez; help me!). \200 Ensure the radio is on (hi-power). Use channel 16 (the default). Press the microphone button. MIPDANIO tells you how to order your call: say \200\234Mayday, mayday, mayday \200 \235 \200\203Identify your- self: \200\234this is \200 \200\235 (type of vehicle; its nam e) \200\203Position \200\203Distress type (eg \200\234 \201 re \200\235) \200\203Assistan ce needed \200\203Number of people at risk \200\203Information (eg \200\234abandoning ship ; no life-raft \200\235) \200\203Over. Release microphone button. Wait 2min. Resend if no r esponse. Pan-pan \211\2103 (said as \200\230pon pon \200\231) means urgency short of imminent demi se. \200 Securite \211\2103 (said as \200\230say-cure-ee-tay \200\231) means \200\234I have important safety infor- mation to transmit. \200\235 Follow \200\230pan-pan \200\231 and \200\230securite \200\231 by saying \200\234all stations, all stations, all stations : this is \200 (ID \200\203Position) \200\235 to alert all listeners. Explain the danger (e g \200\234I am adrift without power in shipping lane \200 \200\235). \200 The major incident Planning For a hospital to be prepared to cope with multiple casu alties there must be planning. Each hospital will produce a detailed Major Incident Plan, b ut additionally the tasks of key personnel can be distributed on individual Action Cards. A t the scene A medical incident offi cer (MIO) will be requested from the near- est hospital or BASICS scheme (eg GP or paramedic volunteers from the British Association for Immediate Care www.basics.org.uk). Mobile medical teams (eg A&E senior doctor/surgeon + anesthetist + 2 \200\2234 nurses) should come from hos- pitals not accepting the main casualties. BASIC S doctors should be requested to the scene by radio via the ambulance station). Further BAS ICS doctors make valuable treatment offi cers, as they arrive. Safety: Is paramount \200 \224your own and others. Be visible (luminous monogram- med jacket) and wear protective clo thing where appropriate (safety helmet; waterproofs; boots; respirator in chemical environm ent). Triage: See p796 \200\2237. Communications: Are essential \200\224and frequently an a rea where improvements are needed. 46 The police are in overall control of the scene. Each emergency ser- vise will dispatch a control vehicle and will have a designated incident off i cer for liaison. Support medical staff from hospital report to the medical commander (SIL VER rank medical incident offi cer, OPPOSITE): his job is to assess then commu- nicate to t he receiving hospital the number and severity of casualties, to assess need for further med ical teams, to oversee triage (p797) and treatment (with the Ambulance Incident Offi cer). He must resist temptation to treat casualties as this compromises his role. Equipment: Must be portable (in small cases/backpacks) and include: triage labels, intubation and cricothy rotomy equipment; intravenous \202 uids (colloid); bandages and dressings; chest drain (p lus \202 utter valve); amputation kit (when required ideally two doctors should concur); drugs \200\224analgesic: morphine; an- esthetic: ketamine (p802); speci \201 c antidote if a chemical threat; cardiac resus- citation drugs; drugs to cover common medical emergencie s: eg GTN spray, sal- butamol inhaler; limb splints; de \201 brillator/monitor; pulse o ximeter; \200\230comfort bag \200\231 for staff and others ( 1 coins, sweets, toilet pape r, etc). Evacuation: Remember: with immediate treatment on scene, the priority for evacuati on may be reduced (eg a tension pneumothorax \200\224RED \200\224relieved can wait for evac uation \200\224becomes YELLOW, but those who may suff er by delay at the scene must go \201 rst (eg unconscious closed head injury; myocardial infarct). Send any severed limbs to the same hospital as the patient, if possible keeping them on ice (not in ice as freezing harms tissues). At the hospital a \200\230major incident \200\231 is declared (eg if >10 s erious injuries). A con- trol room is established and the medical coordinator ensures staff have been summoned, nominates a triage offi cer and supervises the best use of inpatient b eds, intensive care, and theater resources. When the incident is declared clear of casualti es, the major incident may still continue for some time at the hospital. 46 806 \200 e r a c e t a d e m m i i l a t i p s o h - e r P 807 When do major incidents become complex emergencies? \200 If the context involves administ rative, political, or economic anarchy. \200 If the incident sparks a self-perpetuating c hain of violence. \200 If the incident is not a random event, but focused on one ethnic g roup. \200 If competition for wholly inadequate resources compounds their inadequacy. \200 If the incident leads to displacement of children. \200 If the incident promotes a state of war. e r a c e t a i d e m m At the scene of a major incident The following structure has been developed in the UK for t he command and control of a major incident: i l a t i p s o h - e r P The actual incident site is surrounded by the in- ner cordon in the BRONZE area. The outer cordon surrounds the SILVER area, within which is the entire incident site, including the v arious incident stations and the SILVER commands. The GOLD area is the re- gional area with in which the incident has occurred. Each area has a command for each branch of the ser- vic es: police, \201 re, ambu- lance & medical. Concentrating on the medical service, the BRO NZE command (forward medical of \201 cer) will be responsible for supervising doctors in t he BRONZE area (eg immediate treatment and primary triage) as well as direct- ing medical e quipment in and out and (most importantly) communicating with the medi- cal commander. The medical commander is also the medical SILVER command. His role is to communicate with the o ther SILVER command offi cers (police, \201 re & ambulance), delegating tasks to availabl e staff , overseeing secondary triage, and continuing an overall medical as- sessment of th e scene. GOLD command is sited away from the main site eg at a regional head- quarters. The ir responsibility is to liaise with neighboring area services and independent agencies (eg Environment Agency) for support as needed. This is a simpli- \201 cation of the overall m ore complex picture; see the Oxford Handbook of Pre-hospital Care for an in-depth descripti on. GOLD SILVER BRONZE . N O I S S I M R E P H T I Inner cordon W Outer cordon , P U O L A T E S E V A E R G , E R A C L A T I P S O H - E R P Command tabards Recognize the command offi cers from their tabards: F O Police K O O B D N A H Fire D R O F X O Ambulance Medical (text only M O R F \200\230medical commander \200\231) D E T P A D A E G A M I Joining forces In a major incident the police, \201 re service, ambulance service, emerge ncy medical service and the armed forces may all be present. Structures for man- agement ha ve been greatly enhanced over recent years, with clear commu- nication across these service s vital for eff ective planning and execution. We learn more from each major incident as it passes, but importantly co-operation between these services during theoretical and practic e sessions away from the real emergencies has brought together the experiences from each in di- vidual force with great eff ect. Helicopter transportation \200\207It is often better to spend 30min transporting serious i njuries to a well-resourced trauma center with consultants standing by, than to spend 10min transporting such a person to a small hospital where the most skilled help is not immediat ely available (see MINIBOX). If the small hospital has to transfer the casualty to a trauma center, no signi \201 cant savings may have been made compared with immediate helicopter transfer to the center. 48 Identifying appropriateness for transportation is also important to reduce helicopter overuse, as there is a still tendency for most helicopter transfers t o be made in cases of non-life-threatening injury. 49 808 Indications for air ambulance transfer \200 Diffi cult scene access \200 Weather condit ions adverse to ground but not air travel Diffi cult road terrain \200 >15 miles from nearest land base e r a c e t a d e m m The importance of helicopters for casualty rescue/transportation is increasingly recognized \200\224but be aware of the limitations and dangers. Helicopters may be used for transport ing casualties to hospital, or for interhospital transfer. Advantages: \200 Speed over lo ng distances; access to remote areas \200 Delivery of highly trained doctors and special equipment to the scene \200\224eg ready to intubate, paralyze and ventilate, and give manni tol IVI if head injury. 50 Disadvantages: \200 Mid-air crashes in air ambulances have occ urred, and are hard to survive. \200 Noise and general stress, leading to anxiety and dis orientation, and hampering i i l a t i p s o h - e r P communication \200\224reassure and provide with a headset. Vibration exacerbating bleeding and pain from fracture sites. \200 Cold \200\224beware in those hypothermic rescues from sea or mountain. \200 Problems related to altitude; aircr aft limitations, eg weather, landing site, lim- ited carriage space (especially if additional medical personnel). Police craft don \200\231t allow ECG monitor/oximeter due to magnetic radiation. \200 Man y published reports of the advantages of air ambulances lack rigor. The gains of helicopter transfer depend on how many severe injuries occur. One UK study concluded that only 13 li ves would be saved per year in London if it was reserved for the severest cases (injury sev erity score, ISS, >15, p810); in lesser trauma, there is evidence that outcome is less good . 51 Helicopter safety \200 Always approach from the front of the aircraft, in full view of the pilot. \200 Secure loose items, eg headgear. \200 Do not enter/leave the rotor d isc area without permission (thumbs up signal from pilot). Lower your head in the rotor disc area. Do not touch the winch strop/cable until the earthing lead has contacted the ground. Also, be sure to avoid the tail rotor. Make sure no one is smoking within 50m of the aircraft. Speci \201 c problems \200 Decom pression sickness (p813): if air is breathed under pressure (divers), ni- trogen dissolves in blood and tissues. On rapid ascent after a dive the nitro- gen will come out of solution as bubbles, producing joint pains ( \200\230the bends \200\231) rashes, CNS defects and paraesthesia. \200\207Do not \202 y within 12h of a single dive <30m, or within 24h fol lowing multiple dives, dives to >30m or any dive requir- ing a decompression stop. Ischaemic chest pain or infarction is not a contraindication to \202 ying. \200 Psychia tric illness (eg mania) may preclude safe air transportation. \200 Burns >20% need pre \202 ight nasogastric tube insertion (prevents gas expan- sion of an ileus) in- \202 ig ht pressure-controlled ventilation. 52 809 First steps to improving care after major injury The National Audit Offi ce \201 nds that 450 \200\223600 lives would be saved/yr in Eng- land if these points were acted on: tinyur l.com/ybt7w9g e r a c 1 Don \200\231t simply take the casualty to the nearest hospital. Assess complexity of the injuries and take to a hospital with the necessary skills. Helicopter transportation may be the most effi cient way to do this. e t a i d e m m 2 A trauma team with fully-trained neurosurgical and orthopedic staff (with immediate CT av ailable) should meet the patient at the door. In the NHS, 60% of the time the casualty wait s to see the most junior doctor and if the nature of the injuries is recognized, he is pass ed in stages up the line, perhaps only reaching the de \201 nitive specialist when it is t oo late. i 3 More regional trauma networks must be set up. Remember that trauma is the chief cause of death in those <40yrs, and numbers are growing (now about 20,000 major trauma cases/yr in E ngland). l a t i p s o h - e r P All this happens in other countries such as the USA: \200\207survival is 20% better. Problems of altitude (see high-altitude medicine, p814) \200 Hypoxia is unlikely unless t here is cardiac or lung disease, anemia, shock, or chest trauma, as helicopters rarely \202 y high enough to cause PaO2 to fall. Reduction in atmospheric pressure results in an expansion of enclosed gasses on ascent. Thi s produces pain in blocked sinuses, expansion of a pneumotho- rax, abdominal wound dehiscen ce (avoid \202 ying for 10 days post-surgery if possible), and renewed bleeding from a pe ptic ulcer. Drips may also slow down. \200 On descent, beware of endotracheal tube cuff s and militar y antishock trou- sers (MAST*) de \202 ating signi \201 cantly (particularly if applied a t altitude eg on hillside). Rapid descent may induce barotrauma. MAST (=medical anti-shock trousers) Invented during the Vietnam War, MAST were intended to reduce blood \202 ow to the lower limbs, thereby increasing perfusion to vital thoracic o rgans and the brain. Their use has decreased since the 80s and 90s due to concerns about th eir bene \201 t. MAST in \202 ation may impair breathing & ventricular function. 53 They can do damage in those with moderate hypotension (systolic BP 50 \200\223 90mmHg) who face only a short ride to a hospital, especially those with tho- racic injuries. MAST \200\231s role in severe shock or long pre-hospital transportation times remains unclear. However, a Cochrane review suggested that there was no evidence that they reduced mortality, hospital or ICU stay, and some evidence they worsened outcomes. 54 Trauma scoring55 Essence Trauma scoring can be used at the roadside to predict the probabil ity of survival (Ps), and thus the severity of injury, which may in \202 uence where to ta ke the patient (nearby district general hospital, regional hospital, or Trauma Center?); ho wever experts generally consider it purely an audit and research tool. Retrospectively, phy siological data may be combined with an anatomical injury score to compare performance (exp ected vs actual survivors) between hospitals. NB: trauma scoring in children is problematic . See expert literature. 56 Trauma Score (TS) The original score introduced in 1981 in USA to allow para- medics to make an objective decision on whether patient needed Trauma Center facilities. Measures respiratory rate + eff ort; systolic BP; capillary re- \201 ll; Gla sgow Coma Scale (GCS). Maximum score 16. Score \211 13 means mortality \211 10% \200\224U SA take to Level 1 Trauma Center; UK take to large hospital and alert trauma team en route. Revised Trauma Score (RTS) Measures respiratory rate (RR), systolic BP (sBP), and GCS only : other parameters were found to be poorly reproducible on analy- sis of a large North Amer ican database. Each parameter has values coded to give score of 0 \200\2234 (see table, OPP OSITE). These scores are multiplied by a weight- ing coeffi cient, then added together to p roduce the RTS \200\224it is not a suitable roadside tool. RTS has a more reliable correlat ion with Ps than does TS. Triage Revised Trauma Score (TRTS) This uses the same coded value s of res- piratory rate, systolic BP, and GCS from the RTS, but a fall by one point in any parameter is taken as signi \201 cant (thus TRTS \211 11 is signi \201 cant). This is th e most useful pre-hospital trauma triage tool. Limitations: These scoring systems are not v alidated for the very young or elderly; up to 20% may have severity underestimated on their initial assessment (if attended rapidly, before physiological decompensation). Injury Seve rity Score (ISS) TS, RTS, and TRTS use physiological variables to predict Ps; these have th e advantage of changing with the patient \200\231s condition. Anatomical injury (data from operation or post mortem notes, which does not generally change throughout an episode) can also be used \200\224injuries are scored from 1 (minor) to 6 (fatal) using tables from the Abbreviated Injury Scale (AIS). The body is divided into 6 regions and the 3 highest scores from diff erent regions are squared and added. Maximum score is 75 (5 squared \211\210 3) since AIS 6 in any body region is fatal \200\224and therefore awarded a score of 75. ISS c orrelates closely with Ps. ISS \211 16 implies mortality \211 10% and is termed \200\230 major trauma \200\231. Limitations: Injuries can be diffi cult to code; isolated head injur y with AIS of 3 has high mortality, but is excluded from \200\230major trauma \200\231 out come analysis. TRISS methodology Trauma audit programs are established in USA and UK \200 \224 Major Trauma Outcome Study (MTOS). 57 TRISS is a complex formula combining RTS, ISS, a ge, and whether blunt or penetrating trauma. It is poor at predicting individual outcome, b ut allows comparison of overall performance between hospitals, or the same hospital followi ng, say, introduction of trauma teams. ASCOT (a severity characterization of trauma) is new er but not necessarily bet- ter. 58 Similarly, TRISS has been combined with physiological c ategorizations (SAPS-II)1 to improve reliability. Z & M statistics compare outcome in diff erent populations. Z measures the diff erence between the actual and predicted number of de aths. M (the \200\230injury severity match \200\231) compares the range of injury severity with the main data- base \200\224if M <0.88, Z is invalid. 59 810 e r a c e t a d e m m i i l a t i p s o h - e r P 1 SAPS = Simpli \201 ed Acute Physiology Score.60 Revised Trauma Score (RTS) 61 For each of GCS, SBP (systolic BP) and RR determine the attri buted value: Value 811 SBP (mmHg) >89 76 \200\22389 50 \200\22375 1 \200\22349 0 RR (bpm) 10 \200\22329 >29 6 \200\2239 1 \200\2235 0 GCS 13 \200\22315 9 \200\22312 6 \200\2238 4 \200\2235 3 e r a c 4 3 2 1 0 e t a i d e m m Then put into the equation: (0.9368 \211\210 GCS value) + (0.7326 \211\210 systolic BP va lue) + (0.2908 \211\210 RR value) = RTS i l a t i p s o h - e r P Blast injury Blast injury may be encountered in domestic (eg gas explosion) or industrial ( eg mining) accidents, or as the result of a terrorist bomb. Terrorism worldwide is responsi ble for at least 15,000 injured or killed in the last 20 years and most casualties are from bombs. Death may occur without any obvious external in- jury, often due to air emboli, the correct cause \201 rst being recognized by Pierre Jars in 1758 as a \200\230dilatation d \200\231air \200\231 (ie blast wave). Blast injury is split into 4 phases: \200 Primary : injury from the blast wave itself. \200 Secondary: injury from missiles & projectile de bris striking the victim. \200 Tertiary: the victim is thrown by the blast wind, striking surrounding objects. \200 Quaternary: other injuries caused by explosions \200\224eg bur ns, asphyxia, crush 812 \200 e r a c injuries and toxic inhalations. Explosions cause injury in seven ways: e t a d e m m 1 Blast wave A transient (milliseconds) wave of overpressure expands rap- idly away from th e point of explosion, its intensity inversely proportional to the distance cubed. It produc es: (a) cellular disruption at air \200\223tissue inter- face ( \200\230spalling \200\231), ie perforated ear-drum at 100kPa (deafness should prompt thoughts of signi \201 cant blas t injury), \200\230blast lung \200\231 at 175kPa; (b) shearing forces along tissue planes: submucosal/subserosal hemorrhage; (c) re-ex- pansion of compressed trapped gas: bowel perf oration, fatal air embolism (coronary artery or cerebral). i i l a t i p s o h - e r P 2 Blast lung may be delayed (up to 48h). Suspect it if there is a perforated drum, but this is not a prerequisite (as position of drum in relation to blast wave is critical). Intra-a lveolar hemorrhage causes acute respiratory dis- tress syndrome (OHCM p178). Most patients who survive lung blast injury regain good lung function within a year. 62 n=11 3 Blast wind Air displaced by the explosion will totally disrupt a body in the immediate vi cinity. Others may suff er avulsive amputations. Bodies can be carried by the wind with dec eleration injuries on landing (tertiary injury, as above). Glass, wood, stones, and other o bjects are also carried and act as secondary missiles. 63 4 Missiles Penetration or laceration from missiles are by far the commonest injuries. Missi les can arise from the bomb fragmentation: primary if from the casing or secondary if from preformed fragments (eg nails, nuts, bolts, ball- bearings) or from the environmental fabri c (eg glass and wood particularly). 5 Flash burns These are usually super \201 cial and oc cur on exposed skin (hands/face) in those close to explosion. Flame burns arise through ign ition of materials in the environment. 6 Crush injuries Can be the result of eg falling masonry or tertiary injury. 7 Psychologica l Acute fear and panic is the aim of the terrorist. Later, chron- ic intrusive thoughts, an xiety, and poor concentration may form the basis of a post-traumatic stress disorder (p347) . This may be augmented by re- peated watchings of the event on TV/Video. 64 Treatment \200\207Do not approach the scene until the possibility of a secondary device ha s been excluded and it has been declared safe to approach. \200\207Also remember that you are at a forensic scene, so do not disturb the envi- rons (or any dead bodies) unless neces sary to treat a patient. Approach the same as any major trauma with priority to airway and cervical spine, breathing , and circulation with hemorrhage control. Rest and observe any suspected of exposure to si gni \201 cant blast, but without other injury. Sudden death or renal failure may follow re lease of a limb after prolonged crush injury (hyperkalaemia and myoglobinuria): ensure cont inuous ECG and good hydration. Facial burns may compromise airway, which should be secured by intubation or surgical airway. Psychological support will be needed. 813