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 Schemes can help drivers who abuse alcohol, eg the Driver Improvement System for traffi c v iolators, and re-education by driving instructors. Psycho- therapy helps more than lectures . Health education posters picturing tragic consequences to a girl- or boyfriend are succes sful. Laws can save lives \200\224car roadworthiness, drink-driving, seat-belt laws, speed restrictions, and speed cameras 11,12 (especially if infringement leads to re-edu- cation/s peed awareness courses rather than license endorsements). 13 Another eff ective way of redu cing alcohol-related road crashes is to provide good lighting at diffi cult bends or juncti ons. Injury in homes may be prevented by such simple measures as child-proof containers, pu tting holes in polythene bags, using toughened glass throughout the home, and using cooking pans with handles turned in away from toddlers. Accident statistics (UK) Injuries continue to rank as one of the biggest global causes of m orbidity and mor- tality. However, there is a wide variation in the pro \201 le of acciden t statistics through- out the world according to factors such as geography and relative lev el of average income. The World Health Organization (WHO) publishes statistics on global in jury rates. 14 Here we discuss Great Britain, where injury is the commonest cause of death in the \201 rst four decades of life. 792 UK deaths and other injuries 15 \200\22317 On the roads Deaths Serious injuries Less serious injuries Children \200\231s deaths Children seriously injured Deaths in those >65yrs old 2,222 24,690 195,234 81 2590 609 e r a c e t a d e m m i Home-based accidents i Deaths Injuries leading to A&E presentation 4000 2,700,000 l a t i p s o h - e r P Work-based accidents Deaths at work Injuries at work 152 233,000 (26,061) (of which are serious) Accidents in the home Old people are particularly at risk. Over half the males and three-qu arters of females who die from accidents in their homes are 65 years old or older. About 30 % of those falling and fracturing their hip will be dead in 1 year (p752). The commonest ca use of accidental death in children is \201 res; in the 15 \200\22344 age group it is poi soning, and in the over-45s the chief cause is falls. Hospital attendances for accidents 6 million people/year in the UK attend an accident and emergency department following an \200\230accident \200\231. 2 million of these involve children. This costs 146million. H alf these accidents occur in the home. Many more receive treatment from their general pract itioner. Accidents in children \200 10,000 children are permanently disabled by accident s each year. \200 Accidents cause 1 child in 5 to attend the A&E department each year. \200 Accidents are the commonest cause of death among children aged 1 \200\22314yrs, and they cause half of all deaths in those aged 10 \200\22314yrs. Road traffi c accidents are the most common fatal accidents in children \200\224 around half occur with children as pedestrian victims School age children (4 \200\22314yrs) in road crashes restrained with a seat belt are 2 \200\22310 times as safe as unbelted children, and are at least as well protected as adults wearing seat belts.2 Useful contacts and addresses: \200 British Safety Council, 70 Chan cellors Road, London W6 9RS (UK). 18 \200 Royal Society for the Prevention of Accidents ( ROSPA), RoSPA House 28 Calt- horpe Road, Edgbaston, Birmingham B15 1RP (tel. UK 0121 248 20 00)1. 19 \200 Construction Health and Safety Group, St Ann \200\231s Road, Chertsey, Surr ey KT16 9AT (UK); tel. 020 8741 1231. 20 \200 Scottish Chamber of Safety, www.scos.org.uk 21 This page intentionally left blank \200 Basic life support (BLS) Synonyms Arti \201 cial respiration; cardiopulmonary resusc itation (CPR). De \201 nition BLS is the provision of life support \200\224expired air (yo ur own) ventila- tion + external chest compression, without any equipment. The guidelines h ere are in line with the recommendations from the Resuscitation Council (UK). 23 SAFE appro ach \200 As you approach the patient shout for help (pointing to an individual if pos- 794 \200 sible, to activate him or her). Approach him with care \200\224are there any hazards to yourself (p800)? \200 Free the pa tient from immediate danger. \200 Evaluate the patient \200\231s \200\230ABC \200\231 (s ee below)1. e r a c The SAFE approach Shout for help Approach with care Free from danger Evaluate ABC (Airway, Breathing, Circulation) e t a d e m m i Establish unresponsiveness Shake gently by the shoulder while stabiliz- ing the forehead wi th the other hand. Ask \200\234Are you all right? \200\235. If he responds, leave him in t hat position and further evaluate him \200\224if not, call for help and then check airway a nd breathing. Airway & Breathing Open the airway using a chin lift. If breathing, put in th e recovery posi- tion; if not, go to get help now. Once help has been summoned, give 30 che st compressions, open the airway and give 2 rescue breaths (slow in \202 ations, just enou gh to make the chest rise \200\224and achieve a tidal volume of 400 \200\223500mL) and the n perform another 30 chest compressions. Circulation The latest BLS guidelines do not in- v olve assessment of the circulation (for lay rescuers). Chest compressions and rescue breath s continue at a ratio of 30 : 2 until the victim breaths, or the rescuer becomes exhausted. Compressions should be at a rate of 100 \200\223120 min \200\2231, and to a depth of 5 \200\2236cm (adults). Compression only CPR may be as eff ective as combined compression/ven tilation resuscitation in the \201 rst few minutes (in adults). 24 Infants (<1yr) and chi ldren (1 \200\2238yrs) are now rescued with the same algo- rithm involving 5 immediate resc ue breaths if not breathing normally, followed by chest compressions and rescue breaths at a ratio of 15 : 2. For compressions use one hand one \201 nger breadth above xiphisternum (rate 100/min). Avoid blind \201 nger sweep \200\224may impact foreign body in conical u pper airway; do look into the airway for easily removable foreign body. See p238. \200\207 See p238 for the pediatric algorithm of the European guidelines for basic and advanced life support. \200\207See p721 for the adult basic life support algorithm. \200\207Both adult basic and advanced life support algorithms are inside the back cover of OHCM. i l a t i p s o h - e r P Nose-to-mouth breaths Nose-to-mouth rescue breaths may be used if: \200 A good seal canno t be made with mouth-to-mouth \200 There is mouth trauma \200 Underwater 1 BLS by soldiers is deemed inappropriate on the battle \201 eld if the victim has no vita l signs.25 795 \200 Choking Respiratory obstruction by choking on a foreign body is not an infrequent cau se of death \200\224which may be prevented by performing the Heimlich manoeu- vre. If the p erson who is choking is conscious and standing, \201 rst ask him to bend forward and coug h. If this fails, get behind him, and with your arms encir- cle his abdomen, mid-way betwee n umbilicus and xiphoid process. One hand makes a \201 st, positioned thumb-to-abdomen. T he other hand grasps this \201 st, and with a sharp movement presses it up and into the a bdomen, to dislodge the foreign body. If the victim is already comatose, this maneuver can be ac- complished with him lying on his back \200\224using the heel of the hand to press wi th, rather than a \201 st. Repeated thrusts may be needed. In adults, sweep the mouth wit h a \201 nger to remove the foreign body. \200\207Do not perform this maneuver on childr en <1 year, instead use back blows (below) and chest thrusts (similar to cardiac compressio ns). Complications (Rare) If applied incorrectly, direct trauma to abdominal vis- cera may result thrombosis of an abdominal aortic aneurysm or dislodge- ment of thrombus causing bilateral acute leg ischaemia. 26 Back blows These are no better, and no worse, than the He imlich maneuver in relieving foreign body obstruction. Neither should be taught or practice d to the exclusion of the other. Alternate 5 back blows with 5 abdominal/chest thrusts. Use the heel of the hand to strike forcefully between the scapulae, with the patient leaning f orwards. e r a c e t a i d e m m i l a t i p s o h - e r P Use of automatic external de \201 brillators (AED) Each year in the UK, 30,000 people unde rgo an out-of-hospital cardiac arrest. The chances of successful de \201 brillation decrea se by 10% with each minute of delay prior to \201 rst shock. The Resuscitation Council of the UK recommends that although layperson training in the use of AEDs is to be encouraged, it is not necessary for their use by members of the public. \200 Place one pad to the rig ht of the sternum, below the clavicle, and the other in the left mid-axillary line approxim ately over the position of the V6 ECG elec- trode. Whilst most pads are labeled left and ri ght (or have a picture indicating position) it does not matter if their positions are switc hed. Laypeople should then follow the AED voice/visual prompts, ensuring that if a shock is indicated nobody is touching the victim. \200 Road crashes1 \200\2241: assessment and triage 796 \200 If you are the \201 rst on the scene, the following page (which assumes a highly organized response) will seem impossible on a dark night, alone. So the \201 rst priority is to get help. You may be surprised in how short a time it all becomes organized to give the picture described below. Requesting the \201 re service when dialing emergency servic es may be the quickest way to get a dozen trained \201 rst-aiders to the scene with unriv aled skill in extrication. The distribution of trauma deaths is trimodal \200\224immediate (aortic decelera- tion inju ry; head injury), early (hypoxia and hypovolaemia), and delayed (sepsis; multiple organ fai lure). Prevention (speed restriction; road lighting; seat-belt laws; no drunken-driving; ai r bags) is better than cure \200\224and medical interven- tion is too late for the immediat e deaths (but aid given to victims in the \201 rst \200\230golden hour \200\231 can be l ifesaving, p723). Use the following for prioritization at the scene (and see MINIBOX). Comm and Once in attendance the doctor is respon- sible for providing all medical care. She will work closely with the ambulance service, but will have ad- ditional skills (eg giving pote nt IV analgesia). Safety Yourself: First ensure your own safety; do not approach \201 re or chemical hazards (p800) un- til the \201 re service have made the area safe. Always co nsider the possibility of a CBRN risk (chemical, bio- logical, radiological, nuclear). 27 W ear high-visibility clothing, and carry gloves/eye protection/ear defenders. The scene: If \201 rst to arrive, park obliquely behind the incident ( \200\230fend off \200\231) and leave hazard lights/ green beacon on. The casualties: Remove from any immediate danger; pro tect from further injury during extrication (eg cover with blanket when windows broken). \200\207Check for a hidden victim, eg under a car or over a wall. Communications Liaise wit h police (they are in overall command), \201 re service (for any hazards; they can remove the casualty quickly if he is about to die, or in a very controlled manner, eg if an isola ted spinal injury), and paramedics (identify if they have extended skills; use appropriatel y). Speak to the receiving hospital by radio or telephone (p804, radio procedure), and rela y the number and severity of casualties. Assessment Relate vehicle damage to potential inju ries in the casualty ( \200\230read- ing the wreckage \200\231). Is the casualty trapped \200\224relative (cannot move a broken arm to open the door), or absolute (eg feet caught i n pedals)? Triage From the French trier, to sift or sort (coff ee beans), this process sort s casualties into priorities for treatment. Divide into IMMEDIATE (color-code RED, will die in a few minutes if no treatment, eg obstructed airway, tension pneumo- thorax); URGENT (Y ELLOW, may die in 1 \200\2232h if no treatment, eg hypovolaemia); and DELAYED (GREEN, can w ait eg >4h, eg minor fractures). Those who will certainly die are labeled EXPECTANT \200 \224to treat them may delay you helping the salvageable, who then die unnecessarily (BLUE, but not all triage labels have this color \200\224use GREEN). Do not forget to label the de ad (WHITE or BLACK), otherwise emergency personnel may repeatedly take a doctor to the same victim, so wasting time and resources. Note that alcohol or drug abuse (eg cannabis 28,29) which may have caused the accident in the \201 rst place may make assessing casualties m uch harder. \200\207Note that triage is dynamic. It starts with a brief-look assessment (s ee OPPO- SITE), but later may involve a detailed examination. Priorities (and label color) will change while awaiting, and after treatment. Triage in children is even more specialist , and depends on factors such as height, age, or weight. e r a c e t a d e m m i Priorities at scene \200 Command \200 Safety \200 Communications \200 Assessment \200 Triage \200 Treatment \200 Evacuation i l a t i p s o h - e r P 1 RTA (road traffi c accident) is a misnomer: most result from speed and carelessness, and are all too predict- able, rather than being truly accidental.30 How to triage31 This is a simple system: its main virtue is speed. All casualties should be re- assessed when time and resources allow. Go through the following sequence until you ar rive at a triage priority (in colored CAPITALS and in the table be- low) \200\224assign its color label to the casualty and move immediately to the next. \200 DO NOT STOP TO TREAT, or you will surrender control of the incident. 797 e r a c e t a i d e m m 1 Can the patient walk? No \200\203 check for breathing (2) Yes \200\203 DELAYED (Code with GREEN) i l a t i p s o h - e r P 2 Is the patient breathing? Yes \200\203count or estimate the rate <10 to >30 per minute \200\203IMMEDIATE (RED) 10 \200\22330 per minute \200\203check circulation (3) No \200\203 open the airway Are they breathing now? No \200\203 DEAD (WHITE or BLACK) Yes \200\203 IMMEDIATE (RED) 3 Check the circulation Capillary re \201ll >2sec (or pulse >120) \200\203 IMMEDIATE (RED) Capillary re \201ll <2sec (or pulse <120) \200\203URGENT (YELLOW) Triage categories Color code Category Immediate Expectancy Few minutes Urgent 1 \200\2232h Delayed >4h Expectant Moments or Dead N/A or Equipment In your car boot carry the following minimum equipment: Oropharyngeal airway(s) I V cannulae (14G & 16G) Sticky tape You should give a high priority to making yourself safe and visible, eg: re \202 ective jacket, hard hat, wellington boots. Extra equipment Cervic al collars; Mini-Trach II (cricothyrotomy kit); chest drain set; sutures; local anestheti c; analgesia; splints; stethoscope (more a badge of offi ce than a useful tool owing to noi se). Personal transportation Remember also to take care of your own transportation vehi- cl e, making regular checks of tire pressures and treads, oil level, windshield washer \202 uid and wipers, and spare fuel can. The Road Vehicle Licensing Regula- tions 1984 also all ow for emergency medical responders to carry green lights, but check the regulations to ens ure you are compliant. 798 \200 Dressings IV \202 uid (eg Gelofusine ) Scissors + Torch Bandages Giving set Fire extinguisher e r a c e t a d e m m i \200 First aid treatment A: Airway: Remove false teeth and any vomit. Lie in the lateral p osition (see \201 g 1). If trapped in a car, continue to manually stabilize head and neck when a rigid collar is applied. Extricate on to a spinal board, and immobilize the head an d neck with foam headblocks and securing straps. i see also p725 l a t i p s o h - e r P B: Breathing: If spontaneous, give O2 at 15L/min via tight- \201 tting face mask with rese rvoir. If not breathing, ventilate mouth-to-mouth. 32 If available give 100% O2 via bag-val ve-mask and intubate the trachea.1 If tension pneu- mothorax suspected (cyanosis, engorged neck veins, shifted trachea), pierce chest with a large IV cannula in 2nd intercostal space in the midclavicular line, on the side from which the trachea is deviated. If there is an open chest wound, cover with an Asherman chest seal (adhesive disc with central rub- ber \202 utter valve that allows blood and air to escape without re-entering). 33 C: Circulatio n: Is there a pulse? If not, start external cardiac massage. (Sur- vival from traumatic car diac arrest with no vital signs at the accident scene approaches 0%.) If there is bleeding, this will almost always be stopped by pressure and elevation of the part. Avoid tourniquet s: these are often forgot- ten and left on too long. Insert 2 large IV cannulae (eg antecub ital fossae 14G or 16G; secure these well and splint the arm, eg Armlok ) and start \202 uid re- suscitation (eg Gelofusine ). A policeman or \201 reman makes a willing drip- s tand. Ensure that the cannula is not pulled out when the patient is moved. Suspected intern al bleeding and fractures of long bones indicate that IV \202 uid is needed, as blood los s may be considerable (fractured pelvis 2L, femur 1L, tibia, ankle and fractures of several ribs L each). Splinting (eg one leg to the other) helps reduce blood loss as well as re lieving pain. NB: the ATLS target is de \201 nitive hemorrhage control, rather than plas ma volume normalization. D: Disability: Assess responsiveness rapidly with AVPU: A = Alert V = responds to Vocal stimuli P = responds to Pain U = Unresponsive E: Exposure = head-to-toe exam (secondary survey), but is often not practical outside hospi tal. Reassess ABC; quantify coma level (adult Glasgow Coma Scale, p720; child, p201). Remem ber to give analgesia (p802). Transportation: Keep the injured warm. Procedures (eg IV cannulation) can be per- formed in moving ambulances if the patient can be extricated quickly. 1 Rapid sequence intubation (RSI, p626) is as do-able in the \201 eld as in hospital.34 799 e r a c e t a i d e m m Fig 1. How to vomit. The above is one way of positioning the comatose so vomit is not inhal ed and the cervical spine is supported in the midline \200\224minimizing risk of cord injur y. It helps if there are 2 \200\2233 people to \200\230log-roll \200\231 the casualty into this position, so that the neck is never out of alignment with the body. There have been r eports of neurovascular risk to the arm supporting the head, so other positions are being t ried, but none has been formally validated. i l a t i p s o h - e r P \200\230Scoop and run \200\231 \200\224or \200\230stay and play \200\231? \200\230Scoop and run \200\231 refers to rapid evacuation of casualties to trauma centers (or A&E unit) u sually with only basic life support measures (maintenance of spinal precautions / fracture splinting, bag-mask ventilation etc.); \200\230stay and play \200\231 en- tails detailed r esuscitation at the scene of trauma (intubation, IV access, \202 uid resuscitation). In d eciding which is better, take the following into account. \200 There is no single answer for all circumstances. Local geography and the speed and effi ciency of the response servic e play a part, as does the \201 tness of the casualty. Only experience can tell which opt ion is most appropriate \200\224and luck may well play its part too. \200\230Scoop and run \200\231 and \200\230stay and play \200\231 are two ends of a spect rum of activity. Of- ten a minimal amount of resuscitation can be done without causing too much delay, ie get the best of both worlds. 35 For example, to place vascular access during transportation rather than before it. 36 \200 Penetrating chest injuries have been studi ed in a pseudo-randomized trial (N=289; full randomization was impossible but \200\230scoo p and run \200\231 operated for one day, and \200\230stay and play \200\231 for the next). This showed that the balance of bene \201 t probably lies in \200\230scoop and run \200 \231 for this type of injury. Fluid resuscita- tion aiming for normotension without an oper ating theater to hand may be dangerous, as clot may be displaced by the rising BP \200\224w ith subsequent fatal hemorrhage, which could only have been prevented by major surgery. In this study, 70% in the delayed-resuscitation group survived, compared with 62% who received immediate \202 uid resuscitation. Duration of hospital stay was shorter for survivors in the delayed-resuscitation group. But note that the results only achieved signi \201 cance when pre-op and post-op deaths were pooled, and that rates of complications were similar i n the two groups (eg respiratory distress syndrome, coagulopathy, wound infection, and pneu mo- nia). 37,38 \200 An American review concluded there was insuffi cient data to suggest blunt or penetrating trauma patients bene \201 t from prehospital \202 uid resuscitatio n, but in patients with penetrating injuries and short transportation times (<30mins) \202 uids should be witheld if a palpable radial pulse if present and the patient coherent. 35 If \202 uids are necessary they should be given in 250mL boluses. During active bleed ing titration of \202 uids to a systolic blood pressure (SBP) >70 is no worse in terms of mortality than a titration to a SBP >100. 39 \200 Patients with traumatic brain injury r equire \202 uids to be titrated to a SBP >90mmHg. 40 n=598 Road crashes \200\2242: hazards and extrication Hazards Fire: <5% of road traffi c crashes result in \201 re, and <1 : 500 result in signi \201 cant burns. The world \200\231s wor st ever pile-up was in the Salang Tunnel, Afghanistan, in November 1982, which involved a g asoline tanker explosion with an estimated 1100 \200\2232700 killed. Electricity: Power sho rts are common, eg from bird strike, and power may be re- stored after 20min without invest igation \200\224you must phone the power company to ensure the source is turned off . High tension cables can be lethal even when standing several meters away. Rail: An electri \201 ed rail can be short circuited by a bar carried by the \201 re service, or the opera ting rail authority. Remember that cutting power does not stop die- sel locomotives that ma y also operate on the same line: trains may be stopped by signal lights, red \202 ags, or a series of charges placed on the rail \200\224the noise warns the driver. Underground/Tub e/Metro: In addition to the rail hazards above, this scenario may pose additional quandarie s \200\224eg lack of lighting and ventilation, cramped conditions, diffi cult access to and exit from from accident site. Chemical: Lorries carrying hazardous loads must display an o range \200\230HAZCHEM \200\231 board (see OPPOSITE). This contains information on how to \201 ght a \201 re, what protective equipment to wear, if the chemical can be safely was hed down the storm drains, and whether to evacuate the area (TOP LEFT); a United Nations (U N) product identi \201 cation number of four digits (MIDDLE LEFT) \200\224eg 1270 = pet- r ol; a pictorial hazard diamond warning (TOP RIGHT); and an emergency contact number (BOTTOM LEFT). A white plate means the load is non-toxic. The European \200\230Kemler \200\231 pl ate contains only the UN product number (BOTTOM) and a numerical hazard code (TOP \200\224n ote repeated number means intensi \201 ed hazard). 800 e r a c e t a d e m m i i l a t i p s o h - e r P As a concession to freight carriers, mixed loads of <500kg need only be identi- \201 ed by a plain orange square at the front and rear. To obtain information about the chemical at the scene of an accident look at the transporta tion emergency card (TREM card) carried in the driver \200\231s cab; the \201 re service will be linked with CHEMDATA \200\224a computer database at the National Chemical Informati on Center at Harwell; alternatively phone the National Poi- sons Information Service (eg 08 44 892 0111), or use Toxbase (www.toxbase.org). \200\207Do not approach a chemical incid ent until declared safe by the \201 re service. Principles of extrication \200 Stabiliz e the vehicle where it lies \200\224movement may exacerbate injury. \200 Make the vehicle safe \200\224switch off ignition; immobilize the battery; swill away 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