Asthma Asthma often, but by no means invariably, improves during pregnancy. Conventional tr eatment protocols should be followed. Fibroids Fibroids increase in size in pregnancy and torsion or red degeneration may occur. These present (usually after 20 weeks) with abdominal pain and tenderness, vomiting (not al ways present), and fever. Treatment is with rest and analgesia and symptoms usually settle within seven days. In view of the potential for confusion with an acute abdomen, referral f or assessment is appropriate. DVT and pulmonary embolism Both these conditions are more common in pregnancy and a high in dex of suspicion should be maintained. Presenting features include shortness of breath, hae moptysis, pleuritic chest pain, cyanosis, tachycardia, and collapse. Resuscitation should b e commenced with urgent transfer to hospital which should not be delayed. Pyelonephritis Pyelonephritis is common in the second trimester and presents with fever, vo miting, and loin pain. In severe cases, admission may be necessary. This page intentionally left blank CHAPTER 12 Emergency obstetrics and gynecology 660 Preterm labor Preterm labor is defined as labor before 37 weeks \200\231 gestation. Possibl e features include: - Reduced or absent contraction pain - More rapid progression to delive ry - Increased risk of malpresentation - Early rupture of membranes - Risk of cord prolapse . Imminent labor should be managed in situ (with assistance from a midwife if possible, in ti me). Management is as for normal full term delivery. If delivery is not imminent, transfer to an obstetric unit is appropriate. Once the baby is born, the priority is to prevent heat loss by wrapping. Immediate transfer is appropriate. A baby which is significantly smaller than would be expected by dates shou ld raise the possibility of twins. This page intentionally left blank CHAPTER 12 Emergency obstetrics and gynecology 662 Trauma in pregnancy A knowledge of the anatomical and physiological changes in pregnancy is essential for the optimal management of these patients. The most common lifethreatening co nditions are traumatic placental abruption, uter- ine rupture, and pelvic fracture. These c onditions are, fortunately, rare. However, ALL PREGNANT women should be reviewed in hospita l after any significant trauma. Patient management Primary survey The principles of the primary survey are exactly the same in the pregnant as the non-pregnant patient. - A vaginal examination should NEVER be perfo rmed following trauma in pregnancy as it may precipitate torrential vaginal bleeding. In the second and third trimesters, the patient should be managed in the left lateral position. In the presence of significant trauma, fluids should be administered with less caution than in the non-pregnant patient. Secondary survey The secondary survey should be performed after arrival in hospital. An ass essment of fundal height may be performed. Traumatic placental abruption Presenting features - History of trauma - Lower abdominal pai n - Vaginal hemorrhage \200\224 may be concealed or revealed (see Fig. 12.4) - Uterine ten derness - Maternal shock (may be disproportionate to observed blood loss) - Premature labor - Reduced or absent fetal movements (ask the mother) - Increased fundal height (very diffi cult to assess pre-hospital). The presence of a tense hard uterus with contractions and continuous pain suggests the pres ence of a major abruption and a very poor fetal outcome. Placental abruption may follow minor as well as major trauma Immediate management - Follow ABCDE primary survey protocol as for any injured patient - Ma nage the patient in the left lateral position - Administer fluids to maintain a radial puls e but do not delay transfer - Treat other immediately life-threatening injuries - Transfer urgently to hospital - Mark the fundal height on the abdominal wall. TRAUMA IN PREGNANCY1 663 Traumatic uterine rupture Traumatic uterine rupture is, fortunately, very rare. Presenting features - More easily palpable fetus in a severely shocked mother - Vaginal ble eding (not always present) - Abdominal pain (not always present). Immediate management - Follow ABCDE primary survey protocol as for any injured patient - Ma nage the patient in the left lateral position - Administer fluids to maintain a radial puls e but do not delay transfer - Treat other immediately life-threatening injuries - Transfer urgently to hospital. Blunt trauma Engorgement of pelvic venous plexuses during pregnancy significantly increases the risk of catastrophic hemorrhage following blunt trauma. Urgent transfer to hospital of any patient who has suffered significant trauma is, therefore, essential. Conventional pro tocols should be followed with the patient in the left lateral position. Intravenous access should be started en route or at the scene, if this will not delay evacuation. Penetrating trauma The gravid uterus provides some degree of protection to the mother, at t he expense of the fetus, in penetrating injury to the abdomen. Conven- tional management pr otocols should be followed. CHAPTER 12 Emergency obstetrics and gynecology 664 Normal labor First stage What happens - The cervix effaces and then dilates. Once the cervi x is dilated to 10cm, the first stage is complete. After 3cm, dilatation usually occurs at approximately 1cm/hr in a primagravida and 2cm/hr in a multigravida. There is a \200\230show \200\231 of blood-stained mucus from the cervical canal. - The amn iotic sac bulges through the cervical os and ruptures. - Contractions begin and increase in frequency from every 20 minutes to every 2 to 3 minutes. The fetal head descends into the pelvis. Management - Reassure and support mother; tell her that she is in labor - Determine whether there is time to transfer to a delivery suite or call for expert assistance Gather and record information (see box) - Check the patient \200\231s obstetric records - I f a home delivery was planned, a delivery kit may be available - Ensure that the environmen t is warm. If there is no time to transfer the patient - Perform a vaginal examination - Record the pr ogress of labor (length and frequency of contractions is measured by abdominal palpation) Listen to the fetal heart before, during, and after a contraction (a toilet roll tube is effective as a stethoscope). Passage of meconium (dark green, sticky material) during labor may be a sign of fetal distr ess and an indication for transfer to an obstetric unit: - Administer oxygen to mother - Tu rn mother on side - Transfer. History - Expected date of delivery - Place of booking - Problems in this or previous pregn ancies - Time labor started. Examination - Maternal vital signs - Fundal height - Fetal vital signs - Progress of labor. NORMAL labor1 665 (a) Pelvic brim Bladder Cervix beginning to open Normal anus (b) Physiological retraction ring Upper segment (thick) Bladder Lower segment (thick) Vagina distending Anus stretched Cervix fully dilated Fig. 12.5 The birth canal: (a) in the early part of the first stage of labor; (b) at the be ginning of the second stage of labor. Reprinted with permission from Greaves I et al. (2005 ). Emergency care: a textbook for paramedics, 2nd edn. W.B. Saunders Co. Ltd. CHAPTER 12 Emergency obstetrics and gynecology 666 Second stage of labor The second stage of labor is from full dilatation until the delivery of the baby. It is usually marked by the development of an urge to push. Second stage usual ly lasts 1 \200\2233 hours in a primagravida and 1 hour or less in a multigravida. What happens - The perineum bulges, the anus dilates, and the baby \200\231s head appears at the vulva. The baby \200\231s head flexes, then rotates, so that the occiput is anterior and the face posterior (see Fig.12.6) The occiput delivers first, followed by the vertex, forehead, and face. - When the head has emerged from the vagina, it turns to a lateral position to allow the shoulders to pass through the widest part of the outlet. The anterior shoulder will deliver spontaneously; the posterior shoulder follows. The rest of the baby is delivered. Management - The perineum may be protected with a pad, but this probably has little effect on the degree of perineal damage. The head should be supported once it has delivered. - Once the head has delivered, the umbi lical cord should be checked to ensure that it is not around the baby \200\231s neck. If it is, it should be sli pped over the head or cut between two clamps. - Gentle posterior flexion of the head will a id delivery of the anterior shoulder. Gentle anterior flexion of the head will aid delivery of the posterior shoulder. The baby should be delivered onto the mother \200\231s abdomen or onto the bed, dried, and wrapped. Suction of the baby \200\231s airway is only rarely needed and should not be carri ed out routinely. If it is necessary, a double trap device should be used. The umbilical cord is cut between two clamps after 2 \200\2233 minutes (if not already done). Bleeding from a tear is controlled by a sterile dressing and gentle pressure. NORMAL labor1 667 (a) (b) (c) Fig. 12.6 Delivery of the head: (a) delivery; (b) restitution; (c) external rotation. Repri nted with permission from Greaves I et al. (2005). Emergency care: a textbook for paramedic s, 2nd edn. W.B. Saunders Co. Ltd. CHAPTER 12 Emergency obstetrics and gynecology 668 The Apgar score The Apgar score (see Table 12.1) is recorded at 1 and 3 minutes. A score of 7 or above indicates a baby in good condition. If the score is 6 or below: - Dry the baby with a warm towel - Administer oxygen. Provide bag-and-mask ventilation7 Third stage of labor The third stage of labor is from the delivery of the head to the deliv ery of the placenta. The separation of the placenta is often indicated by a small rush of d ark blood and a lengthening of the cord. Management - The placenta will usually deliver itself within 20 minutes. Cord traction is best avoided. Delivery of the placenta can be expedited by rubbing up a uterine contraction or by putting the baby to the breast. NORMAL labor1 669 Table 12.1 The Agpar score Points Sign 0 1 2 Color Pale Blue Pink Pulse 0 <100 >100 Respiration None Irregular Good Tone Limp Some flexion Active flexion Reflex irritability No response Limited response Cry/active movements CHAPTER 12 Emergency obstetrics and gynecology 670 Retained placenta The placenta delivers in 10 minute or less in over 95% of pregnancies. If it has not delivered within 30 minutes, it is unlikely to do so spontaneously. - Remove th e placenta if it is in the vagina - If the uterus is well contracted, the placenta may be i n the cervix and it will probably deliver once the cervix has relaxed Try rubbing up a uterine contraction - Give syntocinon 10 units if not already given - If n o effect, transfer to an obstetric unit for further management. Avoid excessive cord traction Postpartum hemorrhage In the event of a retained placenta and postpartum hemorrhage of more than 500ml: - Rub up a uterine contraction by abdominal massage - Put the baby to the brea st - Give syntocinon 10 units im - Attempt to deliver placenta by controlled cord traction - Establish access and commence an intravenous infusion - Administer oxygen 15l/min via a n on-rebreathing mask - Transfer urgently to the nearest obstetric unit - Obtain intravenous access but do not delay transfer to do so. This page intentionally left blank CHAPTER 12 Emergency obstetrics and gynecology 672 Abnormal labor Prolapsed cord If the umbilical cord is seen at the vulva, this should be ma naged as follows: - Position the mother in the left lateral position and head down (takes pressure of the cord) Cover the cord with a large, damp, warm swab - Transfer to hospital immediately. DO NOT handle the umbilical cord Shoulder dystocia This occurs when the anterior shoulder impacts on the pubic symphysis aft er delivery of the head, preventing complete delivery of the baby. The following may be hel pful: - Request expert assistance. - Flex the mother \200\231s legs up to her abdomen and t ry again. - Roll mother onto her hands and knees and try delivering the posterior shoulder first. Deliver the posterior arm. Insert a hand into the vagina anterior to the baby. Ensure that the posterior elbow is flexed in front of the body and pull to deliver the forearm. The ant erior shoulder will usually follow. Get an assistant to apply suprapubic pressure with the heeal of their hand. Rocking the hand may help. If this fails, ensure expert assistance by the quickest possible method. Transfer if necessary. Malpresentations: breech (see Fig. 12.7) In multiparous women, the delivery of a breech bab y may occur without problems. Otherwise, the only appropriate course of action in non- spec ialist hands is immediate urgent transfer to the nearest obstetric unit. Extended breech This is the most common breech presentation. The buttocks, and often the sc rotum and vulva are visible. Meconium may be seen. Flexed breech In addition to the above, the soles of the feet may be seen. Footling breech A foot or leg (or both feet or legs) emerge first. There is a significant r isk of cord prolapse. Management - If labor is not well established, transfer urgently to hospital. - Do not move to hospital if a presenting part is visible unless advised to do so. Obtain expert advice from an obstetrician and request midwifery assistance. ABNORMAL labor1 673 (a) (b) (c) (e) (d) Fig. 12.7 Common malpresentations: (a) extended breech; (b) flexed breech; (c) footling bre ech; (d) face presentation; (e) transverse lie. Figs.12.7 (a), (b), (c) reprinted with perm ission from Pearlman M et al., (2004). Obstetric and gynecologic emergenices, McGraw \200 \223Hill. CHAPTER 12 Emergency obstetrics and gynecology 674 With the mother in the lithotomy position, once the nape of the neck is visible, lift the b aby by the feet to help deliver the head. DO NOT pull. Encourage the mother to push. If del ivery fails to progress after the hips are delivered: - Seek expert help. - Confirm that as sistance is on its way. - Put patient on her back with her knees drawn as far upwards and outwards as possible. If the baby does not deliver within five contractions, obtain expert obstetric care as rapidly as possible. This may mean moving mother and child to hospital. Other abnormal presentations/abnormal lie (see Fig. 12.7) Some face presentations may deliv er spontaneously, others will require Caesarian section. Brow presentations will normally r equire a Caesarian section. Vaginal delivery is extremely unlikely in transverse or oblique lies. Management - Obtain expert advice - Ensure expert assistance is en route - Do not attempt t ransfer once a presenting part is visible unless instructed to do so If delivery fails to proceed, follow the instructions for obstructed breech as above. This page intentionally left blank CHAPTER 12 Emergency obstetrics and gynecology 676 Multiple birth This can usually be managed exactly the same as the delivery of two babies, one after the other. The babies are usually smaller than single babies and often deliver be fore full term. If the second twin has not appeared within 15 minutes, it is often appropri ate to transfer the mother to the nearest obstetric unit for the second delivery. NEVER give oxytocin or ergometrine until both babies have delivered Obstructed labor - Obtain expert advice - Ensure that expert assistance is on its way - Do not move the patient unless instructed to do so - Provide analgesia. This page intentionally left blank CHAPTER 12 Emergency obstetrics and gynecology 678 Neonatal resuscitation The resuscitation algorithm for neonates is shown in Fig. 12.8. - Su ctioning meconium from the nose and mouth before the delivery of the chest is ineffective a nd not recommended. For the first few breaths, the inflation pressure should be maintained for 2 \200\2233 seconds in order to assist lung expansion. Tracheal adrenaline is not recommended. If there is no alternative, the dose is 100 g/kg. NEONATAL RESUSCITATION1 679 BIRTH Routine care Provide warmth Dry Clear airway if necessary Assess color Term gestation? Amniotic fluid clear? Breathing or crying? Good muscle tone? Yes No Provide warmth Position; clear airway if necessary* Dry, stimulate, reposition A Evaluate breathing, heart rate, color \200 and tone Apnoeic or HR <100 min \200\2231 Give positive pressure ventilation \200 * B HR <60 min \200\2231 Ensure effective lung inflation, \200 * then add chest compression C HR <60 min \200\2231 D Consider adrenaline etc. Tracheal intubation may be considered at several steps \200 Consider supplemental oxygen a t any stage if cyanosis persists Fig. 12.8 Neonatal resuscitation algorithm. Reprinted with permission from the Resuscitatio n Council (UK) (2005). Resuscition Guidelines. This page intentionally left blank Chapter 13 681 Patient rescue and transportation Immobilization and extrication 682 Transportation in pre-hospital care 696 CHAPTER 13 Patient rescue and transportation 682 Immobilization and extrication Principles of extrication Management of the airway, breathin g, and circulation (ABC) is fundamen- tal in pre-hospital care. In general, with the except ion of cervical spine control (Airway and cervical spine control) and control of significan t external hemorrhage due to limb trauma (assessment of Circulation and control of external hemorrhage), fracture management and extrication follows the primary survey unless it is n ecessary to undertake a snatch rescue. Entrapments are relatively common in road traffic collisions but may also be seen in industrial accidents, building collapses, and farming incidents. At the outset, there should be consultation between the senior mem- bers of the emergency s ervices on site to determine an extrication plan and whether any additional resources are n ecessary. An alternative plan should always be available. Plan A The likely time for extrication and the time scale that is acceptable, based on clin ical need, should be determined. Providing these are acceptable, the best mode of extricati on can be determined and a \200\230controlled extrica- tion \200\231 undertaken. Plan B An emergency extrication plan should be agreed in case the patient deteriorates. Thi s may involve compromising some of the routine princi- ples of patient handling, such as sp inal immobilization, if there is an over- riding clinical need. Entrapment Actual entrapment The patient is physically held in the vehicle or area by the s tructure impinging on their body (for example, in road traffic collisions or by fallen maso nry). Relative entrapment The patient is not physically trapped but is unable to extricate them- selves as a result of their injuries or the pain associated with them. Extrication from vehicles When the scene is safe, the clinician can approach the patient, u ndertake a primary survey, correct ABC problems where possible, and establish monitoring wh ich should be visible outside the vehicle. With one person in the car supporting the patien t \200\231s neck (usually from behind), other rescuers should leave the car to allow the fi re service to commence the extrication plan. The first priority is to make space within the vehicle and then to facilitate the agreed plan. The procedure can be halted to allow acces s to the patient for reassessment and interventions as necessary. IMMOBILIZATION AND EXTRICATION1 683 Rapid extrication This commonly involves springing open the door of a vehicle and extricati on on a spinal board either by removing the roof or through the rear hatch. Practice is ess ential in order to understand the principles of extrication and to be a useful member of th e rescue team. Snatch rescue A snatch rescue is retrieval of a casualty from a difficult environment with minimal stabilization and resuscitation until a place of safety is reached. Examples includ e impending scene danger, fire, or the removal of a patient in cardiorespiratory arrest to facilitate resuscitation. CHAPTER 13 Patient rescue and transportation 684 Principles of immobilization The principles of immobilization are straightforward \200\224t o maintain casu- alty safety and comfort and do no harm. During patient packaging, the patient should be regularly reassessed by repeating the prima ry survey and, in the case of significant limb trauma, by repeating a neurovascular assessm ent (sensation, movement, pulses, capillary refill) before and after any limb manipulation. Reduction and immobilization of fractures is necessary to: Prevent further injury - Provide pain relief - Reduce blood loss - Reduce the volume of fat emboli - Facilitate extrication and rescue. Prevention of further injury Appropriate immobilization will reduce the risk of damage to t he adja- cent skin muscles, nerves, and blood vessels. Where the skin is in jeo- pardy, for example, in fracture dislocations of the ankle, realignment and reduction may reduce the r isk of skin necrosis. Similarly, where there is distal vascular compromise, straightening o f the limb will restore circula- tion in most cases. Protruding bone ends should be returne d to a normal anatomical position once major contamination (for example, soil) has been rem oved. Pain relief Fracture immobilization reduces movement at the fracture site, reducing pain fr om the sensitive periosteum. In addition, painful muscle spasm may be reduced and pressure on adjacent nerves, which may result in pain, relieved. Reduction of blood loss The application of a traction splint reduces the potential volume i nto which bleeding may occur, closes down open venous channels, and restores muscle tension so reducing the overall blood loss. IMMOBILIZATION AND EXTRICATION1 685 Reduction of the incidence of fat emboli Fat embolism occurs as a normal pathological proce ss following major long bone fractures. Whether the patient develops fat embolism syndrome (pulmonary and cerebral manifestations and skin petechiae) depends on the magnitude of embo lization and the degree of uncor- rected hypoxia and hypovolaemia. Immobilization of fractures reduces the incidence and magnitude of emboli from fat entering the circulation as a consequence of moving bone ends and open venous channels. Fat emboli can also occur as a result of changes in circulating chylomicrons. Immobilization principles - Support to either side of the fracture but avoiding direct pres sure over the fracture site. Immobilization of the joint above and below the fracture. - The provision of adequate analg esia (titrated opiates, ketamine, or nerve blocks). The reduction of gross contamination in compound factures by irrigation with saline. Polaroid photography of the wound at the scene. Further wound inspections are then not necessary in A&E prior to surgical management. Dressing of compound wounds with a sterile dressing and pad. - Splintage. The features of effective splints are: - Simplicity - Ease of use - Lightness - Cleanabilit y - Strength (to avoid damage during use) - Interchangeability with equipment used in the A &E department. CHAPTER 13 Patient rescue and transportation 686 Methods of immobilization Cervical spine Cervical spine immobilization can be achieved by: - Manual stabilization - A cervical collar, spinal board, head restraints, and straps. A cervical collar alone does not provide adequate immobilization. Manual stabilization The cervical spine should be protected at the outset based on the mech anism of injury and clinical presentation. As the airway is opened or protected, the cervic al spine should be immobilized manually. This can be achieved in road traffic collisions fr om: - Behind the patient - The side of the patient - In front of the patient. Immobilization from behind This is the most frequently used position in road traffic collis ions as it facilitates airway management by jaw thrust if required. The neck should be move d to a neutral position. If the patient is conscious, they should be directed to move their neck to achieve this. The patient should stop if they develop severe pain, pins and needle s, or weakness. The patient undertaking active movement of the neck will not produce cervic al cord compromise. If the patient is unconscious, the rescuer should passively move the ne ck to the neutral position but stop if resistance is felt and maintain stabilization in tha t position. Failure to restore a previously normal neck to a neutral position suggests a si gnificant injury. Traction is not applied under any circumstances. From behind, the rescuer places the hands on either side of the head, ensuring that the ear s are not covered. The thumbs should extend upwards behind the posterior aspect of the skul l and the little fingers to just under the angle of the jaw (Fig. 13.1a). Immobilization from the side This may be the only means of access to the patient initially. One hand supports the patient \200\231s head, with the occiput in the palm, and the other supports the jaw between the thumb and index finger. As before, the head is moved to a neut ral position. (Fig. 13.1b). Immobilization from the front The rescuer \200\231s hands are placed over the patient \200 \231s cheeks with the fingers around the neck and the extended thumbs in front of the ears over the temporomandibular joints. The head is moved to a neutral position (Fig. 13.1c). In the supine patient, the neck is supported in a similar manner to the technique described for immobilization from behind. It is essential that the rescuer practices these technique s. Indications for cervical spine immobilization - Mechanism of injury - History of unconsciou sness in trauma - Head injury in patients under the influence of alcohol and drugs IMMOBILIZATION AND EXTRICATION1 687 Evidence of injuries above the clavicle - Spinal tenderness - Neurological signs/symptoms - Painful distracting injuries - Head and neck trauma (even minor) in patients with rheumato id arthritis and ankylosing spondylitis. Cervical collars should be correctly sized. Ambulance services cur- rently use either a system of collars which are available in a range of size s or single collars which are adjustable. The rescuer should be familiar with the sizing te chnique and adjustment and practiced in collar application. It is important to note that: A collar can only be applied if the neck is in a neutral position. - The cervical spine can not be effectively immobilized by a collar alone. A spinal board, head blocks, and straps are also required. Ill-fitting collars can be harmful and produce airway compromise. - Intracranial pressure i s elevated by well-fitting collars in the unconscious patient. Once fully immobilized on a spinal board, the collar should be loosene d in the unconscious patient. CHAPTER 13 Patient rescue and transportation 688 (a) (b) (c) Fig. 13.1 Cervical spine immobilization (a) from behind; (b) from the side; (c) from the fr ont. Reprinted with permission from Greaves I et al. (2005). Emergency care: a textbook for paramedics, 2nd edn. W.B. Saunders Co. Ltd. IMMOBILIZATION AND EXTRICATION1 689 Limb immobilization Manual methods Methods of self or buddy help include supporting an inju red arm or chest wall at the site of an underlying fracture. Triangular bandages The triangular bandage is the mainstay of first aid treatment for upper limb injuries. It can be used in two ways: - As a broad arm sling - As a high arm sling. In the lower limb, a broad or narrow bandage produced by folding a triangular sling two or three times, respectively, can be used to splint the legs together. Triangular bandages can also be used to secure and hold scalp dressings in place. FRAC Straps TM These are commerc ially available straps with velcro and have a similar function to the broad and narrow band ages described above. They func- tion to secure one leg to the other, with padding between the legs, or to secure the arm to the chest wall (used in conjunction with a triangular ban dage) or to the side of the body. Neighbor strapping Neighbor strapping fingers together or one leg to the other provides som e degree of support. In the case of femoral fractures, it may permit the patient to be move d to a position where more appropriate splintage can be applied. Strapping the legs togethe r in a patient with a femoral fracture sitting in a car may facilitate extrication prior to the application of a traction splint when the patient is on an ambulance trolley cot. Inflatable splints These are clear plastic double-walled splints and require inflation for support. They are used less frequently than before because of the risk of over-inflation an d tissue ischaemia. They are also prone to damage and deflation. Box splints These consist of three long padded boards and a foot piece. The patient \200 \231s shoe and sock are normally removed to facilitate neurovascular assessment before the leg is placed in a splint. The foot piece is designed to hold the ankle at right angles. Th e outer sides of the splint are folded around the leg and secured with velcro straps. Box s plints are suitable for immobilizing ankle and tibial fractures and also injuries around th e knee. In the upper limb, they can be used to splint forearm and elbow injuries. The splin ts are available in two sizes. CHAPTER 13 Patient rescue and transportation 690 Mark the location of the dorsalis pedis pulse with a cross to save time finding it next tim e Traction splints Traction splints can be used for closed and open fractures of the shaft of the femur and tibia. Without traction, they can be used to support inju- ries around the k nee. Contraindications to their use include dislocation of the hip, fracture dislocation of the knee, and ankle injuries. The traction splint is used to secure the leg in an improved and near reduced position. The application of traction involves securing the ankle and applying traction by distracting t he device with the proximal end of the splint pressing against the pelvis (separating two f ixed points). The various types of splint include the Donway splint, Trac3 splint, and the Sager sp lint (Fig. 13.2). The attraction of the last is that it can be used to immobilize both legs (bilateral femoral fractures) at the same time. Before and after application, the rescuer should check the patient \200\231s distal neurova scular status. The techniques for application are similar and the rescuer should be familia r with the splint used by their local ambu- lance service or immediate care scheme and with its application and removal. An exchange splint should be retained in the A&E department. Before any traction splint is applied, appropriate analgesia should be given and enough ass istance must be available. Two people are the mini- mum required for optimal application of a traction splint. Footwear should be removed and the neurovascular status of the limb mus t be assessed and recorded. Donway splint (Fig. 13.2b) The Donway splint consists of two components which, when fitted together, form a trombone-shaped unit. Only one splint can be applied and only one leg spli nted. The Donway splint is bulky and protrudes some distance beyond the patient \200\231s f oot. Method of application 1. The ischial ring is placed under the thigh and the strap and buckl e loosely fastened across the front of the thigh. 2. The air release valve is depressed to ensure that there is no pressure in the system and the locking screws are unlocked. The footplate is raised and placed under the patient \200 \231s foot. 3. The splint is attached to the ischial ring; the side arms of the splint are extended like a trombone. 4. The casualty \200\231s foot is strapped to the foot plate. 5. The pump is used to increa se the pressure within the closed \200\230U \200\231 of the splint which extends, applying traction to the limb. Enough pressure is applied to make the casualty comfortable (approxi mately 10% of body weight). 6. The supports are positioned under the leg at mid thigh and mid calf and the knee support is secured. IMMOBILIZATION AND EXTRICATION1 691 7. The splint stand is lowered and the locking nuts are secured to keep the splint to length. 8. The pressure is released by depressing the air release valve. Trac 3 splint The Trac3 and hare splints (see Fig. 13.2a) are effectively the same and shar e a method of application. Method of application 1. The splint is adjusted for length against the uninjured leg. The s traps are opened and correctly positioned at intervals down the leg. The correct ankle hitc h is selected. 2. The hitch is placed under the ankle , the straps are folded across the front of the ankl e, and the rings are brought together under the foot. 3. Manual traction is commenced with one hand and the leg supported whilst the splint is put in place. (An effective method is t o log roll the patient away from the injured leg, place the splint, and roll the patient ba ck onto the splint). The top padded ring must fit under the ischial tuberosity. 4. The top strap is done up, avoiding the external genitalia. 5. The traction hook is put t hrough the rings and traction taken up (whilst maintaining manual traction). 6. The foot stand is raised and the Velcro straps are positioned and tightened. The Sager splint (Fig. 13.2c) The Sager splint is light and can be used to splint one or bo th femurs. It does not extend significantly beyond the end of the patient \200\231s foot. T he Sager splint is the authors \200\231 splint of choice for pre-hospital use. Method of application 1. The cushioned \200\230seat \200\231 of the splint is placed betwe en the patient \200\231s legs, against the perineum and symphysis pubis. Care should be tak en not to trap the external genitalia. The top strap is fastened around the thigh. 2. The splint is extended until the ankle hitch lies at the normal heel position. 3. The ankle harness is applied behind the heel and wrapped around the malleoli and the cushions adjusted to fit the leg. 4. Traction is applied until the patient is comfortable (approximately 10% of body weight). 5. The thigh strap is tightened and lower straps secured. 6. An identical method is used if both legs are being splinted. CHAPTER 13 Patient rescue and transportation 692 (a) (b) (c) Fig. 13.2 Types of traction splint: (a). Donway; (b). Trac 3; (c). Sager. Figs. 13.2a,b rep rinted with permission from Greaves I and Porter K (1997). Pre-hospital medicine \200\224th e principles and practice of immediate care. Edward Arnold. Fig. 13.2c reprinted with permi ssion from Greaves I et al. (2005). Emergency care: a textbook for paramedics, 2nd edn. W.B . Saunders Co. Ltd. IMMOBILIZATION AND EXTRICATION1 693 Contraindications to traction splintage - Injuries at the ankle - Dislocation of the knee - Fractures around the knee (apply without traction) - Dislocation of the hip - Fracture of the pelvis. Pneumatic antishock garment (PASG) Also known as the military antishock trouser (MAST) suit , this is an inflatable garment that covers the legs and abdomen and can be inflated to a p ressure of 100mmHg. It can be used to: - Splint fractures of the pelvis and lower limbs - F acilitate inter-hospital transfer of patients with intra-abdominal bleeding Provide some degree of tamponade for patients with ruptured abdominal aortic aneurysms. It is no longer recommended for use in the treatment of hypovolaemic shock because of the c atastrophic deterioration that can occur when the splint is deflated. If it is used to faci litate remote transfer, adequate fluid replacement must proceed at the same time. Specific contraindications for its use include: - Cardiac failure - Pulmonary oedema - Significant c hest injuries - Diaphragmatic rupture - Advanced pregnancy. The PASG is difficult and time consuming to apply and its application will delay transfer to hospital. It is therefore con traindicated in all but the most prolonged transfers. Methods of extrication Extrication devices A number of extrication devices are in use in th e UK, all of which are fairly similar in design and use. They include the: - Kendrick extri cation device (KED) - Russell extrication device (RED) - ED 2000 - Telford extrication devi ce (TED). These have been introduced to replace the short spinal board. They provide support and stab ilization particularly to the upper spine. Whilst maintaining inline manual stabilization a nd with the patient wearing a cervical collar, the splint is inserted behind the patient by moving the whole patient slightly forward in the sitting position or by retracting the sea t. The patient is secured to the device by a series of straps around the trunk and by strap s that go around the legs to secure the splint in the groins. Finally, the cervical spine i s immobilized using the supporting neck side pieces of the splint. These are secured in pla ce by two velcro straps, one across the forehead, the other across the cervical collar. The splint is provided with lifting handles to facilitate easy and safe movement. CHAPTER 13 Patient rescue and transportation 694 Scoop stretcher The scoop stretcher provides a means of lifting a patient from a horizon- t al position onto a trolley cot. It can be split in half longitudinally and is applied from both sides of the patient. It has a supporting head cushion and the bottom part of each com ponent must be extended to fit the patient before application. The two parts of the stretch er are placed one on each side of the patient (ensuring that the narrower foot end is at th e patient \200\231s feet), then the two components are locked first at the top end and then at the feet. It may be necessary to lift the pelvis slightly to facili- tate distal lockin g of the splint and to ensure that the buttocks are not pinched between the two sides of th e stretcher. The patient can be moved in the position they are found, an airway protected p osition, or supine position. The scoop stretcher can be used as a means of transpor- tation for short journey times or as a means of lifting a patient onto a vacuum mattress or troll ey cot. Spinal boards Spinal boards are used to facilitate extrication. They provide a stable secur e base to which the patient is strapped for full spinal immobilization. Although not design ed as a transportation device, in UK ambulance practice, spinal boards are commonly used on top of the trolley cot to transfer the patient to hospital. There is a risk of the patient developing pressure sores on the board, especially in those patients with neurological inj uries. If the transportation time is likely to be more than 20 minutes, consideration shoul d be given to scooping the patient off the spinal board and onto a vacuum mattress. In hospital, the patient should be removed from the board at the earliest opportunity. In p atients with significant trauma, this is normally undertaken at the completion of the prima ry survey. In non-urgent cases, for example where the board is used as a precautionary meas ure and where there will be delay in the A&E until the patient is seen by a member of the m edical staff, the patient should be log rolled off the board after the first set of stable clinical observations. The patient is then secured on the hospital trolley using sandbags a nd tape. Extrication using a long spine board In road traffic collisions, whilst inline stabilizatio n is maintained and the whole spine supported, the patient can be carefully maneuvered onto the board in order to carry out a controlled extrication.