Prehospital Care

Chapter

Abstract

You are a first responder doctor to a car accident in the UK. There is one casualty who is unconscious, trapped in the wreckage of her car. You manage the safety of the scene and then attend to the casualty, managing her airway, breathing, and circulation. The extraction is delayed and so you are forced to deal with some life threatening injuries on scene and plan extraction. After the patient is successfully taken to definitive care by air ambulance you discuss with colleagues contrasting approaches towards pre-hospital care.

Keywords

Catheter Convection Europe Transportation Immobilization 

Learning Objectives

  • Learn how to safely approach a trauma site

  • Learn the principles underpinning the ABC trauma approach

  • Learn how to conduct a primary survey

  • Discuss some common forms of life-threatening injury and their management

  • Understand the next steps including the secondary survey

  • Discuss rescue and transport including C-spine management

  • Discuss controversies around prehospital care, including the debate around “stay and play” and “scoop and run” philosophies

  • Discuss the relevance of historical concepts in trauma such as the golden hour and trimodal distribution of death

Initial Scenario

You are a GP volunteering as a first responder doctor with BASICS to keep up your trauma skills [1]. You get a call from a local ambulance dispatch center; there has been a road traffic collision between a lorry and a car on a motorway in your covering area.

You arrive quickly on scene, and the ambulance crew have just unpacked their gear when you arrive. There is only one casualty, and she is trapped in the wreckage of her car and is breathing with difficulty. The driver of the lorry appears unhurt but is walking around, and several people have stopped and got out of their vehicles.

Prompt 1: What Are the Problems Facing You as the First Responder?

Sites of trauma are hazardous, and your first priority is to prevent getting injured yourself and further casualties. Adequate time should be taken assessing personal safety, scene safety, and survivor safety (Box 11.1). This time very rarely ­negatively impacts on patient survival but prevents further casualties and helps extraction [2].

With multiple casualties, all efforts should be spent triaging patients (covered in  Chap. 16). Remember, for each casualty there are a diverse number of possible injuries, many of which may not be present initially and many that could be fatal.

Box 11.1: 1, 2, 3 of Safety at Scenes of Trauma

1. Personal safety

Personal protective equipment, e.g., latex gloves, goggles, high-visibility clothing

Avoiding dangerous areas, e.g., fuel leaks

2. Scene safety

Assessing the scene for hazards

Being aware of fires, sources of explosions, or falling objects

On roads, use two people to stop traffic in both directions

Cover or make visible sharp pieces of metal

3. Survivor safety

Evacuating survivors from places of danger, e.g., falling vehicles, fires, explosions

Preventing confused patients straying into danger

Further Information 1

You don your high-visibility jacket, goggles, and gloves. You ensure traffic is stopped in both directions and onlookers are safe. A minute after you arrive, you move on to attend the patient in the car with breathing difficulties.

Prompt 2: How Should You Approach Treatment of This Patient?

Trauma patients should always be treated using a rigidly structured “ABC” approach regardless of type of trauma (Table 11.1). Trauma kills on predictable timescales; an airway problem kills before a breathing problem, and breathing before a circulation problem.
Table 11.1

The “ABC” approach to trauma or “primary survey”

Airway

Maneuvers to ensure a patent airway, adjuncts, and C-spine immobilization

Breathing

Assessment for life-threatening thoracic injury; oxygen

Circulation

Assessment for signs of hemorrhage and shock; control external bleeding

Disability or neurological status

Best response, alert, responding to pain, voice or unresponsive (AVPU score), and assessment of pupil size, equality, and reactivity.

Extrication to definitive care

Extrication by what means, where to, in what time frame.

Environmental control

Environmental control such as blankets to keep patient warm while remembering to expose the patient and check head to toe for injuries. Remember glucose and noninvasive monitoring of pulse, saturation, and blood pressure

Exposure

Other injuries can be distracting but should never cause the airway and breathing to be overlooked. A few minutes of airway obstruction is all it takes for hypoxia to lead to secondary irreversible brain injury. Following any intervention, it is important to reassess ABC for effect, returning to A if there is any deterioration in the patient’s condition.

Prompt 3: How Do You Assess and Manage a Patient’s Airway (A)?

Look and listen for signs of respiratory compromise. Observe for cyanosis, signs of respiratory distress, maxillofacial trauma, and use of accessory muscles. Hold your ear to patient’s mouth and listen for breathing or any additional noises, stridor or gurgling.

If the patient has decreased consciousness, the tongue can easily fall backward in the mouth preventing the patient from being able to breathe (Fig. 11.1a).
Fig. 11.1

Head tilt and jaw thrust to clear airway [3]. (a) in an unconscious patient the tongue can easily obstruct the airway (b) head tilt and jaw thrust move the tongue forward clearing the airway

If the airway is compromised, perform an airway maneuver; jaw thrust (use 2–3 fingers behind the jaw to move it forward) or chin lift if no neck injury (slightly extend the neck using fingers below the jaw). This clears the upper airway by preventing the tongue obstructing the back of the throat (Fig. 11.1b).

Check mouth for vomit or debris and clear anything that may obstruct breathing. Do not insert finger as you may risk pushing objects down further, but instead, use suction if available, and only suction what you can see since blind suction can trigger airway spasm.

Airway adjuncts can be used if the responder is trained: an oral pharyngeal airway (OPA), nasal pharyngeal airway (NPA), or laryngeal mask airway (LMA) all maintain pharynx patency. They can be inserted with less skill and sedation than full endotracheal (ET) intubation.

If the patient is falling into a coma (unresponsive or only responsive to pain, GCS < 8), she requires endotracheal intubation. This is usually by rapid sequence induction where the patient is given a combination of medicines to quickly sedate and paralyze them and cricothyroid pressure is given to reduce the risk of gastric aspiration.

In all trauma, the spine must be immobilized unless you can confidently exclude a C-spine injury (Box 11.2). An unstable bony or ligamentous injury risks spinal cord damage and total paralysis from the neck down, particularly if the head is moved in an uncontrolled way. Spinal fractures should be given a high index of suspicion in high impact collisions or where there is head injury.

Manual in-line immobilization can be used where one person takes responsibility for supporting the head. This is preferably not the doctor as it stops him from doing other tasks. The person supporting the head leads any log rolls or movements and can give jaw thrust at same time as C-spine immobilization.

If the patient is sitting upright with a suspected C-spine injury, forehead and nape of neck stabilization should be used before applying a semirigid neck collar. Note: A spinal board with straps and bolstering devices is the only way a C-spine is immobilized, it is not stable in a collar alone.

Box 11.2: Clearing a C-Spine Injury Clinically

In the UK, this is usually only done in the hospital setting by a registrar level or consultant. The criteria are as follows:
  • No distracting injury, GCS 15/15, no alcohol

  • No reported pain in neck or bruising

  • Painless neck forward flexion/extension and rotation

  • No point tenderness on palpation of spinal processes of C1–7

If the criteria are not met or are doubtful, the patient needs a CT head and neck or a neck X-ray series (AP, Lateral, and Peg). Note: The gold standard investigation for all polytrauma patients is whole-body CT, with the benefits far outweighing the radiation risks [4]

Further Information 2

The casualty is seated in the front seat of the car. You suspect a cervical spine fracture and so approach from in front, introduce yourself, and explain to her not to move her head, while you then approach from behind. The casualty does not respond and is breathing but with difficulty and you can hear a gurgling noise. You put a spinal collar on her and perform a careful jaw thrust. She appears to breathe a little easier but is still unconscious.

You attach high-flow oxygen through a nonrebreather mask and a saturation probe. You then perform a pinch of the trapezius. The casualty responds to the pain and opens her eyes. Due to decreased consciousness, you know she might not be protecting her airway and so insert an oropharyngeal airway and continue to assess her for potential need to fully intubate when further medical support arrives.

Prompt 4: How Do You Assess and Manage Breathing (B)?

Oxygen must be given to all trauma patients to support breathing in the form of high-flow oxygen (>12 l/min) through a tight-fitting “Hudson” nonrebreathing mask.

Look for external signs of trauma and count respiratory rate (RR). RR is a very sensitive marker of almost any physiological distress. Feel for tenderness, tracheal deviation, or rib fractures. Auscultate and percuss the chest to aid diagnosis and identify and treat common immediate life-threatening conditions in trauma (Table 11.2).
Table 11.2

Life-threatening injuries in trauma [5]

Cause

Description

Symptoms/signs

Treatment

Tension pneumothorax

Air leaking into chest cavity.

Respiratory distress.

Narrow window from symptoms to cardiac arrest.

Intrathoracic pressure increases obstructing blood flowing back to the heart

Hyperresonant percussion note and absent breath sounds on affected side.

Needle thoracostomy.

Tracheal deviation away from affected side

Insertion of chest drain once stabilized

Massive hemothorax (>1,500 ml)

Blood leaking into pleural space due to hemorrhage. Intrathoracic pressure increases obstructing blood flowing back to the heart

Signs present late, typically >1 l blood loss.

Narrow window from symptoms to cardiac arrest.

Respiratory distress, hypotension.

Chest drain insertion once IV access established for circulatory support

Dull percussion and decreased breath sounds on affected side

Flail segment (one of the most common serious injury to the chest)

Two or more ribs broken in two places. Failure of chest wall movement

Respiratory distress. It may be possible to see the flail segment paradoxically move inward on inspiration

Analgesia. Mechanical ventilation is reserved for patients with pulmonary insufficiency despite adequate analgesia

Sucking chest wound

Hole in chest wall allowing air in on inspiration

Respiratory distress

Three-sided airtight dressing.

Obvious open chest wall injury

Insertion of chest drain once stabilized

Aortic disruption

Tear/dissection of aorta or great vessels

Evidence of mediastinal trauma

If the patient is hemodynamically unstable, surgery to control hemorrhage is essential.

Often rapid death

If hemodynamically stable, manage BP with adequate analgesia and antihypertensives

However many patients asymptomatic

Cardiac tamponade

Blood leaking into heart pericardium compromising venous return and heart filling

Muffled heart sounds

Subxiphoid cardiocentesis

Raised JVP/distended neck veins

Hypotension

Pulse oximetry can be very useful for noninvasive recording of blood oxygenation and heart rate. If saturations >95 %, this is strong evidence of adequate peripheral oxygenation, but if the patient is cold or shivering, this may interfere with measurement. If following performing airway maneuvers the patient is still not adequately breathing (i.e., sats < 94 %), a bag valve mask may be used to give manual breaths.

Further Information 3

The patient’s respiratory rate is 40 BPM; you notice the trachea is deviated to the right, and the left side of the chest is resonant to percussion with absent breath sounds. You diagnose a left-sided tension pneumothorax and insert a large needle (wide-bore cannula) into the second intercostal space, midclavicular line above the rib to avoid the neurovascular bundle. You hear a hiss of air as the pressure escapes, and the patient breathes easier; however, the patient soon appears cold and pale, and the saturation probe shows her heart rate has increased to 120 BPM.

Prompt 5: How Do You Assess and Manage Circulation (C)?

Shock is where cardiac output is insufficient to adequately perfuse organs. A good early marker is a capillary refill time (CRT) >3 s. Cold peripheries and increased heart rate (HR) are typically then seen, and it is important not to mistake this as a physiological response to pain and cold. Look for any obvious external bleeding and think about sites of concealed bleeding such pelvic fractures or hemothorax.

Low blood pressure gives a definitive diagnosis of shock; however, a drop in systolic blood pressure (SBP) is a very late sign in shock, only occurring after 30 % blood loss [6]. The early signs are a drop in consciousness level and RR/HR. Anxiety may be another early sign the patient is going into shock, giving way to agitation or confusion as the brain becomes underperfused.

If needed, systolic blood pressure (SBP) can be measured using noninvasive blood pressure monitoring with an automated cuff. If not available, palpable pulses provide a guide; a palpable radial pulse indicates SBP >80, femoral pulse indicates SBP  >  70, and the carotid pulse indicates SBP > 60.

Treat any obvious signs of bleeding with direct pressure, elevation above the level of the heart or pressure on artery upstream. Tourniquets can be considered if pressure is ineffective; this is of particular relevance to military trauma and is covered in  Chap. 13.

Secure IV access ideally with two large-bore IV cannulas. New research indicates this should not be a reason to delay patient transport in many circumstances where urgent surgery is required as a delay in surgical referral costs lives [7]. Blood products can be considered; type of fluid is covered in more detail in  Chap. 13.

Movement of a patient should be minimalized to reduce the risk of dislodging clots, and fractured limbs should be splinted. Permissive hypotension is now regularly employed, only giving fluids (crystalloid/colloid) if a radial pulse if not palpable. If hypotensive, 250-ml boluses should be administered until a radial pulse returns [8].

Note: Concealed bleeding can mask massive blood loss; a hemothorax only becomes clinically apparent when it reaches about 1 l. At this stage, 15–30 % of a patient’s circulating blood volume has been lost into the chest, leaving little time from detection to arrest.

Further Information 4

The fire service informs you the extraction will take a further 20 min. You find the radial pulse is not palpable, but you manage to secure IV access in one arm and give boluses of 250 ml of 0.9 % saline. This does not improve so you give another crystalloid bolus.

The patient’s radial pulse becomes palpable and the heart rate drops from 160 to 120 BPM. However, the casualty starts shivering and saying inappropriate words.

You decide that the patient is critically ill and inform the team that extrication is a priority and air ambulance will be useful. You conduct a secondary survey before the air ambulance arrives and try and prevent environmental exposure to the patient by wrapping her in a blanket.

Prompt 6: How Do You Assess Disability: Neurological Status (D)?

Look and feel for basal skull fractures. CSF otorrhoea/rhinorrhoea and severe tenderness of skull or boggy/depressed fractures can give a clinical diagnosis of a skull fracture. Periorbital ecchymosis and Battle’s sign are late signs that will probably not be seen acutely.

AVPU provides a quick assessment of consciousness (awake/alert, voice response, pain response, unresponsive). Consider performing a full Glasgow coma score (GCS) if time, to monitor for neurological deterioration of patient. You can also consider testing pupils with a torch to test for blown pupil (raised ICP from head injury) or other pathology.

A full neurological exam would be impractical and time-consuming; however, the patient should be asked to wiggle her hands and feet to check for focal neurological deficit and asked about abnormal sensation. Remember that AB and C take priority and reassess them. Causes of decreased consciousness can be from hypotension, brain swelling, or pain.

Prompt 7: How Do You Plan Extrication (E)?

Once the patient has been stabilized and ready for transport, it is important to get her safely to definitive care, in a hospital equipped to deal with her injuries. Ideally, this should be planned at an early stage to give time for support to arrive. Consider the following:
  • Who – will be required to safely extract and transport the patient

  • How – will the patient be extracted

  • Where – will the patient need to go to get definitive care

  • When – do they need definitive care (how urgent)

Prompt 8: What Is the Secondary Survey (E-Exposure)?

Part of secondary survey is the AMPLE history (A – allergies, M – medication history, P – past med history, L – last meal, E – events leading to incident/mechanism).

The secondary survey requires the patient to be fully undressed (Exposure) and is a complete examination of the patient from head to toe, front and back. The aim is to identify any injuries missed by the primary survey of the head, neck, thorax, abdomen, pelvis, and upper and lower extremities. Ears, fingers, nose, and mouth should also be examined with gloved fingers. The patient should then be log rolled to check for bony spinal tenderness followed by a rectal exam to assess for neurological or abdominal injuries. If the patient is critically injured the secondary survey may be completed later in hospital when more stable.

Prompt 9: Why Is Environment Control Important (E-Environment)?

Hypothermia is a separate risk factor for major trauma as it leads to exhaustion and coagulopathy (covered in  Chap. 13). Reducing heat loss through radiation, conduction, convection, and evaporation can prevent it. In practice, this is done by providing blankets for the patient, warmed IV fluids if possible; heated air blankets are useful if available. Note: In hot countries, hyperthermia, heat stroke, and dehydration can also be relevant to casualty management.

Prompt 10: How Do You Communicate the Patient’s Condition to the Hospital?

MIST reporting is a standard trauma reporting system.
  • M – mechanism, e.g., RTC at 60 mph involving car and lorry

  • I – injuries sustained, e.g., pneumothorax

  • S – symptoms and signs, e.g., shock, CRT 4 s

  • T – treatment given, e.g., needle thoracostomy

Then give salient points from AMPLE history.

Further Information 5

You discover spinal tenderness at the C5 level and evidence of a fractured femur and major pelvic fracture. The fire brigade arrives to cut the patient from the vehicle. Another ambulance arrives on scene and informs you that the air ambulance is expected in 5 min. The patient becomes drowsy and starts vomiting.

Prompt 11: What Are the Possible Causes of Vomiting in Trauma and How Should It Be Managed?

There are many causes of vomiting in trauma (e.g., head injury, opiate reaction, abdominal injury, or pain), but it should always prompt a swift response to protect the airway and should heighten the suspicion of serious pathology.

Management involves returning to the ABCDE approach; airway management takes priority over immobilization if breathing is severely compromised. If the patient is immobilized, you can roll the stretcher to the side to avoid risk of aspiration. Suction is useful again if available and an antiemetic should be given where appropriate.

Prompt 12: How Do You Manage Major Orthopedic Fractures?

Major orthopedic fractures can conceal massive hemorrhage, and there is the possibility of lethal fat emboli progressing to the lung. The risks of this can be minimized through immobilization and traction.

Major pelvic fracture always presents a high risk of lethal hemorrhage, due to the energies required to fracture the pelvis and the proximity of major blood vessels. A splint should be applied to control bleeding; this could be done using a “SAM sling,” or one can be improvised using a belt. The legs should be taped together. A femoral fracture can result in 1.5 l of blood loss. The limb should be immobilized in a traction splint. For other lower limb injuries, a stabilizing splint can be used (Fig. 11.2).
Fig. 11.2

Use of a split to stabilize a long bone fracture (Picture by David Nott)

Further Information 5

The patient leaves by air ambulance and you debrief the team. There is discussion about whether the patient should have been transported earlier by standard ambulance.

Prompt 13: How Relevant Are Concepts Such as the Golden Hour of Trauma and Trimodal Distribution of Death?

Dr. R. Adams Cowley coined the term the “golden hour of trauma” in 1963 to persuade police helicopters to transport severely injured patients to trauma centers as soon possible for definitive surgery [9].

It was not based on evidence, and there is nothing magical about 60 min; however, in the early stages of trauma, rapid assessments, decisions, and managements are required to treat life-threatening injuries. The “golden hour” is therefore still a useful concept in that rapid treatment saves lives in trauma [10].

In 1983, another American surgeon Donald Trunkey analyzed trauma deaths in San Francisco and suggested they followed a trimodal distribution (Table 11.3, Fig. 11.3).
Table 11.3

The trimodal distribution of trauma deaths

Peak in mortality

Causes

Discussion

First peak

Seconds to minutes

50 % of trauma deaths

Overwhelming injury, e.g., fatal head injury, rupture of the great vessels, or spinal cord

The first peak tends to be deaths that no matter what intervention or skill level is available would still occur. Very little has changed to this peak mortality, and little can be done in the disaster setting.

  

It can still be reduced by public health measures such as road safety, seatbelts, and helmets

Second peak

Airway problems. Fatal hemorrhage

The second peak tends to be deaths that are preventable through early intervention as part of organized trauma system, e.g., early recognition in the field and subsequent early hospital care. Developments in the last 40 years have markedly reduced these deaths in developed countries, however they still contribute the largest proportion of preventable deaths and play a key role in disaster mortality

Minutes to hours

  

30 % of trauma deaths

  

Third peak

Infection

Almost all of these deaths can be potentially mitigated by good care in the prehospital environment followed by well-managed hospital care. However, they remain a major cause of death in disasters where health services are severely disrupted or overwhelmed

Over 4 h, days to weeks

Multi organ failure

 

20 % of trauma deaths

Blood clots

 
Fig. 11.3

The trimodal distribution of death

Subsequent studies in developed countries have failed to replicate this finding [11]. Moving beyond, both these concepts in developed countries are time-critical treatment considerations for various injuries or pathologies; head-injured patients must receive surgery within 4 h of injury, since hemorrhage and brain swelling can lead to lethal increases in cerebral pressure in this time. Those with severe hemorrhage require surgical intervention within 20 min, as it may be the only way of preventing further bleeding.

Prompt 14: Is a Preclinical Medical System Needed or Can It Be Replaced by a Speedy Transportation System?

There is much debate as to how much care should be given at the scene before transportation to the hospital setting. This depends on many variables such as type of trauma, skill of responder, and time to hospital setting. In this case where the patient is trapped in a vehicle, it is necessary to provide more care on scene. If early transport is available, should it be taken? Two opposing philosophies can be summarized by “stay and play” or “scoop and run.”

Stay and play: The Doctor is brought to the patient resulting in longer prehospital time. In the case of a severely traumatized patient, administration of first aid, infusion therapy, early intubation, and ventilation are preformed to avoid/minimize secondary, shock-related organ damage. This is seen more in mainland Europe (France, Germany) where doctors attend a large proportion of prehospital trauma.

Scoop and run: To take the patient without primary treatment and hurry him to hospital and surgical services, typically by paramedics not doctors. This is seen more in the USA and UK.

As first responders become skilled in procedures, they are more likely to want to use those skills in stabilizing the patient before transport, delaying definitive surgery. Most recent evidence from the USA shows delayed transportation results in worse outcomes [12]. Reasons for this are as follows: there are dangers of increasing blood pressure by fluid resuscitation, with untreated bleeding sources as it can lead to increased bleeding, disturbance of clots, and dilution of coagulation factors [13].

Transport times to definitive care may be comparable to initial resuscitation. Insertion of a peripheral intravenous catheter takes an average of 8–10 min for the experienced rescuer. Transportation times in the USA are on average 8.5 min and take therefore less time than the insertion of a peripheral IV cannula [14].

In the case of severe hemorrhage, surgery may offer the only hope of survival, and speedy transportation to competent surgery is preferred. Ivatury et al. demonstrated that only 2 % of the victims with perforation injury of the chest survived preclinical treatment (oxygen administration, MAST, infusion therapy, and intubation) which took an average of 22 min. In the control group with no preclinical treatment with an average transportation time of 8.5 min, the survival rate was 18 % [7].

When to scoop and run:
  • Suspicion of injury of the great vessels

  • Shotgun and knife injuries of chest/abdomen

  • Brain injury with GCS  <  8

  • Nonpenetrating abdominal trauma

  • Polytrauma

Differences between the approaches of Europe and America may be partly attributable to the fact that in the USA the majority of trauma is caused by penetrating injuries from gunshot wounds and stabbings which tend to be singular and require urgent surgical intervention. In Europe most trauma is from blunt injuries, typically as the result of road traffic collisions, and patients have multiple injuries and extraction may be complicated.

A compromise has been suggested as “run and play” whereby patients are given immediate airway and breathing support and extricated to a trauma center in a vehicle equipped to provide intensive treatment with trained staff.

What these developments show is like the rest of medicine the field of prehospital care is continually evolving and seeks to build an evidence base for continual improvement based on studies rather than intuition.

Case Study: History of the ATLS® Program

Advanced Trauma Life Support (ATLS) has been a massive leap forward in the management of polytrauma patients but like many medical developments, comes from a situation managed badly.

In 1976, a light aircraft being piloted by an orthopedic surgeon Dr. Jim Styner crashed into a field. Dr. Styner’s wife was killed instantly, three of his children received critical injuries, and Dr Styner himself was seriously injured. He managed to keep his children alive as he awaited the emergency services. Unfortunately, the care they received afterward was poor and uncoordinated failing to protect their airway or cervical spine, and they were lucky to survive the 10-h wait for definitive care.

This inspired him to campaign to improve trauma management and led to the development of ATLS. The course philosophy is to teach a simple approach to manage emergency situations. The founding principles being:
  • Trauma is a surgical disease.

  • Treat the greatest threat first.

  • Lack of history should not prevent assessment starting.

  • Lack of precise diagnosis should not prevent treatment starting.

The course teaches one safe system [15] applicable to manage any trauma situation.

ATLS has since become the core philosophy for trauma; however risks becoming the new dogma. Trauma is not purely a surgical disease since many trauma patients may benefit more from supportive medical and respiratory care. Unfortunately, studies have failed to capture better outcomes for patients after responders have completed the course [16].

There are alternatives such as Trauma Evaluation and Management (TEAM) [16] and Anaesthesia Trauma and Critical Care (ATACC) [17], which adopt a slightly different focus.

Despite these criticisms, the philosophy of treating the greatest threat first and treating before diagnosis is known remains as relevant today as when the course was started.

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Copyright information

© Springer-Verlag London 2013

Authors and Affiliations

  1. 1.St Thomas’ HospitalLondonUK

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