PRE-HOSPITAL CARE

Margareta Burell 2008

The stages of prehospital care

• Survey the scene - check for hazards to the rescuers or patient – call for back-up

• Primary survey - rapid assessment to identifyand treat conditions the involve immediate threatof life – initiate airway management , check of life – initiate airway management , check breathing and circulation

• Secondary survey - close look at the scene –more history and physical assessment

• Definitive field management – wound care, stabilization of fractures – packaging for transport

• Ongoing reevalution of the patient´s condition

To think about ….

• Dead heroes can´t save lives, injuried heroes

are a nuisance. So check the scene for

hazards before you lurch in …..

• The people who can shout and scream - they

can also breath - and have open airways…..

• Look more for the silent ones ……

TRIAGE

Sorting of patients based on the need for

treatment and the available resources to

provide that treatment

• Airway• Airway

• Breathing and ventilation

• Circulation

• Diasability – neurological status

• Exposure/environmental control

Airway

Physiology

• The respiratory system is composed of an

upper and lower airway from the nose to the

alveoli in the lungs. alveoli in the lungs.

• About 250 ml of the breating volume is ”dead

space” and will not be chanced

• Normal volume when we breath is about

500 ml

Anatomy of airway

• Trachea

• Epiglottis wiht vocal folds

• Bronchi

• Bronchioli• Bronchioli

• Alveoli – surrounded by capillaries – it is here

the respiratory system meets the blood

system and gas exchange occurs

Breathing - ventilation

• Hypoxi (reduced oxygen in the blood) will

occur when it is inadequate oxygenation of

the patient´s tissues

• Observations of breathing : look – listen – feel

• Normal respiratory rate is 12 – 20 per minute

• Normal minute volume about 500 ml

Gas exchange in the alveolus

• Oxygen is taken up from the alveolus

• Carbon dioxide is released into the alveolus

• Hypoventilation - carbon dioxide elimination is reduced and CO2 accumulates in the blood -reduced and CO2 accumulates in the blood -respiratory acidosis = pH lower than normal 7,35 -7,45

• Hyperventilation - when carbon dioxide elimination is increased – the level of CO2 in the blood falls –respiratory alkalosis = pH higher than normal (concentration of hydrogen ions)

Respiratory insuffience

• A feeling of shortness of breath

• Rapid breathing

• Very deep breathing

• Use of accessory muscles in the neck and • Use of accessory muscles in the neck and abdomen to assist respirations

• Flaring of the nostrils on inhalation

• Bluish tinge to the lips and nail beds (cyanosis)

• If the respiratory center is depressed -- slow, shallow respirations

Oxygen administration

• Catheter in the nose (nasal catheter)

• Face mask

• Flow rate can be up to 12 liter /minute• Flow rate can be up to 12 liter /minute

Causes of respiratory arrest

Airway obstruction• Tongue (in the unconscious patient)

• Foreign body (choking)

• Swelling (edema or spasm in larynx/troat)

• Trauma to the airway

Depression or damage to the respiratory center Depression or damage to the respiratory center • Drugs (narcotics, medicaments ex barbiturates )

• Head injury

• Stroke

• Electric shock

Primay cardiac arrest

Recognition of respiratory problems

To diagnose respiratory arrest

look, listen and feel for breathing

• Help for free airway - tilt the patient´s head• Help for free airway - tilt the patient´s head

back – chin lift

• Mouth- to-mouth ventilation

• Ventilation with a pocket mask

Circulation and bleeding

Circulatory system is just life-

threating as failure of the respiratory

systemsystem

Evaluation of pulse for presence,

quality, regularity

Pulsation

• Tachycardia - rapid pulse

• Bradycardia - slowly pulse

• Arytmia – irregular rhytm

• Normal pulse rate is about 60 -80

Blood volume is about 5 000 ml adult person

Arteria – venous - capillary

Palpation for pulse

• At the neck beside the muscles (carotis)

• At the wrist (radialis)

The pulse can be rapid, weak for example

• When you have low blood pressure - under about 70 mm Hg you cannot feel much of pulsation at the wrist

Blood pressure about 120 mmHg /70 normally

but depending on age, illness etc etc

Fluids and electrolytes

• Body fluids total body water about 60 % of body weight

• Cations are Sodium (Na) Potassium (K)• Cations are Sodium (Na) Potassium (K)

Calcium (Ca) Magnesium (Mg)

• Anions are Chloride (Cl) and bicarbonate(HCO3)

Buffer systems

• The bicarbonate buffer system

• The lungs

• The kidneys

Types of Shock

• Hypovolemic -- loss of volume fluid, blood

or plasma

• Cardiogen - - heart pump function problem

• Neurogenic - - vascular system problem with • Neurogenic - - vascular system problem with

dilatation of perifer blood vessels - or

spinal cord problem

• Mixed types pump and tubing (volume in

blood vessels/other places)

Symptoms and signs of shock

• Restlessness and anxiety

• Thirst

• Nausea – sometimes also vomiting

• Cold, clammy, pale (ev mottled) skin• Cold, clammy, pale (ev mottled) skin

• Weak, rapid pulse

• Shallow, rapid breathing

• Changes in the state of consciousness (confusion, disorientation, coma)

• Fall in blood pressure

Treatment of shock

• Maintain an airway

• Give oxygen

• Control bleeding

• Fluid - intravenous (avoid drinking) • Fluid - intravenous (avoid drinking)

• Keep the patient warm

• Legs elevated

Disability

• Disability is a direct measurement of cerebral

function and also measurement of cerebral

oxygenation

Level of consciousnessLevel of consciousness

• Alert

• Responds to Verbal stimulus

• Responds to Painful stimulus

• Unresponsive

Expose

• Physical examination - undress the patient if

it helps - partly if nescessary

Depends on the situation and where and Depends on the situation and where and

how many causualties …..

Fahrenheit

• Temperature - cold ground often – prevent

risk for cold injuries

• Shock also get cold - give the patient a sheet• Shock also get cold - give the patient a sheet

or something

Get vital signs

• Pulse rate

• Breathing rate – sound etc

• Bloodpressure

• Warm – cold – wet?• Warm – cold – wet?

• Colour – pale -cyanotic?

History

• What happened?

• What hurts?

• What else is wrong?

• The scenario and mechanisms of injury

(position in the train, car, bus etc etc )

• History of the patient – resourses etc etc

To think about ….

Never assume that it is

impossible to talk to a

patient until you have triedpatient until you have tried

Head anatomy

Injuries to the Head, Neck and Spine

• The scalp with skin, hair etc

• The skull ( a hard inflexible box that encloses

the brain) consists of 29 bones

• Inward the skull are the meninges situated• Inward the skull are the meninges situated

dura mater a strong fibrous wrapping

arachnoid, a delicate transparent membrane

pia mater, a thin highly vascular membrane and

firmly adherent to the brain

Head injuries

Bleedings in the skull

• Above the dura - epidural hematom is an

arteriell bleeding

• Under the dura - subdural hematom is a

venous bleeding venous bleeding

Medulla – lower brainstream and

verterbral column

• Medulla - control centre for regulatingrespiration and heart beat

• After medulla - the vertebral column with

7 cervical spines, 12 thoracic spines, 5 lumbar spines, sacrum and coccyx with fusedvertebrae spines

Assessment of the Head-Injuried

Patient

• Any patient wiht significant head injury also

has cervical spine injury until proved

otherwiseotherwise

General Appearance

• Position in which the patient was found

• Level of consciousness

• Behavior and degree of distress

• Skin condition• Skin condition

• Obvious wounds or deformities

Glasgow Coma Scale

• Eye opening - speech and pain (score 1-4)

• Best motor response –commands and pain

(score 1-6)(score 1-6)

• Verbal response - confused or disoriented

(score 1-5 )

Reaction Level Scale -85

• Awake – can get contact ?

• Follow movements with the eys

• Can lift arms etc on demand

• Avoid pain • Avoid pain

Examination of the Pupils

• Dilatated pupils

• Constricted pupils

• Unequal pupils

Signs of increasing intracrainiell

pressure - Summary

• Detoriating level of consciousness

• Hemiplegia (one side pares)

• Vomiting

• Unilateral pupillary reaction• Unilateral pupillary reaction

• Rising blood pressure wiht slowing pulse

• Abnormal respiration or no respiration (apne)

Treatment

• Establish an airway

• Assist breathing

• Administer Oxygen

• Control bleeding

• Cover wounds• Cover wounds

• Infusion – saline

• Do not overheat the patient

• Check for neurological and vital signs – chancing stateof consciousness?

• Immobilize the spine (collar)

• Transportation - carefully

Chest Anatomy• Esophagus

• Trachea

• Clavicle

• Sternum and ribs

• Heart

• Aorta• Aorta

• Lung

• Pericardium

• Pleura a smooth slippery membrane and

a similar membrane nest to the lung – pleura space

• Diaphragm

• Liver

• Stomach

Chest injuries

• Esophageal and trachea injuries

• Pneumothorax

• Hemothorax if blood in the pleura space

• Rib Fractures - flail chest if many ribs are broken

• Pulmonary Contusion• Pulmonary Contusion

• Diafragmatic and mediastinum injuries

• Aorta injury

• Heart injury

• Liver and spleen can be involved and cause bleedings

Treatment

• Check for how the patient can breath in the

best position – maybe half sitting – maybe on

the best side – not injuried

• Assessment – rapid rate? sound? pain? pulse? • Assessment – rapid rate? sound? pain? pulse?

• Assist ventilations

• Oxygen

Abdominal anatomy

• Spleen

• Stomach

• Liver and pancreas

• Diafragm

• Large and small bowel (thin and thick bowel)• Large and small bowel (thin and thick bowel)

• Bladder

• Kidneys

• Bloodvessels – aorta and inferior vena

• For female also reproductive organs

• Pelvis bones

Treatment

• Check for ABC

• Anticipate vomiting

• Immobilize the spine

• Think of bleeding - not to much of infusion –• Think of bleeding - not to much of infusion –

open the bloodvessels in abdomen even

more……..

• Check for pain – where and how? – maybe no

medicament against the pain

Fractures, Dislocations and Sprains

• Fractures - open and closed

• Transversed – greenstick – spiral - oblique –

comminuted – impact spiral

Signs and Symptoms of Fractures

• Deformity – an unnatural position

• Shortening ex hip fracture

• Swelling – blood or/and edema fluid

• Guarding and loss of use -motion• Guarding and loss of use -motion

• Tender to palpation

• Grating or crepitus over the broken bone-end

• Exposed bone ends

• Pain

To think about

• Always check pulses, strenght and sensation

distal to a musculoskeletal injury

• Treat every severe sprain if it were a fracture• Treat every severe sprain if it were a fracture

Symptoms of Disclocations and/or

Sprains

• Pain

• Loss of motion

• Deformity

• Numbness or weakness• Numbness or weakness

• Abscence of distal pulse

Treatment

• Immobilisation - fixation

• Keep the injuried part of the body high to

avoid more swelling

• Release pain with medicament• Release pain with medicament

• Check circulation and sense of feeling and

touch beyond the injuried part of the body

(foot – hand/fingers)

Priorities for evacuation

• Priority I thoracic injuries, airway problems, shock

• Priority II stabilized patients in danger of shock, abdominal trauma, widespread burns, closed headinjury and deteriorating level of cnsciousness

• Priority III patients with spinal cord injuries, eye• Priority III patients with spinal cord injuries, eyeinjuries, hand injuries, compound fractures or injuries to large area of muscle

• Priority IV patients with lesser fractures and soft tissue injuries

• Priority V walking wounded