Prehospital
retrieval and management
The
aim should be for rapid and smooth transfer of patients from the scene of the
accident to a hospital that is well equipped and adequately staffed, with
trained personnel to deal quickly and efficiently with all of the injuries
encountered.
A
‘scoop and run’ policy is best where transfer time to hospital is short. A
‘stay and play’ policy may be required in the face of entrapment but
prehospital personnel must be properly trained and equipped (to PHTLS standards,
for example). In all cases, attention is first paid to securing an adequate
airway. Gloves are worn and a two-finger ‘sweep’ is used to clear solid
material from the mouth and pharynx combined with good suction under direct
vision to remove fluid and debris. Airway patency is then maintained by chin
lift or jaw thrust maneuvers, lifting the mandible forwards and, if
appropriate, inserting an airway device (oropharyngeal/nasopharyngeal or
endotracheal according to clinical
judgement
and expertise available). If unable to open the airway by the above, a surgical
cricothyroidotomy may be performed in patients over the age of 12 years by
inserting a 6-mm paediatric cuffed tracheostomy tube through the cricothyroid
membrane (Fig. 18.3). Under the age of 12 years the cricoid membrane is very
narrow and the cricoid cartilage is the only complete ring preventing airway
collapse. Under these circumstances, a needle cricothyroidotomy may buy some
time (20 minutes) provided that a means of jet-insufflating oxygen through the
needle is available. Proprietary mini-tracheostomy sets should not to be used.
These have a very narrow internal diameter and do not allow spontaneous
ventilation. They are indicated only in critical care environments for bronchial
toilet. Finally, access to the trachea should not be attempted under these
conditions — tracheostomy is time-consuming and fraught with danger.
Meanwhile,
attention is paid to protecting the cervical spine by the use of a well-fitting
semirigid neck brace, sandbags and forehead strapping. Modern spine boards
incorporate neck restraint pads and straps, and may be used in lieu of sandbags
and forehead strapping (Fig. 18.4).
Other
measures include ensuring adequate ventilation and oxygenation, covering and
sealing open ‘sucking’ chest wounds, controlling external bleeding by direct
pressure and monitoring the neurological status. The ‘AVPU’ method is
recommended in the prehospital setting.
Prehospital
mini-neurological examination
•
A-Alert
•
V — Responds to Voice
• P —
Responds to Pain
• U —
Unresponsive
•
Pupils — Size and reaction
If
there is any obvious long bone fracture of an extremity with gross deformity,
the limb should be gently drawn into alignment and a traction splint applied.
Controversy
exists regarding the prehospital role in resuscitation by intravenous fluid
infusion. Vascular access in a cold, shocked injury victim is often difficult
and time-consuming, and there is emerging evidence that a degree of
hypotension (systolic blood pressure 80—85 mmHg) may be safely tolerated (see
later). If circumstances dictate that transfer time will be prolonged, or when
entrapment and difficulty in extrication is encountered, then more
sophisticated and advanced life-support measures may be instituted with the
caveat made at the beginning of this section.