Pre Hospital Care

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 identify and treat conditions the involve immediate threat 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

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Sorting of patients based on the need for treatment and the available resources to provide that treatment 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. • 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 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 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 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

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Oxygen administration • Catheter in the nose (nasal catheter) • Face mask • 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 • • • •

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 back – chin lift • Mouth- to-mouth ventilation • Ventilation with a pocket mask

Circulation and bleeding Circulatory system is just lifethreating as failure of the respiratory system 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) 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 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 Weak, rapid pulse Shallow, rapid breathing Changes in the state of consciousness (confusion, disorientation, coma) • Fall in blood pressure

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Treatment of shock • • • • • •

Maintain an airway Give oxygen Control bleeding 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 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 how many causualties …..

Fahrenheit • Temperature - cold ground often – prevent risk for cold injuries • Shock also get cold - give the patient a sheet or something

Get vital signs • • • • •

Pulse rate Breathing rate – sound etc Bloodpressure 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 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 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

Medulla – lower brainstream and verterbral column • Medulla - control centre for regulating respiration and heart beat • After medulla - the vertebral column with 7 cervical spines, 12 thoracic spines, 5 lumbar spines, sacrum and coccyx with fused vertebrae spines

Assessment of the Head-Injuried Patient • Any patient wiht significant head injury also has cervical spine injury until proved otherwise

General Appearance • • • • •

Position in which the patient was found Level of consciousness Behavior and degree of distress 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) • 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

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 Rising blood pressure wiht slowing pulse Abnormal respiration or no respiration (apne)

Treatment Establish an airway Assist breathing Administer Oxygen Control bleeding Cover wounds Infusion – saline Do not overheat the patient Check for neurological and vital signs – chancing state of consciousness? • Immobilize the spine (collar) • Transportation - carefully

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Chest Anatomy Esophagus Trachea Clavicle Sternum and ribs Heart 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 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? • Assist ventilations • Oxygen

Abdominal anatomy • • • • • • • • • •

Spleen Stomach Liver and pancreas Diafragm 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 – open the bloodvessels in abdomen even more…….. • Check for pain – where and how? – maybe no medicament against the pain

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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 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

Symptoms of Disclocations and/or Sprains • • • • •

Pain Loss of motion Deformity 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 • 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 head injury and deteriorating level of cnsciousness • Priority III patients with spinal cord injuries, eye injuries, 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