Emergency medicine - Pre-hospital trauma care

What to do when faced with an emergency trauma situation, including how to triage and manage casualties and safe resuscitation and bleeding control.

You are driving home from surgery and as you come around the corner you can see a motorcyclist lying in the middle of the road two metres away from his bike, which has come to a stop against a wall.

Your heart is racing. It is 10 years since you did a six month post in emergency medicine and for a second you contemplate driving on. However, your instinct as a doctor to act as a good Samaritan takes over and you decide to stop.

Primary concern

Stay calm. What you do may not only save lives but prevent others from being injured. Before you approach, make an assessment of the scene, assessing the number and severity of casualties, and any potential dangers (for example, other traffic, debris, and leaking fuel).

Safety of oneself and any survivors is of primary importance. If the emergency services have arrived then they may direct you where to park. However, if you are first on the scene, park your car in a safe position and leave the hazard lights on.

Probably the most important contribution you can make is to contact the emergency services, providing them with as much information about the incident as you can. A useful mnemonic to remember is the ETHANE statement (see box).

ETHANE

ETHANE: useful information for the emergency services.

E - exact location
T - type of incident
H - any hazards identified - for example, fuel leakage
A - access and egress
N - number and severity of casualties
E - emergency services present and required

Approach with caution as the environment around the incident may be dangerous, and it may be advisable to wait for approval from the fire brigade or police. If you are on your own, and you are not sure, then wait for more help from the emergency services.

Triage

If there are multiple casualties then one should triage, sorting the patients into an ‘immediate’ group that may die within a few minutes (for example, from an obstructed airway), ‘urgent’ who need treatment within a few hours, ‘delayed’ who need non-urgent treatment, and patients who are already dead.

GMC advice for good Samaritan acts

‘In an emergency, wherever it arises, you must offer assistance, taking account of your own safety, your competence, and the availability of other options for care.’

Source: GMC, Good Medical Practice

Managing casualties

Ideally, wear a high visibility jacket, and gloves. Cover bare skin and wear a helmet. Casualties who are not trapped and can move should be asked to get themselves away from the immediate area.

The main emphasis in pre-hospital trauma management is to treat conditions that will kill the patient. Advanced trauma life support principles advocate performing an initial primary survey, assessing and dealing with problems in a structured process.

You may feel out of touch with trauma management, but the initial primary survey needs basic medical skills for a rapid physical examination, and you could potentially save a life.

Resuscitation using an ‘ABCDE’ approach is advised:

A - airway with cervical spine control
B - assessment and management of breathing problems
C – circulation
D – disability
E - environmental factors

Airway

Maintaining a patient’s airway with simultaneous cervical spine protection is vital. In trauma situations the common reasons for airway obstruction are face and neck injuries, foreign matter in the mouth, and the tongue obstructing the airway in an unconscious patient.

Perform a quick airway assessment by checking if there is an obstruction. If the patient is able to cough and speak, encourage him to clear the obstruction naturally. If the airway is obstructed, try to clear any visible obstruction manually.

Opening the airway using a jaw thrust technique (grasp the angles of the lower jaw and lift with both hands, one on each side, moving the jaw forward) not only relieves the airway, it also helps to maintain inline immobilisation of the neck, protecting the cervical spine. This manoeuvre will open the airway and you can proceed to assess the breathing, looking for chest wall movement and listening to air on exhalation.

If you are alone you may be occupied just performing the jaw thrust manoeuvre and maintaining immobilisation of the cervical spine. When help arrives, continue the assessment or move to another casualty.

Bleeding

In the significantly injured patient, bleeding occurs in four compartments – the chest, abdomen, pelvis, and long bones. Significant bleeding can also occur externally - for example, due to open fractures, or large scalp lacerations.

Remember the mnemonic ‘blood on the floor and four places more’. In a pre-hospital roadside setting, controlling serious bleeding immediately is a priority because this can be fatal within a matter of minutes.

As a first responder you can really only influence external sources of bleeding. Direct pressure on the bleeding site and elevating the injured extremity are effective ways of controlling external bleeding.

Use of a tourniquet is controversial but it can be life or limb saving in cases of ongoing haemorrhage uncontrolled by direct pressure. Tourniquet pressures need to be tight enough to occlude arterial flow as occluding venous flow can augment bleeding. If a tourniquet is needed to stay in place for a long period then you should make a clear note about the decision you made to choose life over limb.

Examination

The chest should be examined to look for life-threatening chest injuries including tension pneumothorax, flail chest, and massive haemothorax.

Palpation for paradoxical chest movement due to multiple fractured ribs, subcutaneous emphysema, or tracheal deviation must be looked for. Assessment of respiratory rate, altered percussion, or reduced air entry can provide useful information.

Assessment of the circulation should include pulse rate and strength, comparing peripheral with central circulation, and trying to identify sites of blood loss, thinking about concealed bleeding in the chest, pelvis, abdomen, or long bones, and obvious external bleeding.

In addition to direct pressure, traction on deformed limbs can reduce pain and haemorrhage. When assessing disability, the AVPU score is a quick assessment tool:

A – alert
- responds to voice
P - responds to painful stimuli
U - unconscious

Trauma patients quickly get cold. Try to keep them covered to reduce heat loss until they can be moved. Make sure patient transportation to the nearest appropriate medical facility is not delayed. Most of the full primary survey and simple procedures can be done in the ambulance.

  • Andrew Webster is a consultant in emergency medicine at Leeds Teaching Hospitals
  • Arvind Byka is a consultant in emergency medicine at Mildura Base Hospital, Victoria, Australia

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This is an updated version of an article that was first published in October 2010.

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