Emergency medicine - Pre-hospital emergency care

Up-to-date life support skills are essential. Professor Malcolm Woollard gives a useful reminder.

If fluid in the airway is suspected, turn the patient on their side
If fluid in the airway is suspected, turn the patient on their side

This article suggests simple life-saving intermediate interventions that can be undertaken while an ambulance is en route to a patient.

Airway
Snoring indicates airway obstruction by a relaxed tongue. Tip the patient's head back and lift their chin to an angle per-pendicular to the floor.

Lift the mandible to avoid pushing on soft tissue that would move the base of the tongue posteriorly. Next, check for adequate breathing.

Turn the patient, ideally into the 'recovery position', although a stable side position with the head tipped back and jaw pulled forward is of greater importance than precise positioning of the arms and legs.

In trauma victims, a jaw thrust is the preferred airway manoeuvre since it maintains the head and neck in a neutral position to protect against secondary damage from a cervical fracture.

Without extending the head and neck, place the fingers behind the angle of the jaw bilaterally with the thumbs on the cheek bones.

Displace the jaw upwards, perpendicular to the floor but without tipping the head.

The jaw thrust is not as effective as the head-tilt chin-lift manoeuvre: if breathing remains ineffective, apply a slowly increasing degree of head-tilt until breathing is noted. If you need to leave the patient position them on their side, as the risk of airway obstruction is significantly greater than that of secondary damage to the cervical cord.

Gurgling indicates fluid in the airway: the concern is aspiration of acid stomach contents leading to fatal pneumonia.

Turn the patient onto their side and tip their head back to facilitate drainage. Sweep the mouth out with gauze-wrapped fingers or preferably use a cheap disposable hand-operated suction unit. Even if the patient is a victim of trauma, lateral positioning will be required to protect the airway.

Oropharyngeal airways (OPAs) are a useful adjunct in airway management but head-tilt chin-lift, jaw thrust or a lateral position will still be required, and it can be harder to detect the presence of regurgitated matter.

An OPA must be sized correctly: too large and it will cause tissue damage and bleeding, and if too small the tongue will not be held out of the pharynx.

The correct length of OPA will approximate to the distance between the incisors and the angle of the jaw. Insert it with the concavity upwards and then rotate at the point the tip meets the junction of the hard and soft palate.

Leave the flange outside the patient's lips and confirm air movement through the device. If gagging occurs during insertion remove it immediately. Do not attempt to use an OPA in the presence of trismus or convulsions.

Breathing
If a pulse oximeter is available, the target saturation in a seriously ill patient is 94-98 per cent. Apply a non re-breathing mask at a flow rate sufficient to ensure the reservoir bag is inflated before each inspiration (approximately 10-15 litres per minute).

Aim for 88-92 per cent if there is a risk of hypercapnic respiratory failure (e.g. COPD, even if unrelated to the current problem).1

Indicators of potential hypoxaemia include added sounds, increased respiratory rate or effort, respiratory rates of <10 or >30 in adults, inadequate effort, increased pulse rate, dysrhythmias, confusion or falling conscious level, and (new) central cyanosis.

Absent or ineffective breathing is treated by mouth-to-mask ventilation. Face masks with soft cushions, large ports with one-way valves, and supplemental oxygen inlets require little practice to use. Place the forefinger and thumb of both hands on top of the mask to seal it against the face, while placing the remaining fingers behind the angle of the jaw to lift it upwards and tilt the head to open the airway.

Attach oxygen at 15 litres per minute to give a concentration of approximately 50 per cent, and blow through the one-way valve only until the chest starts to rise.

Circulation
Life-threatening external haemorrhage is rare and is usually arrested by simple first aid measures. Apply direct pressure over the wound, using a gloved hand initially.

Elevate a bleeding limb, and lie the patient down.

Once a dressing is in situ do not remove it to avoid clot disruption. Use a firmly applied conforming bandage extending beyond the edges of the pad.

If bleeding persists use a windlass: insert a pen through the bandage and rotate it to tighten until the haemorrhage has stopped. Secure the pen in place.

If bleeding continues or appears arterial on initial presentation, apply a commercial tourniquet or a BP cuff close to but proximal to the wound, and tighten until the bleeding stops.

Occasionally the tourniquet may be too narrow: leave it in situ and apply a second tourniquet proximally and tighten until bleeding stops.

Note the time of tourniquet application but never loosen or remove it: remember that during surgery tourniquets are left in place for hours.

Up to 70 per cent of available clotting factors may be utilised in the formation of the first clot, leaving little in reserve if it is destroyed.

In the near future, cheap haemostatic-agent impregnated ribbon gauze dressings will become available, allowing packing of deep wounds where a tourniquet is impossible.

A common error in managing patients with significant bleeding is to focus on IV fluid replacement instead of controlling a compressible haemorrhage.

IV fluids
There is no good evidence that pre-hospital IV fluids save lives, but hypotension appears to assist in haemorrhage control by facilitating clot formation.

In the absence of a penetrating injury to the chest or abdomen, 250ml aliquots of normal saline may be given only if the radial pulse is absent and until it returns.

In penetrating injury to the chest or abdomen, 250ml aliquots of fluid should be given only if the patient is in cardiac arrest (absent carotid pulse) due to the risk of increasing haemorrhage from a large vessel.

Learning points
1. Manage snoring by head-tilt chin-lift or, in trauma, jaw thrust.

2. Manage gurgling by turning patient on their side (even in trauma); clear their airway with gauze-wrapped fingers or a hand-operated aspirator.

3. Target oxygen saturation is 94-98 per cent or 88-92 per cent if risk of hypercapnic respiratory failure.

4. The priority in haemorrhage is to stop the bleeding (up to three dressings, windlass, tourniquet).

5. Pre-hospital IV fluids have no proven benefit.

  • Professor Woollard is director of the pre-hospital, emergency & cardiovascular care applied research group at Coventry University

References
1. O'Driscoll B R, Howard L S, Davison A G. Guideline for emergency oxygen use in adult patients: executive summary. British Thoracic Society, 2008.

Further reading

  • Fisher J D, Brown S N, Cooke M W (eds.). UK Ambulance Service Clinical Practice Guidelines (2006). Joint Royal Colleges Ambulance Liaison Committee, 2006. www.jrcalc.org.uk

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