Download - 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 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