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Text © Richard Pilbery and Kris Lethbridge 2016

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Preliminary edition published 2016

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Acknowledgements

Class Professional Publishing would like to thank the following for their co-operation in the production of this book:

• Iris Murch, Mervyn Murch, Sarah Petter, Steven Petter, Karina Pilbery, Megan Pilbery, Vicky Pilbery and the team at SWAST for modelling

• Daniels for the loan of patslide equipment

• Mike Page for consulting

• Ken Wenman and Claire Warner at SWAST for the loan of the ambulance

• SP Services for the loan of first aid and medical devices

• Ferno for the loan of the stretcher

• Nigel Wilson for photography work

The authors and the publisher would like to thank the following for their invaluable feedback on this text during its development:

• Nic Morecroft, who deserves special thanks

• Rob Horton

• Jamie Todd

• Emma Scott

• Derek Flint

• Richard Rolfe

• Georgina Dunbar

• Ken Wheeler

• Steve Knowles

We would like to thank the following for their kind permission to publish material:

Chapter 5 Alcohol Handrub Procedure. Based on the ‘How to Handrub’ poster © World Health Organization 2009. All rights reserved.

Chapter 5 Handwashing Procedure. Based on the ‘How to Handwash’ poster © World Health Organization 2009. All rights reserved.

Figure 5.4 Clinell wipes. Republished with permission of GAMA Healthcare Ltd. Best practice guidance for infection control wet wipes developed by Clinell and GAMA Healthcare Ltd. © 2016

Figure 7.17 A mechanically powered ambulance stretcher. Republished with permission of Ferno.

Figure 10.11, 10.12 and 10.13 Tracheostomy tubes. Images reproduced by the kind permission of Kapitex Healthcare Ltd.

Figure 11.11 A Firesafe. Image reproduced by kind permission of BPR Medical.

Figure 11.13 Bag-valve-mask with oxygen reservoir bag attached and inflated. Image reproduced by the kind permission of Ambu A/S.

Figure 11.16 The Pneupac paraPac 200D. Image property of Smiths Medical and reprinted with permission from Smiths Medical, ASD, Inc.

Figure 12.14 An aneroid sphygmomanometer. Image reproduced by the kind permission of Welch Allyn.

Figure 13.7 Petechial non-blanching rash and Figure 13.8 Maculopapular rash with scanty Petechiae are courtesy of the Meningitis Research Foundation.

Chapter 15 Procedure for Jext auto-injector. Images republished with the kind permission of ALK.

Figure 19.3 The Abbey pain scale. Source: Abbey, Piller, De Bellis, Esterman, Parker, Giles and Lowcay (2004) ‘The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia’, International Journal of Palliative Nursing. 10:1, 6–13. Copyright 2004 MA Healthcare Ltd. Reproduced by permission of MA Healthcare Ltd.

Figure 20.1 The chain of survival. Image reproduced by the kind permission of Laerdal Medical.

Every effort has been made to secure permission to republish copyright images. If any have been inadvertently overlooked, the copyright holders are invited to contact Class Professional Publishing and the omission will be rectified in the next printing as well as all further editions.

List of Abbreviations

AAP

associate ambulance practitioner

ABC

airway, breathing, circulation

ABCDE

airway, breathing, circulation, disability, exposure/environment

ABG

arterial blood gas

ACP

advance care plan

ACS

acute coronary syndrome

ADRT

advanced decision to refuse treatment (‘living will’)

AED

automated external defibrillator

AF

atrial fibrillation

ANS

autonomic nervous system

ATMIST

age, time of incident, mechanism of injury, injuries, signs and symptoms, treatment given/immediate needs

ATP

adenosine triphosphate

AVPU

alert, voice, pain, unresponsive

BLS

basic life support

BVM

bag-valve-mask

CBRNE

Chemical, biological, radiological, nuclear, explosive

CFR

Community First Responder

CNS

central nervous system

CO

Carbon monoxide

COPD

chronic obstructive pulmonary disease

CPR

cardiopulmonary resuscitation

CRT

capillary refill time

CSF

cerebrospinal fluid

DNA

deoxyribonucleic acid

DNACPR

do not attempt cardiopulmonary resuscitation

ECA

emergency care assistant

ECG

electrocardiogram

ECSW

emergency care support worker

ED

emergency department

EOC

emergency operations centre

ET

endotracheal

FB

foreign body

FGM

Female genital mutilation

GCS

Glasgow Coma Scale

HART

hazardous area response team

HCAI

healthcare-associated infection

HCPC

Health and Care Professions Council

HIV

Human immunodeficiency virus

ICP

intracranial pressure

ICU

intensive care unit

IR

infrared

IV

intravenous

kPa

kilopascal

LAD

left anterior descending artery

LCA

left coronary artery

LOC

level of consciousness

METHANE

major incident, exact location, type of incident, hazards, access, number of casualties, emergency services

MI

myocardial infarction

MILS

manual in-line stabilisation

MIU

minor injuries unit

MOI

mechanism of injury

MTC

major trauma centre

NAI

non-accidental injury

NHS

National Health Service

NIBP

non-invasive blood pressure measurement

NICE

National Institute for Health and Care Excellence

NOI

nature of illness

NSTEMI

non-ST-segment elevation myocardial infarction

OPA

oropharyngeal airway

PDA

posterior descending artery

PEA

pulseless electrical activity

PND

paroxysmal nocturnal dyspnoea

PPE

personal protective equipment

PPV

positive pressure ventilation

RCA

right coronary artery

RNA

ribonucleic acid

ROM

range of movement

ROSC

return of spontaneous circulation

RTC

road traffic collision

SA

sino-atrial

SAD

supraglottic airway device

SAMPLE

signs and symptoms of presenting complaint, allergies, medications, past medical history, last oral intake, events leading to current illness/injury

SARS

severe acute respiratory syndrome

SC

subcutaneous

SCENE

safety, cause including NOI/MOI, environment, number of patients, extra resources needed

SCI

spinal cord injury

SIRS

systemic inflammatory response syndrome

SNS

sympathetic nervous system

SOBOE

shortness of breath on exertion

STEMI

ST-segment elevation myocardial infarction

SVC

superior vena cava

SW

support worker

TBI

traumatic brain injury

TBSA

total body surface area

TILEE

task, individual, load, environment, equipment

TMJ

Temporomandibular joint

TXA

tranexamic acid

UA

unstable angina

UTI

urinary tract infection

WHO

World Health Organization

Chapter 1: Introduction

1 Course guide

1.1 Introduction

This textbook is designed to help prepare you to work as a community first responder (CFR) or similar.

1.2 Getting started

To help get you orientated to the topics covered in this textbook and their relevance to clinical practice, the next section, anatomy of an emergency call, will take you step by step through an emergency attended by a CFR, highlighting the variety of knowledge and skills that you will require in order to be an effective CFR.

Each chapter is split into sections, which are typically laid out in the following way:

• Learning objectives: To clearly highlight what you are expected to learn in the chapter

• Introduction: Setting the scene for the theme of the chapter

• Content: The content!

2 Anatomy of an emergency call

2.1 Introduction

The topics covered in the chapters of this textbook are an essential part of your role as a community first responder (CFR). It can be helpful to find out WHY you need to learn something. In order to see these in context, let’s review a typical clinical scenario that you may be faced with when working on an emergency ambulance (Figure 1.1).

2.2 The emergency operations centre

When Mrs. Brown makes a 999 call, she speaks to a telephone operator who asks her which service she requires. She asks for the ambulance service and is put through to her local ambulance service’s emergency operations centre (EOC, Figure 1.2).

Figure 1.1 Mr. James Brown, a 59-year-old man who has chest pain, with his wife, Patricia

While she talks to the call taker, the dispatcher allocates an ambulance and CFR to the emergency call. Since it has been categorised as a Red call by the medical priority dispatch system, the ambulance needs to arrive as soon as possible. National targets require an ambulance service response within 8 minutes for 75% of Red calls. However, as a CFR, you are tasked to incidents that are close to where you are located, meaning that you may well arrive before the ambulance crew.

Figure 1.2 A dispatcher in the EOC

You will learn more about the ambulance service, including the roles and responsibilities of its staff, and ambulance and clinical quality indicators in The Ambulance Service chapter.

2.3 Arriving on scene

You will have been conducting a scene assessment, even before arriving at the address. This will include the location, time of day, and type of incident, and it is a dynamic process, i.e. should be constantly reviewed as the scene can change rapidly. You will learn more about this in the Scene Assessment chapter.

In addition to scene safety, you will consider the need for personal protective equipment (PPE). At a residential address, this may be limited to a pair of disposable gloves, but other PPE may be required if there is severe bleeding, for example (covered in the Health and Safety chapter).

You retrieve the response bag and automated external defibrillator from your vehicle and head towards the front door, where Mrs. Brown is anxiously waiting (Figure 1.3).

Figure 1.3 The CFR arrives at the address

2.4 Principles of communication

You are shown into the living room where Mr. Brown is sitting on the sofa, clutching his chest and looking rather sweaty. You introduce yourself to Mr. and Mrs. Brown and clarify what Mr. Brown prefers to be called. He tells you to call him Jim (Figure 1.4).

Communication is a fundamental aspect of all ambulance work and your role as a CFR. It is not always easy as you will have to communicate with patients, friends and family members, and other healthcare professionals, and adapt your approach and style appropriately. In addition, you cannot communicate the same way with an elderly person as you would a teenager. Some patients will not, or cannot, communicate with you, because they are depressed or don’t speak English, for example. The Communication chapter will cover this in more detail.

Figure 1.4 The CFR talking to Jim

2.5 Patient assessment

You complete an initial airway, breathing, circulation, disability, exposure/environment (ABCDE) assessment of Jim (reviewed in the Patient Assessment chapter) and obtain a set of baseline observations to support this. Jim’s airway is patent; he is breathing at a rate of 28 breaths per minute, which is outside the normal range. After obtaining permission (actually, consent, an important legal concept, covered in the Legal and Ethical Issues chapter) from Jim, you apply high-flow oxygen (covered in the Breathing chapter). Continuing with the assessment of Jim’s circulation, you check his pulse and measure his blood pressure.

2.6 Patient history

Jim tells you that he experienced a sudden onset of central chest pain radiating to his jaw, back and both arms an hour prior to his wife’s 999 call. It feels like a heavy pressure, which he scores a 7 out of 10, and is associated with shortness of breath, nausea and sweating. His wife states that he has been very pale since the onset of pain.

You enquire about Jim’s past medical history and he tells you that he has high cholesterol and high blood pressure, both of which he is medicated for. You ask for his medication so you can pass it on to the crew (Figure 1.5). He has never suffered from a heart attack (myocardial infarction, MI), but does admit to suffering from occasional chest pain on exertion over the past month or so.

Figure 1.5 Gathering the patient’s medication for the ambulance crew

2.7 Cardiac arrest

You continue to talk to Jim and reassure him and his wife while you wait for the ambulance to arrive. Suddenly, Jim becomes unresponsive. After calling his name and then gently shaking his shoulders, you realise that he may have suffered a cardiac arrest (Figure 1.6). After conducting a rapid Task, Individual, Load, Environment, Equipment (TILEE) assessment (covered in the Manual Handling chapter), you move Jim on to the floor.

Figure 1.6 Jim collapses and is unresponsive

2.8 Basic life support and defibrillation

After confirming that Jim is still unresponsive and showing no signs of life, you instruct Jim’s wife to start chest compressions while you update the EOC and get the AED ready (covered in the Cardiac Arrest chapter). You expose Jim’s chest and ensure that the defibrillator pad sites are free from jewellery, piercings, medication patches, wounds and tumours. Luckily, there is no need to shave his chest.

The AED instructs everyone to stand clear while it analyses Jim’s heart rhythm before instructing you to resume chest compressions. Jim’s wife is looking tired, so you take over. A shock is advised, so once the AED has charged, you ensure that Jim’s wife and yourself are clear of Jim before pressing the shock button (Figure 1.7). As soon the shock is delivered, you immediately resume chest compressions.

Figure 1.7 Using an AED safely is an important CFR skill

After 2 minutes of cardiopulmonary resuscitation (CPR), the AED instructs you to stand clear, so you briefly pause chest compressions to allow it to assess the rhythm. Another shock is advised, which you deliver before immediately resuming chest compressions.

2.9 Crew arrival

The ambulance crew arrive and you provide a structured handover, explaining what has happened (Figure 1.8). The crew take over Jim’s care but ask you to assist them while they reassess and then transfer Jim to the ambulance.

Figure 1.8 Providing a structured handover to the ambulance crew is important to ensure good continuity of care

2.10 Clean up and prepare for the next call

After another 2 minutes of CPR, Jim shows signs of life and begins to breathe spontaneously. You assist the ambulance crew in loading Jim on to the ambulance before returning to the house to gather up your equipment. You find out later that Jim had suffered a heart attack, but the blockage in his arteries was successfully removed and he is doing well.

3 Extended skills

3.1 Your scope of practice

Look out for the extended skill icons throughout the book. These highlight where a skill may be outside of your scope of practice. If you are unsure, talk with your local co-ordinator about these.

Chapter 2: The Ambulance Service

1 Response to a 999 call

1.1 Learning objective

By the end of this section you will be able to:

• Explain how the ambulance service manages an emergency call.

1.2 Introduction

The response to a 999 call can be complex and varies between each incident depending on the degree of need. The three main stages of a response are:

• Call for help and triage

• Ambulance service response

• Onward care of patient.

1.3 Call for help and triage

When someone calls 999 (or 112) in the UK, they are connected to an operator from the national telephone network. Once the nature of the emergency has been established, the call will be forwarded to the police, fire, ambulance service or coastguard, depending on the most appropriate response(s).

Once the call is connected to the ambulance service emergency operations centre (EOC) a qualified call handler will ask a series of questions. Preset questions are designed to triage calls and identify those that need an ambulance most urgently. They can also identify those callers who do not need an ambulance and for whom an alternative care pathway, such as visiting the GP or self-presenting at a Minor Injuries Unit (MIU), would be more appropriate [HSCIC, 2014a].

As the call handler works through the questioning, the triage system will identify how urgently an ambulance is required and arrive at a triage code and a response category.

A number of different triage systems for prioritising calls are in use around the country. In general they divide triage priorities into red, amber and green:

• Red calls are the most life threatening calls and generally require an initial response with 8 minutes.

• Amber are serious but not immediately life threatening.

• Green calls are generally not considered to be emergencies.

These systems can be helpful in identifying to the dispatcher which callers need an ambulance most urgently. They can be subject to error however, especially if the person calling is scared, confused or struggling to answer the questions asked.

During this triage, a clinician is often available to assist in ‘enhanced triage’. This is particularly useful when dealing with patients who have complex needs which the standard pathways system may not be set up to deal with.

Also during triage, the call handler will identify if there is a need for other emergency services, or whether there may be any dangers to the responding ambulance clinicians present (such as an assailant still at scene). Where required, other services will be contacted and ambulance crews can be advised of the risks.

1.4 Ambulance service response

Based on the information gathered during the triage process, the most appropriate response can be determined. There are two main types of response, which are:

• Hear and treat

• Physical response.

1.4.1 Hear and treat

Hear and treat is where the patient is advised how to look after themselves, or recommended to self-present to a more appropriate care provider, such as a GP or MIU over the phone by call handlers or clinicians within the EOC.

1.4.2 Physical response

For the majority of 999 calls, the ambulance service will send a physical response.

Depending on the need of the patient and the scale of the incident, this may include:

• Responder

• Rapid response car

• Response motorcycle

• Emergency ambulance

• Air ambulance

• Specialist practitioner in urgent care

• Hazardous area response team (HART)

• Ambulance service officer/commander

• Specialist operations response team

• Medical support such as British Association for Immediate Care (BASICS).

1.5 Onward care

Where necessary, patients will be transported to hospital for emergency care and treatment. This is frequently to emergency departments (EDs) but now also includes an increasing number of specialist emergency care departments, such as stroke units or cardiac wards.

In addition to this, ambulance clinicians now have a range of alternative care pathways available to them, in order to avoid hospital admission where appropriate. The number of patients being treated without being taken to hospital is increasing and will continue to rise as paramedics and other out-of-hospital clinicians receive more advanced training in the assessment and management of common conditions.

Alternative care providers may include:

• Specialist paramedics in urgent care: Paramedics with additional training who can manage a range of minor injuries and illnesses within the community

• GPs

• GP drop-in centres

• Out-of-hours services

• Mental health teams

• Minor Injury Units

• Pharmacies

• 111

• Social services

• ‘Hospital at home’ teams

• Emergency residential care

• Community hospitals.

2 Roles within the ambulance service

2.1 Learning objectives

By the end of this section you will be able to:

• Identify a number of clinical roles within the ambulance service and briefly explain what the role entails

• Describe the importance of good working relationships.

2.2 Introduction

There are 11 NHS ambulance trusts in England, as well as NHS ambulance services in Scotland, Wales and Northern Ireland, which are statutory providers of ambulance services for the Government within the UK [NHS Choices, 2011]. There are also a range of voluntary services, including St John Ambulance and the British Red Cross, and a variety of independent sector services, ranging from the very small to national scale organisations.

Each service is structured differently, so it is not possible to give a definitive list of the different roles. However, over the following pages are descriptions of some of the roles you may find, which could be broadly divided into:

• Clinical

• Command and control.

2.3 Clinical roles

2.3.1 Community responders

Community responders come from a variety of backgrounds and volunteer their time for the ambulance service. They respond to incidents close to where they live or work, often in remote settings, which can take longer for an ambulance to get to. Responders carry basic life-saving equipment including an automated external defibrillator (AED) and devices for managing a patient’s airway and are trained in the initial management of emergency incidents and how to deliver life-saving skills such as CPR and control of major bleeding.

2.3.2 Co-responders

‘Co-responders’ is the name given to other services or agencies that may initially respond to 999 calls on behalf of the ambulance service. Different ambulance services have different co-responder schemes, but may include [SWAST, 2014b]:

• Fire service

• Coastguard

• Police

• Voluntary ambulance services.

2.3.3 Support worker (SW)

SWs work alongside paramedics on front line ambulances. They are trained in providing emergency care, basic emergency interventions and life support, and are qualified emergency drivers. SWs normally work under the supervision of a qualified clinical colleague. SWs may also work on support vehicles that are used to transport patients to hospital when they have been assessed by another healthcare professional and are deemed as needing a less urgent admission to hospital. SWs have different names in different places, though common names are emergency care assistants (ECAs) or emergency care support workers (ECSWs).

2.3.4 Associate ambulance practitioners

Associate ambulance practitioners (AAP) are non-registered clinicians who normally work alongside a paramedic, but may also work on their own. They have a range of skills relevant to emergency and urgent care and can undertake a number of pre-hospital procedures and administer a range of medications. There is national variation in the skill sets of AAPs and the way in which they are deployed by different services.

AAPs are similar, but not the same as, ambulance technicians, who are also unregistered clinicians that may work independently or under supervision.

2.3.5 Paramedic

Paramedics are qualified and registered clinicians who specialise in working in the urgent and emergency care setting. They are trained in the examination and treatment of emergency conditions, have a wide range of skills and treatment options and are considered specialists in emergency care. Registered with the Health and Care Professions Council (HCPC), paramedics have a degree of autonomy in their practice and can be held accountable to the HCPC for their actions and omissions that arise from providing clinical care to patients.

2.3.6 Specialist paramedic – urgent care (SPUC)

Specialist paramedics have been known by a range of titles including emergency care practitioner and paramedic practitioner. They have undertaken an enhanced course of learning, usually at degree or post-graduate level, along with a range of placements that equip them with the skills and knowledge to treat urgent care patients. These patients include those with acute illnesses such as respiratory tract and urinary tract infections or minor injuries and wounds. Specialist paramedics have a broad range of skills in the management of urgent patients and can administer a greater variety of medications [CoP, 2014].

2.3.7 Specialist paramedic – critical care

Also known as critical care paramedics (CCP), these clinicians have also undertaken enhanced study, but with a focus on dealing with the most critically ill or injured. Specialist paramedics in critical care will often work as part of a multidisciplinary team alongside a doctor who specialises in emergency pre-hospital care [CoP, 2014].

2.3.8 Hazardous area response team (HART)

HARTs are groups of paramedics, and sometimes technicians, who have been specially trained to work in difficult situations and alongside the police and fire service at large and dangerous incidents. They have a special set of skills and equipment, which can include swift water rescues, working at heights, and use of breathing apparatus. This allows them to safely access patients in remote and difficult settings. There is a network of HART bases around the country and their help can normally be requested through the EOC.

2.4 Command and control roles

Inside every large organisation is a command and control structure. This structure is required to co-ordinate and effectively deliver the functions of the organisation, but it becomes particularly relevant in emergency services at times of complex or major incidents. All commanders receive specific training relevant to their role. Different command roles do not necessarily indicate rank or seniority within an organisation, but are instead allocated so that those involved understand their role in managing an incident. Following criticism of emergency services not communicating effectively at previous major incidents, the national Joint Emergency Services Interoperability Programme (JESIP) has been launched in the UK so commanders from all the emergency services know better how to work together and communicate at complex and major incident scenes [JESIP, 2013].

2.4.1 Operational commanders

Operational commanders, broadly equivalent to what were formerly known as ‘bronze commanders’, are present at the scene of large or major incidents and are responsible for organising the delivery of care and the safety of those working at a scene. They have to assess what resources are available to them, or have been made available to them by tactical and strategic commanders, and utilise those resources in the most effective way possible.

Depending on the size of the incident, operational commanders work alongside a number of other officers from both the ambulance and other emergency services to ensure services are being provided in an effective and co-ordinated manner.

Operational commanders receive direction from tactical commanders, with whom they have to constantly liaise closely to ensure they have the resources they require to manage an incident.

2.4.2 Tactical commanders

Formerly known as ‘silver’ commanders, tactical commanders are responsible for ensuring that all the tactical resources an operational commander requires for the management of the incident are in place. They will communicate closely with other emergency services and agencies and may or may not be present at the actual incident, depending on the scale and nature of the incident as well as the amount of time it goes on for.

At some incidents there may be multiple operational commanders, each dealing with different sections of the incident, in which case the tactical commander will be responsible for co-ordinating their actions.

The tactical commander achieves a level of oversight for an incident that cannot normally be achieved by an operational commander on the ground. From this position, the tactical commander can ensure there is effective joint working of agencies and that the deployment of resources and the tactics being used to manage an incident are appropriate.

2.4.3 Strategic commanders

Formerly known as ‘gold’ commanders, strategic commanders are responsible for devising and making available the resources to implement a strategy for managing an incident. The strategic commander usually has control over all of the organisation’s resources and is responsible for making these resources available to the tactical and operational commanders.

Strategic commanders, like tactical commanders, get an oversight of the management of an incident and are responsible for ensuring the tactics being used are appropriate, that all services are working effectively together and that clear lines of communication are in place. Where necessary, strategic commanders are responsible for national level communication to make available further resources if they are required.

2.5 Support structures

As a responder, you will be an integral part of the ambulance service workforce and you should be aware of the support structures around you. Every service will operate in a slightly different model, but you should be allocated a line manager whom you can approach with any challenges or difficulties you have. This line manager will typically be responsible for ensuring you have appropriate equipment, for leading training and regular assessment sessions, and also being a point of contact if you find you need to discuss any incidents you have attended.

It is likely that you will be given key contact information by the organisation you respond for, but if you are unclear, make sure you ask and become familiar with those who are there to support you in your role.

2.6 Working relationships

As you can see, there is a wide range of roles in the ambulance service and it is likely that you will need to work collaboratively with all of them at some time or another. Key to successful collaborative working will be building successful working relationships.

A good relationship with your manager is particularly important. Key principles of good working relationships are:

• Knowledge of responsibilities and limits of own role

• Regular, face-to-face meetings

• Performance feedback sessions

• Opportunities to ask questions so you can develop your skills.

Should you have a problem or encounter bullying from your manager, escalate this to your organisation. The NHS Constitution details that all staff, paid or voluntary, have a right to ‘a good working environment’ [DoH, 2015]. NHS Trusts must strive to provide ‘a positive working environment for staff and to promote supportive, open cultures that help staff do their job to the best of their ability’ and this includes volunteers such as responders as well as paid staff.

Chapter 3: Communication

1 Principles of communication

1.1 Learning objectives

By the end of this section you will be able to:

• Identify the different reasons people communicate

• Explain how communication affects relationships in the work setting

• Describe the factors to consider when promoting effective communication

• Explain how people from different backgrounds may use and/or interpret communication methods in different ways

• Identify barriers to effective communication

• Explain how to access extra support or services to enable individuals to communicate effectively.

1.2 Introduction

As a responder, you will frequently have to engage and communicate with a diverse range of people at every incident you attend. In the pressure of an emergency situation communication can be very challenging, so understanding the basics of communication in advance can be very beneficial.

As inter-personal communication forms such a fundamental aspect of our daily lives we rarely stop to think about how we do it, but, as will be discussed throughout this lesson, effective communication, especially in a high-stress environment, is a skill that requires development and practice.

Poor communication is one of the most frequently received complaints for healthcare organisations, including the NHS [HSCIC, 2013], and poor communication is a well-known cause of disastrous medical and surgical errors, including the removal of incorrect organs and limbs [WHO, 2009b].

1.3 Who you will be communicating with

When working as a responder, either at emergency incidents or just as part of your day-to-day activity with the ambulance service, you will interact with a large range of people, which may include:

• Service users

• Health and care professionals

• Colleagues

• Members of the public

• Staff in EOC

• Other professional services (police, fire etc.).

This communication is likely to occur through a variety of methods including:

• Verbal

• Body language

• Written

• Electronic written (email or electronic patient record)

• Radio

• Telephone.

This will often be under pressure or personal stress, where poor communication or misinformation can have a detrimental effect on patient outcomes. Therefore, mastering communication in the emergency environment is a core skill of anyone working for an ambulance service.

1.4 Basics of communication

Traditionally, communication has been regarded as the sending of a message from one person to another (Figure 3.1) [Corcoran, 2013]. The sender (person A) has a message they wish to pass to the receiver (person B). The message exists within the consciousness of the sender initially, and then they decide on a method of passing that message. Before it can be passed it must be ‘encoded’. This encoding may be the selecting of certain words, certain emphasis during part of the sentence, or other verbal or non-verbal features. The receiver must then ‘decode’ the message as they receive it and try to interpret the original message from all the verbal and non-verbal information they have received. Clearly, this model is not sufficient in healthcare, as it implies a one-way communication, not the two-way communication that is essential for providing best care to patients.

Figure 3.1 Basic model of communication

A modified model has been suggested, which includes the variables of understanding and feedback, and is a cyclic process (Figure 3.2). This inclusion of checking the understanding of the message given, and receiving feedback, is fundamental to ensure that messages have been understood in the way in which they were intended [Corcoran, 2013].

Figure 3.2 Modified model of communication

This is particularly important in high-stress situations or when communicating information a person may not understand well (such as a medical complaint), to ensure that the correct message has been received and understood. In these situations it is very easy for a message to be misinterpreted, with potentially disastrous consequences.

1.4.1 Verbal skills

Verbal communication can be divided into two broad areas [Blaber, 2008]:

• Language and vocabulary

• Paralinguistic features of communication.

Language and vocabulary

Working in healthcare you must be able to adjust your language and vocabulary so that it is suited to the person you are communicating with. When communicating with colleagues and other health professionals you will need to use more complex and professional language. However, there will be times when you need to adjust to communicate with those who have a narrower range of language skills, which may include children or those with cognitive impairment, such as dementia patients or those with learning difficulties.

Guidance for ensuring clear verbal communication includes:

• Do not try to say too much at one time; people can only process a certain amount of new information at once

• Avoid using jargon

• Speak in a clear manner and as concise as possible

• Frequently check that what you are trying to communicate is being understood

• Think about what you want to say and then the easiest way to communicate that to someone else.

Paralinguistic features

Paralinguistics refers to the modification of the way in which we speak and place emphasis in communication. This includes:

• Volume

• Rhythm

• Pitch

• Pace

• Intonation

• Tone.

1.4.2 Non-verbal communication

Non-verbal communication can have a dramatic impact on the message you are sending and the way that it is then interpreted. It can be possible to communicate entirely by non-verbal means [Blaber, 2008] and this can become vital for patients who are unable to communicate verbally due to foreign language, learning difficulties or previous injury.

Examples of non-verbal communication include:

• Eye contact

• Facial expression

• Gesture and posture

• Personal space and touch.

All of these should be used in a manner that is appropriate to the situation. For example, when gathering a history from a patient, if you are head down and writing as they speak then the patient may get the impression you are not paying attention to them and might leave out key details. In contrast, if you are making eye contact, nodding your head and acknowledging their communication with small verbal cues, such as ‘OK’ and ‘yes’ as they are speaking, known as active listening, then they are more likely to continue communicating and reveal all the information you need in order to assess them properly.

Equally, you should observe the body language of those you are communicating with. If the person you are talking to looks as though they are becoming increasingly agitated and frustrated you should respond to this and change the conversation or method of communication.

1.4.3 Written communication

It is likely that every patient contact you have will involve some form of written communication, most commonly as part of the patient record.

Increasingly, written records are completed as part of an electronic record system, but as a responder it is likely you will still have paper records to complete. Your service should make you familiar with the records you have to complete and how this should be done as well as provide on-going feedback on your documentation, but as a set of general principles, it is important that all written communication is neat, legible, concise, and follows a logical structure. Some key pointers for achieving this include:

• Avoid unnecessary abbreviations

• Ensure that your writing is legible and if a carbon copy is being used has transferred through to the carbon copy

• Diagrams can be beneficial but these need to be clear and labelled appropriately

• Ensure you follow a structure. Most organisations use some form of standardised ‘medical model’ to aid this.

1.4.4 Social context

Communication relies heavily on the social context in which it takes place. Consider the two following scenarios and how the changing social context may influence how you communicate [Hartley, 1999]:

• Scenario A: You attend a small child who has fallen and injured their wrist. As part of your assessment you need to look at the wrist, but the child is wary of letting you get close, due to fear of you causing more pain

• Scenario B: You are called to give evidence in court at the case of a serious assault at which you were first on scene. You are placed in the witness box and asked a series of questions by the prosecution, prior to cross-examination by the defence.

In both these scenarios, effective communication is critical to ensure that others receive the message you intended to send; however, the way in which you communicate these messages will be vastly different. Your role is to ensure you encode the message, using both verbal and non-verbal features of communication, in such a way that it is likely it will be decoded in the manner you intended.

This concept extends well beyond the extreme examples cited above and into your daily role as a responder. You will meet people from a wide range of social and cultural backgrounds. Every one of these people will have a different social context in which they exist, and you will need to be mindful of modifying your communication, based on the needs of the individual, to ensure that accurate messages are passed and misunderstanding does not occur.

1.5 Barriers to communication

Barriers to communication are anything that influences your ability to effectively pass on and receive back the message you need. You will frequently encounter difficult-to-manage barriers to communication and will need to think of ways of dealing with them. Here are some examples of barriers to communication and how they can be overcome:

• Physical obstacles: Such as distance or your patient being stuck on the other side of a closed door. The clear answer here is to remove the obstacle, but in some situations this may not be possible, so you will need to think of novel solutions. Examples may include: Establish contact via a phone; use an intermediary to relay messages; signal with your hands or other props

• Language: You will inevitably meet people with whom you cannot communicate in their native language. The use of a family member as a translator can be helpful; alternatively, your service may have provided you with other tools such as phrase books or access to Language Line, a telephone service that provides translators for a wide range of languages over the phone

• Emotions: You will frequently encounter patients and situations where those involved are experiencing extreme emotions. At these times people are less able to understand what is being said to them or asked of them. Use of your verbal and non-verbal skills of communication will be key here to ensure clarity of message

• Age: Young patients in particular will need to be communicated with in a way that is suitable to them and that they can understand. Using pictures, drawings and other props can be an effective means of overcoming barriers to communication.

This is just a short list of examples of barriers that you may experience in communicating. It is worth noting that whenever you adapt your communication to overcome such difficulties there is an increased risk of your message being misinterpreted, so you should make doubly sure that what you wanted to communicate is the message the person has received.

As with all elements of your practice, you should constantly reflect on your communication skills to learn from both positive and negative experiences to continue improving your abilities.

1.5.1 Clarify misunderstandings

In the emergency and urgent care setting it is inevitable that, at times, you will be communicating large quantities of information in a short space of time and subsequently misunderstandings can develop. To combat misunderstandings you should:

• Observe for non-verbal cues that the person you are talking to has not understood what you are trying to communicate

• Confirm the person understands what you are saying to them

• If you suspect misunderstanding, repeat what you are trying to communicate in a different manner.

1.6 Summary

Communication is a natural skill that we all use on a daily basis; however, in your front line role you will routinely be faced with challenging and demanding communication scenarios. To help overcome these, having an understanding of the theory of communication and a strong working knowledge of what resources are available to you locally will be helpful. You will also need to be adaptive, creative, responsive and innovative in overcoming barriers to communication on a daily basis.

2 Practical communication

2.1 Learning objectives

By the end of this section you will be able to:

• Explain the importance of clear, concise reporting of findings to the clinician

• Explain the importance of recording patient observations

• Describe the procedure for clinical handover to medical professionals.

2.2 Introduction

In your role it is likely that you will frequently need to undertake examinations and record observations. Keeping accurate records and gaining accurate observations is critical to safe patient care as it forms a part of the continuity of their care. Changes in observations can indicate a deteriorating or improving patient, so if there are errors in the recorded observations it can create a false perception of the patient’s changing state of health.

The following tips will help to ensure patient safety when undertaking this part of your role:

• Pass on, or record, all the information you obtain. If you are not sure of its relevance, pass it on to the clinician responsible for their care

• If you are asked to undertake procedures, observations or interventions that are outside your skill set, politely inform the responsible clinician that you are not able to do this

• If you are struggling or unsure, make your supervising clinician aware

• Never fabricate, estimate or make up observations. Doing so not only exposes the patient to risk but would also be considered as unprofessional conduct when discovered.

2.3 Handover

As a responder, it is likely you will often arrive at an incident first and on your own. Your initial observation and history gathering is very important and you must be familiar and prepared to hand over this information in an effective and concise manner to all other healthcare staff that may arrive at an incident after you; this will be done via a structured handover.

The process of a handover is passing on the care of your patient to another healthcare provider(s). During handover, all information relevant to the care of the patient should be provided in a concise and effective manner. It is well recognised that handovers are a high-risk aspect of a patient’s care, where important information can be forgotten or missed out [BMA, 2014]. This can lead to errors or omissions on the part of the receiving clinician and then harm to the patient as a result.

This risk of error is increased in high-stress situations, for example where patients are critically ill or injured: just the time when that information needs to be passed on accurately.

There are many models to help facilitate clinical handover and thereby reduce the risk of key information being forgotten. The UK Ambulance Services Clinical Practice Guidelines recommend the use of the ‘ATMIST’ model as a quick and easy way of conducting a handover [AACE, 2016]:

• A: Age of patient

• T: Time of incident

• M: Mechanism of injury

• I: Injuries sustained

• S: Signs and symptoms

• T: Treatment given/immediate needs.

You should practise giving handovers frequently and think about what you can do to make your handovers simpler. It might be that you have a card with a template of ATMIST on it so you can remember the structure.

Other principles to consider when conducting a handover include:

• Make sure the person you are handing over to is the person responsible for the patient’s care

• Make it concise: Especially for the critically ill and injured patient you will have a very limited period of time (often less than 60 seconds) in which to provide a handover

• Make sure you have everyone’s attention prior to beginning your handover

• Provide written copies of all information as well as a verbal account whenever you hand over the care of your patient.

2.4 Electronic communication devices

Being able to communicate with the emergency operations centre (EOC) is essential, not just so you can be dispatched to incidents, but also for your own personal safety. It is likely you will have one of two electronic ways of doing this, either:

• Mobile phone

• Airwaves pager.

Your organisation should train you in the use of the relevant device and you must be familiar with its operation, otherwise you may miss being dispatched to an incident or find you’re not able to request help when you need it. You also need to ensure it is kept charged up!

Chapter 4: Legal and Ethical Issues

1 Being a healthcare volunteer

1.1 Learning objectives

By the end of this section you will be able to:

• Explain what it means to have a duty of care

• Explain how duty of care contributes to the safeguarding or protection of individuals

• Describe how to respond to complaints

• Explain the main points of agreed procedures for handling complaints

• Explain expectations about your work role as expressed in relevant standards

• Describe how your values, belief systems and experiences may affect working practice

• Describe why it is important to adhere to the agreed scope of the job role

• Explain why it is important to work in partnership with others.

1.2 Introduction

This section will describe what it means to be a healthcare volunteer, with a focus on:

• Values-based healthcare

• Duty of care

• Scope of practice

• Standards

• Complaints.

1.3 Values-based healthcare

Working as a member of the ambulance service is an extraordinarily privileged role. As a responder you will often be caring for people when they are at their most vulnerable. The majority of people have less than a handful of contacts with the ambulance service throughout their lifetime, so when they do call, during extreme life events, patients will look to you for help and support in whatever situation they find themselves in. Being in this privileged role, it is important to recognise that you should be patient focused and the attitudes and beliefs that you hold can influence the care you provide to your patient.

1.3.1 Stafford Hospital

Stafford Hospital was an acute hospital that became the focus of a national outcry about standards of care. Following concerns raised by the families of patients around poor standards of care and further concerns around unusually high mortality rates, especially for emergency admission patients [Cure the NHS, 2014], the Healthcare Commission conducted an investigation in 2008 looking into care at the hospital. This uncovered deficiencies at virtually every stage of the pathway of emergency care [HC, 2009].

The resulting public inquiry and report, widely known as the Francis report, painted a damning picture of a place where there were fundamental failures of care. These included [Francis, 2013]:

• Patients were left in excrement-soiled bedclothes for lengthy periods

• Assistance was not provided with feeding patients who could not eat without help

• Water was left out of reach

• Staff treated patients and those close to them with what appeared to be callous indifference.

Although a definitive number has never been released, it is suspected that hundreds of patients died unnecessarily and thousands more suffered as a result of poor care.

The final report made 290 recommendations in total, many of which have been or are being adopted nationally. There have been a number of other reports published since into improving care within the NHS, but perhaps the most influential is the one conducted by the National Advisory Group on the Safety of Patients in England [DoH, 2013b]. This review made a number of key recommendations including:

• The NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning

• Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from ‘wards to the boards’.

Not only does this philosophy make the NHS an organisation that learns from and builds on its errors, but it puts the patient at the core of all activities. Health professionals must always apply a culture of compassionate care when looking after patients, a culture that is best summarised by the 6 Cs:

• Care

• Compassion

• Competence

• Communication

• Courage

• Commitment.

1.3.2 What influences your values and attitudes?

There are multiple aspects that influence our own attitudes, but understanding this and understanding how our attitudes impact on the management of our patients is an important distinction to make. Everyone harbours prejudgements about certain people or groups of people. These can be positive or negative, and these stereotypes are used as a form of mental shortcut [Paul, 1998]. However, this can also be dangerous, as it can lead to judgements being made about people based on limited information. These judgements can even influence the way in which a patient is treated, which in turn can lead to errors.

Consider the following scenario:

You are on call overnight on a Friday evening. You have had a long week at work, and already have been out to one incident earlier in the night. Around 02:00 you are awoken by your pager dispatching you to an incident around half a mile away from your home address. You recognise the address on the pager: it is an elderly female who frequently calls the ambulance, complaining of chest pain on the phone. Despite lengthy tests and examinations, no-one has ever found anything wrong with the patient and it is thought that her calls are more due to loneliness and panic attacks than any critical medical need.

Is there a risk of stereotyping influencing your practice in this scenario? The answer is almost certainly yes, particularly if you approach the incident thinking ‘here we go again’, wondering how long it will be until you can get back home to bed.

Having a certain amount of pre-judgements is probably unavoidable, but you should recognise that this is the case, and not allow these judgements to bias your thinking which may in turn lead to you providing less than optimal patient care.

1.4 Duty of care

Duty of care is a civil law concept within the UK and exists to ensure that one party does not allow unreasonable harm or loss to occur to another [Dimond, 2011].

As a responder, you owe a duty of care to your patient from the point at which they are accepted as a service user [HCPC, 2012]. From that point onwards you must act in a way to prevent harm where a reasonable person could see that harm might occur. If you breach this duty of care and someone suffers as a result, then this can lead to the civil wrong of negligence.

1.5 Negligence

Negligence occurs when duty of care is breached and reasonably foreseeable harm occurs as a result. If a party is guilty of negligence, they can be pursued through the civil courts for damages. There are four stages for negligence to be proven [Pilbery, 2013]:

• Establish a duty of care

• Breach of duty

• Harm occurred

• Causation.

Establishing a duty is usually straightforward, since as a responder you owe a duty to any patient you encounter.

Breach of duty occurs when a reasonably foreseeable consequence of a person’s action leads to harm. The difficult part to measure in this section is what counts as ‘reasonably foreseeable’ and this is a point that the courts may have to decide upon. Harm can take many forms including physical injury, but may also include:

• Mental or emotional distress

• Loss of earnings or loss of potential future earnings.

Causation is the final step in proving negligence. It is not enough for a duty of care to exist and for that duty to be breached. That breach of duty has to go on to cause harm and it should be evident that this breach was the cause of that harm. Also sometimes referred to as the ‘but for’ principle, it is applied by asking ‘But for the (action or omission) would harm have occurred?’ If the answer to this is ‘yes’, then negligence is not proven; if the answer is ‘no’, then it is likely that negligence exists.

If negligence is proven, it is likely that the person suffering harm will receive damages for the harm they suffered. This money, likely to run to thousands, if not hundreds of thousands of pounds depending on the nature and severity of the harm caused, will be paid by the ambulance service under their responsibility of vicarious liability (the ambulance service is responsible for your actions and omissions). However, you should note that in certain exceptional circumstances, you can also be found guilty of certain criminal charges if you are grossly negligent in caring for your patient. Therefore, it is important to ensure you act within your scope of practice to ensure your own safety.

1.6 Scope of practice and standards

Your scope of practice as a responder will be established by the service you are linked to through a series of standards. Such standards are treated as the benchmark for determining whether or not a person is working within their scope of practice and also whether or not they are fit to be a responder.

Standards can cover a wide range of topics, not just clinical skills. It is not possible to list the standards for responders here, as they will vary from organisation to organisation, but you should be aware of the standards expected of you and what your scope of practice is, i.e. what can you actually do when responding to a patient. Not everything included in this book will be within the standard scope of practice for all responders. A number of skills have been marked as extended and it is the decision of your organisation as to exactly what examination and management skills, including medications, are available to you as a responder.

You should not attempt to undertake any activity outside your scope of practice as you are not likely to have the knowledge, skill or experience to do so safely and would therefore be putting the patient and yourself at risk.

What constitutes negligence was outlined earlier, and it should be noted that any activity undertaken outside of your scope of practice, and which leads to harm, is likely to be the grounds for a claim of negligence.

1.7 When things go wrong

All ambulance services strive to be a ‘no harm’ organisation, but it is probably an unavoidable fact that systems as large and complex as modern ambulance services will always have adverse incidents. However, these errors should not lead to patient harm, and lessons should be learnt from mistakes when they occur.

All health organisations should learn from their mistakes. They should also be promoting a learning culture where staff are not unnecessarily blamed for mistakes, and where people feel safe in reporting incidents so that the larger organisation can learn from those incidents, even small ones. Only when organisations can learn from their mistakes will they be able to prevent events from being repeated, meaning that overall, a well-functioning complaints system plays a major role in service improvement and preventing patient harm.

1.7.1 Failure to achieve standards

This concept of reporting extends to yourself and your own practice as well. If you recognise that in the course of your duty you have failed to achieve the expected standards for someone in your role, then you should make this known. Different organisations will have different methods of reporting, but most now have a central system for reporting incidents and a dedicated team that deals with those reports.

1.7.2 Complaints

During the course of your duty it may be the case that someone wishes to make a complaint about you, the ambulance staff, your organisation or another organisation. This can be challenging, as the natural response is to be defensive, but remember that the principles of a learning organisation, together with opportunities to reflect, should be seen as a way of improving our services and should be welcomed as such.

It is likely that your service will have specific guidelines or a policy on handling complaints, which you should be familiar with, but good general guidelines for the actions you should undertake include:

• Record facts and pass them on to appropriate people: Do not undertake the investigation yourself

• If someone wishes to make a complaint, take the details and pass them on to relevant parties, or give the person the contact details of the relevant people inside your organisation

• Do not challenge facts about a complaint; if necessary this can be done later on, once all the facts have been established

• Provide contact details so that patients know how to get in touch should they wish to.

If you become involved in an investigation or complaint then you should do all you can to support the investigation. Withholding key information may be seen as a misconduct offence, which is likely to be handled very differently from learning from a genuine error.

1.7.3 Additional sources of support

Dealing with situations where things have gone wrong can be a challenging time and you may well need further advice and support. In those circumstances, you may find that some of the options below are able to assist you:

• Organisational policy

• Your line manager

• Making experiences count (or similar) investigation team within your organisation [DoH, 2007b].

2 Consent and capacity

2.1 Learning objectives

By the end of this section you will be able to:

• Assess capacity

• Gain consent

• Maintain consent

• Analyse factors that influence the capacity of an individual to express consent

• Describe different ways of applying active participation to meet individual needs

• Describe how to support an individual to question or challenge decisions concerning them that are made by others.

2.2 Introduction

As a responder in a front line role, you will regularly have to seek consent to treat people and should have a basic understanding of mental capacity and how it impacts on patient treatment.

Having a good understanding of the basic principles will make this easier and help to remove doubt when tackling challenging and potentially confusing scenarios.

2.3 Consent

In the United Kingdom, case law has determined that adult patients with mental capacity must give consent before they are touched or treated. Failure to do this leaves the ambulance crew open to civil claims for trespass against the person, which includes assault and battery [Dimond, 2008]; therefore you must seek valid consent to treat your patient.

2.3.1 Valid Consent

In order for consent to be valid, there are three criteria that must be met [NHS Choices, 2014b]; they stipulate that consent must be:

• Given voluntarily, i.e. free from pressure exerted by relatives, partners, ambulance staff or police officers etc.

• Informed: The patient must understand what course of action is being proposed, what the benefits and significant risks are, what alternatives are available, and what the consequences are of doing nothing

• Capacity: The person consenting needs to have the mental capacity to do so. This is usually the patient, but includes someone with parental responsibility in patients less than 18 years of age, or a person who has been given a Lasting Power of Attorney (LPA) or authority by a court to make treatment decisions [DoH, 2009b].

2.3.2 Communicating consent

Communicating consent may take many forms. Often for elective procedures in hospital it will be written. Working out-of-hospital the majority of the time it will be verbal, but it may take another form, particularly if the patient has a disability that would make written or verbal communication impossible. Other forms that you may encounter include, but are not limited to:

• Sign language

• Use of props

• Blinking

• Movement of limbs

• Use of technology, such as speech generators.

2.3.3 Best interest decisions

Generally if your patient is over 18 years of age, only they can consent to any intervention. Lying unconscious in the street after being involved in a road traffic collision does not imply consent but instead you would treat them under a principle of ‘best interest’, whereby you can apply life-saving treatments without the patient’s consent, as long as, to the best of your knowledge, they have not previously made a declaration refusing such treatment, also known as an advance decision to refuse treatment (ADRT).

2.3.4 Advance decision to refuse treatment (ADRT)

An ADRT is an order made by a person over the age of 18 when they still have capacity, to refuse specified medical treatment at a future point in time when they may lack the capacity to consent to or refuse treatment.

If faced with an ADRT you should be confident that it is valid before working to it. For it to be valid you should where possible confirm whether the patient:

• Has done anything that clearly goes against their advance decision

• Has withdrawn their decision

• Would have changed their decision if they had known more about the current circumstances

• Has subsequently conferred the power to make that decision to an LPA.

Generally an ADRT does not have to be written – it can be verbal – but if it refers to life-saving treatment then it must:

• Be in writing

• Be witnessed and signed, and

• State clearly that the decision applies even if life is at risk.

If you believe an ADRT exists, is valid and applicable then you should follow the instructions contained within.

2.4 Mental capacity

Case law has clearly laid out the right of a mentally competent adult to refuse any treatment, including life-saving interventions, regardless of the reason, or for no reason at all. This has now been incorporated into several statutory frameworks. In England and Wales, this framework is the Mental Capacity Act 2005 (MCA), and in Scotland, the Adults with Incapacity (Scotland) Act 2000. The purpose of this legislation is to protect the rights of individuals from having treatment forced upon them in all but rare circumstances.

Central to capacity and consent is the concept of personal autonomy, that is, the right of an individual to ‘govern themselves’ according to their own set of personal values, preferences, commitments and character traits [Freyenhagen, 2009]. This can come into conflict with an ambulance crew’s tendency towards beneficence (i.e. serving the best interests of patients [Moye, 2007]) and wanting to safeguard their job.

Mental capacity is the ability to make a decision, and covers everything from when to get up to how much alcohol to drink and whether to go to hospital as advised by an ambulance crew. A lack of capacity is defined as an inability of your patient to make a specific decision at the time they are required to make it, due to an impairment of, or disturbance in the functioning of, the mind or brain. It does not matter if this impairment or disturbance is temporary or permanent. Examples of impairment include:

• Temporary:

• Post-ictal following a convulsion

• A diabetic suffering a hypoglycaemic event

• Ingestion of alcohol or drugs

• Permanent:

• Dementia

• Significant learning disabilities

• Long-term effects of brain damage.

2.4.1 What to do if you suspect a lack of capacity

As a responder, it is unlikely you will receive the specific training required to undertake a capacity assessment. Instead, if you have a patient that is refusing life-saving treatment and you believe may lack capacity then you should contact control as soon as possible and inform them about the situation. A clinician in the emergency operations centre (EOC) may be able to assist you and they can make sure you are receiving appropriate backup as quickly as possible.

All clinicians that back you up should be able to undertake a capacity assessment and may, in certain circumstances, depending on the immediate risk facing the patient, decide to treat them against their will.

While you are waiting for backup, you should explain clearly and simply, in a way the patient will understand, why you want to treat them, what it is you want to do and what the risks are associated with their refusing treatment.

2.5 Summary

As a responder, you are subject to the same laws as any other clinician in respect of consent. Be sure that, where possible, you seek valid consent from your patient and that you are not accidentally forcing unwanted treatment on them.

You should also have a general understanding of what mental capacity is and what you should observe for when you believe your patient may lack capacity. If you believe your patient may lack capacity a clinician will undertake an assessment and decide on the best course of action.

3 Confidentiality and information governance

3.1 Learning objectives

By the end of this section, you will be able to:

• Explain the meaning of the term ‘confidentiality’

• Demonstrate ways to maintain confidentiality in day-to-day communication

• Define information governance

• Explain your role in information governance.

3.2 Introduction

Any responders, like other healthcare professions, have a duty of confidentiality to their patients, whereby they must protect all patient information and handle it in an approved manner. Failure to follow strict organisation polices and, where relevant, codes of conduct in relation to handling information can be a source of distress for patients and embarrassment for organisations. It can also result in legal or disciplinary action for both organisations and individuals [NHS England, 2014].

Information governance is broadly defined as the framework organisations have in place to bring together all the legal rules, guidance and best practice that apply to the handling of information [HSCIC, 2015]; these rules and guidelines include:

• The Data Protection Act 1998

• The Confidentiality NHS Code of Practice

• The Freedom of Information Act 2000

• The Records Management NHS Code of Practice

• The Information Security Management NHS Code of Practice.

Within your role, you will routinely have access to confidential, patient-identifiable information. This information, or data, should be protected: this means that you should record, handle and store this information in such a way that you are not likely to misplace any information or accidentally breach confidentiality by making an unauthorised or unnecessary disclosure, which could lead to civil or criminal legal proceedings being brought against you or the organisation you work for.

3.2.1 What should be considered patient-identifiable information?

Patient-identifiable information is anything that may enable a patient to be identified, either directly or indirectly [AACE, 2016]. This includes obvious personal information, such as name, address, date of birth etc. However, it also includes less commonly considered things, such as:

• Clinical record numbers

• Images or voice recordings of a patient

• Rare disease information.

Consider the following scenario:

You work in a small town with a population of around 25,000 people. In this town lives a patient who suffers from Addison’s disease: a rare endocrine disorder. The patient frequently suffers from Addisonian crises, and when this happens family members call for an ambulance. You attend this patient suffering from a crisis one day; as this is not a condition you are familiar with, next time you visit a local ambulance station you ask an ambulance crew for some information about the condition. You are mindful not to disclose the name or location of the patient (to prevent a breach of confidentiality), but instead describe the incident and ask for advice.

Considering that Addison’s is a rare disease and this one person, in a small community, frequently requires ambulance assistance, is it reasonable that, on the balance of probabilities, the crews would be able to identify whom you are talking about, just by describing the condition?

Any information that has the potential to identify the patient, however remotely, should be considered as identifiable and managed in such a way as to help avoid a breach of confidentiality from occurring [AACE, 2016].

3.3 Maintaining confidentiality

Organisations should have policies in place to describe how they handle information and protect confidentiality. You have a legal obligation to maintain confidentiality so should have a good working knowledge of these policies [NHS England, 2014].

During the course of your duties, it may be necessary to discuss or share patient-identifiable information on a number of occasions. Such occasions may include:

• Discussing the care of your patient with another healthcare professional

• Handing over the care of your patient.

These communications can take many forms including:

• Face to face

• Written

• Telephone.

Different systems will have different strengths and weaknesses in their security of managing data. Most records in the out-of-hospital setting are recorded either on paper, or increasingly frequently on electronic patient record devices. Below are some of the security features of each type of storage:

• Electronic record keeping

• All data is transferred and stored securely. No data is left ‘hanging around’ once it is no longer required

• No physical copies of records means it is less likely records will be ‘misplaced’

• Physical records

• Once completed should be submitted into a secure storage system

• Copies of the record are only passed to patients or patients’ relatives with permission once completed.

Regardless of which system you use, you should consider how best to maintain confidentiality. Your employer or volunteer organisation should make a copy of its policy available, but some good practice guidelines include [NHS England, 2014]:

• Seek consent before sharing information: Before you share patient information you should seek consent from the patient to do so. However, in a limited range of situations it may be appropriate to share information without the patient’s consent, for example:

• It is not possible to gain consent – this would most likely be due to the patient’s condition, i.e. unconscious

• Share only that information which is necessary: If you phone the EOC after an incident to book clear, you are probably going to speak to a dispatcher. It is unlikely that person needs to know all the medical details of the patient, so you should limit your discussion to relevant points and not disclose confidential information unnecessarily

• Maintain physical security of information: Part of your role is likely to include making notes and records on the patients you attend. It is unlikely that you would keep these records once you have treated the patient; instead they should go with the patient to be passed to the ambulance crew that backs you up.

You may decide to keep a record of incidents that you attend for your own development; however, this must not include any personal identifiable information: it must not be possible to identify any patients from such a log.

If you find following an incident that you have accidentally retained a copy of patient identifiable information then you should immediately inform your line manager and follow their instructions on how to deal with it appropriately.

3.4 Key points

Remember these key points relating to confidentiality:

• Patients are the owners of information or data relating to them

• Patient-identifiable information comes in many forms and is communicated in a range of ways

• Patient-identifiable information should not be shared without consent except in specific circumstances

• Only share information that is necessary

• Consider how to maintain security of data in order to prevent accidental disclosures

• Organisations should have policies in place for protecting information and you should be familiar with these.

4 Equality and diversity

4.1 Learning objectives

By the end of this section you will be able to:

• Explain what is meant by

• Diversity

• Equality

• Inclusion

• Discrimination

• Describe the potential effects of discrimination

• Explain how inclusive practice promotes equality and supports diversity

• Explain how legislation and codes of practice relating to equality, diversity and discrimination apply to your own work role.

4.2 Introduction

Promoting equality should be at the heart of a healthcare organisation’s values. It ensures that organisations work in a way that is fair, so that no community, group or individual is left behind [NHS England, 2015].

It is helpful to understand what the terms ‘diversity’, ‘equality’ and ‘inclusion’ mean:

• Diversity: This involves recognising and valuing the differences between individuals across groups. Such differences should be seen as ‘assets to be valued and affirmed, rather than as problems to be solved’ [Thompson, 2006b]

• Equality: In its simplest form, equality is about being treated fairly. Equality recognises that people are different (diversity) but that those differences do not mean that a person should be discriminated against, as everyone should be treated fairly and equally. Equality also recognises that inequality exists and needs to be overcome for a truly fair society

• Inclusion: This involves positively striving to meet the needs of different people and taking deliberate action to create environments where everyone feels respected and able to achieve their full potential [NIHR, 2012].

4.3 Equality in healthcare

At first glance, it may not be obvious how equality and diversity can have an influence on healthcare or influence outcomes; however, various health inequalities do exist [NICE, 2012b]. The King’s Fund (2015) discusses how men and women from the richest social groups live an average of 7 years longer than those from the poorest social class. Issues that are thought to influence health inequalities include:

• Employment

• Education

• Availability and accessibility to healthcare

• Housing.

4.4 Discrimination

Discrimination occurs when someone treats one person less favourably than they would another, because of a personal characteristic. This is often due to stereotyping.

Under the Equality Act 2010, it is unlawful for a person to discriminate against another with respect to certain protected characteristics.
The nine characteristics are:

• Age

• Disability

• Gender

• Gender reassignment

• Marriage and civil partnership

• Pregnancy and maternity

• Race

• Religion and belief

• Sexual orientation.

As well as the Equality Act, the Human Rights Act 1998 also provides for ensuring certain equalities, including:

• The right to life

• The right to a fair trial

• The right to education

• The right to participate in free elections.

4.4.1 Discrimination in your role

In order to make sense of society and those in it, we naturally group individuals together when they share common characteristics. Based on these characteristics we may expect people within the group to act in similar ways or to have similar responses to the same situations; this is the process of stereotyping [Judd, 1993].

Using these stereotypes is a natural process as it allows us to ‘shortcut’ our thinking, but often they are not accurate. Making such shortcuts in emergency care can be dangerous as we will make incorrect assumptions about our patients and fail to challenge our own thought processes.

Applying such stereotypes is probably unavoidable, but we must be prepared to challenge our own thinking and the assumptions made on the basis of that thinking. For example, elderly patients have very varied life expectancies. Some patients may suffer from a multitude of medical conditions in their early seventies and therefore have a relatively limited life expectancy, whereas many people will live late into their nineties and beyond with very few medical concerns. If all of these patients were treated the same purely on the basis of their age you would not be treating patients as individuals and would be likely to provide poor care as a result – potentially even leading to the avoidable early death of a patient. Remember that age is a protected characteristic and it is both unethical and unlawful to discriminate against someone on the basis of one of these characteristics.

4.4.2 Further support

If you observe discrimination then you will need support in understanding how best to resolve the situation. In this instance help would normally be available from your:

• Line manager

• Organisation Equality and Diversity lead.

If a patient wishes to make a complaint in relation to being discriminated against then you should support them in doing this.

Remember, everyone is responsible for promoting equality, recognising diversity and challenging discrimination. Only by doing this will you be able to ensure your patients are receiving the best care possible and you are practising in a non-discriminatory manner. Do not assume that others will tackle the issue.

Chapter 5: Health and Safety

1 Health and safety policies and legislation

1.1 Learning objectives

By the end of this section you will be able to:

• Identify key legislation relating to health and safety in the ambulance service

• Explain the main points of health and safety policies and procedures

• Analyse the main health and safety responsibilities for:

• Yourself

• Your employer/volunteer organisation and manager

• Others in the work setting.

1.2 Introduction

Some of the legislation that relates to the ambulance service has been reviewed in the Legal and Ethical Issues chapter, but it is also important that you are aware of the legislation relating to health and safety, and in particular, that you know your and your employer’s legal responsibilities.

1.3 Health and Safety at Work etc. Act 1974

All workers, including volunteers, have a right to work in places where risks to their health and safety are properly controlled. Health and safety is about stopping you getting hurt at work or ill through work. Your employer is responsible for health and safety, but you must help [HSE, 2009].

Employers must do the following in order to comply with the Act [HSE, 2009]:

• Decide what could harm you in your job and what precautions could prevent it. This is part of risk assessment

• In a way you can understand, explain how risk will be controlled and tell you who is responsible for this

• Consult and work with staff and the health and safety representatives, to protect everyone from harm in the workplace

• Provide (free of charge) health and safety training and provide equipment and protective clothing that you need to do your job

• Provide toilets, washing facilities, drinking water and adequate first-aid facilities

• Notify the Health and Safety Executive in the event of any major injuries and fatalities at work

• Have insurance that covers staff in the event of injury at work

• Display a physical or electronic copy of the current insurance certificate where you can easily read it

• Work with other employers or contractors sharing the workplace to ensure that everyone’s health and safety is protected.

You have a number of responsibilities as an employee, even if you are a volunteer, too [HSE, 2009]:

• Follow the training you have received when using any work item your employer has provided

• Take reasonable care of your own and other people’s health and safety

• Co-operate with your employer on health and safety

• Tell someone (for example your employer, line manager or safety representative) if you think that a method of working or inadequate precautions are putting anyone’s health and safety at serious risk.

1.4 Management of Health and Safety at Work Regulations

The Management of Health and Safety at Work Regulations 1999 require employers to put in place arrangements to control health and safety risks. These include [HSE, 2013b]:

• A written health and safety policy

• Assessments of the risks to employees, contractors, customers, partners and any other people who could be affected by work-related activities, and record significant findings in writing

• Arrangements for the effective planning, organisation, control, monitoring and review of the preventive and protective measures that come from risk assessment

• Access to competent health and safety advice

• Providing employees with information about the risks in the workplace and how those employees are protected

• Instruction and training for employees in how to deal with the risks

• Ensuring there is adequate and appropriate supervision in place

• Consulting with employees about their risks at work and current preventive and protective measures.

1.5 Manual Handling Operations Regulations

Any transporting or supporting of a load (including the lifting, putting down, pushing, pulling, carrying or moving thereof) by hand or by bodily force is considered to be a manual handling operation by the Manual Handling Operations Regulations 1992.

Employers are required to make a suitable and sufficient assessment of the risks to the health and safety of their employees while at work. Where this assessment indicates the possibility of risks to employees from the manual handling of loads, the Regulations require a hierarchy of measures that must be adhered to. These include avoiding hazardous manual handling operations so far as is reasonably practicable and assessing any hazardous manual handling operations that cannot be avoided so as to reduce the risk of injury, as far as is reasonably practicable.

No doubt you have noticed the term ‘reasonably practicable’ appearing a couple of times. This means that the employer’s duty to avoid manual handling or to reduce the risk of injury can be limited, if the employer can show that the cost of any further preventive steps would be grossly disproportionate to their perceived benefit.
Employees are also expected to play their part by following appropriate systems of work laid down by their employer to promote safety during the handling of loads [HSE, 2004b].

1.5.1 Emergency services

Preventing all potentially hazardous emergency service manual handling operations would result in an inability to provide the general public with an adequate rescue service. As a volunteer for an ambulance service, you may be asked to accept a greater risk of injury than someone employed to move inanimate objects (like boxes). In this case, additional relevant factors may include:

• The seriousness of the need for the lifting operation

• The ambulance service’s duty to the public overall and the patient who requires assistance.

Taking these factors into account, the level of risk which an employer may ask an employee to accept may, in appropriate circumstances, be higher when considering the health and safety of those in danger, although this does not mean that employees can be exposed to unacceptable risk of injury [HSE, 2004b].

2 Risk assessment

2.1 Learning objectives

By the end of this section you will be able to:

• Define the term ‘risk’

• Describe the process of carrying out a risk assessment

• Explain the importance of carrying out a risk assessment

• Compare different uses of risk assessment in health and social care

• Explain why risk assessments need to be regularly reviewed and revised.

2.2 Introduction

All healthcare staff and responders have a duty to protect patients, their colleagues and themselves as far as is ‘reasonably practicable’, by minimising the chance that they are harmed by something, whether that be a procedure, drug administration or working in dangerous environments.

It is helpful to understand what is meant by the terms ‘hazard’ and ‘risk’ [HSE, 2014b; NPSA, 2007]:

• Hazard: Anything that might cause harm, such as chemicals, electricity, working from ladders, an open drawer etc.

• Risk: The chance, high or low, that somebody could be harmed by these and other hazards, together with an indication of how serious the harm could be

• Clinical risk: Also known as a healthcare risk, this is the chance of an adverse outcome resulting from clinical investigation, treatment or patient care.

2.3 Structured risk assessments

Your employer is responsible for undertaking structured assessments of risks that it is reasonably foreseeable you will come across while undertaking your duties as a responder.

These assessments are usually completed undertaking a structured risk assessment template and rating chart. Where possible your employer will then reduce the risk so far as practicable. An example of this is your employer providing your equipment in bags, which are not too heavy or difficult to handle.

Copies of these risks assessments are available from your employer. Details of how and when your employer undertakes structured risks assessments will be available in your organisation’s health and safety policy.

2.4 Dynamic risk assessments

As an operational member of staff you are responsible for undertaking a whole range of dynamic risk assessments. Dynamic risk assessments are undertaken in a less structured method, inasmuch as they are not usually formally recorded and documented, but they should still follow a process.

These dynamic risk assessments are a continual process to ensure your safety and the safety of those around you. Two of the dynamic risks assessments you will undertake, at every incident you attend, are the SCENE and TILEE assessments.

2.4.1 SCENE assessment

Every time you approach a scene you need to assess whether it is safe to approach and treat the patient or if you should withdraw to protect yourself and others.

This is covered in detail in the Scene Assessment chapter but is highly dynamic as every situation is different, and even the same situation can change dramatically from having been safe to becoming unsafe after you have been there for a period of time.

2.4.2 Moving and handling assessment

Every time you perform a moving or handling task you will need to undertake a risk assessment of how to safely perform the procedure. Although your organisation will have undertaken a general structured risk assessment for moving and handling, it is clearly not possible to formally assess every location you will be attending in advance. Subsequently you have to undertake an assessment following the TILEE approach.

This is covered in detail in the Manual Handling chapter and is something you should be very familiar with, as you will need to perform this risk assessment very frequently.

3 Infection prevention and control

3.1 Learning objectives

By the end of this section you will be able to:

• Explain what is meant by infection and how infections can occur and be transmitted

• Describe how to manage and dispose of sources of infection safely while avoiding causing harm to self or others

• Outline the current regulations, legislation and responsibilities relating to infection control

• Describe the different types of personal protective equipment (PPE) and how to use them appropriately

• Explain the role of regulators and other bodies in infection prevention and control

• Describe the key principles of good personal hygiene

• Describe the correct sequence for handwashing and when it should be carried out

• Describe the services that Occupational Health provides to employees.

3.2 Introduction

Infection prevention and control is a collective term for those activities intended to protect people from infections [Dougherty, 2011].

An infection is the body’s adverse response to the presence of a pathogen, or disease-causing microorganism [Betsy, 2012]. Damage to tissues caused by an infection can either be limited to the site of infection (localised) or spread throughout the body, typically via the blood (systemic).

Sometimes, however, a pathogen in or on the body may not lead to an infection. This is known as colonisation [Weston, 2014].

A healthcare-associated infection (HCAI) is any infection acquired as a result of a healthcare-related intervention or during the course of healthcare that the patient may reasonably expect to be protected from. HCAI has replaced the term ‘hospital-acquired infection’, since many healthcare interactions take place outside of hospital (including the ambulance service) [Dougherty, 2011]. The scale of the problem is staggering, with an estimated 300,000 patients each year in England acquiring an HCAI, with a significant number of deaths and a cost to the NHS of around £1 billion [NICE, 2012a].

3.2.1 Own health

As well as passing disease and illness on to patients any health professional and associated staff, including responders, can also be made unwell by poor infection and prevention control. Some diseases, such as norovirus, a viral infection which causes gastroenteritis [NHS Choices, 2014c], is very infectious and spreads easily from person to person. In winter, when it is most prevalent, it is likely you will come into contact with patients suffering from this on a frequent basis. If you do not apply adequate infection prevention controls then it is likely that you may also become unwell and contract the illness. This could mean that you are off sick for several days or weeks from work, impacting not only on your health, but potentially the health and well-being of family and friends as well.

Equally, you can spread illness to your patient. If you are not well, then you should not be available to respond as you might spread illness to already unwell people. For many of our patients, including the elderly, those with chronic lung conditions or receiving chemotherapy, only a small infection will place a major strain on their immune system and an illness that may not be a major issue for a healthy person could kill someone already unwell.

3.3 Regulations and legislation

Earlier in the chapter, some of the relevant legislation relating to infection prevention and control was reviewed, in particular the Health and Safety at Work etc. Act 1974. This requires employers to provide training and appropriate personal protective equipment (PPE) to prevent harm, and employees to follow the training that they have received, use PPE provided, and report any situations where they believe that patients’ and/or staff’s health and safety are at serious risk.

However, the Health and Social Care Act 2008 specifically highlights infection prevention and control and also makes the Care Quality Commission responsible for ensuring that ambulance (and other care) services meet the requirements of the code of practice that accompanies the legislation.

3.4 Microorganisms

Microorganisms are very small organisms that live outside and inside larger organisms such as the human body. The four main types that enter the body and cause infection are:

• Bacteria

• Viruses

• Fungi

• Parasites.

3.4.1 Bacteria

These are probably the most important microorganisms in relation to infection control as they are responsible for many opportunistic infections in healthcare. There are around ten times as many bacteria as there are cells in the human body and many have functions that are essential, such as Escherichia coli (E. coli), which aids digestion in the gut. However, it can cause a urinary tract infection (UTI) if it gains access to the urinary tract [Dougherty, 2011].

Bacteria are fairly simple, single-celled microorganisms and are often classified by their shape. For example, they may be termed bacillus (rod-like), coccus (spherical or ovoid) or spiral (corkscrew or curved). Examples of common bacteria include Streptococcus A, which can cause throat and ear infections, and Staphylococcus, which can cause impetigo and pneumonia. You may have heard of a particularly troublesome strain of Staphylococcus which is resistant to many antibiotics and is called methicillin-resistant Staphylococcus aureus (MRSA) [Betsy, 2012].

3.4.2 Viruses

Viruses are even smaller than bacteria and have no cellular structure. They typically just consist of a core containing genetic material such as deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) and are sometimes surrounded by a membrane called an envelope. Viruses can reproduce only by using the cellular machinery of other organisms and so are rather like parasites [Tortora, 2013].

Common viruses include the rhinovirus, which is responsible for the common cold, respiratory syncytial virus (RSV), which can cause serious respiratory tract infections in infants and children, and the varicella-zoster virus (VZV), which causes chickenpox and shingles [Betsy, 2012].

3.4.3 Fungi

You are probably most familiar with fungi as mushrooms or as yeast used in bread making and brewing. Some fungi are responsible for opportunistic infections, such as dermatophytes which can cause athlete’s foot, and Candida albicans, yeast that can cause vaginal thrush [Dougherty, 2011].

3.4.4 Parasites

Parasites are organisms that live at the expense of another organism or host. Pathogenic parasites include bacteria, viruses, protozoa (animal-like single-celled microorganisms) and animals such as roundworms, flatworms and arthropods. Examples of parasitic infections include malaria and toxoplasmosis [Betsy, 2012].

3.5 Infection

3.5.1 Chain of infection

Transmission of infection is a complex process, involving a number of factors, which must all be present and are collectively known as the chain of infection (Figure 5.1) [Ross, 2014; Dougherty, 2011].

Pathogen

An infectious agent is required, such as a bacterium, virus, fungus or parasite. This link can be broken by cleaning, sterilisation of equipment and the treatment of the patient, using antibiotics for bacterial infections, for example.

Reservoir

A reservoir is a place where the pathogen can live and replicate; it includes the human body, but also animals, water and the soil, for example.

Figure 5.1 Chain of infection

This link can be broken by cleaning equipment and the environment (such as the ambulance) and removing stagnant water by running low-use taps and showers, for example.

Exit route

The exit route is a method for the pathogen to leave its reservoir. In humans, this usually involves urine, faeces, vomit and sputum as well as the aerosolised form, such as after sneezing or coughing. Asking a patient with active tuberculosis to wear a mask would help break this chain.

Route of transmission

The transmission route can be direct, such as through touching, sexual intercourse and faecal– oral via ingestion, or indirectly via contaminated bedding, clothing, blood and bodily fluids and then the hands of healthcare workers. One of the most effective ways of breaking this chain is using good hand hygiene.

Entry route

Entry routes include the respiratory, gastrointestinal and genitourinary tracts, but also mucous membranes and via the skin. Direct access to the blood is also possible if the pathogen is inadvertently injected into a person. “Covering an open wound with a waterproof plaster would be a good example of breaking the chain by blocking the route of entry.”

Susceptible host

Some people are more vulnerable to infection than others, for example those with a weak immune system due to old age, medication or pre-existing disease. Others may have their natural defences compromised by wounds, surgery, intravenous cannulas and urinary catheters. This chain can be broken by ensuring that healthcare workers are vaccinated and that adequate nutrition and personal hygiene are provided to vulnerable groups.

3.6 Hand hygiene

Good hand hygiene is the primary measure to reduce HCAIs. It is a straightforward method and inexpensive, but poor compliance among healthcare workers is a worldwide problem [WHO, 2009a].

You should clean your hands in the following circumstances [NICE, 2012a]:

• Immediately before every episode of direct patient contact or care, including aseptic procedures

• Immediately after every episode of direct patient contact or care

• Immediately after any exposure to body fluids

• Immediately after any other activity or contact with a patient’s surroundings that could potentially result in hands becoming contaminated

• Immediately after removal of gloves.

Use an alcohol-based handrub to decontaminate your hands, except when your hands are visibly soiled or potentially contaminated with body fluids, and when it is suspected that alcohol-resistant organisms (such as Clostridium difficile or other organisms that cause diarrhoeal illness) are involved.

In order to ensure that you can clean your hands while at work, you should [NICE, 2012a]:

• Be ‘bare below the elbows’ when delivering direct patient care

• Not wear any wrist or hand jewellery

• Ensure that fingernails are short, clean and free of nail polish

• Cover cuts and abrasions with waterproof dressings.

3.6.1 Alcohol handrub

Procedure

This is the World Health Organization (WHO) recommended procedure for hand hygiene with handrub. This procedure should take 20–30 seconds [WHO, 2009a].

1. Apply a palmful of the alcohol rub in a cupped hand, covering all surfaces

2. Rub hands palm to palm

3. Right palm over left dorsum with interlaced fingers and vice versa

4. Palm to palm with fingers interlaced

5. Backs of fingers to opposing palms with fingers interlocked

6. Rotational rubbing of left thumb clasped in right palm and vice versa

7. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa

8. Once dry, your hands are safe

Based on the ‘How to Handrub’ poster. © World Health Organization 2009. All rights reserved.

3.6.2 Handwashing

Handwashing procedure

This is the WHO recommended procedure for hand washing. This procedure should take 40–60 seconds [WHO, 2009a].

1. Wet hands with water

2. Apply enough soap to cover all hand surfaces

3. Rub hands palm to palm

4. Right palm over left dorsum with interlaced fingers and vice versa

5. Palm to palm with fingers interlaced

6. Backs of fingers to opposing palms with fingers interlocked

7. Rotational rubbing of left thumb clasped in right palm and vice versa

8. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa

9. Rinse hands with water

10. Dry hands thoroughly with a single use towel

11. Use towel to turn off taps

12. Your hands are now safe

Based on the ‘How to Handwash’ poster. © World Health Organization 2009. All rights reserved.

3.6.3 Skincare

Work-related skin problems are very common, with contact dermatitis being the most common form of work-related skin disease. It is more common in healthcare staff due to their need to wash their hands regularly and skin frequently coming into contact with chemicals or rubber materials as used in personal protective equipment [HSE, 2015c].

When washing your hands frequently it is important to use hand cream to replace the natural oils that are lost in the washing process [HSE, 2015c] and to observe for signs of contact dermatitis developing. These signs include:

• Dry itchy skin

• Reddening

• Flaking, cracks of blisters.

If you suffer from contact dermatitis, or any other form of skin disease, then you should see your GP or occupational health team to try to find a personal solution for improving your skincare.

3.7 Personal protective equipment

Personal protective equipment (PPE) is used to prevent the spread of infection to you, your colleagues, patients and other members of the public. Your choice of PPE (including not wearing any) should be based on an assessment of the risk of transmission of infection [DoH, 2010].

Typical items of PPE to prevent infection include:

• Gloves

• Aprons

• Face masks

• Eye protection

• Sleeve protectors

• Protective suits (these are generally only for specially trained personnel, such as hazardous area response team (HART) members, and are not covered in this text).

3.7.1 Gloves

Gloves should only be worn (Figure 5.2):

• If there is a risk of contact with blood and/or bodily fluids

• When sharp and/or contaminated items are handled

• If there is likely to be contact with non-intact skin or mucous membranes during contact with a patient.

Gloves should not be worn longer than required and never when driving to or from scene. Don’t forget that hand hygiene is required before and after wearing gloves. Put gloves on immediately prior to patient contact and change them between each patient task, when caring for different patients and as soon as they are contaminated. Once you have removed your gloves, discard appropriately [DoH, 2010].

Figure 5.2 Non-latex disposable gloves should be worn when there is a risk of contact with blood, such as when checking a patient’s blood sugar

3.7.2 Aprons

Aprons should be worn in the following situations:

• Your clothing is likely to be contaminated with blood and/or other bodily fluids

• Carrying out cleaning that may lead to contamination of your clothing.

Aprons should be disposed of appropriately following a single use. Unfasten or break the ties and then pull the apron away from your neck and shoulders. Only touch the inside of the apron. Once away from your body, turn it inside out and then fold it into a bundle before discarding appropriately [DoH, 2010].

3.7.3 Face masks

There are two types of face mask in common use by ambulance services (Figure 5.3):

• Surgical face mask

• Filtering face piece (FFP3) mask.

Surgical face masks are ineffective against airborne infection, but provide protection against splashes of blood and bodily fluids on to the face and into the mouth and nose. In addition, they are also useful for patients who are prone to bouts of coughing and sneezing. Some surgical face masks come with a clear shield to protect the eyes from splash contamination. They should be used if you believe there may be a risk of you being splashed by bodily fluids from the patient.

FFP3 masks, when fitted correctly, provide protection against airborne infections such as severe acute respiratory syndrome (SARS) [NHS England, 2013].

Figure 5.3 Surgical face mask (left) and FFP3 mask (right)

3.7.4 Eye protection

Eye protection, such as goggles, should be worn if a procedure being undertaken is likely to lead to splashing of bodily fluids, including blood, into the eyes, e.g. when trying to stop a major bleed. Eye protection used should be single-patient use [NEAS, 2010].

3.7.5 Sleeve protectors

Most ambulance services have a ‘bare below elbows’ policy, making contamination of long-sleeved clothing less likely. However, cross-contamination can occur if you are manual handling multiple patients while wearing long-sleeved clothing such as your hi-visibility jacket or fleece. Sleeve protectors can help protect your clothing from wrist to elbow.

They are for single-patient use, can be worn over the top of gloves and should be disposed of as clinical waste [DoH, 2010].

3.7.6 Wearing and removing PPE

The amount of PPE required will vary depending on the patient and not all items are always required. In the event that an apron, mask and eye protection are required, adopt the following procedures for putting on and removing PPE [DoH, 2009a]:

Procedure

Take the following steps when putting on PPE:

1. Put on apron as shown and fasten at back of waist

2. Apply face mask:

• Secure ties or elastic bands at middle of head and neck

• Fit flexible band to nose bridge

• Fit snug to face and below chin

• Fit check if using a respirator [NHS England, 2013]

3. Put on eye protection. Place over face and eyes and adjust to fit

4. Put on disposable gloves. Extend to cover wrists

Procedure

Take the following steps to remove PPE:

1. Remove gloves:

• Grasp the outside of the glove with the opposite gloved hand; peel off

• Hold the removed glove in the gloved hand

• Slide the fingers of the ungloved hand under the remaining glove at the wrist

• Peel the second glove off over the first glove and discard appropriately

2. Remove apron:

• Unfasten ties

• Pull the apron away from the neck and shoulders, touching the inside of the apron only

• Turn the apron inside out, fold or roll into a bundle and discard

3. Remove eye protection. Handle by headband or earpieces and discard appropriately

4. Remove face mask. Untie or break bottom ties, followed by top ties or elastic. Remove by handling ties only and discard appropriately

3.8 Managing healthcare waste

Healthcare waste must be segregated immediately by the person generating the waste into appropriate colour-coded waste disposal bags or containers and labelled, stored, transported and disposed of appropriately [NICE, 2012a].

You should be aware of your organisation’s policy on managing healthcare waste, but below are a number of basic principles that apply to most healthcare organisations.

3.8.1 Types of healthcare waste

It’s very important that all waste is segregated correctly as the way in which different waste is processed varies greatly based on the risk it presents. There are also significant cost variations, with domestic waste being far cheaper to process than infectious waste. Therefore, if infectious waste was filled with unnecessary packaging it can lead to substantial unnecessary costs.

There are four main types of waste you will encounter; they are:

• Mixed sharps: Sharps are items that could cause cuts or puncture wounds, including needles, scalpels, knives, broken glass and open drug ampoules

• Infectious or potentially infectious waste: Items where the concentration of harmful microorganisms is likely to be high enough to potentially lead to illness being transmitted. This would include the bodily fluids of a patient known to be suffering from an infectious disease

• Offensive/hygiene waste: Non-infectious waste, from human healthcare. Likely to include items contaminated by bodily fluids, but where the patient is known to not be suffering from an infectious illness

• Domestic waste: This form of waste presents no risk to human health and is similar to the domestic waste you would produce at home. Most of the packaging for products used on an ambulance, gloves without visible signs of soiling and wipes that have been used to clean a patient’s finger for a blood glucose reading that is not visibly soiled can all be disposed of this way.

Table 5.1 provides examples of typical waste arising from ambulance service activity.

Table 5.1 Types of waste emerging from ambulance service activity

3.8.2 Storing and handling healthcare waste

All waste should be stored in appropriate receptors, in line with your organisation’s procedures. As a responder it is likely that you will pass any waste you have on to an ambulance crew that backs you up so they can dispose of it appropriately. You should not be carrying waste around in your own vehicle.

When handling healthcare waste consider the risks it poses and protect yourself appropriately by using PPE. At minimum when handling infectious or offensive waste bags, or containers, wear gloves and also use other appropriate PPE if you anticipate any leakage of waste contained within.

3.9 Cleaning and decontamination

Decontamination is a key principle of infection prevention and control. It prevents both healthcare workers and patients from contracting infectious diseases that could be avoided, preventing patient death and patient discomfort as well as reducing costs.

Decontamination is divided into three separate processes:

• Cleaning is defined as the process that removes physical dirt or visible contamination from surfaces, but without necessarily destroying potentially infectious microorganisms [SWAST, 2013].

• Decontamination or disinfection refers to the destruction of microorganisms so that they no longer represent a danger of initiating infection, or other harmful response [HSE, 2015a].

• Sterilisation is the process that removes all viable microorganisms including viruses.

Cleaning, decontamination and sterilisation may not all be required; it depends on the item.

Think back to the chain of infection: decontamination is all about trying to break the transmission of potentially infective processes from reaching a new susceptible host.

3.9.1 Cleaning schedules

Your organisation should have a cleaning schedule, which will provide a schedule for the cleaning of ambulance stations, ambulance and equipment. Much of this is probably not relevant to your role as a responder, but you should seek out information about cleaning the equipment you use and the clothing you wear. It is likely that the following are guidelines that will be similar to those of your organisation:

• All patient equipment should be wiped clean after each use

• If equipment is visibly soiled and unable to be fully cleaned it should be swapped

• Bags and other equipment, which doesn’t frequently come into contact with patients, should be cleaned regularly (weekly), by being wiped down

• Clothing should be changed daily, or sooner if visibly soiled.

3.9.2 Cleaning and decontaminating procedures

Cleaning

Cleaning is the first step of effective decontamination and refers to removing visible dirt, including organic matter, and reducing the presence of microorganisms. Cleaning should include the use of detergent and hot water to remove all visible contamination and then be allowed to thoroughly dry [SWAST, 2013].

Decontaminating (disinfecting)

This should be carried out after a detergent clean and uses a range of products to reduce the number of viable microorganisms still remaining. A general principle is that disinfection should be minimised and instead single-use equipment used wherever possible [SWAST, 2013].

Depending on what you are trying to clean you may use different products, but one product you are likely to have available is some form of sanitising wipes. Clinell® combined detergent and disinfectant wipes are found widely in healthcare settings for decontaminating solid items and surfaces; instruction for their use are shown in Figure 5.4.

Figure 5.4 Clinell wipes

Republished with permission of GAMA Healthcare Ltd. Best practice guidance for infection control wet wipes developed by Clinell and GAMA Healthcare Ltd © 2016.

3.9.3 PPE for decontamination

A number of chemicals involved in the procedure of decontamination can be harmful to health if you are exposed to them inappropriately or in high doses. Whenever you are decontaminating you should protect yourself from coming into direct contact with chemicals or any microorganisms on surfaces that you may be attempting to clean. Be sure to use the appropriate PPE; this is likely to include:

• Gloves

• Apron

• Sleeve Protectors

• FFP3 face mask protection: If you are having to scrub something to clean it then there is a high possibility the liquid will become aerosoled, meaning you could inhale associated microorganisms.

3.10 Sharps injury

If handled correctly, there should be minimal risk of a sharps injury occurring, especially to responders. However, accidents do happen, so you should be aware of the action to undertake if you are injured by a sharp object. You should take particular care with any ‘used sharps’ as these present a risk for transmitting infection. To reduce the risk of sharps injury you should:

• Keep sharps covered whenever possible

• Immediately dispose of used sharps into approved containers

• Know where your sharps are stored and check the integrity of packaging frequently

• Ensure that others around you are aware when you are using a sharp item.

If you do receive a sharps injury, then you should [HSE, 2015c]:

• Encourage the wound to gently bleed, ideally holding it under running water

• Wash the wound using running water and plenty of soap

• Don’t scrub the wound while you are washing it

• Don’t suck the wound

• Dry the wound and cover with a waterproof plaster or dressing

• Seek urgent medical attention as prophylaxis may be required

• Report the injury.

Sharps injuries from needles and cannulation equipment are considered to be high risk and can potentially spread infections of blood-borne viruses, including:

• Hepatitis B

• Hepatitis C

• Human immunodeficiency virus (HIV).

You should seek expert medical help as soon as possible after a sharps injury. Your employing organisation will most likely have a procedure in place for doing this, which you should be aware of.

3.11 Splash contamination

There is a risk of diseases being transmitted if blood or other bodily fluids are splashed onto healthcare workers in a location where they can easily enter the body. These locations include:

• Open cuts or wounds

• Mucosal membranes including the eyes and mouth.

If this happens you should immediately irrigate the area with copious amounts of tap water.

Following this, you should attend an ED or MIU so that a risk assessment can be undertaken and post exposure prophylaxis administered, if it is thought to be necessary, along with gathering blood samples [SWAST, 2013].

3.12 Reporting incidents

Any incidents relating to infection prevention and control should be recorded through the usual incident reporting system in place within your organisation.

4 Fire safety

4.1 Learning objectives

By the end of this section, you will be able to:

• Describe practices that prevent fires from:

• Starting

• Spreading

• Explain emergency procedures to be followed in the event of a fire in the work setting.

4.2 Introduction

Fire is a chemical reaction that requires three elements:

• Heat

• Oxygen

• Fuel.

Figure 5.5 The fire triangle

“Fire triangle”. Licensed under CC BY-SA 3.9 via Wikimedia Commons

Together, they make up the fire triangle (or triangle of combustion, Figure 5.5). For combustion or burning to occur, oxygen must combine with a fuel. Fuels can be in solid, liquid or gas form to start with, but for flaming combustion to occur, a solid or liquid fuel must be converted into a vapour, which then reacts with oxygen. An oxygen concentration of about 16% is required for combustion to occur and air contains 21%, which is plenty [HMFSIPS, 1998].

4.3 Fire prevention

Prevention is better than cure and there are a number of things you can do to prevent fires from starting [HMG, 2006]:

• Do not smoke in the workplace. The NHS has prohibited smoking in all areas other than those dedicated as smoking zones. Take care with cigarettes and matches: always discard in a suitable place and ensure they are fully extinguished

• Do not allow the build-up of rubbish or other combustible materials in your work area, corridors or stair enclosures as this is fuel and may create an obstruction to escape routes

• Do not have fabric, paper or other readily combustible material near electric fires or portable gas heaters

• Do not leave hotplates or containers, e.g. frying pans, unattended when in use

• Flammable gases and liquids should be stored in the designated location, e.g. the medical gases store

• Defective electrical wiring or equipment must be turned off immediately, marked as defective and reported to the Estates Department. If possible, also remove from general access

• Switch off all electrical and gas appliances when they are not in use

• Check your working area before you leave for the day

• Ensure that manual fire-fighting equipment is accessible, undamaged and maintained.

4.4 What to do in case of fire

If you discover a fire [DoH, 2013a]:

• Stay safe: Never compromise your own safety

• Raise the alarm: Press your thumb against the glass of the nearest and safest fire call point (fire break glass). Alternatively, repeatedly shout ‘FIRE’ to warn others

• Phone 999 (or 9 999 from some phones) and request the fire service: Activation of a building fire alarm does not mean the fire and rescue service is automatically alerted; you should make the emergency call every time

• Get out and close the door: Go to the designated fire assembly point immediately.

If you hear the fire alarm you should [DoH, 2013a]:

• Leave your place of work: Close windows and doors behind you if this can be done quickly

• Calmly exit: Make your way to the nearest and safest fire exit. Do not run or stop to collect personal belongings

• Encourage others to exit: Attempt to offer assistance to anyone who appears to be confused or having difficulties, especially people with disabilities. If your usual exit route is blocked by smoke or flames, stop, change direction and find an alternative escape route. You should still meet at the normal assembly point for your workplace

• Do not use lifts: Their movement assists fire travel and they may stop suddenly if there is a power failure. They may also take you to the scene of the fire. Use the stairs at all times

• Move to your designated assembly point: Make yourself known to the fire marshal or person who is co-ordinating the evacuation. Note that fire marshals are typically only appointed in larger premises (i.e. not ambulance stations) and are identified by a yellow tabard

• Form an orderly group: Remain together until a head count is established and until further instructions are given.

4.4.1 Vehicle fires

If a fire breaks out in a vehicle, take the following actions [SCAS, 2013]:

• Stop

• Switch off the ignition and press the battery isolator button (if the vehicle has one)

• Release the bonnet, DO NOT open

• Get everyone out of the vehicle

• Remove medical gas cylinders if possible

• Move yourself and any other people away from the burning vehicle; this may need to be as much as 200 metres away

• Warn oncoming traffic (if safe to do so)

• Summon help by dialling 999 and requesting the fire and rescue service and the police

• If and only if you believe it is safe to do so, attempt to put out the fire with a dry powder extinguisher if you are able to do so. If the fire is in the engine compartment, do not open the bonnet; use the extinguisher through the grill or under the edge of the bonnet. Use with caution, and if in doubt do not attempt to tackle the fire.

5 Stress

5.1 Learning objectives

By the end of this section, you will be able to:

• Describe common signs and indicators of stress

• Compare strategies for managing stress.

5.2 Introduction

Stress is the adverse reaction people have to excessive pressures or other types of demand placed on them. There is a clear distinction between pressure, which can create a ‘buzz’ and be a motivating factor, and stress, which can occur when this pressure becomes excessive [HSE, 2007].

Six broad areas have been highlighted as being the primary sources of stress at work [HSE, 2007]:

• Demands: This includes issues such as workload, work patterns and the work environment

• Control: How much say the person has in the way they do their work

• Support: This includes the encouragement and resources provided by the organisation, line management and colleagues

• Relationships: This includes promoting positive working to avoid conflict and dealing with unacceptable behaviour

• Role: Whether people understand their role within the organisation and whether the organisation ensures they do not have conflicting roles

• Change: How organisational change (large or small) is managed and communicated in the organisation.

5.3 Signs of stress

Stress can cause changes in those experiencing it, making it important for everyone to look out for changes in a person’s or a group’s behaviour, particularly in NHS ambulance services, where half of employees experience work-related stress [PIE, 2014]. However, in many cases, only you will notice the changes that occur as a result of the stress you experience [HSE, 2008a].

Stress can show itself in many different ways and people will exhibit different signs and symptoms. Some of the well-known signs and symptoms of stress include [HSE, 2014a]:

• Changes to behaviour such as:

• Difficulty sleeping

• Altered eating habits

• Smoking and/or drinking more

• Avoiding friends and family

• Sexual problems

• Physical symptoms:

• Tiredness

• Indigestion and nausea

• Headaches

• Aching muscles

• Palpitations

• Mental symptoms:

• Increased indecision

• Difficulty in concentrating

• Poor memory

• Feeling inadequate

• Low self-esteem

• Emotional symptoms:

• Mood swings, becoming irritable or angry

• Increased anxiety

• Feeling numb

• Hypersensitivity

• Feeling drained and listless.

5.4 Managing stress

Although stress is not an illness, it can cause serious illness, both mental and physical, if not identified and managed. The success of coping strategies to help reduce the effects of stress will vary from person to person. Consider some of the strategies that have been recommended [NHS Choices, 2014a]:

• If you’re not sure about the trigger for your stress, keep a diary of stressful episodes for 2–4 weeks

• Take action to help relieve stress:

• Exercise: Physical activity can help remove some of the emotional intensity of stress

• Eat and drink healthily: Eat a balanced diet and avoid excessive amounts of caffeine and alcohol

• Take control: This can be easier said than done but identify problems and think about possible solutions. Having a suggestion adopted by an organisation to help in your daily work, particularly when it is benefiting patients, is very satisfying [Pilbery, 2013]

• Talk to someone: Sharing work troubles can help ease the stress as well as provide an opportunity for others to understand how you are feeling and help you see things a different way

• Avoid unhealthy habits: Don’t rely on alcohol, smoking and caffeine as a method of coping. The temporary relief they provide can lead to long-term health problems

• Accept the things you can’t change: There are inevitably going to be aspects of the job that you cannot change. Accept those and focus on areas where you can have an impact and take control.

You should not wait until stress has made you physically or mentally unwell before seeking help. Because of your role, a number of support services are available to assist you, but many people wait too long to access these services. Small problems with stress treated early can prevent more significant health problems developing later.

Chapter 6: Safeguarding Adults and Children

1 Identification and management of adult and child abuse

1.1 Learning objectives

By the end of this section you will be able to:

• Define the various types of abuse

• Identify the signs and/or symptoms associated with each type of abuse

• Describe factors that may contribute to an individual being more vulnerable to abuse

• Explain the actions to take if there are suspicions that an individual is being abused

• Explain the actions to take if an individual alleges that they are being abused

• Identify ways to ensure that evidence of abuse is preserved

• Identify national policies and local systems that relate to safeguarding and protection from abuse

• Explain the roles of different agencies in safeguarding and protecting individuals from abuse

• Identify reports into serious failures to protect individuals from abuse

• Identify sources of information and advice about your own role in safeguarding and protecting individuals from abuse

• Explain how the likelihood of abuse may be reduced

• Describe unsafe practices that may affect the well-being of individuals

• Explain the actions to take if unsafe practices have been identified

• Describe the action to take if suspected abuse or unsafe practices have been reported but nothing has been done in response.

1.2 Introduction

As a responder, you hold a trusted and privileged position and one from which you can potentially identify and assist victims of abuse or neglect. In order to do this, you will need to have a good understanding of the forms abuse can take, the signs and symptoms of those suffering, what increases a person’s risk of being a victim of abuse, and also how to get help and support for victims.

Before going further, consider some of the key phrases associated with safeguarding:

• Safeguarding: The process of promoting the welfare of individuals and groups and protecting them from harm, often putting controls and measures in place to do so

• Protection: To keep safe from harm

• Abuse: Any action that causes significant harm to an individual. Harm may take many forms in this definition

• Harm: Physical or psychological damage or injury

• Maltreatment: Includes all forms of physical and emotional ill-treatment or abuse.

We will mainly be discussing safeguarding for children (according to legal definitions, a child is anyone under the age of 18) and vulnerable adults.

1.3 Learning from previous cases

The vast majority of abuse and neglect happens behind closed doors and rarely reaches the attention of the public. However, over recent years there have been a number of notable cases, including:

• Winterbourne View: In 2011 a BBC Panorama programme showed staff at Winterbourne View, a private hospital caring for patients with disabilities, abusing their patients in a range of both physical and psychological manners. A national outcry followed, and in the subsequent investigation 11 staff were convicted of criminal offences and the hospital was shut. The investigation also identified that there were serious warning signs evident at the hospital for a long time prior to the discovery of abuse, which had not been properly looked into [DoH, 2013c]

• Daniel Pelka: Daniel died aged 4 years and 8 months following a period of sustained abuse and neglect by his mother and her partner. His death was caused by a serious head injury, but he had been physically beaten and starved for a prolonged period prior to his death. In the serious case review following his death, it was identified that although the family and Daniel were well known to police, social services, healthcare services and his school, the warning signs had not been correctly picked up on or appropriate action taken. The report said that Daniel was ‘invisible against the backdrop of his mother’s controlling behaviour’ and that professionals involved in his case had failed to ‘think the unthinkable’ [CSCB, 2014].

Sadly, this failure to notice warning signs is not unique and other equally tragic cases, such as the murders of Victoria Climbié and baby Peter Connelly (Baby P), reached very similar findings in their investigations.

Abusers can be skilled at explaining away injuries or unusual behaviour and making professionals feel relaxed about the situation they find. In your front line role, you may be the only individual that comes into contact with a vulnerable person over a prolonged period of time, so you must be prepared to identify and raise concerns where necessary, in order to help prevent further similar cases like those above. You must be prepared to ‘think the unthinkable’.

1.4 Vulnerability

People are considered to be vulnerable when they are at a greater than normal risk of abuse. For vulnerable adults, this can include [NHS Choices, 2015a]:

• Those with learning difficulties

• Older people who are isolated

• Those with memory problems

• Those who are dependent on others for support

• Those whose carer is addicted to alcohol or drugs

• Those who live with a carer.

1.4.1 Abusers of vulnerable adults

Vulnerable adults may be abused by a wide range of people, including relatives and family, professional staff, paid care workers, volunteers, other service users, neighbours, friends and those who deliberately target and exploit the vulnerable [DoH, 2000].

1.4.2 Risk factors for child abuse

All children are vulnerable to abuse, but those who may be more so include those in the following situations [NICE, 2009]:

• Parental or carer drug or alcohol misuse

• Parental or carer mental health problems

• Intra-familial violence or history of violent offending

• Previous child maltreatment in members of the family

• Known maltreatment of an animal by the carer or parent

• Vulnerable and unsupported parents or carers

• Pre-existing disability in the child.

What is common to most of these scenarios for both adults and children is that the abused tend to have reduced support networks or social contacts around them who they can turn to for help and support. The victim tends to have a degree of reliance on the abuser and this gives the abuser a position of power with which to control and manipulate the victim.

1.5 Forms of abuse

There are four types of abuse common to both adults and children [DfE, 2013; DoH, 2011]:

• Physical abuse

• Psychological/emotional abuse

• Sexual abuse

• Neglect.

For vulnerable adults there is also [Age UK, 2014c]:

• Financial abuse

• Discriminatory abuse.

Additionally, you should also be aware of Female Genital Mutilation (FGM), a form of child abuse.

1.5.1 Physical abuse

Physical abuse, also known as non-accidental injury (NAI), involves contact intended to cause, or resulting in, pain, injury or other physical harm. It may include striking someone (with or without an object), kicking, grabbing, biting or inappropriate restraint [DfE, 2013]. For older patients in particular, it may also include being handled roughly, or moved in a way that causes pain without the appropriate lifting or moving aids [Age UK, 2014c].

Physical harm can also be caused when a carer or parent fabricates illness, or induces symptoms of an illness, in an adult or child (Munchausen’s syndrome by proxy).

Signs may include:

• Bruising at multiple stages of repair

• Bruises on children who are not yet crawling

• Injuries inconsistent with age of patient

• Frequent attendance at hospital

• Inappropriate history for injury demonstrated

• Specific injuries, such as cigarette burns and ‘hand-grip’ bruises

• Fear of those around them

• Fear of making mistakes

• Being very withdrawn and quiet

• Delays in seeking help for illness or injury.

1.5.2 Psychological/emotional abuse

Psychological, also known as emotional, abuse is a form of abuse characterised by damaging a person’s psychological well-being. This is often seen in situations of power imbalance, such as abusive relationships. It may include conveying a feeling of unworthiness, unimportance or being unvalued. It may also include making a person feel ashamed or humiliated through the words or actions of another person.

Over a prolonged period, this form of abuse can allow the abuser to mentally control the abused person and seriously damage emotional and psychological development. All forms of abuse usually contain an element of psychological abuse, as abusers will try to control the actions and behaviour of their victim [DfE, 2013; Age UK, 2014c].

Signs may include:

• Lack of social skills

• Low self-worth

• Depression

• Self-harm

• Poor relationships with others

• Helplessness

• Excessive fear or anxiety.

1.5.3 Sexual abuse

Sexual abuse involves forcing or enticing a person to take part in sexual activity against their wishes, or for which they are not able to consent. Activities may involve physical assault, including penetration (for example rape or oral sex), or they can be non-penetrative, such as kissing, masturbation or touching the outside of clothing. Sexual abuse can also include non-contact activities such as indecent exposure, or forcing a person to watch, or to be involved in the production of, explicit sexual material. Grooming a person in preparation for abuse is also a form of sexual abuse [DfE, 2013; Age UK, 2014c].

Signs may include:

• Physical signs such as anal or vaginal soreness

• Sexually transmitted infection

• Unusual discharge

• Inappropriate use of sexual language for age

• A child being sexually active at a young age

• Guilt or shame

• Appearing frightened by or avoiding being near to certain people.

1.5.4 Neglect

Neglect is the persistent failure to meet a person’s physical and/or psychological needs. A carer or parent should take reasonable steps to prevent harm from occurring to a dependant, and failure to do so may be neglect. Neglect can be deliberate or accidental, due to not fully understanding the needs of a dependent person.

Neglect may include:

• Failure to provide adequate food, warmth or shelter for a dependant

• Failure to ensure adequate access to appropriate medical care.

Signs of neglect include:

• Poor appearance and hygiene

• Untreated injuries or dental issues

• Poor physical development for age

• Poor language or communication skills for age

• Pressure sores

• Signs of malnourishment or dehydration

• Dirt, urine or faecal smell in person’s environment.

1.5.5 Financial abuse

This is the unlawful use of a person’s property, money or other valuables. It may include an individual being pressured into lending or giving money or other belongings to another person. A carer could start to take control of personal finance and then use that control to gain profitably without consent. It may also include charging excessive amounts of money for simple services or goods. Relatives are often perpetrators of this kind of abuse and may move into a patient’s house in order to be able to exert the influence required to take financial control [Age UK, 2014c].

Signs of financial abuse can include:

• Unexplained loss of money

• Unusual bank account activity

• Rapid deterioration in a person’s standard of living as they can no longer afford essential goods and services

• A relative or carer moving into the home and taking control.

1.5.6 Discriminatory abuse

A person can be discriminated against based on their age, gender, race, ethnicity, religion, culture, beliefs or some other aspect or value of their life. It could include a failure to take into account personal or religious beliefs in the provision of care, and could impact on the spiritual welfare of a person. Age-related discrimination is an offence under the Equality Act 2010 [Age UK, 2014b].

1.5.7 Female Genital Mutilation (FGM)

FGM is the partial, or complete, removal of the female genitalia, also known as female circumcision or cutting. It is a practice most commonly observed in certain African countries and also the Middle East [UNICEF, 2013].

FGM is a deeply routed tradition that acts as a complex form of control over women’s reproductive and sexual rights, and although it can be performed at any age from birth through to marriage or first pregnancy, it most commonly takes place between the ages of 5 and 8 [HO and DoE, 2014]. Being subject to FGM can have long-term physical and mental health impacts on well-being.

FGM is a criminal offence in the UK, and it is also an offence for anyone to take a child in order for FGM to be performed abroad [NSPCC, 2015]. You are legally required by the Female Genital Mutilation Act 2003 to report to the police if you:

• Are informed by a girl under the age of 18 that she has undergone an act of FGM

• Observe physical signs that an act of FGM may have been carried out on a girl under the age of 18.

1.6 Managing abuse or disclosures of abuse

The primary goal in the management of a patient who has suffered abuse should be their long-term safety. The situation may be highly emotionally charged, not least for you as a responder, but your actions in the immediate moments on scene may influence the entire course of protecting a vulnerable person.

You should remain calm and professional, and not judge those around you. Situations are rarely as simple as they may initially appear, and in the amount of time you will be in contact with a person it is unlikely that you will discover the full truth.

As a responder, it is likely you will pass your concerns on to a crew or other health professional responding to the same incident as you and they will take on responsibility for making appropriate referrals; however, this may change between organisations and you should be aware of these key principles in managing a safeguarding concern [AACE, 2016]:

• Consider not just the patient, but also others present. For example, you may be called to manage an adult with chest pain initially, but if you are concerned about the welfare of a child living in the same house you have the same duty to report and raise concerns as if that child was the original patient

• Your first priority should be to manage the presenting condition and ensure medical well-being, i.e. provide the usual clinical management for the presenting complaint

• Limit your questioning to that which is relevant: Stop questioning if your suspicions are confirmed, as unnecessary questioning or probing may affect the credibility of subsequent evidence

• Accept any given explanation. Even if you do not believe the answer, do not make suggestions to the patient on how an incident may have occurred

• Do not directly accuse parents or carers of abuse, as to do so may result in refusal of further care or transport, thereby increasing the risk a patient faces

• Wherever possible you should work in partnership with the parents or carers, and inform them of your concerns and the need to share these concerns with other agencies. The only exemption to this rule is when you believe that doing so may put the patient at greater risk of harm. You will have to exercise professional judgement on this point and should record in detail your justification for not informing, if that is the option you choose

• Take any and all accusations seriously: It is not your role to decide on their validity or to investigate further, but instead you should refer your concerns to the other health professionals who also attend the incident

• If a person makes a disclosure, make sure you treat them with respect and dignity, and act in a manner which suggests you believe them. Body language and your words can have a massive influence on a patient’s behaviour and confidence in you, and if they feel you do not believe them then they may not disclose what they were going to

• Complete full and accurate records of events. Where possible try to record word for word what the patient has disclosed.

1.6.1 Reporting an urgent concern

An urgent concern exists where you believe a person may be at immediate risk of further harm. In those circumstances all at scene should ensure the immediate safety of the patient. This can often be best achieved by transporting the patient to hospital where they can be monitored and assessed while awaiting the support of other services.

In the most serious circumstances it may be necessary to contact the police via the emergency operations centre with your concerns to ensure immediate patient safety. Remember that in certain circumstances including the prevention or detection of a serious crime, such disclosures can be made to the police without the patient’s consent. It would normally be the decision of the most senior clinician on scene to do this.

1.7 Safeguarding referrals

Whenever you believe a person is being abused or neglected, or is at risk of either, a safeguarding referral should be completed. Your organisation will likely have a policy on how this should be achieved, and as a responder it is likely that one of your clinical health professional colleagues will take on the responsibility for making a referral, including any concerns you may have raised.

You should be aware of your local policies for making such referrals but should also have a general understanding of these guidelines for making a referral:

• Report all concerns: Any concern, however small, should be reported through safeguarding referral pathways. Experienced and qualified safeguarding professionals can judge for themselves whether further investigation or action is required. They will also know whether the patient, place of care or family is known for previous safeguarding concerns, information that may not be available to you

• Additional sources of help: All services should have safeguarding teams including named professionals responsible for safeguarding. These teams are experienced in the management of safeguarding issues and have established relationships with the multidisciplinary teams that work around those issues

• Role of social services: In most areas, social services are the main organisation around which safeguarding concerns articulate. Social workers are experienced in dealing with vulnerable people and with cases of abuse and neglect, and can be a great source of support and advice

• Escalating concerns: All care organisations should be well prepared for managing safeguarding concerns, but in the unlikely event that you do not believe that your concerns are being managed in an appropriate manner, you have a duty to escalate your concern [AACE, 2016]. To do this you should speak to a senior manager, colleague or a named professional. Ensure you make records of all concerns that you pass on

• Preserve evidence: If you suspect abuse you may need to consider how to preserve evidence. This could take many forms depending on the form of abuse and might include not touching items you believe have been used to assault a victim, or encouraging a person not to wash or change their clothes if they have been subject to physical or sexual abuse in order to retain evidence [AACE, 2016].

1.8 Summary

Safeguarding can be a highly emotive topic for all concerned, and this should be at the front of your mind when managing a situation where safeguarding is a concern. Try to remain calm, impartial and factual and keep the immediate safety of patients as your primary goal. Remember the cases of Winterbourne View and Daniel Pelka, where key signs were missed and professionals failed to ‘think the unthinkable’.

Be aware of the signs of abuse or neglect and immediately raise any concerns you have through local policy for doing so. Also be mindful that dealing with safeguarding incidents can be emotionally traumatic for all responders and health professionals, and following such incidents you may need to make use of your organisation’s counselling or support services.

Chapter 7: Manual Handling

1 Musculoskeletal anatomy and physiology

1.1 Learning objective

By the end of this section you will be able to:

• Identify and describe the anatomy and physiology of the musculoskeletal system and its relation to safe moving and handling.

1.2 Introduction

Although often considered together, the skeleton is usually thought of as a system, whereas skeletal muscle (as opposed to smooth muscle found in blood vessels, for example) is a tissue and not a system. However, both are closely related as can be seen by their respective functions.

The skeletal system serves six basic functions [Tortora, 2008]:

• Support: It is the structural framework for the body, supporting soft tissues and providing points of attachment for tendons and the majority of the skeletal muscles

• Protection: Many of the most important internal organs are protected by the skeleton, for example the brain, heart, lungs and spinal cord

• Movement: Since the majority of skeletal muscles attach to bones, when they contract, bones are made to move

• Mineral storage: Bones store a number of minerals, mostly calcium and phosphorus, which can be released as required

• Blood cell production: Some bones contain red bone marrow, which produces red and white blood cells, and platelets

• Energy storage: Bone containing yellow bone marrow, which is mostly made up of fat, provides an energy reserve.

Skeletal muscle performs a range of functions, either through sustained contraction, or by alternating contraction and relaxation [Marieb, 2013]:

• Body movement: This is not just a function of muscles on their own, but an integrated process of bones, muscles and joints

• Stability of body position: Skeletal muscle contractions stabilise joints and maintain body posture, such as sitting upright, or keeping the head upright

• Generating heat: Contracting muscular tissue generates heat, known as thermogenesis. Involuntary skeletal muscle contraction to generate heat is better known as shivering.

1.3 Anatomical terms

In order to be able to accurately describe the location of an organ or a wound, or the movement that resulted in an injury, it is necessary to be able to use terms that describe position and direction. These always relate to the standard anatomical position (Figure 7.1). When referring to left and right, it is always the patient’s right and left, not yours.

1.3.1 Terms of position and direction

Common terms used to describe position and direction include [Kapit, 2001; Tortora, 2008]:

• Superior: Towards the head or upper part of a structure or the body; above. For example, the head is superior to the abdomen

• Inferior: Away from the head or towards the lower part of a structure or the body; below. For example, the abdomen is inferior to the head

• Anterior: Towards or at the front of the body. For example, the sternum is anterior to the spine

• Posterior: Sometimes also called dorsal. Towards or at the back of the body; behind. For example, the heart is posterior to the sternum

• Medial: Towards or at the midline of the body. For example, the heart is medial to the lungs

• Lateral: Away from the midline of the body. For example, the arms are lateral to the chest

• Proximal: Closer to the point of attachment of a limb to the body torso. For example, the elbow is proximal to the hand

Figure 7.1 Anatomical terms of position and direction

• Distal: Further from the point of attachment of a limb. For example, the knee is distal to the hip

• Superficial: Towards or at the body surface. For example, the skin is superficial to the skeletal muscles

• Deep: Away from the body surface. For example, the lungs are deep to the skin.

1.3.2 Terms of motion

Common terms used to refer to motion of the body and/or limbs include [Kapit, 2001]:

• Extension: Normally, straightening of a joint. Extreme (abnormal) extension is called hyperextension. At the ankle, extension is called plantar flexion

• Flexion: Bending a joint, or reducing the angle between the bones of a joint. Flexion of the ankle joint is called dorsiflexion

• Abduction: Movement of a joint that results in a bone or limb moving away from the midline

• Adduction: Movement of a joint that results in a bone or limb moving towards the midline.

1.4 Joints

Since bones do not bend without getting damaged, connective tissues form joints that keep the bones together, while allowing some degree of movement (usually). There are three basic types [Tortora, 2008; Kapit, 2001]:

• Fibrous: These joints have limited or no movement, such as the sutures that hold the bones of the skull together

• Cartilaginous: As with fibrous joints, these permit little or no movement. An example of this type of joint is the intervertebral disc

• Synovial: These are freely moveable joints which contain a cavity between the articulating bones. The ends of the bones within the joint are covered in a smooth, slippery articular cartilage, which reduces friction and helps to absorb shocks.

1.4.1 Synovial joints

There are different types of synovial joint; Table 7.1 describes four of these and gives examples of where they can be found in the body [Kapit, 2001].

Table 7.1 Types of synovial joint

Joint name

Movement

Example location

Ball and socket

All directions

Hip and shoulder

Hinge

One direction; flexion; extension

Elbow

Pivot

Rotation

1st and 2nd cervical vertebrae

Gliding

Gliding movements over two flat articulating surfaces

Acromioclavicular joint

Table 7.2 Types of bones

Bone type

Description

Example

Long

As their name suggests, these bones are longer than they are wide. They are made up of a shaft (diaphysis) and a variable number of ends (epiphyses) and are slightly curved to increase their strength

Humerus (upper arm)

Short

These are more cube-like bones of almost equal length and width, and make up many of the bones in the wrist and ankle

Trapezoid (wrist)

Flat

These bones provide protection for underlying organs and a point of attachment for muscles. Examples include the skull and sternum

Sternum

Sesamoid

These develop in tendons that are subject to high levels of friction, tension and stress, such as the palms of the hand and soles of the feet. They do not develop in everyone, with the exception of the patella (kneecap), which virtually everyone possesses

Patella (kneecap)

Irregular

Bones are considered irregular if they have a complex shape that does not fit in any of the other categories. Examples include the vertebrae and hip bones

Vertebra

1.5 The skeletal system

There are 206 bones in the adult human skeleton and they are generally split into two groups: the axial and appendicular skeleton (Figure 7.2). The axial skeleton consists of 80 bones, including the skull, vertebrae, sternum and ribs. The appendicular skeleton consists of the remaining 126 bones, including the shoulder and pelvic girdles and bones of the arms, wrists, hands, thighs, legs and feet [Kapit, 2001].

Breaks in bones (fractures) are more common in the appendicular skeleton, but tend to be more serious if they occur in the axial skeleton [Tortora, 2008].

Figure 7.2 Axial and appendicular skeleton. The axial skeleton is in blue.

1.5.1 Types of bones

Virtually all of the bones in the human body can be classified by their shape (Table 7.2) [Tortora, 2008].

1.5.2 Skull

The skull is made up of 22 bones, with 8 forming the cranial cavity, and the remainder, the facial bones, forming the face (Figure 7.3). Regions of the brain, which are located within the cranial bones, are generally named after the cranial bone which is located superficially, for example the front and temporal lobes.

The bones that form the foundation for the face are the [Purcell, 2010; Drake, 2005]:

• Frontal bone: This lies under the forehead and forms the superior, and part of the medial, aspect of the orbits

• Paired nasal bones: Located just inferior to the medial aspect of the frontal bone and joining in the midline. Along with the maxilla, they form the large opening into the nasal cavity known as the piriform aperture

Figure 7.3 Views of the skull. Anterior (top left), posterior (top right), lateral (bottom left) and superior (bottom right)

• Lacrimal bones: Located just anterior to the ethmoid bone, the lacrimal bones make up a part of the medial wall of the orbit and help form the lacrimal groove, where the lacrimal (tear) sac sits

• Zygomatic bones: These are the cheekbones and form part of the middle third of the face. They extend from the zygomatic processes of the maxillae and frontal bones, arching laterally and posteriorly towards the ears, where they join the zygomatic processes of the temporal bones, forming the roof of the temporomandibular joints (TMJ)

• Maxillae: The maxillae are a pair of bones that meet in the midline and form the main structure of the middle third of the face. In addition, they make up the inferior rim of the orbits and the lateral aspect of the nose, form the upper portion of the mouth and hold the upper teeth

• Inferior nasal concha: This is one of the three conchae (turbinates) that extend medially across the nasal cavity and curve anteriorly to form a lip that increases the surface area of the nasal cavity

• Vomer: Located in the anterior portion of the base of the skull, the vomer is found in the midline, sitting on the sphenoid bone. It forms part of the bony nasal septum

• Mandible: This is the jaw bone, which contains the lower teeth and forms the chin. It is made up of two symmetrical L-shaped bones which meet in the midline (the mandibular symphysis). They articulate with the temporal bones at the TMJ.

1.5.3 Vertebral column

The vertebral column (spine) is made up of 33 irregular bones known as vertebrae (Figure 7.4) [Kapit, 2001]:

• 7 cervical

• 12 thoracic

• 5 lumbar

• 5 sacral – although these usually fuse into a single bone, the sacrum

• 4 coccygeal – again, these normally fuse to form the coccyx.

It functions as a strong, flexible rod that allows for a range of movements (ROMs), while supporting the head, protecting the spinal cord and providing points of attachment for the ribs, pelvis and back muscles.

Figure 7.4 The vertebral column

In between the vertebrae are intervertebral discs; these form strong joints, allowing for a range of movements while absorbing vertical forces. When compressed, the discs flatten, but in some cases they can bulge or protrude, leading to compression of spinal nerve roots. In this case, they are said to be herniated (or slipped) discs [Tortora, 2008].

1.5.4 Thoracic cage

The thoracic cage is the bony part of the thorax, which is usually used to refer to the whole chest. It encloses the organs and vessels within the thoracic cavity and is made up of the sternum (consisting of the manubrium, body and xiphoid process), costal cartilages, ribs and thoracic vertebrae (Figure 7.5) [Tortora, 2008].

There are 12 pairs of ribs, with the first 7 known as true ribs as they physically connect with the sternum thanks to a strip of costal cartilage. The remaining pairs of ribs are called false ribs as they do not directly connect with the sternum, or (as in the case of the 11th and 12th pairs of ribs) do not connect with the sternum at all [Marieb, 2013].

1.5.5 Upper limbs

Each of the upper limbs consists of 30 bones (Figures 7.6 and 7.7) [Kapit, 2001]:

• 1 in the upper arm (humerus)

• 2 in the lower arm (radius and ulna)

• 8 in the wrist (carpal bones)

• 5 in the palm (metacarpals)

• 14 in the fingers (phalanges).

1.5.6 The hand

The bones and muscles of the hand, in conjunction with the forearm, are capable of a wide range of movements that allow for fine dexterity and are essential for many activities. Thus injuries to the hand can have a major impact on the patient.

The bones of the hand consist of five metacarpal bones that articulate proximally with the distal four carpal bones, and distally with the five phalanges. The metacarpals are the main structure of the palm of the hand. The phalanges, or fingers, are formed by three separate phalanxes, which are referred to as proximal, middle and distal (Figure 7.8).

1.5.7 Pelvic girdle

The pelvic girdle comprises two hip bones (sometimes called coxal bones), which themselves are composed of three bones, which have fused by the time adulthood is reached (Figure 7.9): ilium, ischium and pubis. Anteriorly, the hip bones meet at the pubic symphysis joint, and posteriorly, with the sacrum at the sacroiliac joints. Together, these bones form a bowl-like structure known as the bony pelvis [Tortora, 2008].

Figure 7.5 The anterior (left) and posterior (right) thorax

Figure 7.6 The upper limb – anterior view

1.5.8 Lower limbs

Each of the lower limbs consists of 30 bones (Figure 7.10) [Tortora, 2008]:

• 1 femur (thigh)

• 1 patella (kneecap)

• 1 tibia and 1 fibula (lower leg)

• 7 tarsals (ankle)

• 5 metatarsals and 14 phalanges (foot).

Figure 7.7 The upper limb – posterior view

1.5.9 The knee

The knee is the largest synovial joint in the body and consists of the weightbearing articulation between the femur and tibia and the non-weightbearing articulation of the patella and the femur (Figure 7.11).

The knee is basically a hinge joint, although it does allow for a small amount of rotation. It is strengthened by the collateral ligaments, located on either side of the joint, as well as the two cruciate ligaments, which join the adjacent ends of the femur and tibia, resisting anterior and posterior movement of the joint. Other soft tissues, such as the muscles and the menisci, also serve to stabilise the joint. The knee also has an efficient locking mechanism, which reduces the amount of muscle energy required to keep the joint extended when standing [Drake, 2005].

Figure 7.8 The bones of the hand

Figure 7.9 The pelvic girdle

1.5.10 The foot

The foot is a mobile structure and functions to support bodyweight and transmit power for walking, running etc. It is shaped like an arch, with the heel and metatarsal heads making contact with the ground. This helps to absorb and distribute downward forces from the body when standing and moving across various terrains. There are 26 bones in the foot and they are shown in Figure 7.12.

Figure 7.10 The lower limb

Figure 7.11 The knee joint

Figure 7.12 The bones of the foot

1.6 Skeletal muscles

Skeletal muscles produce movement by exerting a force on tendons, which pull on bones or other structures. They do this by contracting, and since the two articulating bones do not generally move equally, the point of attachment of the muscle tendon to the bone that initiates the movement is called the origin. The point of attachment to the other bone is called the insertion [Tortora, 2008]. Figures 7.13 and 7.14 highlight a number of skeletal muscles; you do not need to know the names of all of the muscles, but being familiar with some of the main ones, especially those you can feel when examining the patient, can be helpful.

1.6.1 Mechanics of movement

To produce movement, bones act as levers and joints as the fulcrum, the fixed point around which the lever (bone) can move. A lever is affected by two forces: the effort, which causes movement (the muscles), and the load, or resistance, which acts in opposition to the effort [Tortora, 2008].

A lever allows a given effort to move a heavier load, or move it further or faster, than it could without the lever [Marieb, 2013]. If the load is close to the fulcrum and the effort applied is far away, a small effort over the large distance will move a heavier object over a small distance. This lever is said to operate at a mechanical advantage, or is a power lever. Conversely, if the load is far from the fulcrum and the effort applied is near, the effort required must be greater than the load for movement to occur. This lever is said to operate at a mechanical disadvantage and is called a speed lever. This is because this lever can move a small load rapidly over a large distance [Tortora, 2008]. There are three types of levers, determined by the position of the fulcrum (F), effort (E) and load (L), as shown in Table 7.3.

Figure 7.13 Anterior view of the superficial muscles

Figure 7.14 Posterior view of the superficial muscles

Table 7.3 Classes of lever

Class of lever

Mechanism

Examples

First

Effort and load opposite each other with the fulcrum in the middle

Second

Effort applied at one end, with fulcrum at the other end and load in the middle. Uncommon in the human body

Third

Effort between load and fulcrum. Allows for rapid and extensive movements, such as throwing

2 Principles of manual handling

2.1 Learning objectives

By the end of this section you will be able to:

• Define manual handling

• Explain principles for safe moving and handling

• Describe what action should be taken if an individual’s wishes conflict with their plan of care in relation to health and safety and their risk assessment.

2.2 Introduction

Manual handling of patients places responders and the patient at risk of injury. Proportionally, injuries to ambulance staff are much more frequent compared with other professions. In 2012/13, there were 659 handling injuries sustained by ambulance staff that were either classed as major (led to a fracture, amputation or dislocation, for example) and/or led to an absence from work of more than 7 days [HSE, 2013a]. There are around 17 Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) reportable handling injuries per 1000 ambulance staff [HSE, 2013a], but this could be as high as 178 per 1000, with 90% of these injuries occurring in accident and emergency crews as opposed to the patient transport service [Ferreira, 2005].

As a responder, it is unlikely you should need to frequently move patients, and you should only undertake any movement which your organisation has trained you to do, but occasionally it may be unavoidable, such as moving a patient from a chair to the floor to perform CPR.

2.2.1 Definitions

The Health and Safety Executive [2004a] define manual handling operations as any transporting or supporting of a load (including the lifting, putting down, pushing, pulling, carrying or moving thereof) by hand or bodily force.

A load is defined as a discrete moveable object and may include packages, such as your responder equipment kept in the boot of the car, or patients, whether it be helping them to sit in a chair, or guiding them by the arm when they feel unsteady on their feet.

2.3 Consequences of poor manual handling

Responding for an ambulance service, it is inevitable that occasionally you will need to perform some moving and handling tasks. It is well known that poor moving and handling techniques, as well as repetitive tasks, significantly increase the risk of musculoskeletal injuries, particularly in the back. Musculoskeletal injuries are the second largest cause of sickness and the leading cause of back injury for ambulance service staff [LAS, 2012].

One of the most common injuries is a ‘slipped disk’, also known as a herniated disc (Figure 7.15).

2.3.1 Herniated disc

In the anatomy and physiology section, we looked at how the spinal column is constructed of vertebrae, with intervertebral discs in between. These discs, which are designed to help take the load through the spine and to cushion the vertebrae, can be damaged by repetitive action or sudden movements, causing the outer layer (the annulus fibrosis) to rupture and protrude out beyond the normal diameter of the vertebrae.

As you can see, when this happens it pinches on the nerves, causing significant pain and even potential nerve damage (Figure 7.16) [Nellist, 2013]. Most commonly, due to the natural curvature and the increased weight in this area, this occurs in the lumbar region, meaning that the nerves involved often include the sciatic nerve and lead to sciatic leg and back pain, which is very uncomfortable.

Figure 7.15 Herniated disc

2.3.2 Consequences to others

You should also consider that it would not be just you who can be injured by poor or inappropriate techniques. It is likely that any inappropriate technique will also lead to injury of ambulance staff and even potentially your patient.

It is an unavoidable issue that sometimes you will need to undertake moving and handling procedures in high-pressure emergency environments, but even then you should continue to apply good principles of moving and handling to ensure that nobody is injured by such actions.

2.4 Risk assessment

In the Health and Safety chapter you learned about risk assessment, and manual handling is a perfect example of a set of actions that need a risk assessment to be undertaken before taking action. The difficulty in emergency situations is that the time available to make this risk assessment may be short.

There are five steps to take [HSE, 2006]:

• Identify the hazards

• Decide who might be harmed and how

• Evaluate the risk and decide on precautions

• Record your findings and implement them

• Review your assessment and update if necessary.

Figure 7.16 Lumbar spine

This is not very user-friendly or specific to manual handling, and so these steps can be encapsulated in the TILEE acronym [HSE, 2011; Gregory, 2010b]:

• Task: Consider whether the lift:

• Involves holding the load away from the body

• Involves long distances

• Requires strenuous effort or twisting

• Individual: Consider whether the lift:

• Requires specialist training

• Presents a hazard

• If you and the ambulance crew are capable of performing the lift

• If you or your colleagues are pregnant

• Load: Is the load:

• Heavy or bulky

• Difficult to get hold of

• Unstable

• Unpredictable

• Harmful

• Likely to grab out when alarmed at being carried down the stairs

• Environment:

• Determine the presence of:

• Constraints on posture, e.g. low ceiling, confined spaces

• Poor, uneven flooring

• Hot/cold/wet weather

• Poor lighting

• Noise

• Equipment: Consider what equipment:

• Is available

• Will reduce risk to you and the patient

• Is safe to use

• You are trained and competent in the use of.

2.4.1 Reducing risk

Legal responsibility

The Manual Handling Operations Regulations 1992 [HSE, 2004a] bring together European Directive 90/269/EEC on the manual handling of loads, general duties placed on employers by the Health and Safety at Work etc. Act 1974 and the requirements of the Management of Health and Safety at Work Regulations 1999 to detail how employers should reduce the risk from moving and handling injury so far as is reasonably practicable.

This should be done by assessing the risk, reducing the risk so far as is practicable and then regularly reviewing the risk to see if further controls are required.

An example of this is ambulance stretchers. Stretchers used to have to be lifted manually by two people and this led to a large number of injuries. To help reduce the risk, a new generation of ambulance stretchers was introduced that included hydraulic foot pumps, thus reducing the manual-handling load. More recently, mechanically powered stretchers have been introduced (Figure 7.17). This further reduces the load and therefore the risk of injury.

Figure 7.17 A Ferno mechanically powered ambulance stretcher

Reducing the load in practice

Once you have identified a risk relating to manual handling, you will need to determine how best to manage this. Strategies for managing risk are best considered in advance, for example during your training, or by consulting manuals or guidance provided by your service and the Health and Safety Executive. When you are at the patient’s side, however, these approaches are not suitable. You will seldom work alone, so ask colleagues for advice and don’t be afraid to request additional help if your risk assessment suggests this would be beneficial. This is especially true for larger patients or where manoeuvres will be difficult due to limited access.

You should not use equipment you are not familiar with, but some equipment does come with a manual or simple diagrams printed on its surface, which you can use to remind yourself about the correct way round it should be used, or the sequence of actions required. Don’t forget that other manual handling equipment may be available in your location, such as hoists, which can help reduce the risk to you and the patient. However, this will usually rely on a trained member of staff being available to help you.

2.5 Biomechanics

Biomechanics is the application of the physical laws of mechanics to the human body. In order to reduce the risk of injury and facilitate manual handling, it is important to be aware of the following mechanical principles [Smith, 2011b]:

• Force

• Gravity and equilibrium

• Friction

• Stress and strain

• Pressure

• Levers

• Moment of force or turning force

• Stability and equilibrium.

2.6 General principles

You are going to learn about specific moving and handling equipment and techniques in the next section, but it is helpful to know the basic principles to adopt when approaching a manual handling task [HSE, 2003].

Procedure

1. Think before handling. Plan the manoeuvre. Can handling aids be used? Where is the load going to be placed? Will help be needed with the load? Remove obstructions such as discarded wrapping materials. Can you reduce the moving and handling manoeuvre? For a long lift, consider resting the load midway on a table or bench to change grip

2. Prepare the load. Whatever your load may be, prepare it so that it is as safe as possible to move. This may include securing items if carrying a load of medical stores, or warning a patient what is going to happen and instructing them not to grab out with their hands when on a chair

3. Adopt a stable position. The feet should be apart with one leg slightly forward to maintain balance (alongside the load, if it is on the ground). The worker should be prepared to move their feet during the lift to maintain their stability. Avoid tight clothing or unsuitable footwear, which may make this difficult

4. Start in a good posture. At the start of the lift, slight bending of the back, hips and knees is preferable to fully flexing the back (stooping) or fully flexing the hips and knees (squatting). Don’t flex the back any further while lifting. This can happen if the legs begin to straighten before starting to raise the load

5. Keep the load close to the waist. Keep the load close to the body for as long as possible while lifting. Keep the heaviest side of the load next to the body. If a close approach to the load is not possible, try to slide it towards the body before attempting to lift it

6. Avoid twisting the back or leaning sideways, especially while the back is bent. Shoulders should be kept level and facing in the same direction as the hips. Turning by moving the feet is better than twisting and lifting at the same time

7. Keep the head up when handling. Look ahead, not down at the load, once it is held securely. Move smoothly. The load should not be jerked or snatched as this can make it harder to keep control and can increase the risk of injury. Don’t lift or handle more than can be easily managed. There is a difference between what people can lift and what they can safely lift. If in doubt, seek advice or get help

8. Put down, then adjust. If precise positioning of the load is necessary, put it down first, then slide it into the desired position

There is no such thing as completely ‘safe’ handling, but try to keep the weights for lifting and lowering in the zones shown in Figure 7.18. If you are twisting, reduce weights by 10% if you are required to twist beyond 45°, and by 20% if you must twist beyond 90° [HSE, 2012].

2.7 Handling aids

Your organisation should provide aids to assist in manual handling. In the ambulance service, this may include:

• Patient handling slings

• Handling belts

• Slide sheets

• Transfer (banana) boards

• Turntables

• Lifting cushions

• Powered ambulance stretcher

• A carry chair

• Tail lifts on the back of the ambulance.

As a responder, it is unlikely that you will have many, if any, of these available to you all the time and you should limit your moving and handling to only that which is immediately required, and that you can perform safely.

Figure 7.18 Guideline weights for lifting and lowering

All illustrations are published by the Health and Safety Executive. Crown copyright

The ambulance staff that will be backing you up will have been trained extensively in moving and handling and will have aids for reducing the risk so you should wait for this wherever possible.

3 Moving and handling equipment and techniques

3.1 Learning objectives

By the end of this section you will be able to:

• Describe the aids and equipment that may be used for moving and positioning

• Describe the impact of specific conditions on the correct movement and positioning of an individual.

3.2 Introduction

This section provides guidance on different techniques that can be utilised for moving and handling patients. As has already been mentioned, as a responder you may not be trained in all of these techniques by your service and should only perform those that you have been trained in, can safely undertake on your own and which cannot wait until additional help arrives.

3.3 Patients on the floor

The usual advice from a call handler in response to a 999 call is to advise the caller not to move the patient. Usually this will be the case for you as a responder as well and the patient should not be moved until an ambulance crew has assessed them as being uninjured.

There are a number of techniques for helping a patient to get from the floor to seated in a chair by themselves and these have been included below; however, these have been included for information in case you should ever need to assist an ambulance crew in performing them, as it is unlikely you would ever utilise these techniques yourself without an ambulance crew being present.

For patients who are unable to get themselves up from the floor, it is likely a lifting device, such as a lifting cushion, will be required. You should be aware of such equipment being carried by your service and in some circumstances it can be helpful if you let the emergency operations centre know this while you are awaiting backup as they can ensure they send the appropriate resource.

3.3.1 Instructing a patient to get off the floor – one-chair method

In order to undertake this procedure, the patient needs to be able to roll on to their side and be able to kneel, so it may not be suitable for patients with knee and hip problems.

Procedure

Take the following steps to instruct a patient to get off the floor using a single chair [Smith, 2011b]:

1. Position a chair at the head end of the fallen patient. Instruct them to bend their knees up and to bring one arm across their chest

2. Instruct the patient to move their other arm away from the body

3. Instruct the patient to roll on to their side, and to bring their arm over their body so that it is flat on the floor

4. Instruct the patient to push up on their hand and at the same time push up on their forearm that is resting on the floor, until they are half-sitting

5. Continue to verbally support the patient as they continue to push upwards, until they end up on all fours facing the chair

6. While holding the chair steady, instruct the patient to lower their arms on to the chair and ask them to lean on to the seat of the chair

7. Instruct the patient to raise their stronger leg and place the foot of that leg on the floor

8. Instruct the patient to push up and straighten their legs

9. Instruct the patient to sit on the chair

3.3.2 Instructing a patient to get off the floor – two-chair method

This procedure is preferred when the patient cannot kneel and requires no physical intervention by the responder.

Procedure

Take the following steps to instruct a patient to get off the floor using two chairs [Smith, 2011b]:

1. Position a chair at the head end of the fallen patient. Instruct them to bend their knees up and roll into side lying. They should then bring one arm over the chest until their hand is flat on the floor. Instruct them to push up with one hand and lower arm into a side sitting position as in the one-chair method

2. Instruct the patient to face the chair and place their forearms on the chair

3. Instruct the patient to bend one knee and place the foot of that leg onto the floor, while at the same time pushing up on their forearms and hands

4. Place a second chair behind the patient, ensuring it is under their hips

5. Instruct the patient to sit backwards onto the chair

3.3.3 Chair to floor

On occasion, it may be necessary to move a patient from a seated position to the floor; this is most likely when the patient has collapsed and is unresponsive so you can assess them and place them in the recovery position or perform CPR if necessary.

This procedure is best performed with three rescuers. When this is not possible it can be performed with two or one; however, the fewer the rescuers the greater the risk to those performing the manoeuvre.

As a responder, it is likely you will need to perform this procedure on your own so you should be aware of the risks and only perform the procedure when required and waiting would be detrimental to the patient.

Procedure

Take the following steps to move a patient from a seated position to the floor when they are unresponsive [RCUK, 2015].

1. Kneel on the floor, to one side of the patient

2. Position the patient’s arm that is closer to you across their chest and push their trunk away from you

3. Push against the patient’s lower thigh which is nearer to you with both hands to position the patient’s hip towards the front of the chair

4. Place one hand behind the patient and around their further hip. Place your other hand on the patient’s thigh closer to you

5. Pull with the hand that is on the hip and push with the hand that is on the thigh to move the patient down to the floor

3.3.4 Recovery position

An unresponsive patient who is breathing normally will probably need to be placed in the recovery position to help protect their airway. This procedure is covered in the Airway chapter, but you should remember the principles of safe moving and handling covered in this chapter when undertaking this procedure.

Chapter 8: Scene Assessment

1 Scene assessment and safety

1.1 Learning objectives

By the end of this section you will be able to:

• Outline and explain the parts of an initial scene assessment

• Explain the importance of ensuring scene safety prior to approaching any incident for:

• Patients

• Yourself

• Your colleagues

• Bystanders.

1.2 Introduction

Despite the name, scene assessment begins before you physically arrive at the patient’s location. You will be passed details of the incident, although initially this may only include the address, with further details provided as you respond. The address may be recognised as belonging to a frequent and/or violent caller, having access issues and/or a location prone to high-speed road traffic collisions, for example [Bledsoe, 2014].

To help you cover the essential aspects of a scene assessment, consider using the SCENE mnemonic [AACE, 2016]:

• S: Safety

• C: Cause including the nature of illness (NOI) or mechanism of injury (MOI)

• E: Environment

• N: Number of patients

• E: Extra resources needed.

1.3 Safety

Maximising the safety of everyone on scene requires risk assessment. The ambulance service has many formal, written risk assessments, but these cannot legislate for all eventualities. In order to reduce the risk to you as a community first responder (CFR), patients and bystanders, it is necessary to undertake a more fluid and mental (i.e. in your head as opposed to a written down) risk assessment. This is known as a dynamic risk assessment (DRA) and relates to the fact that the environment or situation is dynamic, rather than the risk itself. DRA underpins subsequent decision making and is focused on thinking before you act, and not the other way around [Asbury, 2014].

One simple tool to help you structure DRA is the US Navy’s Time Critical Risk Management (TCRM) ABCD tool [US Navy, 2009]:

• A: Assess the situation

• B: Balance resources and options

• C: Communicate intentions

• D: Do and debrief.

1.3.1 Assess the situation

Situation awareness is a fancy term for knowing what is going on around you. It consists of gathering relevant information, interpreting it and anticipating what might happen in the future [Asbury, 2014]. This is important, because scene safety is not just something you should assess on arrival and then fail to re-evaluate. Instead, you should be constantly reviewing the environment/situation to identify signs that the risk to your safety and that of those around you is increasing.

1.3.2 Balance resources and options

In an ideal situation, you would have unlimited staff, equipment and expertise available on scene. However, that is unlikely to happen, so it is important that you review your options based on what you have available now and/or what can be made available and the timeframe involved. For example, an obese patient whom you have successfully defibrillated, and for whom you have achieved a return of spontaneous circulation, may prove difficult to extricate with just yourself and two members of an ambulance crew. In this situation, if you were first on scene, notifying the emergency operations centre (EOC) that an additional crew and bariatric equipment were required could save valuable time. A wait of 15 minutes (or more) might be acceptable if manual handling would not be safe to either the crew or the patient. However, if the house were to catch fire then this clearly would be too long and alternative options would have to be considered.

1.3.3 Communicate intentions

Once you have made a plan, it is important to communicate that to the patient and your colleagues as well as others, for example the EOC, other emergency services etc. It also presents an opportunity for other team members to identify potential problems with your plan. Although you may not be the primary decision-maker, you may well spot something that someone else has missed, particularly if they are under a lot of pressure, for example because the patient is very sick and requiring ongoing treatment.

1.3.4 Do and debrief

In time-critical situations, you will have to get on and ‘do the job’ to the best of your abilities and with the minimum amount of risk given the circumstances. However, once the incident is over, it is important to review how things went, whether the actions taken did reduce the risk, how well the team communicated and what aspects you would change next time. This should involve everyone and be documented, should you subsequently be required to justify the actions you took.

Given the nature of emergency work, it is unlikely that risk can be completely eliminated, but by taking a few moments to think before taking action, you can minimise the chance of harm coming to you, your patient and anyone else on scene.

1.4 Cause

Although you are likely to have been passed some details about the incident or call you are attending, you should not be completely led by this. Establishing the presenting complaint from the patient’s perspective will come later on in the assessment process, but you may be able to determine what has happened from the scene. However, it is important to keep an open mind even at this stage. For example, a medical-sounding call, such as a patient with low blood sugar, may also have a traumatic component if, for example, they fell and injured themselves as a result [Pilbery, 2013].

If it turns out that your patient has been injured, find out about the mechanism of injury (MOI), which you will cover in the Trauma chapter. Knowledge of the MOI can assist in determining what injuries may have been sustained. Equally, for medical patients, establishing the nature of illness (NOI) can assist with the diagnosis, particularly in cases where bystander and/or patient information is limited (for example if the patient was discovered unresponsive). Clues from the scene, for example medical equipment such as home oxygen or hoists, medication and/or care notes, may provide clues as to the underlying problem [Bledsoe, 2014].

1.5 Environment

Consider whether there are any environmental factors that need to be taken into account, for example, the risk of harm to the patient due to the development of hypothermia. Other risky environments include confined spaces, where there may be a risk of low levels of oxygen and/or the presence of toxic/explosive substances (such as carbon monoxide). These require specialist equipment and rescue knowledge that is typically provided by hazardous area response teams (HART) or the fire and rescue service [Bledsoe, 2014].

1.6 Number of patients

Usually, you will only be called to incidents where there is a single patient. However, if you come across a road traffic collision, for example, it is important to determine the number of patients early on in your assessment.

In addition, since most acts of terrorism are covert (i.e. there is often no prior knowledge of the time, location or nature of the attack), it is possible that you could be responding first to the aftermath of a terrorist attack. In these cases, the number of patients involved may provide the most important indication that a chemical, biological, radiological, nuclear, explosive (CBRNE) event has occurred [Pilbery, 2013]. In these cases, you should use the STEP 1-2-3 Plus method [JESIP, 2013]:

• Step 1: One casualty and no obvious reason. Approach using normal procedures

• Step 2: Two casualties and no obvious reason. Approach with caution, consider all options. Provide a report on arrival to the emergency operations centre (EOC)

• Step 3: Three or more casualties in close proximity and no obvious reason. Use caution and follow Plus, the Joint Emergency Services Interoperability Programme (JESIP) first responder flowchart.

1.7 Extra resources

You will always have at least one member of ambulance staff backing you up on scene. However, depending on your assessment, it may be clear that you require additional help and/or equipment from other emergency services. For example, you may require the police to keep a scene safe, or additional ambulances, including the air ambulance, for patient transport. Do pass on your assessment early to the EOC so additional help can be organised.

2 Major incidents

2.1 Learning objectives

By the end of this section you will be able to:

• Define the term ‘major incident’

• State the ambulance service’s responsibilities with regard to a major incident

• Describe the mnemonic METHANE.

2.2 Introduction

A major incident is commonly defined in the NHS as any occurrence that presents a serious threat to the health of the community, disruption to the service, or causes (or is likely to cause) such numbers or types of casualties as to require special arrangements to be implemented by hospitals, ambulance trusts or primary care organisations [DoH, 2005].

Details of the exact number of major incidents declared nationally by ambulance services are hard to determine in the absence of a national database. Estimates from work done in the 1990s suggest 4–6 major incidents per year [Carley, 1998], although a more contemporary audit places the average around 15 major incidents per year [NAO, 2002].

You are very unlikely to be called to attend a major incident as a CFR. However, it is important for you to have an awareness since by their nature, major incidents typically have a significant impact on an ambulance service’s ability to maintain a ‘normal’ response to routine emergency calls.

2.3 Classification of incidents

2.3.1 Major, mass and catastrophic incidents

NHS organisations are required to develop emergency preparedness arrangements for three levels of incident [DoH, 2007a]:

• Major: Involving tens of patients and handled by individual trusts. An example is the Suffolk train crash on August 17th, 2010

• Mass: Involving hundreds of patients and requiring mutual aid response from neighbouring trusts. An example would be the July 7th, 2005 London bombings

• Catastrophic: Involving thousands of patients and severely disrupting health and social care and other support functions. An example would be the Great East Japan Earthquake on March 11th, 2011.

2.3.2 Types of incident

Major incidents are often divided into a number of types [SWAST, 2014a; EEAST, 2013]:

• Big bang: A serious transport accident, explosion or series of smaller incidents

• Rising tide: A developing infectious disease epidemic, or a capacity/staffing crisis

• Cloud on the horizon: A serious threat such as a major chemical or nuclear release developing elsewhere and needing preparatory action

• Headline news: Public or media alarm about a personal threat

• Internal incidents: Fire, breakdown of utilities, major equipment failure, healthcare-associated infections, violent crime and internal security issues

• Deliberate: Release of chemical, biological, radiological, nuclear and explosive (CBRNE) materials

• Mass casualties

• Pre-planned major events that require planning: Demonstrations, sports fixtures, air shows.

2.4 Role of the ambulance service

National Health Service (NHS) Ambulance Trusts have the responsibility for alerting, mobilising and co-ordinating the NHS response to short-notice or sudden-impact emergencies. This includes [NARU, 2015]:

• Initiating and maintaining a Command and Control System to provide appropriate support and guidance to all NHS responders and other agencies

• Co-ordinating all NHS communications on scene

• Managing the health, safety and welfare of all NHS responders

• Providing casualty triage, treatment and transport, including the selection of appropriate receiving hospitals

• Provision of specialist incident response capabilities, including hazardous area working, decontamination of casualties and active shooter incident.

During a major incident, the response of the ambulance service revolves around seven key principles [Mackway-Jones, 2012]:

• Command and control: Each emergency service on scene has an incident commander, but the police usually take overall command

• Safety: Personal safety is paramount and the appropriate personal protective equipment (PPE) must be worn. This does not always happen when crews are faced with a major incident. Of particular concern are hazardous materials or CBRNE incidents

• Communication: This is the most common failing at major incidents [Mackway-Jones, 2012; JCO, 2010]. The terrestrial trunk radio (TETRA) network should in theory alleviate some of the problems that have occurred in the past, but the use of runners should be considered if required

• Assessment: A rapid initial assessment of the scene can provide an estimate of the number of those injured and the severity of their injuries. This can be refined as the incident unfolds

• Triage: This is the dynamic process by which casualties are sorted into priorities for treatment. It needs to be repeated frequently

• Treatment: ‘Do the most for the most’ is the standard mantra. This depends on skills of the providers, severity of injuries and time on scene. The nature of the environment and casualty load may restrict the ability of the providers to give ‘gold standard’ care

• Transport: Most patients will probably be transported to hospital by ambulance, but alternative methods of transport can be used. The aim is to get the right patient to the right place at the right time.

2.5 METHANE

The mnemonic METHANE is designed to provide the initial communication surrounding details of the major incident. It consists of [NARU, 2015]:

• Major incident declared or standby. The person making the report should be explicit whether this is a major incident declaration or a standby in anticipation of the occurrence of a major incident

• Exact location of the incident. Where possible the grid reference or GPS co-ordinates should be included, along with any landmarks or iconic sites

• Type of incident. What is the exact nature of the incident? For example rail, chemical, road or terrorist

• Hazards. What hazards are known to be present or could potentially manifest themselves?

• Access and egress. What are the agreed or best routes to and from the scene?

• Number of casualties. How many casualties are there and, if possible to determine, what are the level and severity of injuries?

• Emergency services. Which emergency services are present and which are required? Include specialist resource request if known.

3 Hazardous materials

3.1 Learning objectives

By the end of this section you will be able to:

• Describe the systems for labelling hazardous substances

• Describe how to find out information about a hazardous substance

• Describe the risks when attending a hazardous substance incident

• Describe actions which need to be undertaken when attending a hazardous substance or CBRNE incident.

3.2 Introduction

There’s a good chance if you have a look in the cupboard under your kitchen sink or shed/garage that you will find a hazardous/dangerous substance. Since the key component of scene assessment is safety for yourself, patients and bystanders, it is important that you appreciate how readily available hazardous substances are. Patients who are contaminated with a hazardous substance can easily contaminate others. On a grander scale are incidents involving transport vehicles, most commonly on the road, but also by rail, sea and air. You won’t be tasked to these types of incidents, as you will not have the training or equipment to be able to safely do so. These are incidents for the fire and rescue service and hazardous area response team (HART) to deal with. However, if you can identify the hazardous substance early, this can assist commanders in determining what resources are required.

Information about the hazardous material can be obtained from a number of sources [HSE, 2014c]:

• The packaging and associated warning labels

• Emergency telephone advice from services such as Chemsafe or TOXBASE (typically accessed through the emergency operations centre)

• The driver and the documentation being carried in the case of vehicular incidents.

3.3 Labelling of hazardous substances

In June 2015, the Classification, Labelling and Packaging (CLP) Regulation came into force, which defines what information must be provided on the label of a hazardous substance or mixture (Figure 8.1). This includes [ECA, 2011]:

• Name, address and telephone number of the supplier(s)

• The nominal quantity of the substance or mixture in the package where this is being made available to the general public, unless this quantity is specified elsewhere on the package

• Product identifiers

Figure 8.1 An example label for a hazardous mixture [EC, 2013]

• Hazard pictograms, where applicable

• The relevant signal word, where applicable

• Hazard statements, where applicable

• Appropriate precautionary statements, where applicable

• A section for supplemental information, where applicable.

This replaced the former regulations, the Dangerous Substances Directive (DSD) and Dangerous Preparations Directive (DPD). However, it is likely that you will encounter packaging with both, so it is important that you are familiar with them.

3.3.1 CLP pictograms

The CLP has introduced nine pictograms, which have replaced the older orange square warning symbols (Table 8.1). In addition, there are two signal words that accompany the pictograms [EC, 2013]:

• Danger: Substances and mixtures with the most severe hazards

• Warning: Substances and mixtures with less serious hazards.

3.4 Danger labels

Danger labels are displayed on vehicles and packaging/containers of dangerous goods that are to be transported (Figure 8.2).

Table 8.1 CLP pictograms and sample hazard statements

Figure 8.2 Danger labels

3.5 CFR actions at scene

In the event that an ‘ordinary’ emergency call turns out to involve hazardous substances, or you come across an incident that appears to involve hazardous substances, withdraw and await specialist teams, such as the hazardous area response team (HART). Inform the EOC as soon as possible that the incident involves hazardous substances.

Chapter 9: Patient Assessment

1 Patient assessment process

1.1 Learning objectives

By the end of this section you will be able to:

• State the components of the patient assessment process

• Describe the ABCDE approach to initial patient assessment including:

• Airway

• Breathing

• Circulation

• Disability

• Exposure/environment

• State the components of the tool AVPU to assess level of consciousness

• Outline how to obtain a patient history using the acronyms SAMPLE, OPQRST and SOCRATES

• Describe the steps in a ‘head-to-toe’ assessment.

1.2 Introduction

Once you have completed your scene assessment, the next step is to conduct a patient assessment. This chapter will break down the patient assessment process into its separate parts so you can explore them further. Figure 9.1 shows the patient assessment process from start to finish. This chapter and some of the subsequent chapters are going to cover this in some detail, so just concentrate on the order of the assessment process, rather than on what it is you are expected to do during each stage [Pilbery, 2013; AACE, 2016].

1.3 Primary survey

The primary survey (Figure 9.2) is a swift patient assessment and management process, which can be completed within 60–90 seconds. It is designed to be a step-wise approach, meaning that any abnormalities identified in one step should be addressed before moving on to the next. Patients who have suffered traumatic injuries should have a check for life-threatening

Figure 9.1 The patient assessment process (or catastrophic) haemorrhage, before you check the patient’s airway. In addition, in this group of patients you should give consideration to the patient’s cervical spine and avoid unnecessary movement of the head and neck. This is covered in more detail in the Trauma chapter.

Figure 9.2 The primary survey

1.3.1 General impression

The general impression is your first and immediate assessment of the patient and their current location, which will give you an early indication as to how sick and/or injured your patient is. Some of this information you will have already gathered from your scene assessment. However, now your focus is on the patient. Note the patient’s approximate age, gender and ethnicity as your management and expectations of what the patient can do will vary. For example a 1-year-old child will not present in the same way as an adult. In addition, patient positioning can give you early clues. Is the patient sitting up and smiling (Figure 9.3a) or are they lying apparently lifeless on the floor (Figure 9.3b)? This step relies heavily on experience and intuition and can be challenging [NAEMT, 2011].

This is also your chance to assess how responsive the patient is. If the patient is awake, introduce yourself with ‘Hello, my name is . . .’ and identify yourself as being a community first responder (CFR) from the ambulance service. Ask how they would prefer to be addressed.

If the patient appears not to be awake or is unconscious, check for responsiveness by asking them if they are alright, or try giving them a

Figure 9.3a General impression. Patient sitting up and smiling

Figure 9.3b General impression. Patient lying apparently lifeless on the floor command like ‘Open your eyes’. If they do not respond, gently shake the patient’s shoulders. Patients who fail to respond are critically ill until proven otherwise [Nolan, 2016].

1.3.2 Catastrophic haemorrhage

Bleeding that is likely to cause death in minutes is referred to as a catastrophic haemorrhage. This bleeding needs to be stopped, even before assessing the airway, to prevent the patient from bleeding to death. This is covered in Chapter 16: Trauma.

1.3.3 Airway

Assessment of the airway involves three steps:

• Look for signs of airway obstruction

• Listen for noisy or absent breathing

• Feel for air movement as the patient breathes.

Remember, the primary assessment proceeds in a step-wise manner. Any signs of obstruction such as snoring or gurgling sounds need to be addressed now, before moving on to breathing. You will learn how to deal with airway problems in the Airway chapter.

1.3.4 Breathing

Once you have a patent (open) airway, you are ready to move on to breathing. As with the airway, you will adopt a look, listen, feel approach.

The first question you should ask is whether the patient is breathing. If they aren’t, then you will have to provide breaths for the patient, i.e. ventilate them. If they are breathing, you will need to decide whether it is adequate. You can start with the respiratory rate and depth of breathing (indicated by chest movement).

1.3.5  Circulation

In medical patients, circulation is the next step following airway and breathing. You can obtain a good idea of the patient’s circulation by looking at the colour of their limbs (usually the hands as they are most accessible and normally visible). Feeling for a pulse is covered in the Circulation chapter; it can tell you the heart rate and adequacy of the cardiac output, particularly if distal pulses such as the wrist are absent when a central pulse (such as found in the neck) is palpable. Clearly, a patient who does not have a pulse needs CPR immediately! This is covered in the Cardiac Arrest chapter.

1.3.6 Disability

Disability in the primary assessment refers to the patient’s level of consciousness, or how awake they are. There are many causes of unconsciousness and these are covered in the Disability chapter. During the primary assessment, you will need to check three things to assess the patient’s disability [AACE, 2016]:

• Level of consciousness

• Pupils

• Blood sugar.

Level of consciousness

A rapid assessment of the patient’s level of consciousness (LOC) can be undertaken using the acronym AVPU:

• A: Alert

• V: Responds to verbal stimulus

• P: Responds to pain

• U: Unresponsive.

Pupils

When looking at a patient’s pupils, you are interested in whether they are of equal size and react to light. There are a number of reasons why this may not be the case and you’ll find out about these in the Disability chapter later on.

Blood sugar

Hypoglycaemia, or low blood sugar, is a cause of reduced level of consciousness, which can usually be corrected by the administration of glucose, either orally (by mouth) or intravenously. In addition, there are drugs which can mobilise the body’s own glucose stores and you’ll be learning about these in the Medical and Surgical Emergencies chapter.

1.3.7 Exposure/Environment

You will undertake a full ‘head-to-toe’ assessment later on in the patient assessment process, but a quick look early on will provide you with clues to obvious illness/injury that needs to be managed quickly. For example, some types of rashes (e.g. non-blanching) signal serious illness such as sepsis or anaphylaxis. It also provides a chance to identify sites of hidden bleeding that you did not pick up on earlier on in your assessment.

Working out of hospital, however, you do need to be mindful about maintenance of patient privacy by not unnecessarily exposing them as well as ensuring that they do not lose body heat.

1.4 History taking

1.4.1 Presenting complaint

The presenting complaint is usually the reason you have been called to the patient (Figure 9.4). The majority of presenting complaints fall into the categories of pain, discomfort and/or abnormal body function. Sometimes this is explicit (‘I have terrible chest pain’) but can be vague, particularly in the elderly (‘I just don’t feel right today’) [Gregory, 2010b]. Avoid using words like problem or complaint when finding out the reason for the emergency call.

Figure 9.4 History taking

SAMPLE history

Once you know the presenting complaint, you will need to ask further questions. At the bare minimum, this should include the parts of the SAMPLE acronym [Pilbery, 2013]:

• S: Signs and symptoms of the presenting complaint

• A: Allergies (particularly to medication, food allergies might be relevant)

• M: Medications

• P: Past medical history

• L: Last oral intake

• E: Events that led to the current illness or injury.

Signs and symptoms of the presenting complaint

To help you organise the signs and symptoms of the presenting complaint, there are two acronyms that you can use: OPQRST [Wardrope, 2008] and SOCRATES. These were originally designed with assessment of pain in mind, but can be helpful for other presenting complaints.

OPQRST:

• O: Onset. When did it (the presenting complaint) start?

• P: Provocation/palliation. What makes it worse/ better? Include self-treatment such as taking analgesia

• Q: Quality. How does the patient describe their symptom, particularly pain? Is it sharp or dull, for example?

• R: Region/radiation/referral. Where is the symptom located? In the case of pain, does it stay in one place (can the patient point to it with one finger) or does it go elsewhere?

• S: Severity. On a scale of 0 to 10, where 0 is no pain and 10 is the worst pain imaginable, what score does the patient give it now?

• T: Time. How long has the patient had it and if it has been relieved, what time was this? In the case of pain, also consider whether the pain is intermittent (comes and goes).

SOCRATES is very similar:

• S: Site

• O: Onset

• C: Character. Same as Quality above

• R: Radiation

• A: Association. Are there any other signs and symptoms associated with the presenting complaint?

• T: Timing

• E: Exacerbating/relieving factors. Same as Provocation/palliation above

• S: Severity.

1.4.2 Allergies and medication

Allergies

The range of drugs that you can administer is limited, but there is still scope for patient harm if administered inappropriately. You should always ask the patient about any allergic reactions to medication they have received in the past. It is also a good idea to ask about other allergies, such as those caused by food, animals, pollen or metal [Douglas, 2005].

Medication

Ask if the patient’s medication can be made available for the ambulance crew when they arrive. It is also a good idea to ask about any over-the-counter medicines (i.e. those not prescribed by a doctor, but obtained from a pharmacist or supermarket), as well as herbal and homeopathic remedies [Pilbery, 2013].

Strictly speaking there are no drugs called ‘over-the-counter’. They are either general sales list medications, which can be sold without the supervision of a pharmacist, or pharmacy medicines, which, as the name suggests, require a pharmacist to oversee the purchase, usually because it is necessary to check that they are appropriate for the patient.

1.4.3 Past medical history

You will probably cover some of the patient’s medical history while obtaining the history of the presenting complaint, but the following questions will help you uncover other medical illnesses or surgery that may prove helpful [Douglas, 2005; Gregory, 2010b]:

• Have you had any illnesses that you saw your GP about?

• Have you had to take any time off work because of ill health?

• Have you had any operations?

• Have you been admitted to hospital, and if so, why?

• Have you suffered any injuries?

1.4.4 Last oral intake and events leading to illness/injury

Last oral intake

Find out when the patient last had anything to eat or drink. This information is useful for patients who are unconscious or who may require surgery, as patients with a full stomach are at risk of aspiration. Also, you may be able to identify the onset of food poisoning and/or food allergies [Gregory, 2010b].

Events leading to the illness or injury

This is also known as the history of the presenting complaint and if you have used either of the OPQRST or the SOCRATES acronyms, you will have already obtained most of the information required.

Additional information that is useful to obtain includes [Gregory, 2010b]:

• Associated symptoms: For example, does the patient have shortness of breath and nausea with their chest pain?

• Previous episodes: Find out what happened last time, including any diagnoses made or hospital admissions

• Effect on daily living: Does the presenting complaint interfere with getting to the toilet or making a cup of tea, for example?

1.5 Secondary survey

The secondary survey is often tailored to your findings from the primary survey and history (Figure 9.5). For example, if the presenting complaint is shortness of breath, then you are going to ensure that you obtain a respiratory rate and oxygen saturations, and auscultate the lungs.

Figure 9.5 The secondary survey

1.5.1 Vital signs

Your ambulance service may have a specified minimum set of observations to obtain, but this will generally include:

• Respiratory rate

• Oxygen saturations

• Pulse rate

• Blood pressure

• Level of consciousness (AVPU)

• Pain score

• Blood sugar

• Temperature.

Being able to record vital signs accurately is a fundamental skill and these will be explored in depth in the relevant chapters as you progress through the book.

1.5.2 ‘Head-to-toe’ assessment

It is not always appropriate to perform a ‘head-totoe’ or full-body examination for every patient, but in cases of multiple injury, or in cases when the patient is found collapsed and the history is limited or non-existent, it can be helpful to identify signs of injury, or illness. The assessment outlined here is a rapid full-body assessment which should take around 60–90 seconds to complete. Clinicians that you work with are likely to perform more thorough assessments on specific areas of the body depending on the presenting complaint.

Procedure

Take the following steps to perform a ‘head-to-toe’ assessment [Pilbery, 2013]:

  1. Look at the face for obvious injuries such as lacerations, bruising, fluid and deformities

  2. Inspect the area around the eyes and eyelids

  3. Check the eyes for redness and the presence of contact lenses

  4. Assess the pupils with a pen torch, to ensure that they react to light

  5. Look behind the ears for bruising and in the ear for signs of fluid or blood leaking out

  6. Look for bruising, lacerations and deformity around the head and then gently feel for tenderness and depressions of the skull

  7. Feel the cheekbones for tenderness, symmetry and instability

  8. Feel the maxilla (the bone just below the nose)

  9. Check the nose for blood and fluid leaking out

10. Feel the jaw

11. Assess the mouth and nose for cyanosis (blue-tinged skin), foreign bodies (including loose teeth and/or dentures), bleeding, lacerations and deformities

12. Smell the patient’s breath for specific odours (such as pear-drops, which can be present in some diabetic patients)

13. Look at the neck and note any obvious lacerations, bruises and/or deformity. Look for bulging veins in the neck and feel the trachea to ensure it is centrally located

14. Feel the back of the neck for tenderness and deformity

15. Look at the chest for any obvious injury and watch the chest rise and fall as the patient breathes

16. Gently feel the ribs to ensure they are intact and to identify if they are tender. Don’t press over any obvious bruising or fractures

17. Check the abdomen and pelvis for obvious injury and gently feel the abdomen, which should be soft and non-tender

18. Look at the pelvis for signs of injury, then gently feel the iliac crests for signs of instability, tenderness or crepitus. Do not compress the pelvis (sometimes called ‘springing’)

19. Check the extremities (arms and legs) for lacerations, bruises, swelling, deformities and the presence of medical bracelets. Feel for distal pulses and check motor and sensory function. Compare the right and left sides

1.6 Reassessment

The first thing you’ll probably notice about the reassessment section is that it contains many of the things you have already undertaken as part of the patient assessment process (Figure 9.6). As with scene safety, a patient’s clinical condition is dynamic and frequently changes, either due to the illness and/or injury they have acquired, or as a result of an intervention you have performed, such as defibrillation. Frequent reassessment will mean that you will not miss these changes.

Figure 9.6 Reassessment

Chapter 10: Airway

1 Airway anatomy

1.1 Learning objective

By the end of this section you will be able to:

• Identify and describe the structures of the upper and lower airway.

1.2 Introduction

The respiratory system is made up of a number of structures (Figure 10.1):

• Nose

• Mouth

• Pharynx (throat)

• Larynx (voicebox)

• Trachea (windpipe)

• Bronchi

• Lungs.

Structurally, the respiratory system is split into two halves: the upper and lower respiratory systems. The upper consists of everything above

Figure 10.1 The structures of the respiratory system the cricoid cartilage, and the lower, the cricoid cartilage and lower structures.

1.3 Nose

This is mostly constructed from cartilage, and is external to the skull. Its orifices (nostrils, or nares) open into the nasal cavity of the skull, which is divided by the nasal septum. The nasal cavity contains the superior, middle and inferior turbinates (Figure 10.2), which increase the internal surface area of the nasal cavity, which in turn increases the temperature and humidity of air that passes through during breathing [Drake, 2005].

Figure 10.2 The upper airway

1.4 Mouth

The mouth (or oral cavity) starts at the lips and is continuous with the oropharynx posteriorly. The roof of the mouth is made up of the hard and soft palates, with the floor made up of mostly soft tissue, including the tongue. The tongue is a muscular, non-compressible tissue that attaches to the mandible, stylohyoid process and hyoid bone (Figure 10.3). The tongue, in the past, has been accused of being the most common cause of obstruction. However, research conducted on adult anaesthetised patients has demonstrated that it is usually the soft palate and epiglottis that cause obstruction of the airway, not the tongue [Nolan, 2016].

Figure 10.3 The oral cavity

1.5 Pharynx

The pharynx is a funnel-shaped tube extending from the back of the nasal cavity to the top of the oesophagus. Although a continuous structure, it is typically divided into three sections anatomically:

• Nasopharynx

• Oropharynx

• Laryngopharynx.

1.5.1 Nasopharynx

This is the area at the back of the nasal cavity, above the level of the soft palate. It is bordered by the sloping base of the skull above, and mostly skeletal muscle on either side, forming a domed vault at the top of the pharyngeal cavity.

Elevation of the soft palate during swallowing helps to ensure that food does not rise up into the nasal cavity. The tissues that cover the top of the nasopharynx contain the pharyngeal tonsil. Enlargement of this is known as adenoids and can, in severe cases, block the nasopharynx.

1.5.2 Oropharynx

This is the area posterior to the oral cavity, below the level of the soft palate but continuous with the nasopharynx, and above the margin of the epiglottis (which marks the start of the laryngopharynx). Anteriorly, the palatoglossal folds mark the boundary between the oral cavity and oropharynx.

1.5.3 Laryngopharynx

This is continuous with the oropharynx, running from the superior margins of the epiglottis to the top of the oesophagus around the level of the sixth cervical vertebra (spinal bone) in adults.

1.6 Larynx

The larynx is a hollow structure made up of muscles and ligaments. In adults, it is cylindrical in shape, with the narrowest part of the airway at the level of the vocal cords. It is continuous with the trachea below and opens into the laryngopharynx posteriorly.

The larynx is suspended from the hyoid bone above, and trachea below, by a series of membranes and ligaments, which makes it very mobile within the neck (Figure 10.4). During swallowing, it moves upwards and forwards causing the epiglottis to swing downwards, effectively closing the laryngeal inlet while at the same time opening the oesophagus.

Figure 10.4 The larynx

As well as acting as a valve to close off the respiratory tract during swallowing, the larynx also produces sound for speech, singing etc.

1.7 Trachea

The trachea extends from the cricoid cartilage to the level of the sixth thoracic vertebra where it splits into the left main bronchus and right main bronchus (together, the bronchi) at the carina (Figure 10.5). In an adult, the trachea is approximately 12–15 cm long and consists of C-shaped cartilages, which are completed posteriorly by the trachealis muscle [Kovacs, 2011].

Figure 10.5 The lower airway

1.8 Bronchi

The left main bronchus and right main bronchus split into secondary bronchi, tertiary bronchi, the bronchioles, and finally the terminal bronchioles. The right main bronchus is more vertical, wider and shorter than the left, which explains why objects that are inhaled (foreign bodies) tend to end up here. In a similar design to the trachea, the main bronchi are incomplete rings of cartilage.

1.9 Lungs

The lungs are a pair of spongy, cone-shaped organs located in the thoracic (chest) cavity. They are separated by the mediastinum, a region in the thoracic cavity that contains the heart, major vessels, oesophagus and trachea, among others. This means that in the event that one lung collapses, due to air entering the thoracic cavity after a traumatic injury, for example, the other lung may remain inflated.

The lungs are covered by the pleura, which consists of two layers: the parietal pleura, which covers the wall of the thoracic cavity, and the visceral pleura, which covers the lungs. In between is the pleural cavity, a potential space filled with fluid to prevent friction and allow the pleura to slide over each other during breathing. It also helps the membranes stick together due to the surface tension of the fluid in a similar way that a glass with a wet bottom lifts the coaster it was sitting on.

The lungs extend from the diaphragm to just above the clavicles. The left lung is smaller than the right due to the space taken up by the heart. It also has only two lobes, the upper and lower, whereas the right lung has three, the upper, lower and middle lobes [Tortora, 2008].

2 Assessing and managing the airway

2.1 Learning objectives

By the end of this section you will be able to:

• Identify clinical signs that indicate a need to manage the airway

• Explain factors that affect airway patency and the step-wise approach to airway management

• Explain how to perform a range of manual airway manoeuvres

• Describe the equipment required for suction and its safe use.

2.2 Introduction

More often than not, your patient will be conscious and able to talk, scream or cry, indicating that they have a patent airway. For some, however, you will need to assist them in opening and maintaining their airway. Basic manoeuvres with nothing more than your hands are often enough to open and keep open a patient’s airway, but things can change and it is important that you frequently reassess airway patency, i.e. perform a dynamic airway assessment.

In this section, the following manoeuvres will be described:

• Head tilt–chin lift

• Jaw thrust

• Jaw thrust with head tilt

• Recovery position.

Once the manual manoeuvres have been covered, the following more advanced procedures will be described:

• Suction

• Oropharyngeal airways.

2.3 Assessing the airway

In the Patient Assessment chapter you were introduced to the three-step approach to airway assessment:

• Look: As you approach the patient, note their position as it can give you an indication of the patency of the airway. Conscious patients who have adopted a tripod position (Figure 10.6) or who are showing other signs of increased work of breathing may have a partially obstructed airway

• Listen: Even without a stethoscope, you can sometimes hear sounds that indicate a potential airway obstruction. High-pitched inspiratory (although sometimes can be expiratory too) sounds can be a sign of upper airway narrowing (known as stridor). Lower pitch sounds usually heard on expiration (wheeze) are a sign of lower airway partial obstruction, particularly in acute exacerbations of conditions such as asthma or chronic obstructive pulmonary disease (COPD). Other sounds include snoring, typically due to the soft tissues of the pharynx relaxing, and gurgling, due to fluid, secretions and vomit etc. Snoring can usually be remedied with manual airway manoeuvres or an adjunct such as an oropharyngeal airway, whereas gurgling is an indication that the patient’s airway requires suction

• Feel: You will not always need to place your ear close enough to your patients to feel their breath on your cheek! However, in unresponsive patients it is important to determine if there is airflow and not just rely on chest movement. The chest can move even in complete airway obstruction, and is sometimes associated with a see-saw, paradoxical movement of the abdomen, with the chest. So, as the chest expands, the abdomen sinks and vice versa.

Figure 10.6 A patient in the tripod position

2.4 Step-wise approach to the airway

In general, you will start with basic manoeuvres, such as the head tilt–chin lift or recovery position for patients who have an obstructed airway. Depending on the patient’s condition and potential threats to their airway, you may elect to escalate their management to include an airway adjunct, such as the oropharyngeal airways (OPAs).

2.5 Manual airway manoeuvres

Manual airway manoeuvres can be achieved with just your (or a colleague’s) hands. They are great for the initial management of the airway, and in some cases may be all that is required.

2.5.1 Head tilt–chin lift

When to do it (indication)

• An unresponsive patient who has an airway obstruction caused by loss of pharyngeal muscle tone.

When not to do it (contra-indication)

• If the patient has a suspected spinal injury.

Advantages

• No equipment is required

• Technique is simple and non-invasive.

Disadvantages

• Does not protect the airway from aspiration

• Not suitable for patients with cervical spinal injury.

Procedure

Take the following steps to perform a head tilt–chin lift [Pilbery, 2013; Nolan, 2016]:

1. With your patient lying on their back (supine), position yourself at the patient’s side. Place the hand closer to the patient’s head on their forehead and gently tilt the head backwards

2. Place two fingers on the bony part of the chin and gently lift upwards

2.5.2 Jaw thrust

When to do it (indication)

• An unresponsive patient who has an airway obstruction caused by loss of pharyngeal muscle tone.

When not to do it (contra-indication)

• A responsive patient unless they have a fractured jaw.

Advantages

• No equipment is required

• Technique is simple and non-invasive

• Maintains neutral alignment of the head when cervical spinal injury suspected.

Disadvantages

• Does not protect the airway from aspiration

• Difficult to maintain for prolonged periods

• Requires second person to provide ventilations, if required.

Procedure

Take the following steps to perform a jaw thrust [Nolan, 2016]:

• With your patient lying on their back (supine), position yourself at the patient’s head

• Identify the angle of the mandible

• Place your fingers behind the mandible and lift in an upwards and forwards direction (Figure 10.7)

• Using your thumbs, open the patient’s mouth

2.5.3 Jaw thrust with head tilt

When to do it (indication)

• An unresponsive patient who has an airway obstruction caused by loss of pharyngeal muscle tone and jaw thrust alone is not sufficient to open the airway.

When not to do it (contra-indication)

• A responsive patient.

Advantages

• No equipment is required

• Technique is simple and non-invasive.

Figure 10.7 Lifting the mandible

Disadvantages

• Does not protect the airway from aspiration

• Difficult to maintain for prolonged periods

• Requires second person to provide ventilations, if required.

Procedure

Take the following steps to perform a jaw thrust with head tilt:

• With your patient lying on their back (supine), position yourself at the patient’s head

• Identify the angle of the mandible

• Place your fingers behind the mandible and lift in an upwards and forwards direction

• Using your thumbs, open the patient’s mouth

• Tilt the head backwards

2.5.4 Recovery position

When to do it (indication)

• A spontaneously breathing but unconscious patient who does not have a spinal injury.

When not to do it (contra-indications)

• Patients with spinal injuries

• Patients who require assisted ventilations or insertion of an advanced airway.

Advantages

• Simple and quick to perform, even for a single rescuer

• Does not require equipment

• Encourages postural drainage of secretions or vomit from the patient’s mouth.

Disadvantages

• Not a definitive airway, i.e. does not guarantee that the patient will not aspirate

• Sometimes difficult to assess patient’s breathing.

There are a number of variations of the recovery position. This is the method that the European Resuscitation Council recommend [Zideman, 2015]:

Procedure

Take the following steps to place a patient in the recovery position:

1. Kneel beside the patient and straighten both of their legs

2. Place the arm nearer to you at right angles to their body, with the arm bent at the elbow and palm of the hand facing upwards

3. Bring the other arm across the chest and hold the back of their hand against the cheek that is nearer to you. Don’t let go

4. With your other hand, grasp the leg further away from you just above the knee and lift upwards so the leg flexes. Keep the foot on the ground

5. While supporting the head, pull the leg towards you, so that the patient rolls to face you

6. Adjust the upper leg so that the patient’s hip and knee are bent at right angles

7. Tilt the head back to ensure the airway remains open. Adjust the patient’s hand that is under their cheek, if required, to maintain head tilt and keep the patient facing slightly downwards, to allow free drainage of secretions from the mouth. Reassess frequently

2.6 Suction

If you can hear gurgling in the airway, then you should think suction. Suctioning an airway involves removing vomit, blood and secretions with suctioning equipment. If you have suction available, it is likely to be a hand-operated device (Figure 10.8). Make sure you are familiar with the operating instructions for the devices you carry.

When to do it (indication)

• In patients who cannot maintain and clear their own airway and in whom vomit, blood or secretions are at risk of entering the lower respiratory tract.

Figure 10.8 Hand-operated suction device

When not to do it (contra-indication)

• In patients who can maintain and clear their own airway.

Advantage

• Prevents aspiration of vomit, blood and secretions.

Disadvantage

• Suctioning removes air as well as secretions. Keep suction times short.

Procedure

Take the following steps to perform suction using a handheld suction device [Randle, 2009; Roberts, 2014]:

1. Prepare your equipment. You will need:

• Suction device assembled

• Gloves

• Protective eyewear

• Oxygen

2. Explain the procedure to the patient and obtain consent if conscious

3. Pre-oxygenate if possible

4. Put on gloves and eyewear

5. Open the patient’s mouth and insert the catheter into their mouth without suctioning. Make sure you can visualise the end of the suction catheter at all times

6. Generate suction and gently withdraw the catheter. Suction for no more than 15 seconds

7. Re-oxygenate the patient and reassess the airway. Further suction attempts may be required.

Notes

In cases of severe bleeding or active vomiting, positioning the patient to allow for postural drainage is more important: for example, turning a patient on to their side when they are immobilised on an orthopaedic stretcher [Nutbeam, 2013].

Although prolonged suctioning will cause hypoxia (which is why suctioning for no more than 15 seconds is suggested), an airway obstructed by blood or vomit will not allow any air exchange and is likely to result in aspiration. In this case, patient positioning and aggressive suction will be required until the airway is at least partially clear. Re-oxygenation can then be performed and suction repeated as required [NAEMT, 2014].

2.7 Airway adjuncts

Airway adjuncts are devices that assist in airway management. Probably the most commonly used airway adjunct is the oropharyngeal airway (Figure 10.9).

Figure 10.9 A collection of oropharyngeal airways

2.7.1 Oropharyngeal airway (OPA)

When to do it (indication)

• An unresponsive patient with an absent gag reflex.

When not to do it (contra-indication)

• Any patient who has a gag reflex.

Advantages

• Easy to place

• Technique is simple and non-invasive.

Disadvantages

• Tongue can be pushed back during insertion, making obstruction worse

• Does not protect against vomiting.

Procedure

Take the following steps to insert an oropharyngeal airway [Nolan, 2016]:

1. Select the correct size OPA by measuring the vertical distance between the patient’s incisors and the angle of the jaw

2. Open the patient’s mouth and check it is clear of foreign bodies, vomit, blood or secretions. Suction if required

3. Insert the airway ‘upside down’ along the roof of the mouth until it reaches the soft palate

4. Rotate the OPA through 180°

5. Advance the OPA until it rests in the pharynx. Remove immediately if the patient gags. Continue to provide manual manoeuvres such as head tilt–chin lift or jaw thrust as appropriate

3 Tracheostomies

3.1 Learning objectives

By the end of this section you will be able to:

• Explain the difference between laryngectomy and tracheostomy

• Describe how to manage the airway of a patient with a laryngectomy or a tracheostomy.

3.2 Introduction

A tracheostomy is an artificial opening made into the trachea through the neck (Figure 10.10). Patients have them inserted for a number of reasons including [Feber, 2006; Bowers, 2007]:

• Following trauma or surgery to the head and neck which leads to an airway obstruction

• Bypassing a tumour which obstructs the upper airway

• For prolonged ventilation

• For some types of chronic disease where minimising the anatomical dead space is beneficial

• To provide access to chest secretions in the event of respiratory insufficiency

• To protect from aspiration in the event of impaired swallow reflex (for example, neuromuscular disorders).

As the name suggests, a laryngectomy is the removal of the larynx. This is typically due to involvement of the larynx in oral, pharyngeal and laryngeal cancers. If the patient requires a total laryngectomy, the larynx is removed and the trachea cut and stitched to the front of the neck [NTSP, 2014]. This is important for subsequent management, because these patients cannot be ventilated from the mouth and/or nose.

Figure 10.10 The anatomical differences between A) tracheostomy and B) laryngectomy

3.3 Tracheostomy tubes

There are a wide variety of tracheostomy tubes, which can seem rather overwhelming. However, tubes are broadly classified into the following categories [NTSP, 2014]:

• Cuffed/uncuffed

• With/without inner cannula

• Fenestrated/unfenestrated.

3.3.1 Cuffed/uncuffed tubes

A cuffed tracheostomy tube has a soft balloon around the distal end, which is inflated by injecting air into the pilot balloon via the injection port (Figure 10.11). These are used when patients require positive pressure ventilation (PPV) and/or when the patient cannot protect their own airway from secretions. Note that if the cuffed tube is inflated and the lumen becomes blocked or occluded, the patient will not be able to breathe!

Uncuffed tubes tend to be used in longer-term patients, but since they lack the cuff, it is important that these patients have an effective cough and gag reflex to minimise the chance of aspiration. These tubes are not suitable for positive pressure ventilation.

Figure 10.11 A cuffed, unfenestrated tracheostomy tube (top). Inner cannula with no fenestrations (middle). Pilot balloon and inflation valve for tracheostomy cuff (bottom)

3.3.2 Inner cannulas

Tracheostomy tubes with an inner cannula (sometimes called double-cannula or double-lumen tubes) consist of an outer tube or cannula which maintains airway patency, and an inner cannula, which can be removed for cleaning and/or disposed of and replaced (Figure 10.12). Uncuffed, double-cannula tracheostomy tubes are the safest type to use in the community [NTSP, 2014].

Figure 10.12 An uncuffed, fenestrated tracheostomy tube (top). Inner cannula with opening for fenestrations (middle). Inner cannula with no fenestrations (bottom)

3.3.3 Fenestrated tubes

These tracheostomy tubes have an opening on the outer cannula which allows air to pass through the patient’s oropharynx and nasopharynx. This is helpful because it allows the patient to talk and produce an effective cough. However, fenestrations increase the risk of aspiration and prevent positive pressure ventilation unless a non-fenestrated inner cannula is used. Non-fenestrated inner cannulas should also be used if the patient requires suction (Figure 10.12).

3.4 Management of the tracheostomy patient

Patients with tracheostomies have a potentially patent upper airway, since the upper airway and trachea are anatomically connected. However, it is quite possible that the reason the patient had a tracheostomy in the first place is that their upper airway is difficult or impossible to manage [McGrath, 2012].

3.4.1 Help and equipment

You will not be able to manage on your own and assistance is vital. If a relative or carer is present, it is quite possible that they know more about tracheostomy management than you do, so listen to their advice and encourage them to help.

Patients may well have equipment to hand, such as replacement tubes, but you can manage with the equipment from your response bag:

• Airway adjuncts such as oropharyngeal and nasopharyngeal airways

• Bag-valve-mask.

3.4.2 Airway and breathing

Check and open the upper airway as normal. Look, listen and feel for breathing at the face and tracheostomy site for no more than 10 seconds.

If the patient is breathing, apply high-flow oxygen to both face and tracheostomy. This may require two cylinders, or the addition of a flowmeter into the Schrader valve of the oxygen cylinder. If the patient is not breathing, making agonal gasps or there are no signs of life, start chest compressions and follow the basic life support (BLS) algorithm while continuing to troubleshoot the tracheostomy, since this may be the cause of the cardiac arrest [Perkins, 2015].

3.4.3 Tracheostomy patency

Start by checking for and removing the following:

• Decannulation caps (used when removing tracheostomies) block the end of the tracheostomy

• Obturators (inserted inside the tracheostomy when first inserting a tube into the patient, Figure 10.13)

• Speaking valves, which should not be used with an inflated cuffed tube (Figure 10.14)

• Blocked humidification devices such as Swedish noses.

If the tracheostomy tube is a double-cannula design, remove the inner cannula, but remember that with some types of tubes the connector required for bag-mask ventilation is mounted on the inner cannula. Pass a suction catheter through the tube and into the trachea to check patency. It should pass easily through the tube. If the suction catheter passes through the tube, suction the tube and attempt to ventilate the patient. If this fails and the tube has a cuff, deflate it and reassess the patient using the same look, listen and feel technique as before at both the face and the stoma site.

Figure 10.13 A tracheostomy tube with an obturator inside

Figure 10.14 A selection of speaking valves. These should be fitted to cuffed tubes

3.4.4 Next steps

If everything attempted thus far has failed to improve the patient’s condition, remove the tube. Reassess the patient again and hopefully they will be breathing. If the patient is in cardiac arrest continue with BLS. Attempt to oxygenate the patient via the oral route, but don’t forget to cover the stoma site with swabs or a gloved hand. Use standard airway adjuncts to achieve effective ventilation. Alternatively, a paediatric face mask can be placed over the stoma and the patient ventilated. If there is a large air leak from the mouth and/or nose, occlude them both during PPV.

3.5 Management of the laryngectomy patient

Unlike patients with a tracheostomy, laryngectomy patients do not have any connection between the upper airway and their lungs. Do not attempt to ventilate via the mouth/nose. Laryngectomy patients do not normally have tracheostomy tubes either, but may have a tracheo-oesophageal puncture (TEP) valve fitted to allow for speech. This may be visible inside the stoma, but should not be removed. They are usually fitted with a one-way valve to prevent aspiration [NTSP, 2014].

Since these patients have, in effect, no upper airway, it cannot be obstructed by an inappropriate head position, and due to the reduction in anatomical dead space, chest compressions typically generate sufficient tidal volume to negate the need for PPV if this proves difficult to administer. Instead, just provide a supply of high-flow oxygen to the stoma site.

Tracheostomies are ten times more commonly performed than laryngectomies, so in the event that there is any uncertainty about whether the stoma is a laryngectomy or tracheostomy site, it is better to apply oxygen to both face and stoma.

3.5.1 Help and equipment

As with tracheostomy patients, these are not patients that you can manage alone, and assistance is vital. If a relative or carer is present, it is quite possible that they know more about laryngectomy management than you do, so listen to their advice and encourage them to help.

Patients may well have equipment to hand such as replacement tubes, but you can manage with the bag-valve-mask from your response bag.

3.5.2 Airway and breathing

Check and open the upper airway as normal unless you are sure the patient has a laryngectomy. Look, listen and feel for breathing at the stoma site for no more than 10 seconds. If the patient is breathing, apply high-flow oxygen to the stoma site. If the patient is not breathing, making agonal gasps or there are no signs of life, start chest compressions and follow the BLS algorithm while continuing to troubleshoot the laryngectomy stoma, since this may be the cause of the cardiac arrest.

3.5.3 Laryngectomy stoma patency

Most patients will not have a tube in place, but you should remove any stoma cover (sometimes called a ‘button’) if present. If a tracheostomy tube is in place and is of a double-cannula design, remove the inner cannula, but remember with some types of tubes the connector required for bag-mask ventilation is mounted on the inner cannula.

Pass a suction catheter through the stoma and into the trachea to check patency. It should pass easily into the trachea. If it does, the stoma is patent, so suction the trachea and attempt to ventilate the patient if they are not breathing. If this fails and there is a cuffed tracheostomy tube in place, deflate it and reassess the patient.

3.5.4 Next steps

If everything attempted thus far has failed to improve the patient’s condition, remove any tracheostomy tubes, if present. Reassess the patient again and hopefully they will be breathing. If the patient is in cardiac arrest continue with BLS.

Attempt to ventilate the patient using a paediatric face mask placed over the stoma. If this fails, a suitably qualified clinician will need to intubate the stoma with either a smaller diameter tracheostomy or endotracheal tube.

4 Choking in adults

4.1 Learning objectives

By the end of this section you will be able to:

• Define choking and list some common causes

• State the signs that an adult is choking

• Describe the procedure for managing the choking adult.

4.2 Introduction

Choking is a mechanical obstruction of the airway occurring anywhere between the mouth and carina (where the left and right bronchi split from the trachea). Common causes include [Walls, 2012]:

• Foreign bodies

• Blood

• Secretions

• Teeth

• Vomit.

It is not known how common choking is in adults. Death from choking is thankfully rare, mostly because choking episodes are witnessed [Perkins, 2015]. In England and Wales, around 370 people die each year as a result of a foreign body in the respiratory tract. Most of these are over 65 years of age [ONS, 2013].

4.3 Recognition

The signs of choking in an adult depend on the severity of the airway obstruction that has occurred. Typically, the episode will have occurred while eating, and if the patient is still conscious, they may clutch their neck (Figure 10.15).

In the case of a mild airway obstruction, if you ask the patient if they are choking, they will still be able to speak and confirm that this is the case. They will also be able to breathe and cough.

However, in cases of severe airway obstruction, the patient will be unable to speak, so may only be able to respond to you by nodding their head in response to your question about whether they are choking. Any attempts at coughing will be silent, and if this continues the patient will lose consciousness, possibly before your arrival [Nolan, 2016].

Figure 10.15 A choking victim clutching their neck

4.4 Management

Start by determining the severity of the obstruction. In adults, this is typically determined by the patient’s response to the question ‘Are you choking?’ A patient who can reply ‘Yes’, i.e. can speak, cough and breathe, is classified as mild, whereas the patient who is clutching their throat, is unable to speak and who cannot breathe falls into the severe category.

4.4.1 Conscious and choking

If the patient is coughing, do not perform any interventions other than encouraging the patient to continue coughing.

If the obstruction is severe, administer up to five back blows, by standing just to the side and slightly behind the patient, leaning them forward, and then administering sharp blows between the shoulder blades with the heel of one hand.

If this fails, move on to abdominal thrusts. Position yourself behind the patient and place a clenched fist just under the xiphisternum. Grasp the fist with your other hand and pull sharply upwards and inwards up to five times.

Repeat the back blows/abdominal thrusts until the obstruction is relieved, or the patient becomes unconscious [Nolan, 2016].

4.4.2 Unconscious and choking

Lay the patient on their back and start chest compressions and ventilations at a rate of 30:2. Before each set of ventilations, check the mouth to see whether the chest compressions have expelled the foreign body, enabling you to remove it.

4.4.3 Adult choking management algorithm

Figure 10.16 shows the choking management algorithm, which summarises the explanation provided in the previous section.

Figure 10.16 The choking algorithm for adults

5 Choking in the paediatric patient

5.1 Learning objective

By the end of this section you will be able to:

• Demonstrate how to manage a choking paediatric patient.

5.2 Introduction

It is estimated that around 20 children aged 0–14 years of age per 100,000 population will experience at least one food-related choking episode each year. It is more common in boys and children under 1 year of age [Chapin, 2013]. Since most choking episodes involving infants and children are witnessed by an adult, intervention can commence straight away, as long as the adult knows the correct action to take [Skellett, 2016].

5.3 The paediatric airway

Children’s airways more readily obstruct than those of adults, and are particularly sensitive to soft-tissue swelling. With a tracheal diameter of around 4 mm in infants compared with 8 mm in the adult, small amounts of swelling dramatically increase airflow resistance and the work of breathing required to maintain adequate ventilation.

The most dramatic differences are found in infants. By the age of 10–12 years, children have mostly adult anatomy, albeit smaller in size [Walls, 2012; Benger, 2009]. Other differences include [ALSG, 2010; Fuchs, 2012; AAP, 2013]:

• Infants have a large, prominent occiput, which results in neck flexion if they are laid supine on a flat surface. Use padding under the torso to maintain a neutral alignment

• The glottic opening is at the level of the 1st cervical vertebra (C1) in infants, descending to C3–C4 by the age of 5, resulting in a high, anterior larynx

• The epiglottis is horseshoe (or omega) shaped, floppy and proportionally larger than that of an adult

• The tongue is proportionally larger than that of adults, occupying more of the mouth

• Children possess a small cricothyroid membrane, and in children under 3–4 years of age it is virtually non-existent, making needle cricothyroidotomy very difficult

• The narrowest portion of the airway in children is at the level of the cricoid ring due to their funnel-shaped larynx compared to the more cylindrical shape of the adult larynx.

5.4 Recognition

Major choking episodes in children and infants usually occur during feeding or playing and are often witnessed by a carer. However, remember to ask about any recent history of playing with or eating small objects and consider choking in any child with a sudden onset of breathing problems.

The severity of the obstruction can be determined by the effectiveness of the patient’s ability to cough. An effective cough is better than external manoeuvres, so an actively coughing child should be encouraged to continue to do so. Other signs of a mild obstruction include [Maconochie, 2015]:

• Crying/verbal response to questions

• Long cough

• Able to take breaths before coughing

• Fully alert.

Contrast this with signs of a severe airway obstruction and an ineffective cough:

• Unable to verbalise

• Quiet/silent cough

• Unable to breathe

• Cyanosis

• Decreasing level of consciousness.

5.5 Management

The management of the choking paediatric patient depends on their ability to effectively cough and on whether they are conscious or unconscious (Figure 10.17) [Maconochie, 2015].

5.5.1 Conscious and choking Infants

Start with back blows. If your patient is an infant, sit on a chair or kneel on the floor and place the infant across your lap in a prone (face down) position. Support their head with the thumb and fingers of one hand at the angle of their jaw, taking care not to compress the soft tissues. Administer up to five sharp blows between their scapulae with the heel of your other hand.

If these fail, turn the infant on to their back with their head downwards. Locate the landmarks for chest compression (i.e. one finger width above the xiphisternum) and administer up to five chest compressions, making them sharper and slower than those administered during cardiac arrest.

Figure 10.17 Management of choking in the paediatric patient

Children (over 1 year of age)

If the patient is a child, support them in a head-down position and administer up to five inter-scapular blows. If this does not clear the obstruction, administer abdominal thrusts by standing behind the child and leaning them forward. Place a clenched fist midway between the xiphisternum and belly button. Grasp the fist with your other hand and pull inwards and upwards, up to five times.

Frequently reassess and alternate between back blows and chest thrusts in the infant, and back blows and abdominal thrusts in the child.

5.5.2 Unconscious and choking

If a child or infant becomes, or is, unconscious, place them on their back with appropriate padding to maintain an open airway. Check the mouth for a visible obstruction and make a single attempt to remove it if a foreign body (FB) is visible.

Attempt to ventilate, but if this does not cause chest expansion try repositioning the head and try again. If after five attempts you still cannot ventilate the child, move on to chest compressions and alternate with further ventilations using a ratio of 15:2. Don’t forget to check the airway for a dislodged FB after re-opening the airway prior to ventilating.

Chapter 11: Breathing

1 Respiratory system physiology

1.1 Learning objective

By the end of this section you will be able to:

• Describe and explain the function of the respiratory system.

1.2 Introduction

In the Airway chapter, you learnt about the structure (or anatomy) of the respiratory system, but it is important to also understand its function (physiology). Functionally, the respiratory system is split into two portions [Tortora, 2008]:

• Conducting portion: This is made up of the interconnecting cavities and tubes starting at the mouth and nose and ending at the terminal bronchioles. These filter, warm and moisten the air and transfer it to the lungs and out again

• Respiratory portion: This is made up of the tissues inside the lungs which exchange the gas. It consists of the respiratory bronchioles, alveolar ducts and sacs, and the alveoli. This is where gas exchange between the air and blood occurs

• These portions combined enable the respiratory system to perform its functions:

• Gas exchange: Imports oxygen, which is taken up into the blood and delivered to the body’s cells. Expires the waste gas carbon dioxide

• Assists in the regulation of blood acidity levels

• Removes small amounts of heat and water

• Filters inspired air, produces vocal sounds and contains receptors providing a sense of smell.

1.3 Respiration

Respiration is the process of gas exchange in the body (mainly of oxygen and carbon dioxide). It consists of three steps [Tortora, 2008]:

• Pulmonary ventilation: The process of moving air into and out of the lungs. It is divided into inspiration (inhalation), when air is moved into the lungs, and expiration (exhalation), when air is moved out of the lungs [Pilbery, 2013]

• External respiration: The exchange of gases between the alveoli of the lungs and the blood inside the pulmonary capillaries

• Internal respiration: The exchange of gases between the blood in capillaries around the body and tissue cells.

1.4 The lungs

In order to understand ventilation and external respiration, we just need to cover a little more anatomy. Recall from the Airway chapter that the lungs extend from the diaphragm to just above the clavicles. The left lung is smaller than the right due to the space taken up by the heart. It also has only two lobes, the upper and lower, whereas the right lung has three, the upper, lower and middle lobes [Tortora, 2008].

The lungs are divided into lobes by deep grooves known as fissures. Both lungs have an oblique fissure, but the right lung also has a horizontal fissure (Figures 11.1, 11.2 and 11.3).

Figure 11.1 Anterior view of the lungs in relation to surface anatomy

Figure 11.2 Posterior view of the lungs in relation to surface anatomy

Figure 11.3 Lateral view of the lungs in relation to surface anatomy

1.4.1 Lobes, lobules and alveoli

Each lobe of the lung has its own secondary branch (bronchus), branching from the right and left primary bronchi (Figure 11.4).

These in turn divide into tertiary bronchi, each supplying a segment of lung called a bronchopulmonary segment. Within these are many much smaller components known as lobules, within which are contained three to five respiratory units, which is where the gas exchange occurs. Respiratory units (or acini) emerge from the terminal bronchioles and consist of several respiratory bronchioles, which subdivide into alveolar ducts and, finally, the alveoli [Patel, 2008].

Figure 11.4 The lower respiratory tract showing the left and right bronchi

Alveoli

The alveoli are cup-shaped pouches with very thin walls that enable the exchange of oxygen and carbon dioxide with the pulmonary capillaries that surround them. There are around 140–150 million in each normal lung, creating a surface area for gaseous exchange in the region of two tennis courts [Patel, 2008]!

1.5 Mechanics of breathing

1.5.1 Air pressure

Air moves into and out of the lungs because ventilation changes the pressure inside the alveoli. This is achieved by changing the volume of the thoracic cavity (the contents of the body surrounded by the ribs and diaphragm). As the volume inside this cavity increases, the pressure inside decreases (a relationship known as Boyle’s Law). This causes the lungs to expand, increasing their volume and so decreasing the alveolar pressure.

Since air moves from areas of high pressure to low pressure, once the pressure inside the alveoli drops below that outside the body, i.e. atmospheric pressure, air enters the lungs.

At the end of inspiration, the volume of the thoracic cavity decreases, and the pressure rises; once it becomes higher than that of atmospheric pressure, air leaves the lungs [Patel, 2008].

1.5.2 Inspiration

During normal, quiet respiration, most of the work of respiration is undertaken by the diaphragm. This is a dome-shaped muscle that seals the thoracic cavity from the abdomen. When it contracts, it flattens and descends, increasing the volume inside the thoracic cavity, and is responsible for about 75% of the air entering the lungs.

The remaining 25% of air entering the lungs is as a result of the external intercostal muscles contracting, which pulls the ribs upwards and outwards like a bucket handle [Tortora, 2008].

1.5.3 Expiration

During normal, quiet respiration, breathing out (expiration) is a passive process as no muscles are involved. This is because of elastic recoil, a property of the thoracic wall and the lungs to ‘spring back’ to their original position when they are stretched by the muscles of inspiration.

1.5.4 Forceful breathing

When exercising and in other instances when the body requires more oxygen, additional, accessory, muscles can be used to aid in inspiration and expiration (Figure 11.5). These can often be seen in use by patients in respiratory distress.

Figure 11.5 Muscles of inspiration and expiration

1.6 Gas exchange

You have already read that gas moves from areas of high pressure to low, and it turns out that this is the case even for a mixture of gases. Take room air, which you are breathing in. It is made up of the following (percentages are approximate) [Tortora, 2008]:

• Oxygen (O₂): 20.9%

• Nitrogen (N₂): 79%

• Carbon dioxide (CO₂): 0.04%

• Other gases/water vapour: 0.06%

The pressure each of the gases exerts to make up the pressure of air is known as the gas’s partial pressure. For example, the partial pressure of oxygen (PO₂) in the air is 21 kilopascals (kPa).

Each gas acts independently of the others, so in the alveoli, oxygen moves from an area of higher pressure (the alveoli) to an area of lower oxygen pressure (the pulmonary circulation), by a property known as diffusion.

1.6.1 Diffusion

Diffusion is a process by which molecules (such as oxygen and carbon dioxide) move around. It has two key characteristics [Patel, 2008]:

• Diffusion occurs from areas of high concentration to areas of low concentration

• Diffusion continues until both areas have the same concentration of molecules.

Oxygen diffuses from the alveoli into the pulmonary circulation, whereas carbon dioxide has a higher partial pressure inside the pulmonary circulation so moves across into the alveoli, where it can be expired. In this way, oxygen is taken up by the body and the waste gas, carbon dioxide, is removed [Kapit, 2000].

1.7 Control of breathing

The muscles of respiration are dependent on the nervous system to tell them to contract and relax. This is achieved with two types of nervous system control [Kapit, 2000; Tortora, 2008]:

• Voluntary (or conscious) control: This originates in the cerebral cortex and is the way you can control your breathing by holding your breath or controlling the flow of air in order to play a wind instrument, for example. In addition, other centres in the brain, such as the hypothalamus and limbic system, can stimulate respiration, allowing laughing and crying to affect the breathing pattern

• Automatic control: These originate from groups of nerve cells (neurons) in the brain stem (mainly the pons and medulla). The neurons in the medulla are responsible for the basic rhythm of breathing and send impulses to the inspiratory muscles via the phrenic and intercostal nerves. Expiratory neurons generally become active only during forceful breathing, such as when exercising.

The respiratory centres containing these inspiratory and expiratory neurons are influenced by sensory input from nerves around the body. For example, stretch receptors prevent the lungs from being overinflated and others are linked to receptors that can detect movement, stimulating the respiratory centres to increase ventilation during exercise.

Breathing is also regulated by the partial pressures of oxygen (PaO₂) and carbon dioxide (PaCO₂), and hydrogen ion concentration (pH) in the blood. PaCO₂ is the most important and has the most profound effect on respiration. Special sensory neurons called chemoreceptors are located close to the medulla (central chemoreceptors) and in the walls of the aortic and carotid arteries [Tortora, 2008].

Note: The extra ‘a’ in PaO₂ denotes the partial pressure of oxygen in arterial blood.

2 Using medical gases safely

2.1 Learning objectives

By the end of this section you will be able to:

• Describe dangers of using compressed gas

• Outline the safe use, storage and handling of medical gases

• State the guidelines for the use of oxygen therapy including:

• Indications

• Contra-indications

• Outline the safe use of entonox including:

• The properties of entonox

• Complications of environmental temperature with regards to entonox

• The benefits of entonox therapy

• Indications

• Cautions and contra-indications

• Explain the use of facial barriers, the bag- valve-mask and mechanical ventilators.

2.2 Introduction

There are two main medical gases in use by ambulance services: oxygen and entonox. These gases are compressed into cylinders of varying sizes. Typically, you will have a small, portable cylinder for carrying into a patient’s house, but there are likely to be larger, heavier cylinders which are fitted to the ambulance and are generally removed only when empty and need replacing (Figure 11.6). Note that entonox is usually only provided as the smaller, portable cylinder.

Oxygen behaves differently to air, compressed air, nitrogen and other inert gases. It is very reactive.

Figure 11.6 Oxygen cylinders – CD (portable) and HX (fitted to ambulance)

Pure oxygen, at high pressure, such as from a cylinder, can react violently with common materials such as oil and grease. Other materials may catch fire spontaneously. Nearly all materials including textiles, rubber and even metals will burn vigorously in oxygen [HSE, 2008b].

Even a small increase in the oxygen level in the air to 24% can create a dangerous situation. It becomes easier to start a fire, which will then burn hotter and more fiercely than in normal air. It may be almost impossible to put the fire out. A leaking valve or hose in a poorly ventilated room or confined space can quickly increase the oxygen concentration to a dangerous level.

The main causes of fires and explosions when using oxygen are [HSE, 2008a]:

• Oxygen enrichment from leaking equipment

• Use of materials not compatible with oxygen

• Use of oxygen in equipment not designed for oxygen service

• Incorrect or careless operation of oxygen equipment.

2.3 Medical gas cylinder storage

Most ambulance stations have a medical gas cylinder store (Figure 11.7). It should meet all of the following requirements [DoH, 2006a]:

• On ground level, as close as possible to delivery point

• Clearly identifiable, so it can easily be located in an emergency

• Not close to any installation that may cause a fire risk (such as the fuel pump)

• Have a level floor, made of concrete or other non-combustible material

• Well ventilated

• Only containing medical gases

• Adequate means of securing large cylinders to prevent falling

• Clear and separate areas for full and empty cylinders

• Kept free from naked flames and marked with signage such as ‘No Smoking’

• Not prone to excessively hot or cold temperatures

• Contain shelving to store smaller cylinders horizontally

• Be secure enough to prevent theft and misuse.

Figure 11.7 An ambulance station medical gas cylinder store

Depending on local arrangements, you may be able to replace your empty oxygen cylinder from this store. However, it is probably more practicable to exchange empty cylinders with the ambulance on scene.

2.4 Anatomy of a medical gas cylinder

Integrated valve cylinders (Figure 11.8) are the most common type found in UK ambulance services and are covered in this section. You may find, however, that your service still uses the older style cylinders, which require a regulator head to be fitted before they can be used, and you should seek guidance on their use.

There is a British Standard (BS EN 1089-3:2011) relating to the labelling of medical gases to ensure that they are easy to identify and so inappropriate administration is avoided [BSI, 2011]. Medical gases always have a white body, but have different coloured collars to indicate the type of gas. The most commonly encountered gases that you will find on an ambulance are oxygen (black collar), entonox (blue and white collar) and air (black and white collar).

Important components of the cylinder are [BOC, 2013a]:

• Flow selector

• Desired flow rate can be selected by rotating the dial

• Positive ‘click’ between flow rates to ensure correct setting is chosen

Figure 11.8 CD-sized integrated valve oxygen cylinder

• ‘Live’ contents gauge

• Shows contents of cylinder, even when turned off

• Green = full

• Red = low/empty

• Handwheel

• Simple on/off dial. No spanner required

• Turn anti-clockwise to open

• Turn clockwise to close

• Clear product identity

• Name of gas is written on cylinder collar and body

• Flat base

• Easier to handle

• Improves stability

• Firtree

• Attachment point for oxygen tubing

• Batch label

• Located on guard or collar

• Shows expiry date

• Required when reporting cylinder defect

• Schrader outlet

• Push-fit connector for other methods of administration/connection to artificial ventilators

• Gas-specific to avoid inadvertent inappropriate administration

• Out sleeve (capstan) can be twisted to release.

2.5 Safety first

Prior to using a medical gas, there are a number of safety checks required [BOC, 2013a]:

• Make sure your hands are clean. If you have used an alcohol-based hand rub, ensure that it has evaporated completely

• Check the cylinder to ensure it is clean and free from damage

• Ensure the cylinder is free from oil and grease, especially around the Schrader and firtree outlets

• Both oxygen and entonox are non-flammable, but strongly support combustion. Keep away from naked flames, sources of ignition and combustible materials.

If the medical gas is entonox, check that it has not been allowed to get too cold. Below –6°C the nitrous oxide will separate from the gas mixture. To prevent this, it should be stored above 10°C for at least 24 hours prior to use. If this is not possible and the bottle is of a portable size, warm the bottle to 10°C and then invert three times prior to use to mix the gases.

2.6 Preparing a new cylinder for use

Procedure

The following steps apply to both oxygen and entonox cylinders [BOC, 2013a, 2013b]:

1. Ensure you have the correct medical gas by checking the cylinder label

2. Check the expiry date on the batch label fitted to the cylinder

3. Make sure the contents gauge is in the green zone. This indicates that the cylinder is full

4. Remove the tamper-evident handwheel cover by pulling the tear ring

5. Remove the valve outlet cover. Pull the grey cover downwards. It stays attached to the cylinder

6. Ensure the flow selector on top of the cylinder is set to zero and the handwheel is turned off before connecting equipment

2.7 Oxygen

The most common size of oxygen cylinder that you will be supplied with is the CD size. Table 11.1 shows how long a CD-sized cylinder will supply oxygen for (in minutes) based on the flow rate and gauge level.

Table 11.1 CD-sized oxygen cylinder (460 litres)

2.7.1 Oxygen delivery devices

The firtree connector (Figure 11.9) is used to connect oxygen tubing to the cylinder, which in turn can provide oxygen to a variety of masks and other devices (Figure 11.10).

Figure 11.9 Oxygen firtree connector

Figure 11.10 A variety of devices to administer oxygen

Note: Oxygen masks and nasal cannulae all require the patient to be spontaneously breathing in order to work. If the patient is not breathing effectively, they require assisted ventilation with a bag-valve-mask or pocket mask.

Procedure

Follow the steps below to provide oxygen to the appropriate oxygen delivery device [BOC, 2013a]:

1. Attach tubing from mask or nasal cannulae to the firtree outlet. Ensure the tubing is pushed on securely

2. Slowly turn on the cylinder by rotating the handwheel anti-clockwise until it comes to a complete stop. Do not use excessive force

3. Set the prescribed flow by rotating the flow selector dial. Ensure that the correct flow rate number is clearly visible in the flow selector window. Check the gas is flowing

Supplemental oxygen delivery devices

Non-rebreathe mask

This mask is used when the patient requires a high concentration of oxygen. At 15 l/min, the mask can deliver up to 85% inspired oxygen. It consists of a mask and reservoir bag that is fitted with a one-way valve, ensuring that the patient can only inhale oxygen from it and not exhale into the bag. The bag must be inflated in order to ensure maximum inspired oxygen.

Medium concentration face mask (simple face mask)

This face mask has ports on either side to allow room air to be drawn inside. At 10 l/min, it will deliver around 40% oxygen, but this is variable depending on how well fitting the mask is.

Venturi mask

This mask also draws in (or entrains) room air, but allows for more accurate oxygen delivery than the medium concentration face mask. It comes with a variety of spigots, which are capable of delivering a variety of oxygen concentrations. The percentage of oxygen and flow rate required are usually clearly marked on the spigot. They are particularly useful when providing oxygen to patients with chronic obstructive pulmonary disease (COPD).

Nasal cannulae

These deliver oxygen via two nasal prongs, which sit just inside the patient’s nostrils. Oxygen flow rates are typically limited to 1–4 l/min as higher rates lead to irritation of the nasal lining. They are often used by patients on long-term oxygen therapy and may be preferred by patients who do not tolerate a face mask.

Nebuliser

This is used to deliver aerosolised drugs. The pressurised chamber when powered by oxygen turns the liquid drug inside (usually salbutamol or ipratropium) into a mist (i.e. aerosolises the drug), which is then inhaled by the patient. Some nebulisers (particularly if the patient has one at home) are powered using compressed room air.

Firesafe

You may notice a small device inserted into a patient’s tubing if they are on home oxygen (Figure 11.11). This is a Firesafe, a cannula valve that is designed to cut the oxygen supply to the patient in the event of a fire. It will not affect the oxygen flow to the patient as long as it is inserted the correct way around (the arrow shows the direction of gas flow).

Figure 11.11 A Firesafe

2.7.2 Assisted ventilation

Patients who are breathing inadequately, for example because they have a slow respiratory rate or an irregular pattern of respiration, and patients whose breathing is too shallow or who are not breathing at all, require assisted ventilation. Assisted ventilation can be provided with a pocket mask, BVM or oxygen-powered ventilation device.

Gastric distension

In contrast to the normal way we breathe (i.e. the negative pressure inside the chest cavity draws air into the chest), assisted and artificial ventilation requires the use of positive-pressure ventilation, actively blowing air into the lungs. This has some disadvantages as high inflation pressures can result in air going into the stomach instead of the lungs, leading to gastric distension and ultimately vomiting. This is more likely if:

• High inflation pressures are used

• Ventilations are performed too fast

• The airway is partially obstructed.

A distended stomach is bad for the patient as vomit can rise up into the airway and be inhaled (aspirated). It also pushes up the diaphragm, reducing the amount of space for lung expansion [Pilbery, 2013].

Mouth-to-mouth ventilation

The most basic ventilation device is your mouth and lungs, using mouth-to-mouth ventilation. However, healthcare professionals and members of the public are sometimes reluctant to perform mouth-to-mouth on people they do not know. In addition, there are risks relating to exposure to blood and other body fluids through direct contact with the patient’s mouth and nose. In certain cases, direct mouth-to-mouth contact is not appropriate, such as in cases of poisoning [Nolan, 2016].

Procedure

Take the following steps to perform mouth-to-mouth ventilation [SJA, SAA, BRC, 2014]:

1. Place the patient on their back (supine)

2. Open the airway using a head tilt–chin lift, or jaw thrust if cervical spine injury suspected

3. Pinch the patient’s nose to close the nostrils

4. Take a breath and seal your lips over the patient’s mouth

5. Blow steadily for about 1 second, just enough to make the chest rise

6. While maintaining the head tilt–chin lift, take your mouth away from the patient and watch the chest fall

7. Repeat, aiming to provide a breath to an adult every 6 seconds

Note: If the patient is not breathing and has no signs of life, commence chest compressions, not ventilations (this is covered in the Cardiac Arrest chapter).

Facial shields

To provide some protection for yourself, a face shield can be used, which provides a plastic barrier between you and the patient. They are also fitted with a filter which fits over the patient’s mouth. As with mouth-to-mouth ventilation, this method does not allow for the administration of supplemental oxygen. The technique is the same as for mouth-to-mouth ventilation.

Mouth-to-mask ventilation

Using a pocket mask to provide mouth-to-mask ventilation uses your lungs as before, but does not require direct contact with the patient’s mouth. The one-way valve also prevents you coming into contact with blood and secretions from the patient’s mouth. You use both hands to hold the mask to the patient’s face, which makes it easier to get a good seal and deliver effective ventilations (Figure 11.12) [Pilbery, 2013].

Figure 11.12 Mouth-to-mask ventilation

Some pocket masks also have an oxygen port, allowing administration of supplemental oxygen. Even with pocket masks without an oxygen port, oxygen tubing can be placed under one side of the mask.

Procedure

Take the following steps to perform mouth-to-mask ventilation [Nolan, 2016]:

1. Place the patient supine with their head in the sniffing position (neck slightly flexed and head extended)

2. Apply the mask to the patient’s face using the thumbs of both hands

3. Grip the jaw and perform a jaw thrust, while pressing down with the thumbs to make a tight seal

4. Blow gently for 1 second through the valve and watch the chest rise

5. Stop inflation and watch the chest fall

6. Repeat every 6 seconds or as instructed by the senior clinician.

Leaks between the face and pocket mask can be reduced by increasing the jaw thrust, or changing finger position and pressure being applied. Oxygen, if available, should run at 10 l/min.

2.7.3 Bag-valve-mask ventilation

The bag-valve-mask (BVM) consists of a self-inflating bag, one-way valve and mask. When used without oxygen, it delivers room air (21% oxygen). This can be increased to 45% when high-flow oxygen is attached, but it should generally be used with a reservoir bag attached, as this can result in oxygen concentrations of around 85% (Figure 11.13) with oxygen supplied at 10 l/min [Nolan, 2016].

Figure 11.13 Bag-valve-mask with oxygen reservoir bag attached and inflated

The BVM can be used by one person, but this requires considerable skill. Where possible, a two-person technique is generally recommended [Monsieurs, 2015].

Procedure – One-person ventilation

Take the following steps to perform BVM ventilation with one person [EEAST, 2014]:

1. Use appropriate personal protective equipment (PPE)

2. Choose the correct mask size, which should rest on the bridge of the nose to the chin

3. Prepare the BVM, by connecting the mask and high-flow oxygen. Ensure the reservoir bag is inflated

4. Position the mask on the patient’s face and ensure an adequate seal

5. Form a ‘C’ shape with the thumb and index finger and rest this on top of the mask; place the middle and ring fingers on the ridge of the jaw and the little finger behind the angle of the jaw (Figure 11.14)

6. Gently squeeze the bag just enough to see the chest rise

Figure 11.14 Correct hand position for one-person BVM use

Procedure – Two-person ventilation

This is the same as one-person, with the exception that another person holds the mask to the patient’s face using the same method as for the pocket mask (Figure 11.15) [EEAST, 2014].

Figure 11.15 Two-person BVM technique

2.7.4 Mechanical ventilation

There are a wide variety of transportable mechanical ventilators and you are unlikely to be provided with one. However, your local ambulance service will have ventilators on their ambulances, so ensure that you are familiar with the one used locally. One of the most commonly used ventilators in UK ambulance services is the Pneupac® paraPAC® ventilator (Figure 11.16); the instructions listed here apply to this ventilator, although the steps are likely to be similar to other ventilators.

Indications for the use of the ventilator will also depend on the service, but use will typically be restricted to patients who have a supraglottic device or endotracheal tube inserted, who are in respiratory or cardiac arrest and being transported to hospital [NEAS, 2014].

Figure 11.16 The Pneupac® paraPac® 200D

Procedure

Take the following steps to prepare a mechanical ventilator for use [EEAST, 2014]:

  1. Connect to the gas supply and switch the main pneumatic switch to CMV/DEMAND

  2. Allow the ventilator to complete a self-check for approximately 60 seconds

  3. Ensure the pressure indicator shows O₂ (red – no supply, white – supply)

  4. Set frequency and tidal volume (VTDEL) controls for ADULT, CHILD or INFANT

  5. Set air mix control to NO AIR MIX for respiratory arrest, CPR or in a contaminated atmosphere

  6. Set relief pressure control to 40 cmH O₂ and set the ventilation parameters to suit the patient

  7. Temporarily occlude the patient connection to confirm the relief pressure and alarm function, and adjust if required

  8. Connect the mask/ET tube in the correct manner

  9. Check for air-tightness and adequate chest movement, and adjust the tidal volume as appropriate

10. Check the correctness of the indicated air pressure:

• A high-pressure alarm may indicate an excessive tidal volume, incorrect airway position or kinked ET tube

• A low-pressure alarm may indicate a leakage or insufficient tidal volume

Schrader outlet

In order to connect a mechanical ventilator to the oxygen supply, it is necessary to use the Schrader outlet. In addition to being present on the integrated valve cylinders, there are usually several wall outlets on ambulances, though they may have a pressure-compensated flowmeter in place already (Figure 11.17). These flowmeters have a small ball inside a tube which rises or falls depending on the oxygen flow rate. Because they are affected by gravity, it is important that they remain upright.

Figure 11.17 Pressure-compensated flowmeter attached to a Schrader outlet

Procedure

Take the following steps to prepare a pressure-compensated flowmeter for use [BOC, 2013a]:

1. Insert the oxygen probe into the Schrader outlet. Ensure the probe clicks securely into place

2. Slowly turn on the cylinder by rotating the handwheel anti-clockwise until it comes to a stop. Do not use excessive force

3. Check for leaks, which may be indicated by a hissing sound. If you suspect that you have a leak, turn off the cylinder and check the equipment is properly connected. Turn on the cylinder and re-check for leaks. If the leak continues, turn off and remove the cylinder from service. Report it using your ambulance service equipment defect procedure

2.7.5 Oxygen administration

The UK Ambulance Services Clinical Practice Guidelines [AACE, 2016] have divided oxygen administration for adults into four categories, which are provided here. However, you MUST follow local instruction about oxygen administration.

Note: Children are not included here. They should always receive high-concentration oxygen if they have a significant illness or injury.

Indications (when to administer the drug)

• Critical illnesses requiring high levels of supplemental oxygen

• Serious illnesses requiring moderate levels of supplemental oxygen if the patient is hypoxaemic

• COPD and other conditions requiring controlled or low-dose oxygen therapy

• Conditions for which patients should be monitored closely but oxygen therapy is not required unless the patient is hypoxaemic.

Contra-indication (when not to administer the drug)

• Explosive environments.

Cautions

• Oxygen increases the fire hazard at the scene of an incident

• Defibrillation: Ensure pads are firmly applied to reduce spark hazard.

Side effects

• Non-humidified oxygen is drying and irritating to mucous membranes over a period of time

• In patients with COPD there is a risk that even moderately high doses of inspired oxygen can produce increased carbon dioxide levels, which may cause respiratory depression and this may lead to respiratory arrest.

Dosage and administration

• Measure oxygen saturation (SpO₂) in all patients using pulse oximetry, where possible

• For the administration of moderate levels of supplemental oxygen, nasal cannulae are recommended in preference to simple face masks as they offer a more flexible dose range

• Administer the initial oxygen dose until a reliable oxygen saturation reading is obtained

• If the desired oxygen saturation cannot be maintained with a simple face mask, change to a reservoir (non-rebreathe) mask

• For dosage and administration of supplemental oxygen, refer to Table 11.2 for patients with critical illnesses, Table 11.3 for serious illnesses and Table 11.4 for patients who need controlled or low-dose oxygen therapy

• For conditions where NO supplemental oxygen is required unless the patient is hypoxaemic, refer to Table 11.5.

Table 11.2 High levels of supplemental oxygen for adults with critical illnesses

Administer the initial oxygen dose until the vital signs are normal, then reduce oxygen dose and aim for target saturation within the range of 94–98%

Condition

Initial dose

Method of administration

• Cardiac arrest or resuscitation:

• basic life support

• advanced life support

• foreign body airway obstruction

• traumatic cardiac arrest

• maternal resuscitation

• Carbon monoxide poisoning

Maximum dose until vital signs are normal

Bag-valve-mask (BVM)

• Major trauma:

• abdominal trauma

• burns and scalds

• electrocution

• head trauma

• limb trauma

• neck and back trauma (spinal)

• pelvic trauma

• immersion

• thoracic trauma

• trauma in pregnancy

• Anaphylaxis

• Major pulmonary haemorrhage

• Sepsis, e.g. meningococcal septicaemia

• Shock

15 l/min

Non-rebreathe mask

• Active convulsion

• Hypothermia

Administer 15 l/min until a reliable SpO₂ measurement can be obtained and then adjust oxygen flow to aim for target saturation within the range of 94-98%

Non-rebreathe mask

Table 11.3 Moderate levels of supplemental oxygen for adults with serious illnesses if the patient is hypoxaemic

Administer the initial oxygen dose until a reliable SpO₂ measurement is available, then adjust oxygen flow to aim for target saturation within the range of 94–98%

Condition

Initial dose

Method of administration

• Acute hypoxaemia (cause not yet diagnosed)

• Deterioration of lung fibrosis or other interstitial lung disease

• Acute asthma

• Acute heart failure

• Pneumonia

• Lung cancer

• Postoperative breathlessness

• Pulmonary embolism

• Pleural effusions

• Pneumothorax

• Severe anaemia

• Sickle cell crisis

SpO₂ < 85%
10–15 l/min

SpO₂ > 85–93%
2–6 l/min

SpO₂ > 85–93%
5–10 l/min

Non-rebreathe mask

Nasal cannulae

Simple face mask

Table 11.4 Controlled or low-dose supplemental oxygen for adults with COPD and other conditions requiring controlled or low-dose oxygen therapy

Administer the initial oxygen dose until a reliable SpO₂ measurement is available, then adjust oxygen flow to aim for target saturation within the range of 88–92% or pre-specified range as detailed on the patient’s alert card

Condition

Initial dose

Method of administration

• Chronic obstructive pulmonary disease (COPD)

• Exacerbation of cystic fibrosis

4 l/min

Increase flow rate to 6 l/min if respiratory rate is > 30 breaths/ min (i.e. 50% above minimum specified for the mask)

28% Venturi mask (or patient’s own)

• Chronic neuromuscular disorders

• Chest wall disorders

• Morbid obesity

4 l/min

28% Venturi mask (or patient’s own)

Note: If the oxygen saturation remains below 88% change to simple face mask

5–10 l/min

Simple face mask

Note: Critical illness AND COPD or other risk factors for hypercapnia

As for Table 11.2

As for Table 11.2

Table 11.5 No supplemental oxygen required for adults with these conditions unless the patient is hypoxaemic but patients should be monitored closely

If hypoxaemic (SpO₂ < 94%) administer the initial oxygen dose, then adjust oxygen flow to aim for target saturation within the range of 94–98% as per the table below

Condition

Initial dose

Method of administration

• Myocardial infarction and acute coronary syndromes

• Stroke

• Cardiac rhythm disturbance

• Non-traumatic chest pain/discomfort

• Implantable cardioverter defibrillator firing

• Pregnancy and obstetric emergencies:

• birth imminent

• haemorrhage during pregnancy

• pregnancy-induced hypertension

• vaginal bleeding

• Abdominal pain

• Headache

• Hyperventilation syndrome or dysfunctional breathing

• Most poisonings and drug overdoses (see Table 11.2 for carbon monoxide poisoning and special cases below for paraquat poisoning)

• Metabolic and renal disorders

• Acute and sub-acute neurological and muscular conditions producing muscle weakness (assess the need for assisted ventilation if SpO₂ < 94%)

• Post-convulsion

• Gastrointestinal bleeds

• Glycaemic emergencies

• Heat exhaustion/heat stroke

SPECIAL CASES

Poisoning with paraquat:

Patients with paraquat poisoning may be harmed by supplemental oxygen so avoid oxygen unless the patient is hypoxaemic. Target saturation 88-92%.

SpO₂ < 85%
10-15 l/min

SpO₂ > 85-93%
2-6 l/min

SpO₂ > 85-93%
5-10 l/min

Non-rebreathe mask

Nasal cannulae

Simple face mask

2.7.6 After use

Procedure

Once you have finished administering oxygen to a patient, take the following steps [BOC, 2013a]:

1. Remove the mask or nasal cannulae from the patient

2. Turn off the cylinder by rotating the handwheel clockwise until it comes to a stop. Do not use excessive force

3a. Disconnect equipment. Remove the tubing by firmly pulling the tube while holding the cylinder handle

3b. If you have used the Schrader valve, release by twisting the capstan clockwise

4. Turn the flow selector to zero

5. Replace the outlet cover by pulling up the hinged grey cover

6. Check the cylinder gauge and replace if necessary

2.8  Entonox – extended skill

Entonox is a combination of 50% nitrous oxide and 50% oxygen. The cylinders that contain entonox have a blue and white collar (Figure 11.18).

Figure 11.18 An Entonox cylinder

The UK Ambulance Services Clinical Practice Guidelines [AACE, 2016] for entonox administration are as follows:

Indications

• Moderate to severe pain

• Labour pains.

Contra-indications

• Severe head injuries with impaired consciousness

• Decompression sickness (the bends) where entonox can cause nitrogen bubbles within the bloodstream to expand, aggravating the problem further. Consider anyone that has been diving within the previous 24 hours to be at risk

• Violently disturbed psychiatric patients.

Action

• Inhaled analgesic agent.

Caution

• Any patient at risk of having a pneumothorax, pneumomediastinum and/or a pneumoperitoneum, e.g. polytrauma, penetrating torso injury.

Side effects

• Minimal side effects.

Dosage and administration

Adults:

• Entonox should be self-administered via a face mask or mouthpiece, after suitable instruction. It takes about 3–5 minutes to be effective, but it may be 5–10 minutes before maximum effect is achieved.

Children:

• Entonox is effective in children provided they are capable of following the administration instructions and can activate the demand valve.

Additional information

• Administration of entonox should be in conjunction with pain score monitoring.

• Entonox’s advantages include:

• Rapid analgesic effect with minimal side effects

• No cardio-respiratory depression

• Self-administered

• Analgesic effect rapidly wears off

• The 50% oxygen concentration is valuable in many medical and trauma conditions

• Entonox can be administered while preparing to deliver other analgesics.

2.8.1  Preparing entonox for administration

Procedure

Take the following steps to prepare Entonox for administration [BOC, 2013b]:

1. Ensure the demand valve is clean and ready for use

2. Fit a new microbial filter to the demand valve. They are single use

3. Insert the probe on the hose connected to the demand valve into the Schrader outlet on the entonox cylinder. Push firmly to ensure the probe clicks into place

4. Slowly turn the cylinder on by rotating the handwheel anti-clockwise until fully open. Do not use excessive force

5. Check the demand valve is operative by pushing the ‘test button’. You should hear the gas flowing

6. Check for leaks which may be indicated by a hissing sound. If you suspect that you have a leak, turn off the cylinder and check the equipment is properly connected. Turn on the cylinder and re-check for leaks. If the leak continues, turn off and remove the cylinder from service. Report it using your ambulance service equipment defect procedure

2.8.2 After use

Procedure

Take the following steps once the patient has finished using the entonox [BOC, 2013b]:

1. Remove the demand valve from the patient. Dispose of the filter and mouthpiece

2. Turn off the cylinder by rotating the handwheel clockwise until it comes to a stop. Do not use excessive force

3. Vent any residual gas in the hose by pressing the test button on the demand valve. Keep pressing until the gas has stopped venting

4. Disconnect the probe from the cylinder outlet. Holding the probe, twist the capstan and withdraw the probe from the Schrader outlet

5. Replace the outlet cover by pulling up the hinged grey cover. Check the cylinder gauge and replace if empty

3 Assessment of breathing

3.1 Learning objectives

By the end of this section you will be able to:

• Record the following observations:

• Respiratory rate

• Oxygen saturations.

3.2 Respiratory rate

A normal adult respiratory rate is 12–20 breaths per minute (breaths/min) [Nolan, 2016].

The respiratory rate is often overlooked as an important vital sign, but in adults, respiratory rates of 25 breaths/min or more are an indicator of serious illness and a warning that your patient may deteriorate quickly [Smith, 2011a; BTS, 2008]. Patients with a respiratory rate of less than 10 breaths/min or more than 30 breaths/min may need assisted ventilations [AACE, 2016].

3.2.1 Measuring respiratory rate

How fast are you breathing now? Before considering this question, it is likely that you weren’t even thinking about your respiratory rate. So it is with patients. Don’t tell them that you are going to record their respiratory rate!

Ideally, you want to measure your patient’s respiratory rate for a full minute using one of the following techniques [Gregory, 2010b]:

• Watching the chest rise and fall

• Using an oxygen mask with an integral respiratory rate indicator (Figure 11.19).

Figure 11.19 Non-rebreathe masks with integral respiratory rate indicator

3.3 Oxygen saturations

Oxygen is transported around the body bound to haemoglobin in the blood (oxyhaemoglobin), as it travels from the lungs to the body’s tissues. Oxygen saturation is the ratio of oxyhaemoglobin to the total amount of haemoglobin and is usually shown as a percentage [Tortora, 2008].

Oxygen saturations are measured in two ways: invasively and non-invasively. In hospital, it is common for patients to have an arterial blood gas (ABG) sample taken, whereby a small amount of blood from an artery (often the radial) is taken and the arterial oxygen saturation measured (SaO₂). However, this is not practical to undertake outside of hospital, so oxygen saturations are measured non-invasively using a technique known as pulse oximetry (SpO₂) [Gregory, 2010b].

3.3.1 Pulse oximetry

Pulse oximetry works by shining red and infrared light through a part of the body that is relatively translucent and has an arterial pulse, such as a finger, toe or earlobe. The amount of light transmitted through the tissue depends on the amount of oxyhaemoglobin present; this enables the pulse oximeter to calculate the oxygen saturation and will also provide the pulse rate.

If you refer back to the oxygen guideline, you will see that the target oxygen saturation for most patients is 94–98%, and in a normal, healthy person oxygen saturations should be 95% and above [Pilbery, 2013].

3.3.2 Indications and limitations

Indications

Pulse oximetry is useful for [Gregory, 2010b; Walls, 2012]:

• Assessing severity of respiratory illness or injury

• Providing early warning of a patient who is deteriorating

• Providing feedback about the effectiveness of oxygen therapy

• Detecting pulses in limbs which have been fractured.

Limitations

Like any tool, the pulse oximeter can produce inaccurate results, particularly in the presence of the following [Pilbery, 2013; Walls, 2012]:

• Bright ambient light: Simple to solve with a towel over the probe

• Excessive patient motion: Such as shivering, convulsions or a bumpy ambulance ride

• Poor perfusion: Since the pulse oximeter requires an arterial pulse to work, conditions that result in poor peripheral perfusion can lead to problems. Examples include patients in shock, cardiac arrest and who are cold

• Nail varnish/polish: Some dark-coloured nail varnish can affect the accuracy of pulse oximeters, although this is not likely to be too serious. Finger probes can be rotated 90° if this is a worry, but if a reliable and consistent reading is being obtained through nail varnish, then the reading is probably accurate [Chan, 2003; Hinkelbein, 2007]

• Low blood pressure: Pulse oximetry becomes more inaccurate as the systolic blood pressure drops below 80 mmHg

• Abnormal haemoglobin: Other molecules can attach themselves to haemoglobin and create an artificially high oxygen saturation reading. Carbon monoxide is probably the most well known, so don’t be reassured by a high oxygen saturation in a patient who is a victim of smoke inhalation, for example

• Response time: Pulse oximetry is not instantaneous; typically, a reading can take up to 20 seconds depending upon the patient’s physiological state. Probes closer to the heart (such as one sited on an earlobe) usually respond faster than probes on fingers and toes.

3.3.3 Recording oxygen saturations

Procedure

Take the following steps to record a patient’s oxygen saturations [WHO, 2011]:

1. Turn the pulse oximeter on

2. Select the appropriate probe with particular attention to correct sizing and where it will go (usually the finger, toe or ear). If used on a finger or toe, make sure the area is clean. Consider removing nail varnish, or rotate the probe 90°

3. Connect the probe to the pulse oximeter

4. Position the probe carefully; make sure it fits easily without being too loose or too tight. If possible, avoid the arm being used for blood pressure monitoring as cuff inflation will interrupt the pulse oximeter signal

5. Allow several seconds for the pulse oximeter to detect the pulse and calculate the oxygen saturation

6. Look for the displayed pulse indicator that shows that the machine has detected a pulse. Without a pulse signal, any readings are not reliable

7. Once the unit has detected a good pulse, the oxygen saturation and pulse rate will be displayed

8. Like all machines, oximeters may occasionally give a false reading – if in doubt, rely on clinical judgement, rather than the machine

9. If in doubt, check the pulse oximeter is working properly by placing it on your own finger.

4 Common respiratory conditions

4.1 Learning objectives

By the end of this section you will be able to:

• Describe the following conditions of the respiratory system:

• Asthma

• Chronic obstructive pulmonary disease (COPD)

• Pneumonia

• Pulmonary embolism.

4.2 Asthma

4.2.1 Definition

Asthma is a condition characterised by intermittent, reversible, airway obstruction [Simon, 2010].

4.2.2 Pathophysiology

Asthma is caused by a chronic inflammation of the bronchi, making them narrower. The muscles around the bronchi become irritated and contract, causing sudden worsening of the symptoms. The inflammation can also cause the mucus glands to produce excessive sputum which further blocks the air passages.

The obstruction and subsequent wheezing are caused by three factors within the bronchial tree:

• Increased production of bronchial mucus

• Swelling of the mucosal cells that line the bronchi and bronchioles

• Spasm and constriction of bronchial muscles.

These three factors combine to cause blockage and narrowing of the small airways in the lung. Because inspiration is an active process involving the muscles of respiration, the obstruction of the airways is overcome on breathing in. Expiration occurs with muscle relaxation, and is severely delayed by the narrowing of the airways in asthma. This generates the wheezing on expiration that is characteristic of this condition.

4.2.3 Medication

Asthma is managed with a variety of inhaled and tablet medications. Inhalers are divided into two broad categories: preventer and reliever.

Preventer

The preventer inhalers are normally anti-inflammatory drugs and these include steroids and other milder anti-inflammatories such as Tilade. The common steroid inhalers are beclomethasone (Becotide), budesonide (Pulmicort) and fluticasone (Flixotide). These drugs act on the lung over a period of time to reduce the inflammatory reaction that causes the asthma. Regular use of these inhalers often eradicates all symptoms of asthma and allows for a normal lifestyle.

Reliever

The reliever inhalers include salbutamol (Ventolin), terbutaline (Bricanyl), tiotropium bromide (Spiriva) and ipratropium bromide (Atrovent). These inhalers work rapidly on the lung to relax the smooth muscle spasm when the patient feels wheezy or tight-chested. They are used in conjunction with preventer inhalers. Inhalers are often used through large plastic spacer devices (Figure 11.20). This allows the drug to spread into a larger volume and enables the patient to inhale it more effectively. In mild and moderate asthma attacks some patients may be treated with high doses of ‘relievers’ through a spacer device. This has been shown to be as effective as giving a salbutamol nebuliser [BTS, 2012].

Figure 11.20 An inhaler with a spacer device

4.2.4 Signs and symptoms

History

Patients will typically tell you about increasing shortness of breath with wheezing over the past 6–48 hours, with increasing inhaler use. The reliever inhalers may also be proving less effective than normal.

Ask specifically about:

• Repeated attendances at ED for asthma care in the past year

• Previous admissions for asthma

• Previous near-fatal asthma, e.g. previously required ventilation/intensive care

• Heavy use of reliever inhalers

• Brittle asthma.

Assessment of severity

The signs and symptoms of asthma are organised according to their severity [BTS, 2012]. Table 11.6 shows the broad categories of asthma severity, which in turn will determine the most appropriate interventions for your patient [AACE, 2016].

Table 11.6 Assessing asthma severity

Moderate

Severe

Life-threatening

SpO₂ $ 92%

SpO₂ $ 92%

SpO₂ < 92%

Adults:

Respiratory rate

< 25 breaths/min

Heart rate < 110 beats/min

Adults:

Respiratory rate $ 25 breaths/min

Heart rate $ 110 beats/min

Adults:

Silent chest

Poor respiratory effort

Exhaustion

Altered consciousness

Cyanosis

Arrhythmia

Hypotension

Children > 5 years

Able to talk Respiratory rate # 30 breaths/min

Heart rate < 125 beats/min

Children > 5 years

Too breathless to talk Using accessory neck muscles Respiratory rate > 30 breaths/min Heart rate >125 beats/min

Children > 5 years

Silent chest

Poor respiratory effort

Agitation

Altered consciousness Cyanosis

Children 2-5 years

Able to talk

Respiratory rate # 40 breaths/min

Heart rate # 140 beats/min

Children 2-5 years

Too breathless to talk

Using accessory neck muscles

Respiratory rate

> 40 breaths/min

Heart rate > 140 beats/min

Children 2-5 years

Silent chest

Poor respiratory effort

Agitation

Altered consciousness Cyanosis

Children < 2 years

Audible wheezing
Using accessory muscles
Still feeding

Children < 2 years

Cyanosis

Marked respiratory distress
Too breathless to feed

Children < 2 years

Apnoea or poor respiratory effort Bradycardia

Note: Only one sign or symptom is required to qualify a patient for a higher severity. For example, an SpO₂ of 91% would place a patient in the life-threatening column, irrespective of other observations.

4.2.5 Management

The management of asthma depends on the assessment of severity and the patient’s response to treatment [BTS, 2012; AACE, 2016]. Encourage patients to use their own reliever inhalers, such as salbutamol, and administer high-flow oxygen. Patients with life-threatening asthma may require assisted ventilation if they lose consciousness.

4.3 Chronic obstructive pulmonary disease

4.3.1 Definition

Chronic obstructive pulmonary disease (COPD) is an umbrella term for a range of respiratory diseases that result in airflow obstruction. This obstruction is usually progressive and, unlike asthma, is not fully reversible and does not change markedly over several months [NICE, 2010a].

It is estimated that there are around 3.7 million people with COPD in the United Kingdom (UK), but only 90,000 have been diagnosed. COPD kills about 30,000 people a year in the UK, making it the fifth biggest killer [BLF, 2007].

The two most important respiratory diseases related to COPD are chronic bronchitis and emphysema. Emphysema is a permanent enlargement of the air spaces below the terminal bronchioles as a result of the destruction of the alveolar walls. Chronic bronchitis, on the other hand, is defined clinically as a persistent cough with sputum production for at least 3 months of the year for two consecutive years [Patel, 2008].

4.3.2 Pathophysiology

COPD

The most important causative factor in chronic bronchitis and emphysema is smoking, although only 15% of smokers develop COPD [Patel, 2008]. The general effects of smoking on COPD are:

• Inflammation resulting from activation of inflammatory cells, which release substances that trigger an immune system response. This activates enzymes that can damage lung tissue, although normally these are kept in check. However, in COPD, so many enzymes are produced that they overwhelm the neutralising mechanism, and lung tissue is digested and destroyed. This is thought to be particularly important in the development of emphysema

• Inflammation as a direct result of inhaling oxidants in the cigarette smoke (you may have heard of free radicals) which damage the cells directly.

Both of these mechanisms lead to alveolar destruction and production of excess mucus, which is made worse by the impairment of the respiratory cilia, hair-like projections that line the airways and move debris and mucus upwards and out of the respiratory tract [Tortora, 2008].

Chronic bronchitis

Cigarette smoking, occupational exposure and/or recurrent bronchial infections lead to inflammation that narrows the airways, and an increase in mucus secretions coupled with inhibition of the cilia, which leads to an accumulation of secretions and bronchoconstriction due to irritant receptor activation, which also causes the chronic productive cough [Patel, 2008].

Emphysema

In emphysema, the walls of the alveoli are destroyed by enzymes called proteases. These are usually kept under control by another group of enzymes imaginatively called anti-proteases. Once the balance is upset (due to smoking, for example) destruction of the alveoli occurs, leading to a collapse of the airways, resulting in obstruction. In addition, as the walls of the alveoli are destroyed, bullae (small, blister-like air pockets) form on the lung. If these bullae form, air can directly enter the pleural cavity, causing a pneumothorax and collapse of the lung on the affected side [Patel, 2008].

4.3.3 Oxygen and COPD

Research studies and audits suggest that over-oxygenation increases mortality and morbidity, but careful pre-hospital titration of oxygen administration to patients with COPD can significantly reduce mortality [Austin, 2010].

The most significant effect of hyperoxia (excessive oxygen) on the respiratory system is hypercapnic respiratory failure in vulnerable populations (such as patients with severe COPD). This can occur even with a partial pressure of arterial oxygen (PaO₂) within normal or near-normal values. It is thought that there are a number of mechanisms that are responsible [O’Driscoll, 2008].

4.3.4 Signs and symptoms

Patients will usually call for an ambulance during an exacerbation of COPD. Their clinical presentation will depend on which of the two diseases (chronic bronchitis or emphysema) is more dominant. In reality, most patients will have elements of both, but Table 11.7 shows the two ends of the spectrum of illness.

Table 11.7 Chronic bronchitis vs emphysema

Chronic bronchitis

Emphysema

Also known as

Blue bloater

Pink puffer

Hyperinflated chest

Yes

Yes

Body size

Obese

Thin

Cyanosis

Yes, centrally

No

Blood levels of CO₂

High

Low

Features of an acute exacerbation of COPD include [AACE, 2016]:

• Increased dyspnoea

• Increased sputum production/purulence (containing pus)

• Increased cough

• Upper airway symptoms, such as cold and sore throat

• Increased wheeze

• Reduced exercise tolerance

• Fluid retention

• Increased fatigue

• Acute confusion.

Features that warn of a severe episode of COPD include [AACE, 2016]:

• Marked dyspnoea

• Tachypnoea

• Purse-lip breathing

• Use of accessory muscles

• New-onset cyanosis

• New-onset peripheral oedema

• Marked reduction in activities of daily living.

Despite the lists above, it is not always clear that the patient with difficulty breathing has COPD and only 35% of patients will tell you that they have COPD [Durrington, 2005]. Therefore you should consider this as a possibility for any patient who meets the following criteria [NICE, 2010a]:

• Over 35 years of age

• Smoker (or ex-smoker)

• Has any of:

• Exertional breathlessness

• Chronic cough

• Regular sputum production

• Wheeze

• Has no clinical features of asthma.

4.3.5 Management

The management of the patient with COPD depends on the presence of any time-critical features:

• Major ABCD problems

• Extreme breathing difficulty (compared to normal)

• Cyanosis (although peripheral cyanosis can be normal)

• Exhaustion

• Hypoxia unresponsive to oxygen (in COPD patients hypoxia is considered to be an SpO₂ below 88%).

These patients require a blue-light transfer to the nearest emergency department, so be sure to update the emergency operations centre [AACE, 2016].

For patients with no time-critical features, you should ask if they have a treatment plan and follow this, if available. Treatments typically include [AACE, 2016]:

• Oxygen: Target range of 88–92%. Venturi masks are a good choice for delivering accurate percentages of oxygen, although nasal cannulae may be better tolerated by patients

• Bronchodilators: Salbutamol and ipratropium (once only). If the nebuliser is powered by oxygen, nebulisation should be limited to 6 minutes

• Patients may need taking to hospital, but depending on how well they respond to treatment, they may be suitable for referral to their GP, respiratory team or advanced paramedic. The ambulance staff will decide the most appropriate management.

4.4 Pneumonia

4.4.1 Definition

Pneumonia is an infection of the terminal bronchioles and alveoli (lung parenchyma) [Patel, 2008]. It is more common in the elderly and during the winter months [Simon, 2010].

It is often classified in three main ways, although the first is the most commonly used [Dunn, 2005; Osler, 2012]:

• Setting: i.e. hospital or community acquired pneumonia

• Anatomy: Lobar, if the infection is localised to a lobe of the lung, or bronchopneumonia if the infection is more widespread

• Organism: Bacterial, viral, fungal.

4.4.2 Risk factors for community acquired pneumonia (CAP)

These are factors that undermine the lung’s natural defences and so increase the risk of pneumonia [Patel, 2008]:

• Excessive alcohol

• Cigarette smoking

• Chronic heart and lung diseases

• Bronchial obstruction

• Immunosuppression (e.g. due to chemotherapy for cancer)

• Drug abuse.

4.4.3 Pathophysiology

This inflammatory process is typically due to a bacterial or viral infection, which has usually entered the lungs having been inhaled from the environment or nasopharynx. Normally, these organisms should be destroyed by the body’s lung defences, but if they survive and multiply, infection results. This leads to a build-up of fluid and blood cells (red and white) in the alveoli, known as consolidation [Porth, 2003].

4.4.4 Signs and symptoms

When taking a history, the following symptoms are suggestive of pneumonia [Johnson, 2012]:

• Fever with or without rigors

• Cough (often productive with green, bloodstained or rusty-coloured sputum)

• Pleuritic chest pain

• Muscle or joint pain

• When examining a patient you may notice the following signs:

• High temperature (pyrexia)

• Increased respiratory rate (tachypnoea)

• Increased heart rate (tachycardia).

4.4.5 Management

Not all patients with pneumonia need to go to hospital. However, while waiting for an ambulance, patients who have difficulty breathing should receive oxygen.

4.5 Pulmonary embolism

4.5.1 Definition

An embolus is a blood-borne substance (including air) that is transported from one part of the circulation to another, lodging in a vessel which is too small to allow the embolus to pass. When the embolus lodges in the pulmonary vessels, it is termed a pulmonary embolism (PE) [Patel, 2008]. Deep vein thrombosis (DVT) and pulmonary embolism represent the spectrum of one disease known as venous thromboembolism (VTE) [Tapson, 2008]. Although an embolus can consist of air, fat or amniotic fluid, for example, the most common is a clot from a DVT [Porth, 2003; Torbicki, 2008].

4.5.2 Risk factors

The risk factors for developing a venous thromboembolism are well known and can help to identify patients who may have a PE [Torbicki, 2008]:

• High risk:

• Fracture (hip or leg)

• Major general surgery

• Major trauma

• Spinal cord injury (SCI)

• Moderate risk:

• Chronic heart or respiratory failure

• Chemotherapy

• Hormone replacement therapy

• Cancer

• Oral contraceptive therapy

• Paralytic stroke

• Post-partum

• Previous VTE

• Thrombophilia

• Low risk:

• Bed rest for more than 3 days

• Immobility due to sitting (e.g. prolonged car or air travel)

• Increasing age

• Obesity

• Pregnancy

• Varicose veins.

4.5.3 Pathophysiology

Thrombi (blood clots) most often form in the deep veins of the calf (hence the name, deep vein thrombosis!) and can grow to lengths of 30–50 cm [Tapson, 2008]. The proximal end of the thrombus can extend into the popliteal vein, where the risk of embolisation is greater. Once the thrombus (or a portion) breaks off, it becomes an embolus, travelling up the femoral vein and into the iliac veins. From there it is free to ascend via the inferior vena cava to the heart. It continues into the right atrium, the ventricle and finally into the lungs via the pulmonary trunk and left and right pulmonary arteries (the only arteries to carry deoxygenated blood), which divide and sub-divide until they form capillaries around the alveoli.

In healthy patients, an obstruction of up to 25% of the pulmonary arterial bed will only cause mild respiratory symptoms, such as shortness of breath. Once this increases to 30–50% there will also be cardiovascular compromise, including cardiac arrest. Patients with pre-existing respiratory and/or cardiovascular disease will be symptomatic at much lower percentages [Torbicki, 2008; Wood, 2002].

4.5.4 Signs and symptoms

Common signs and symptoms of PE include difficulty breathing (dyspnoea) and rapid breathing (tachypnoea). Pleuritic chest pain is the most common symptom [AACE, 2016].

Other signs and symptoms include:

• Signs:

• Respiratory rate greater than 20 breaths/min

• Pulse rate greater than 100 beats/min

• Pulse oximeter reading (SpO₂) less than 92% in air

• Signs of a deep vein thrombosis (DVT), which includes pain, swelling and/or tenderness on only one leg, often in the calf [Simon, 2010].

• Symptoms:

• Cough

• Haemoptysis (blood from the respiratory tract, usually coughed up)

• Syncope (faint).

4.5.5 Management

Patients with suspected PE need swift transport to hospital. Treatment is mainly supportive of the ABCs (airway, breathing and circulation). Place the patient in a position of comfort (often sitting up, unless they have low blood pressure), provide oxygen if required, to maintain the SpO₂ in the range 94–98%, and be prepared for cardiac arrest [AACE, 2016].

Chapter 12: Circulation

1 Cardiovascular system anatomy and physiology

1.1 Learning objectives

By the end of this section, you will be able to:

• State the functions of the cardiovascular system

• Describe the anatomy and function of the heart

• State the components of the electrical pathway of the heart

• Explain the difference between arteries and veins

• Describe the stages of the cardiac cycle.

1.2 Introduction

At the most basic level, the cardiovascular system is composed of blood vessels that transport blood around the body thanks to the work of a pump, the heart. The heart is actually two pumps (the ventricles), each with its own reservoir (the atria), which normally serve two different circulations. The right side of the heart pumps blood to the pulmonary circulation, which travels around the lungs enabling the blood to take up oxygen and give up carbon dioxide. This blood then returns to the left side of the heart, where it is pumped into the systemic circulation to be transported all around the body via the largest artery in the body, the aorta. Both these pumps operate simultaneously and, thanks to valves in the heart, in one direction.

The main functions of the cardiovascular system are [Evans, 2012]:

• Transport of nutrients, such as oxygen, glucose (sugar), fatty acids and water

• Removal of waste products from metabolic processes, such as carbon dioxide, urea and creatine

• Hormonal control, by delivering hormones to their target organs (and secreting some of its own)

• Regulation of temperature by controlling heat distribution between the core and skin of the body

• Reproduction, by producing penile erection and providing nutrition for the unborn fetus

• Host defence, by transporting immune cells and other mediators.

1.3 Heart

The heart is relatively small, considering the work it has to do; it is only about the size of your fist. It sits within the mediastinum, a region in the thoracic cavity that extends from the sternum to the vertebral column, and sits between the lungs. About two-thirds of the heart sits to the left of the body’s midline. It is cone-shaped, with the pointed apex orientated anteriorly (to the front), inferiorly (downwards) and to the left, and the flat base directed posteriorly (to the back), superiorly (upwards) and to the right [Tortora, 2008].

1.3.1 Pericardium and heart wall

The pericardium is a fibrous sac that surrounds and protects the heart, keeping it fixed within the mediastinum, but allowing for the vigorous contractions required to move blood around the pulmonary and systemic circulations [Tortora, 2008]. The outer, parietal, layer is fixed to the fibrous pericardium, whereas the inner, visceral, layer (also called the epicardium) forms the outer layer of the heart wall.

The wall of the heart is made up of three layers:

• Epicardium: Also known as the visceral layer of the pericardium

• Myocardium: The heart muscle, which makes up most of the bulk of the heart and is responsible for the pumping action that moves blood around the body

• Endocardium: The smooth inner layer which also covers the valves of the heart and is continuous with the innermost lining (endothelium) of the blood vessels attached to the heart.

1.3.2 Chambers of the heart

The heart has four chambers. The two superior chambers are called atria and the two inferior chambers, the ventricles (Figure 12.1) [Tortora, 2008; Kapit, 2001; Evans, 2012].

Figure 12.1 Chambers of the heart and related anatomy

Right atrium

The right atrium receives deoxygenated blood from the body, via large veins called the superior and inferior vena cavae, and from the coronary (heart) circulation via the coronary sinus.

It is separated from the left atrium by a thin partition known as the interatrial septum, and from the right ventricle by the tricuspid valve, so called because it is made up of three cusps. This valve is also sometimes referred to as the right atrioventricular valve.

Right ventricle

The right ventricle makes up most of the anterior surface of the heart and receives blood from the right atrium via the tricuspid valve. To prevent this valve from everting (turning inside out like an umbrella in strong winds!) during contraction of the ventricles, the valve is anchored by tendon-like cords known as the chordae tendineae, which connect to papillary muscles. Like the atria, the ventricles are separated by a partition, known as the interventricular septum.

Blood leaves the ventricle via the pulmonary valve, where it enters the pulmonary trunk, which splits into the left and right pulmonary arteries. As you will discover later in the lesson, these arteries are unusual because they transport deoxygenated blood.

Left atrium

The left atrium makes up the majority of the base of the heart. Blood enters the atrium from the lungs via four pulmonary veins and exits through the bicuspid (two cusps) valve. This is also known as the mitral valve (because of the valve’s resemblance to a bishop’s mitre or hat) and the left atrioventricular valve.

Left ventricle

This forms the apex of the heart and also contains the chordae tendineae and papillary muscle assembly to secure the mitral valve. Blood exits via the aortic valve where it travels up the ascending aorta. Some blood leaves here and enters the coronary arteries to provide oxygen and nutrients to the heart itself. The remaining blood is transported throughout the body.

1.3.3 Electrical conduction pathway

In order to ensure an effective pumping action of the heart, there is a network of specialised auto-rhythmic (self-excitable) muscle cell fibres that trigger co-ordinated muscle contraction (Figure 12.2), forcing blood around the heart chambers in the direction dictated by the heart valves.

Sino-atrial node

The sino-atrial (SA) node is the main pacemaker of the heart and in textbooks is typically shown as a small area of tissue at the junction of the superior vena cava (SVC) with the right atrium. However, electrophysiology studies have shown that the pacemaker site can spontaneously move down the terminal crest of the right atrium, giving rise to the phenomenon of the wandering pacemaker and suggesting that there is a much larger area of pacemaker cells [Boyett, 2009]. Electrical impulses travel from the SA node to the atrioventricular (AV) node and also cross the interatrial septum via a set of specialised cells known as Bachmann bundles.

Figure 12.2 The electrical conduction pathway of the heart

Atrioventricular node and bundle of His

The AV node is found in the right atrial wall, close to the opening of the coronary sinus and septal leaflet of the tricuspid valve. Its primary function is to delay the electrical impulse from the SA node long enough for the atria to depolarise, allowing time for atrial muscle contraction to squeeze additional blood into the ventricles (known as the atrial kick). Between the AV node and bundle branches is the bundle of His, which originates in the wall of the right atrium and straddles the interventricular septum. In normal physiology, this is the only way electrical impulses can pass between the atria and ventricles [Garcia, 2004].

Left bundle branch

The left bundle branch starts at the end of the bundle of His, travelling through the interventricular septum, providing fibres which innervate the left ventricle and left side of the interventricular septum. It splits into two fascicles: anterior and posterior. The left posterior fascicle is a fan-like structure that provides innervation to the posterior and inferior left ventricle via the Purkinje system. Being so widely distributed, it is hard to completely block. The left anterior fascicle, on the other hand, is a single strand, innervating the anterior and superior portions of the left ventricle [Garcia, 2015].

Right bundle branch

The right bundle branch also originates from the bundle of His and sprouts fibres that innervate the right ventricle and right face of the interventricular septum, stimulating the Purkinje fibres. These fibres (named after a Czech physiologist, Jan Purkinje) consist of individual cells located just under the endocardium, and directly innervate myocardial cells causing them to depolarise [Boyett, 2009].

1.3.4 Coronary arteries

The heart requires its own blood supply in order to function properly. There are two main arteries that serve the heart, the right and left coronary arteries, which originate at the base of the ascending aorta (Figure 12.3).

Figure 12.3 Coronary artery anatomy

Right coronary artery

The right coronary artery (RCA) runs down the right side of the heart in the coronary sulcus (depression) between the right atrium and ventricle. Most people (around 80%) are right dominant; the RCA gives rise to the posterior descending artery (PDA). In around 8%, this artery arises from the left circumflex (Cx) artery (termed left dominance), with the remainder being served by both arteries [Goldberg, 2007]. The PDA serves the inferior wall of the left ventricle as well as the inferior part of the septum.

Left coronary artery

The left coronary artery (LCA) passes behind the pulmonary trunk and splits almost immediately into two branches, the anterior interventricular branch (often referred to as the left anterior descending artery, LAD) and the circumflex artery (Cx). The LAD descends obliquely towards the apex of the heart in the anterior interventricular sulcus, supplying the anterior part of the septum and anterior wall of the left ventricle via one or two diagonal branches [Drake, 2005].

1.4 Blood

Blood is a connective tissue consisting of a liquid (plasma) and cells performing a range of essential functions for the body [Tortora, 2008; Munden, 2002]:

• Plasma makes up around 55% of blood and carries antibodies (an important part of the immune system), and nutrients to the body’s tissues, and removes waste products

• The formed elements make up the remaining 45% and consist of red and white blood cells and platelets

• Red blood cells (erythrocytes) carry oxygen to the tissues and remove carbon dioxide

• White blood cells (leukocytes) are an important part of the immune and inflammatory processes

• Platelets (thrombocytes) along with clotting factors are an essential component of normal blood clotting, particularly in cases of bleeding (haemorrhage).

1.5 Blood vessels

There are five main types of blood vessels in the body. The largest are the elastic arteries that leave the heart before subdividing into medium-sized muscular arteries. These further subdivide into even smaller arteries known as arterioles. These are important vessels as they control blood flow into the capillaries, thin-walled vessels that allow for the exchange of substances between the blood and tissues. The capillaries unite to form small veins, known as venules, which subsequently merge to form larger and larger veins that return blood to the heart [Tortora, 2008].

1.5.1 Vessel structure

Most blood vessels (except capillaries) are made up of three layers or tunics (Figure 12.4). The internal layer (tunica intima or interna) consists of a smooth inner layer (the endothelium), a basement membrane and, in medium-sized arteries, a layer of elastic tissue that helps to maintain blood pressure. Ordinarily, the endothelial layer is the only one that comes into contact with blood in the lumen of the artery [Kapit, 2001].

Figure 12.4 The structure of blood vessels

The medium-sized veins have one-way valves formed from the endothelial layer. These are designed to prevent blood flow from travelling in the wrong direction (i.e. away from the heart). They resist gravity-induced pooling, particularly in the lower limbs (i.e. the legs).

The next layer is the tunica media. This is made up of smooth muscle and elastic fibres, and is most developed in the medium-sized arteries and least developed in the veins. In the aorta and other large arteries there is a higher proportion of elastic fibres, making the walls highly compliant and able to stretch easily without tearing when subjected to pressure changes. This is advantageous, because as blood is ejected from the heart, the walls of the aorta stretch, acting as a pressure reservoir which can ensure blood flow continues, even when the ventricles are relaxed [Tortora, 2008].

The final layer is the tunica externa, which is constructed mostly from elastic and collagen fibres, but is also home to the vasa vasorum (the blood supply to the arteries) and nervi vasorum (motor nerves) [Kapit, 2001].

1.5.2 Arteries

Figure 12.5 shows the main arteries that branch from the aorta. Don’t worry about memorising them all.

Figure 12.5 The aorta and its branches

1.5.3 Veins

Figure 12.6 shows the main veins that are drained by the superior and inferior vena cavae.

1.6 Cardiac cycle

During a single cardiac cycle, both the atria and ventricles take it in turns to contract and relax, forcing blood from an area of high pressure (due to the contracted muscle) to low pressure.

Figure 12.6 Veins of the body

The cycle is short, just 0.8 seconds in a person with an average heart rate of 75 beats/min [Tortora, 2008; Garcia, 2015; Kapit, 2000].

1.6.1 Atrial systole

This takes about 0.1 second. It starts with the sino-atrial (SA) node generating an action potential (electrical signal) when it depolarises (its voltage changes from negative to positive). This in turn causes the depolarisation of the atrial cardiac muscle cells, which contract (atrial systole). Blood is forced out of the atria, through the atrioventricular (AV) valves and into the ventricles, topping them up.

During this period, the electrical impulses from the SA node reach the AV node, pause to allow for atrial muscle contraction and then continue down the bundle of His, the bundle branches and into the Purkinje fibres, leading to ventricular depolarisation.

1.6.2 Ventricular systole

This lasts about 0.3 seconds, and during this time the atrial muscle relaxes (atrial diastole). Ventricular depolarisation causes the ventricular muscles to contract, and as the pressure inside the ventricles increases, the AV valves close and there is a brief period where all four valves of the heart are shut. This is known as isovolumetric contraction and lasts 0.05 seconds.

Contraction of the ventricles continues and eventually overcomes the pressure in the pulmonary and systemic circulations, causing the pulmonary and aortic valves (collectively known as the semilunar valves) to open. Blood is ejected into the pulmonary trunk and ascending aorta.

Meanwhile, the cardiac cells reset their voltage from positive (depolarised) to negative, a process known as repolarisation.

1.6.3 Relaxation period

This is the longest period in a cardiac cycle (around 0.4 seconds) and now both the atria and the ventricles are relaxed. This period is the most shortened when heart rate increases.

Ventricular repolarisation leads to relaxation of the ventricles (ventricular diastole), and as the pressure inside the ventricles falls, the semilunar valves close. As with systole, there is a brief period where all four valves are closed (isovolumetric relaxation). The pressure continues to fall, leading to the AV valves reopening and passive filling of the ventricles begins. By the end of diastole, the ventricles will be 75% full, just in time for another action potential from the SA node to start the process all over again.

Figure 12.7 An example of a 12-lead ECG

1.7 Electrocardiograms

The electrical signals that are responsible for the muscle contraction and relaxation during the cardiac cycle can be recorded on an electrocardiogram (ECG, Figure 12.7). They are useful for determining cardiac rhythm disturbances (arrhythmias) and detecting myocardial injury, such as occurs during a heart attack (myocardial infarction).

As the heart’s muscle cells depolarise and repolarise during the cardiac cycle, a potential difference (voltage) is generated, which can be detected on the surface of the body. Each cell generates its own electrical impulse, which has a strength and direction. The sum of all of these vectors is known as the heart’s electrical axis and this is recorded on the ECG.

Recording the ECG is achieved with the use of electrodes that are placed in specific locations on the body, to capture the electrical activity of the heart. They are often compared to cameras placed around the heart to build up a three-dimensional picture. In reality, we do not refer to these electrical views as cameras, but as leads, which are not to be confused with the physical leads that the electrodes are attached to. To record a 12-lead ECG, for example, you will only actually place 9 or 10 physical leads on the patient.

1.7.1 The ECG complex

An ECG complex is made up of a series of waves (a deflection from the baseline), segments and intervals which represent electrical events in the heart (Figure 12.8) [Garcia, 2015]:

• P wave: Atrial depolarisation

• PR segment: This is the part of the complex between the end of the P wave and the start of the QRS wave. It should be along the baseline (the line from one TP segment to the next)

• QRS wave. It should be 0.12–0.20 seconds (three to five small squares)

• QRS complex: This represents ventricular depolarisation and is typically made up of a Q, R and S wave. It should be less than 0.12 seconds or three small squares in duration

• ST segment: This is the part of the complex between the end of the QRS wave and the start of the T wave. The point at which the QRS wave ends and the ST segment begins is known as the J point. The ST segment should be on the baseline

• T wave: This wave represents ventricular repolarisation and is the first deflection (positive or negative) that occurs after the ST segment. It should begin in the same direction as the QRS complex.

Figure 12.8 Basic components of an ECG complex

2 Assessment of circulation

2.1 Learning objectives

By the end of this lesson you will be able to:

• Describe how to accurately measure the following:

• Pulse

• Capillary refill time

• Blood pressure.

2.2 Introduction

If you are asked to assess a patient’s pulse, or obtain a manual blood pressure, you have been given a big responsibility, since only you will know how fast, regular and strong the pulse feels, or when you can hear the Korotkoff sounds in your stethoscope as the blood pressure cuff is deflated.

Treatment decisions are made on the basis of clinical observations, so make sure you record observations accurately.

2.3 Pulse

The alternating expansion and recoil of the elastic arteries after ventricular systole creates a pressure wave, called a pulse, that can be felt in any artery that lies near the surface of the body and which can be compressed against a bone or other firm structure [Tortora, 2008].

Pulses are assessed for two main reasons [Gregory, 2010b]:

• To determine the patient’s cardiovascular status

• To provide reassurance and gain a bond with patients who may be anxious.

2.3.1 Pulse locations

Pulses are palpable all over the body, but you should be able to confidently locate the radial, brachial and carotid pulses (Figure 12.9). The other sites are useful for specific conditions, for example, checking that a patient with a leg fracture has a dorsalis pedis pulse.

Radial pulse

The radial artery can be palpated at the wrist, on the radial side (thumb side) of the palmar (inner) aspect of the forearm. It is lateral to the long flexor tendons of the forearm (Figure 12.10) [Allan, 2004].

Figure 12.9 The location of common palpable pulses

Figure 12.10 Palpating a radial pulse

Brachial pulse

There are two locations for measuring this pulse. The first is in the mid-arm and can be found medially in the cleft between the biceps and triceps muscles (Figure 12.11). However, this is where a blood pressure cuff is usually placed, so in that instance you can also palpate the pulse in the crease of the elbow (antecubital fossa, Figure 12.12). The pulse can be palpated just medial to the biceps tendon [Drake, 2005].

Carotid pulse

The carotid artery can be palpated between the larynx and the sternocleidomastoid muscle. Gently press to feel the pulse (Figure 12.13) [Gregory, 2010b].

Figure 12.11 Palpating a brachial pulse between the biceps and triceps muscles

Figure 12.12 Palpating a brachial pulse in the crease of the elbow

Figure 12.13 Palpating a carotid pulse

2.3.2 Assessment

When you assess a patient’s pulse, you are looking for four things:

• Rate

• Rhythm

• Volume

• Character.

Rate

The normal pulse rate for an adult is 60–100 beats/min [Allan, 2004]. If the pulse rate is less than 60 beats/min this is termed bradycardia, and if greater than 100 beats/min, tachycardia [Talley, 2006; Douglas, 2005].

Causes of bradycardia include:

• Sleep

• Athletic training

• Hypothyroidism

• Medications such as beta-blockers

• Hypothermia

• Some types of arrhythmia (abnormal electrical activity within the heart).

Causes of tachycardia include:

• Exercise

• Pain

• Excitement/anxiety

• Hyperthyroidism

• Fever

• Some types of stimulant drugs such as caffeine and cocaine

• Some arrhythmias.

Rhythm

In healthy patients, the rhythm should be regular. However, in certain arrhythmias this regularity can be interrupted. Try to identify whether the irregularity is regular, i.e. seems to occur in a pattern, or the beats are apparently completely random, i.e. irregularly irregular [Gregory, 2010b].

Volume and character

The volume reflects the strength of the pulse. A high volume is typically noted during times when the cardiac output is high, such as during exercise, stress, heat and pregnancy. On the other hand, a low-volume pulse can be due to heart failure or peripheral vascular disease. A weak (also described as ‘thready’) pulse is most often seen in patients who are suffering from a decreased blood volume (hypovolaemia, or shock) [Douglas, 2005].

The character of the pulse is slightly different as you need to picture how the pulse changes during the cardiac cycle. This is tricky to master and will require practice.

2.3.3 Recording a pulse

Procedure

Take the following steps to record a pulse [Gregory, 2010b]:

1. Explain the procedure and obtain consent from the patient

2. Place your index, middle and ring fingers along the artery and press gently. Avoid using the thumb as it has its own pulse. Don’t push too hard, or you will occlude the artery. As a general rule, palpate the radial pulse first in conscious patients, and the carotid pulse first in unconscious patients

3. In pulses with a regular rhythm, count for 15 seconds and then multiply by 4. If the pulse is very fast or slow and/or irregular then count for a full 60 seconds

4. Record the pulse rate on the patient record.

2.4 Capillary refill time

Capillary refill time (CRT) is defined as the time taken for a distal capillary bed to regain its colour after pressure has been applied to cause blanching [Pickard, 2011]. It was introduced during World War 2 to estimate the degree of shock in battlefield survivors. In 1981, an upper limit of 2 seconds was arbitrarily chosen as the acceptable upper limit; this has become the acceptable normal value and is published widely [King, 2014].

This presents a problem, because subsequent research has generally determined that it is not a good indicator of the degree of hypovolaemia in seriously ill and injured adult patients, and should not be used [Lewin, 2008].

It does have a place in the assessment of children, although it should not be taken in isolation, i.e. take into account the other aspects of patient assessment that you will undertake, such as pulse rate, respiratory rate, work of breathing, level of consciousness etc. [King, 2014].

Because the usefulness of CRT is uncertain, you will need to follow local guidance about when to use CRT and in which age group.

2.4.1 Assessment

Be aware of the following external factors that can affect the accuracy of capillary refill time (CRT) measurement in children and neonates [King, 2014]:

• Temperature: Children in cool environments will have a prolonged CRT, even when they are completely healthy. There is no evidence that CRT is affected by a child’s body temperature, such as when they are feverish due to an illness

• Ambient light: Assessing CRT in poor light leads to errors. Ensure you are somewhere well lit

• Site: CRT is longer in neonates if the heel is used. One study demonstrated that fingertip and sternum CRT s are different in children [Crook, 2013]. Current paediatric guidelines advocate only using the sternum to assess CRT in children [Skellett, 2016]

• Pressure application: It is not known how long pressure should be applied prior to assessing CRT, but current paediatric guidelines suggest pressing on the sternum for 5 seconds [Skellett, 2016]

• Observer: When different people (observers) measure CRT at the same time, on the same child, they end up with different results! As a rule of thumb, try to ensure that the same clinician assesses CRT each time.

2.4.2 Recording the capillary refill time

Procedure

Follow these steps to obtain a capillary refill time (CRT) [Gregory, 2010b; King, 2014]:

1. Ensure the environment is warm and well lit

2. Explain the procedure to the parent, and to the child if they are able to understand

3. Apply pressure to the sternum for 5 seconds to compress blood from the tissues. Only apply enough pressure to cause blanching of the skin

4. Release the pressure and count how long it takes for the colour of the skin to return to that of the surrounding tissues. This is the CRT

5. Document your findings

6. Consider this result in the light of other assessments of the child’s cardiovascular status.

2.5  Blood pressure – extended skill

Blood pressure (BP) is the measurement of the pressure by the blood on the walls of a blood vessel. It is highest in the aorta and large systemic arteries and lowest in the large veins [Tortora, 2008].

A BP that you record consists of two measurements [Gregory, 2010b]:

• Systolic blood pressure: The BP during the systole phase of the cardiac cycle, when the ventricles contract and blood is forced out of the heart. This is the higher reading of blood pressure

• Diastolic blood pressure: The BP during the diastole phase of the cardiac cycle, when the ventricles are relaxed. This is the lower reading of blood pressure

• It is usually measured in millimetres of mercury (mmHg) and recorded as the systolic value over the diastolic, for example 120/80 mmHg.

2.5.1 Assessment

Blood pressure (BP) values

The normal range for adult BP is a systolic value of 120–129 mmHg and/or diastolic of 80–84 mmHg. Hypertension (high BP) is defined as a systolic value of 140 mmHg or higher and/or a diastolic of 90 mmHg or higher [Mancia, 2013].
Hypotension is usually defined as a systolic blood pressure of less than 90 mmHg in adults [AACE, 2016].

Measurement of BP

Blood pressure can be measured directly, by inserting a sensor into a patient’s artery, or indirectly using a cuff, which is applied to a patient’s arm. The advantage of direct measurement is that it is accurate and continuous; it is typically used in hospital intensive care units. This method is not practicable outside of hospital and so non-invasive methods are used.

Non-invasive blood pressure (NIBP) measurement

There are two methods of NIBP measurement used by the ambulance service [Gregory, 2010b]:

• Auscultatory: This method uses a stethoscope and an aneroid sphygmomanometer, a device consisting of an inflatable cuff and an aneroid manometer to measure the pressure on a dial (Figure 12.14)

• Automated: This consists of an inflatable cuff with a sensor inside that detects the oscillations generated by turbulent blood flow and calculates systolic and diastolic values using an algorithm.

Figure 12.14 An aneroid sphygmomanometer

Image reproduced by the kind permission of Welch Allyn®

Korotkoff sounds

When using the auscultatory method of measuring BP, you will place a stethoscope over the patient’s brachial artery and listen for turbulent blood flow, known as the Korotkoff sounds, after a Russian surgeon, Nikolai Korotkoff, who first described them in 1905 [Talley, 2006].

The sounds are split into five phases [O’Brien, 2003]:

1. The first appearance of faint, repetitive, clear tapping sounds that gradually increase in intensity for at least two consecutive beats is the systolic blood pressure. This corresponds to the restoration of blood flow, and is confirmed by the presence of a palpable pulse

2. A brief period may follow during which the sounds soften and acquire a swishing quality. In some patients, sounds may disappear altogether for a short time

3. The return of sharper sounds, which become crisper, to regain or even exceed the intensity of phase 1 sounds

4. The distinct, abrupt muffling of sounds, which become soft and blowing in quality

5. The point at which all sounds finally disappear completely is the diastolic pressure.

Note that in some groups of patients, the phase 4 sounds may be heard until the BP measurement reaches 0 mmHg. In these cases, the onset of phase 4 is taken to be the diastolic BP measurement [O’Brien, 2003].

2.5.2 Blood pressure measurement

Procedure – manual blood pressure measurement

Take the following steps to manually record a blood pressure [Mancia, 2013; Kauffman, 2014; Gregory, 2010b; O’Brien, 2003]:

1. Ideally, allow the patient to sit for 3–5 minutes before measuring, and obtain consent

Ask about any medical conditions that might prevent a BP being recorded on a particular arm, e.g. mastectomy or arterio-venous shunts in dialysis patients

Ensure the arm is free of restrictive clothing and bare the arm. Do not apply a cuff over clothes

2. Palpate the brachial artery. This can be found by placing the pads of the index and middle fingers of one hand on the biceps tendon and then move medially and press deeply. If you have trouble locating the brachial pulse, ask the patient to extend their arm, which will bring the artery into a more superficial position. Once it is located, ask the patient to relax their arm so that their wrist rests on their thigh

3. Ask the patient to remain still and not talk during the BP measurement

Select the appropriate cuff size. A standard bladder is 12–13 cm wide and is 35 cm long, but have smaller and larger sizes available

Ensure the cuff is at heart level and wrap snugly around the patient’s upper arm and clear of the antecubital fossa, so that the cuff will not touch the stethoscope

Place the artery marker on the cuff over the patient’s brachial artery

4. Palpate the brachial artery and inflate the cuff until the pulse disappears. Continue to inflate 30 mmHg above this point

Slowly deflate the cuff and note when the pulse returns. This gives an estimation of the systolic blood pressure

5. Wait 30 seconds and then place the diaphragm of the stethoscope over the brachial artery

Rapidly inflate the cuff 30 mmHg above your estimation of the systolic blood pressure

Deflate at a rate of 2–3 mmHg per pulse beat

Note the pressure at which you first hear the Korotkoff sounds (systolic BP), the point at which they become muffled (phase 4) and then disappear (phase 5). The disappearance of sounds is usually taken to be the diastolic blood pressure

Document the blood pressure including which arm the measurement was taken from

Automated blood pressure measurement procedure

Follow the manufacturer’s instructions for the measurement of an automated blood pressure. The steps below apply to recording a BP using a LifePak 15 monitor/defibrillator [Physio-Control, 2009]:

1. Press ON

2. Select the appropriately sized cuff and apply it snugly to the arm

3. Connect the tubing to the cuff and to the NIBP port on the monitor

4. Change the initial inflation pressure, if necessary

5. Position the arm in a relaxed and supported position at approximately the same level as the patient’s heart. Inform the patient that the cuff will inflate and cause a ‘big squeeze’ around the arm and that the patient’s fingers may tingle

6. Press NIBP to start the measurement, and check that the patient’s arm is not moving. When the measurement is complete, the blood pressure measurements are displayed.

3 Cardiovascular system disorders

3.1 Learning objectives

By the end of this section you will be able to:

• Describe the following conditions of the cardiovascular system and their management:

• Coronary artery disease

• Stable angina

• Acute coronary syndromes

• Heart failure

• Explain the types, causes and stages of shock and their management.

3.2 Introduction

Many of the cardiovascular conditions you are going to learn about in this section are most commonly caused by the consequences of coronary artery disease (CAD), which worldwide is the most common cause of death, with around 7 million people dying from it each year [Steg, 2012].

3.3 Coronary artery disease

Coronary artery disease (CAD, sometimes called ischaemic heart disease) is almost always caused by atherosclerosis of the coronary arteries. This is a systemic, lipid (fat) driven immune/inflammatory disease of the medium and large arteries. Over time (usually decades), atherosclerosis causes the formation of plaques: collections of lipids and cholesterol that accumulate in the intimal layer of arteries, some of which attract macrophages (a type of white blood cell). The macrophages secrete protein-dissolving enzymes and engulf the lipids, leaving behind a lipid-rich ‘necrotic core’ [Falk, 2003].

The interface between the plaque and the lumen of the artery is known as the fibrous cap. If it becomes thickened it can cause narrowing of the artery lumen (stenosis), which if significant leads to cardiac ischaemia, particularly when myocardial oxygen demand rises, such as when the patient exercises. This can lead to stable or exertional angina. If the plaque ruptures, the artery can become occluded (blocked), leading to an acute coronary syndrome [Aaronson, 2004].

3.4 Stable angina

Angina is a pain or discomfort usually felt across or in the centre of the chest as a tightness or indigestion-like ache. This can radiate to one or both arms, the neck, back or epigastrium (the portion of the abdomen between the diaphragm and umbilicus or belly button). It can be accompanied by belching, which may be wrongly assumed to be due to indigestion [Nolan, 2016].

To be classed as stable it should consist of [Montalescot, 2013]:

• Classic chest discomfort as described above

• Provoked by exertion or emotional stress

• Relieved by rest and/or nitrates (drugs that dilate the vessels) within minutes.

Stable angina is caused by significant stenosis (> 70%) of at least one coronary artery due to coronary artery disease (CAD). This causes narrowing of the artery, which at rest still allows sufficient oxygenated blood to the myocardium. However, during exercise or stress, coronary oxygen demand increases. This demand can be met by increasing blood flow through increasing the diameter of the arteries. However, this is not possible in stenosed vessels and the resulting imbalance of oxygen supply and demand leads to myocardial ischaemia [Aaronson, 2004].

3.5 Acute coronary syndrome

Acute coronary syndrome (ACS) represents a spectrum of three dangerous conditions, all of which constitute medical emergencies and result from a sudden decrease in coronary artery blood flow [Aaronson, 2004]. These three conditions, in order of increasing severity, are:

• Unstable angina (UA)

• Non-ST-segment elevation myocardial infarction (NSTEMI)

• ST-segment elevation myocardial infarction (STEMI).

Since the treatment of UA and NSTEMI is similar, they are usually considered together. The ST-segment in NSTEMI and STEMI refers to the portion of an ECG complex which may change (STEMI) or not (NSTEMI) during a myocardial infarction (heart attack).

3.5.1 Pathophysiology

The steps that lead to an ACS consist of [Aaronson, 2004]:

1. Rupture of the fibrous cap leads to platelet aggregation (clumping together)

2. Intraplaque thrombus (blood clot) expands the plaque and can occlude the artery if large enough

3. Intraluminal thrombus resulting in partial or complete occlusion of the artery

4. Release of vasoconstricting substances associated with platelet aggregation, which makes the vessel constrict and narrow

5. Endothelial damage promotes further vasoconstriction.

3.5.2 Assessment

The most common presentation of ACS is chest pain felt just under the sternum (sub-sternal) that may be described as heavy, squeezing, crushing or tight, that has lasted for more than 15 minutes and has not been relieved by GTN. The pain radiates to the left arm in about 40% of patients, although it can also radiate to the right arm/shoulder or both left and right arms [Body, 2010]. In addition, it can also radiate to the neck, jaw, upper back or epigastrium. The pain can be confused with indigestion and patients may even have tried antacid medication to relieve the discomfort. Pain is not typically altered by deep breathing or coughing. The patient may have other symptoms, such as [AACE, 2016]:

• Nausea and vomiting

• Marked sweating (diaphoresis)

• Pale, clammy skin

• Shortness of breath

• A feeling of impending doom.

Note that up to 5% of patients do not have chest pain [Valensi, 2011]. These are more likely to be women, and have diabetes or a history of heart failure [Canto, 2012].

3.5.3  Aspirin – extended skill

The indications and contra-indications listed below are taken from the UK Ambulance Services Clinical Practice Guidelines [AACE, 2016]. However, you should be familiar with your own service guidelines as restrictions on administration may exist.

Presentation

• 300 milligram (mg) aspirin (acetylsalicylic acid) in tablet form (dispersible).

Actions

• Has an anti-platelet action which reduces clot formation

• Analgesic, antipyretic and anti-inflammatory.

Indication

• Adults with clinical or ECG evidence suggestive of myocardial infarction or ischaemia.

Contra-indications

• Known aspirin allergy or sensitivity

• Children under 16 years (see additional information)

• Active gastrointestinal bleeding

• Haemophilia or other known clotting disorders

• Severe hepatic disease.

Cautions

• As the likely benefits of a single 300 mg aspirin tablet outweigh the potential risks, aspirin may be given to patients with:

• Asthma

• Pregnancy

• Kidney or liver failure

• Gastric or duodenal ulcer

• Current treatment with anticoagulants.

Side effects

• Gastric bleeding

• Wheezing in some asthmatics.

Dosage and administration

• Route: Oral – chewed or dissolved in water

• 300 mg tablet, no repeat dose

• In suspected myocardial infarction a 300 mg aspirin tablet should be given regardless of any previous aspirin taken.

3.5.4  GTN – extended skill

The indications and contra-indications listed below are taken from the UK Ambulance Services Clinical Practice Guidelines [AACE, 2016]. However, you should be familiar with your own service guidelines as restrictions on administration may exist.

Presentation

• Metered dose spray containing 400 micrograms glyceryl trinitrate per dose

• Tablets containing glyceryl trinitrate 2, 3 or 5 milligrams for buccal administration (depends on local ordering).

Actions

• A potent vasodilator drug resulting in:

• Dilatation of coronary arteries/relief of coronary spasm

• Dilatation of systemic veins resulting in lower pre-load

• Reduced blood pressure.

Indication

• Cardiac chest pain due to angina or myocardial infarction.

Contra-indications

• Hypotension (systolic blood pressure < 90 mmHg)

• Hypovolaemia

• Head trauma

• Cerebral haemorrhage

• Sildenafil (Viagra) and other related drugs – glyceryl trinitrate must not be given to patients who have taken sildenafil or related drugs within the previous 24 hours. Profound hypotension may occur

• Unconscious patients.

Side effects

• Hypotension

• Headache.

Dosage and administration

• Route: Sub-lingual for spray and buccal for tablets

• Sub-lingual spray: 1–2 sprays providing 400–800 micrograms of GTN

• Buccal: 2, 3 or 5 mg tablet

• Repeat every 5–10 minutes

• No maximum dose, although side effects may limit repeat dosages.

3.5.5 Management

The management of ACS includes [AACE, 2016]:

• Correction of major ABC problems

• Oxygen, if the patient has oxygen saturations of less than 94% on air

• Administration of aspirin

• Assisting the patient to take their own GTN

• Being prepared to resuscitate the patient if they suffer a cardiac arrest.

3.6 Heart failure

Heart failure is an abnormality of cardiac structure or function, leading to failure of the heart to deliver oxygen at a sufficient rate to meet cell and tissue metabolic needs, despite normal filling pressures [McMurray, 2012].

Patients who have been suffering from heart failure for some time are classed as having chronic heart failure. If their signs and symptoms have not changed in the past month, then it is considered to be stable. On the other hand, if there is an acute deterioration in these patients, they are considered to be suffering from acute decompensated heart failure (often just called acute heart failure, AHF) [Allen, 2007].

Although the most common cause of AHF is sudden worsening of chronic heart failure, about 20–30% of cases are a new-onset heart failure, with a small percentage due to malignant hypertensive crisis (blood pressure that is high enough to damage the body’s organs) or cardiogenic shock. Up to 25% of cases are caused by an acute coronary syndrome, although these are normally considered separately from ‘typical’ AHF because of the differing presentation, pathophysiology and treatment [Howlett, 2011].

3.6.1 Assessment

Heart failure can be difficult to diagnose in the pre-hospital environment, since many of the symptoms are non-specific (Table 12.1), making it difficult to differentiate AHF from other conditions such as pneumonia, chronic obstructive pulmonary disease (COPD) and pulmonary oedema [Williams, 2013]. The more specific symptoms (such as orthopnoea, paroxysmal nocturnal dyspnoea (PND) and haemoptysis) are less common [Dobson, 2009].

3.6.2 Management

The management of acute heart failure includes [AACE, 2016]:

• Correction of major ABC problems

• Oxygen, if the patient has oxygen saturations of less than 94% on air.

3.7 Shock

Shock is a clinical state in which the delivery of oxygenated blood (and other nutrients such as glucose) to the body’s tissues is not adequate to meet metabolic demand [Skellett, 2016].

The types of shock vary between textbooks, but five types are included here:

• Hypovolaemic shock

• Distributive shock

• Cardiogenic shock

• Obstructive shock

• Dissociative shock.

3.7.1 Hypovolaemic shock

This is an acute loss of circulating blood volume either from dehydration (loss of fluids and electrolytes) or from bleeding (haemorrhage) externally or internally. Shock due to blood loss (haemorrhagic shock) has been classified into four classes (stages) [NAEMT, 2014]:

• Class 1: The body is able to cope with losses and there are no obvious clinical signs

• Class 2: This is the compensated stage. Blood loss is more significant, but the body has mechanisms to maintain blood pressure despite the reduction in blood volume

• Class 3: This is the decompensated stage. Despite the compensatory mechanisms, blood loss is now too severe to maintain blood pressure. These patients require blood and urgent surgical intervention to stop the bleeding

• Class 4: The irreversible stage. Even if the circulation is restored, the patient is still likely to die.

Table 12.1 History, signs and symptoms of heart failure

History

Signs

Symptoms

Patient age

Tachypnoea

Shortness of breath

Coronary artery disease

Crackles

Dyspnoea

Hypertension

Dullness to percussion

Orthopnoea

High cholesterol

Reduced SpO₂

Fatigue

Valvular disease (e.g. mitral regurgitation or aortic stenosis)

Haemoptysis

Paroxysmal nocturnal dyspnoea

Known heart failure or myocardial injury

Tachycardia

Reduced exercise tolerance

Loop diuretic use (e.g. furosemide)

Peripheral oedema

Ankle swelling

Arrhythmias

Enlarged liver

Note that the original stages of shock described by the advanced trauma life support (ATLS) and pre-hospital trauma life support (PHTLS) courses included blood loss estimates and clinical observations (such as heart and respiratory rate, blood pressure and level of consciousness) which would indicate the stage of shock the patient was experiencing [ATLS, 2008; NAEMT, 2014]. These have been shown by numerous studies to be inaccurate and so are not included here [Guly, 2010; Mutschler, 2013; Mutschler, 2014]. You will, however, still find them in many textbooks.

Signs of hypovolaemic shock

The classic signs of hypovolaemic shock include [AACE, 2016]:

• Pallor

• Cool peripheries

• Anxiety and abnormal behaviour

• Increased heart and respiratory rates.

Note that these may not appear until 1000–1500 ml of blood has been lost, and even later in some patient groups such as pregnant women, patients on medication such as beta-blockers, and fit individuals.

3.7.2 Distributive shock

This type of shock is caused by widespread dilation of the peripheral vascular system because of dilation of the arterioles and/or venules. This in effect creates a larger container for the same blood volume, leading to decreased tissue perfusion. In addition, in causes such as anaphylaxis and sepsis, the vessels become ‘leaky’, allowing fluid to escape into the tissues and so becoming removed from the general circulation [Pilbery, 2013].

Common causes of distributive shock include:

• Anaphylaxis

• Sepsis

• Nervous system related cause such as spinal cord injury [Pilbery, 2013].

3.7.3 Cardiogenic shock

This is due to a primary cardiac problem when the heart is unable to circulate sufficient blood to meet the body’s metabolic needs. This is most common following a myocardial infarction, but can also be caused by acute heart failure or arrhythmia.

3.7.4 Obstructive shock

This is an uncommon cause of shock and is due to an obstruction of blood flow to/from the heart. It can be caused by a tension pneumothorax, cardiac tamponade or a massive pulmonary embolism [Evans, 2012].

3.7.5 Dissociative shock

This occurs when the oxygen-carrying capacity of the blood is affected because of inadequate numbers of red blood cells available to carry sufficient oxygen (anaemia) or when competing molecules take up space on the red blood cells that would normally be used to carry oxygen, such as in cases of carbon monoxide poisoning [Skellett, 2016].

3.7.6 Management

Your management of shock will include [AACE, 2016; Zideman, 2015]:

• Identify and control sources of external bleeding

• Administer high levels of supplemental oxygen via a non-rebreathe mask

• Place patients supine and, if there is no history of trauma, raise their legs. Note that this is only likely to provide transient improvement in vital signs (typically less than 7 minutes).

Chapter 13: Disability

1 Nervous system anatomy and physiology

1.1 Learning objectives

By the end of this section you will be able to:

• State the functions of the nervous system

• Describe the anatomy and physiology of the nervous system.

1.2 Introduction

The nervous system performs three main functions in order to carry out a complex range of tasks including controlling body movements, regulating heart rate, creating memories and producing speech [Tortora, 2008; Briar, 2003]:

• Sensory function (perception): Receptors located around the body detect internal stimuli, such as a change in blood pressure, and external stimuli, such as a bad odour, and transmit this via afferent nerves through the cranial and spinal nerves and into the brain and spinal cord

• Information transfer and processing: Nerve cells (neurons) have special projections (axons) that allow the conduction of electrical impulses. These can be delivered to other neurons, and/or modified by or integrated with other impulses to create a complex web that can process sensory information received from afferent neurons

• Motor function: This is the nervous system’s response to the processing stage and is communicated via efferent nerves, which carry electrical impulses from the brain via cranial or spinal nerves. This enables the brain to control the body as well as control ventilation and circulation.

1.3 Anatomy and physiology

The nervous system (Figure 13.1) consists of the brain and spinal cord (generally referred to as the central nervous system, CNS) and a network of peripheral nerves either originating from the brain (as 12 pairs of cranial nerves) or the spinal cord (as 31 pairs of spinal nerves). Together with small collections of neurons known as ganglia, these form the peripheral nervous system (PNS).

Figure 13.1 The nervous system

The PNS consists of two divisions. The first is the sensory, or afferent, division, which is composed of large numbers of sensory receptors in the skin. Their nerve impulses are conveyed by somatic sensory fibres, as well as internally around the body (impulses from which are transmitted by visceral sensory fibres), and an extensive network of neurons around the gastrointestinal tract, collectively known as the enteric plexus, which helps regulate digestion. The other division of the PNS is the motor, or efferent, division. This is split into the somatic nervous system and the autonomic nervous system [Marieb, 2013; Tortora, 2008].

1.4 Brain

The portion of the central nervous system that is contained within the skull is known as the brain. The brain occupies 80% of the cranial vault, with the remaining 20% made up of cerebral blood (12%) and cerebral spinal fluid (8%). It has a wide range of functions as well as serving as the centre for intellect, emotions, behaviour and memory. The brain is generally divided into four major sections (Figure 13.2) [Tortora, 2008]:

• Brain stem

• Cerebellum

• Diencephalon

• Cerebrum.

Figure 13.2 The brain

1.4.1 Brain stem

The brain stem consists of the medulla oblongata, pons and midbrain. Their functions include:

• Medulla oblongata

• Relays sensory and motor input between other parts of the brain and spinal cord

• Together with pons and midbrain, controls level of consciousness

• Contains centres to manage heart rate, blood pressure and breathing

• Contains origins of a number of cranial nerves

• Pons

• Relays nervous impulses from one side of the cerebellum to the other and between medulla and midbrain

• Contains origins of a number of cranial nerves

• Contains centres to regulate breathing

• Midbrain

• Relays motor output from the cerebral cortex and sensory input from the spinal cord to the thalamus

• Controls and co-ordinates movement

• Contains origins of two cranial nerves.

1.4.2 Cerebellum

This part of the brain is responsible for co-ordinating complex and skilled movements and regulates posture and balance.

1.4.3 Diencephalon

The diencephalon consists of two of the brain’s structures:

• Thalamus

• Relays sensory input to the cerebral cortex

• Provides perception of touch, pressure, pain and temperature

• Hypothalamus

• Controls and integrates autonomic nervous system activity

• Regulates behavioural patterns and circadian rhythms

• Controls body temperature

• Regulates eating and drinking behaviour.

1.4.4 Cerebrum

The cerebrum allows you to read, write and speak. Various regions are responsible for a range of other functions:

• Sensory areas are involved in perception of sensory information

• Motor areas control muscular movements

• Association areas are responsible for complex functions such as memory, personality and intelligence.

The cerebrum is split into two hemispheres and consists of an outer rim of grey matter and an internal region of white matter. The outer rim of grey matter contains the cerebral cortex which, although thin, contains billions of neurons. Each hemisphere can also be further divided into four lobes: frontal, parietal, occipital and temporal.

1.4.5 Meninges

In addition to the skull, the brain is protected by the meninges. There are three of them [Tortora, 2008]:

• Dura: Tough outer layer consisting of connective tissue

• Arachnoid: Middle layer. The sub-arachnoid space (between arachnoid and pia layers) is filled with cerebrospinal fluid

• Pia: Delicate inner layer containing small blood vessels which supply oxygen and nutrients to the brain.

1.4.6 Cerebrospinal fluid

Cerebrospinal fluid (CSF) is a clear, colourless liquid, which protects the brain and spinal cord from physical and chemical injury. It also carries oxygen, glucose and other nutrients that are essential for normal brain function, as well as removing waste products [Tortora, 2008].

1.5 Spinal cord

The vertebral column consists of 33 vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral and 4 coccygeal. Part of their function is to provide physical protection for the spinal cord, which the vertebrae encapsulate. Additional protection is provided by vertebral ligaments, meninges and the cerebrospinal fluid (CSF) [Tortora, 2008]. Rather confusingly, there are 31 pairs of spinal nerves: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal (Figure 13.3).

Figure 13.3 Spinal nerves

The spinal cord is almost cylindrical in shape, although slightly squashed in the anterior– posterior dimension. Its average diameter is just 12 mm, and in adults it extends from the medulla oblongata to the superior border of the second lumbar vertebra (L2), i.e. it does not extend the full length of the vertebral column. Instead, it tapers to form a cone-like structure called the conus medullaris [Tortora, 2008]. Nerves that originate distal to the conus medullaris form the cauda equina (meaning horse’s tail). These nerves have a dorsal root containing afferent fibres which transmit sensation, and a ventral root containing efferent motor fibres [Gitelman, 2008].

1.6 Somatic nervous system

The somatic nervous system is also sometimes known as the voluntary nervous system, since it allows the person to consciously control their skeletal muscles thanks to somatic nerve fibres which conduct impulses from the central nervous system to skeletal muscles [Marieb, 2013]. However, the somatic nervous system also includes an involuntary component: reflexes. These are primarily a protective mechanism, for instance removing your hand when you touch something hot [Tortora, 2008].

1.7 Autonomic nervous system

The autonomic nervous system (ANS) is divided into three parts. These are the sympathetic, parasympathetic and enteric nervous systems. They are called autonomic because it was originally believed that they functioned completely independently from the central nervous system (CNS). However, it is now known that the hypothalamus and brain stem regulate ANS activity [Tortora, 2008]. The enteric division is an extensive network of neurons which reside within the walls of the gastrointestinal (GI) tract, pancreas and gall bladder. It has a sensory nervous function enabling the monitoring of the mechanical state of the alimentary canal and the chemical status of the stomach and intestines. In addition, it can output motor signals to modify the motility and secretions of the gut, as well as controlling the diameter of local blood vessels [Briar, 2003].

1.7.1 Sympathetic and parasympathetic divisions

The sympathetic and parasympathetic divisions of the ANS are often thought of as being at either end of a see-saw. This is true in some organs such as the heart, but in reality this is rather a simplistic view. Some parts of the body receive inputs from only one division, whereas in others, the effects of the sympathetic and parasympathetic divisions are similar. However, their actions are carefully controlled and co-ordinated by the hypothalamus.

This is often referred to as the fight-or-flight division as its actions prepare the body to respond to stress, facilitating sudden strenuous exercise and increased vigilance. In addition, it helps control blood pressure, thermoregulation, and gut and urogenital function.

The parasympathetic division is often referred to as the rest-and-digest division. Actions of the parasympathetic division include antagonising some effects of the sympathetic division, for example heart rate, gut motility and bronchiole diameter, and controlling many body functions in non-stress states such as GI secretion to aid digestion, micturition and defaecation.

Another important difference between the sympathetic and parasympathetic divisions is their structure. Parasympathetic neurons are clustered at either end of the spinal cord, whereas the sympathetic neurons originate from the thoracolumbar section.

2 Assessment of disability

2.1 Learning objectives

By the end of this section you will be able to:

• Describe how to undertake and record the following:

• Pupillary response

• Face, arm, speech test.

2.2 Introduction

A complete assessment of the nervous system is involved and requires a number of tests, which is beyond the scope of the CFR. However, there are a couple of useful and simple tests that you can perform, which will uncover the presence of serious neurological problems in your patient and help determine the most appropriate management for them. You have already met one of them, AVPU, in the Patient Assessment chapter.

2.3 Pupillary response

Before switching on your pen torch to check the patient’s pupils, have a look at the pupils’ relative size to determine whether they are unequal. This is known as anisocoria and is a normal finding in around 20% of the population [Kaeser, 2010]. Look for changes in shape (e.g. oval in acute angle-closure glaucoma, asymmetrical in a penetrating injury).

2.3.1 Pupillary reactions

Test pupillary reaction by assessing direct response to light [James, 2011]:

• Shine your pen torch directly on each eye in turn for 3 seconds. This should cause a prompt constriction of the pupil. Failure to do so is known as an afferent pupillary defect and indicates severe optic nerve pathology (transected nerve). There will also be failure of the opposite pupil to constrict. If there is no pupillary reaction but the opposite pupil does constrict, consider a traumatic iris paresis.

2.4 Face, arm, speech test

With the advent of clot-busting drugs (thrombolytics) for the management of acute stroke, the need for prompt recognition of stroke has never been greater. A simple tool that can be used to identify a patient suffering from a stroke is the Newcastle face, arm, speech test (FAST) [NAO, 2010].

The FAST consists of three components [Harbison, 2003]:

• Facial palsy: Ask the patient to smile or show their teeth. Look for new lack of symmetry. This is positive if there is an unequal smile, grimace or obvious facial asymmetry

• Arm weakness: Lift the patient’s arms together to 90° (45° if they are lying on their back) with the palms uppermost (Figure 13.4). Ask them to close their eyes and hold that position for 5 seconds. Look for one arm drifting or falling rapidly

• Speech impairment: During the course of a conversation (if the patient can speak), look for new speech disturbance. This may require asking someone who knows the patient. Specifically, look for slurred speech and word-finding difficulties. Ask the patient to identify common objects (such as keys, a cup, chair and pen). If the patient has a severe visual disturbance, place the object in the patient’s hands and ask them to name it.

The presence of one or more of these signs constitutes a positive FAST (Figure 13.5).

Figure 13.4 A patient performing the FAST

Figure 13.5 A positive FAST, due to a facial palsy and arm weakness

3 Disorders of the nervous system

3.1 Learning objectives

By the end of this section you will be able to:

• Explain the pathophysiology relating to a range of neurological disorders

• Describe the management of a range of neurological disorders

• List several causes of coma.

3.2 Introduction

In this section, you will learn about a range of nervous system disorders. The nervous system is extremely complex and you will learn about only a few of the many disease processes. However, it is important to be able to recognise patients with epilepsy, stroke, meningococcal disease and patients who are unconscious. Timely and appropriate management can result in better outcome: in some cases, literally the difference between life and death, and/or life-altering disability.

3.3 Epilepsy

Epilepsy is not a single condition, but a term used to describe a tendency to have recurrent, unprovoked convulsions (also called seizures and fits). It is the commonest of the serious neurological conditions [Smithson, 2012].

Convulsions result from the synchronised and excessive activation of neurons in the cerebral cortex. How this presents clinically depends on where this activity starts and how far and fast it spreads through the brain [Briar, 2003]. Convulsions are divided into two broad categories:

• Partial (focal) convulsions: As the name suggests, these originate from a specific area of the cortex, typically the temporal or frontal lobes. They are split into two sub-types [Smithson, 2012; Briar, 2003]:

• Simple partial: Patients remain conscious but may complain of ‘butterflies’ in their stomach, fear, illusions and hallucinations. These are usually brief

• Complex partial: Complex refers to an altered level of consciousness and is characterised by the patient chewing, lip-smacking and fiddling with their hands. These usually resolve within a few minutes

• Generalised convulsions: These convulsions are also divided into two sub-types:

• Tonic-clonic: These convulsions consist of two phases. In the tonic phase, the patient goes stiff (and may cry out), falls (if standing) and bites their tongue as the jaw clenches. This is followed by the clonic phase, characterised by regular jerking movements, which start in the upper limbs. These eventually slow and stop, which may herald the onset of incontinence. Patients typically experience a post-ictal period following a tonic-clonic convulsion, where they may be sleepy and confused. This usually resolves within 20 minutes

• Absence convulsions: These typically begin in childhood and adolescence and consist of ‘day-dreaming’, with a few seconds of staring into space, eyelid fluttering, swallowing and head flopping.

3.3.1 Febrile convulsions

Patients with febrile convulsions are not considered to be epileptic, since the convulsion is provoked by a sudden increase in temperature. The most commonly affected age group is from 6 months to 6 years. They are not associated with an increased risk of developing epilepsy in later life [Lissauer, 2007].

3.3.2 Status epilepticus

Status epilepticus has traditionally been defined as a generalised convulsion lasting for more than 30 minutes, or a series of convulsions, where the patient does not become fully conscious between convulsions, lasting more than 30 minutes [ILAE, 1993]. However, it has been suggested that shortened timescales should be used since most convulsions last less than 5 minutes and those that last more than 5 minutes generally require therapeutic intervention, because they will not stop on their own [Brophy, 2012].

In adults and children, common causes of status epilepticus are withdrawal from or sub-therapeutic doses of anti-epileptic drugs. In children, the most common cause is febrile illness, whereas in adults, stroke is the most common cause. Approximately 16–38% of children diagnosed with status epilepticus are known epileptics. In adults, this figure increases to 42–50% [Chin, 2004; Neligan, 2010].

3.3.3 Post-ictal phase

For patients who suffer a generalised tonic-clonic convulsion, they typically enter a post-convulsion (post-ictal) phase which is characterised by a period of unresponsiveness and then a gradual return of consciousness. The patient is likely to be drowsy and disorientated, which can last 15 minutes to an hour (and in some cases, longer). Complaints of a headache are common [Kumar, 2012].

3.3.4 Management of convulsions

As with all patients, start by ensuring they have a patent airway. This can be achieved by a combination of patient positioning (e.g. the recovery position) and airway adjuncts. An oropharyngeal airway can be difficult to insert when patients are convulsing and should not be forced into the patient’s mouth [AACE, 2016].

Administer high-concentration oxygen (as close to 100% as possible) via a non-rebreathe mask (or bag-valve-mask) at a flow rate of 15 l/min. In adults, once a reliable pulse oximetry reading has been obtained, oxygen administration can be titrated to maintain saturations of 94–98%. Children should continue to receive high concentrations of oxygen irrespective of the pulse oximeter reading [AACE, 2016].

3.4 Stroke

Stroke is a syndrome consisting of rapidly developing (usually seconds or minutes) symptoms and/or signs of focal central nervous system (CNS) function. The symptoms last more than 24 hours or lead to death. A transient ischaemic attack is essentially the same thing as a stroke, with the exception of the duration of symptoms, which last less than 24 hours and are not caused by a haemorrhage [Ginsberg, 2004]. Stroke is the third most common cause of death in England; around 110,000 strokes occur in England every year, a quarter of them in people under 65 years of age [NAO, 2005].

3.4.1 Anatomy and physiology

The brain cannot store oxygen or glucose and so is dependent on a constant supply of blood, which is provided by two pairs of vessels, the vertebral and internal carotid arteries (Figure 13.6). These arteries are interconnected in the cranial cavity to produce an arterial circle (the circle of Willis), which provides an alternative pathway for blood flow should one of the vessels become occluded [Drake, 2005].

3.4.2 Risk factors

Non-modifiable risk factors for stroke include age, sex, race and family or previous medical history of

Figure 13.6 Arteries supplying the brain. Note all arteries shown are right-sided except the basilar artery stroke, transient ischaemic attacks or myocardial infarction. The chance of having a stroke roughly doubles each decade after the age of 55 years, and although it is more common in men, over half of all stroke deaths occur in women. People of South Asian, African or African-Caribbean origin are more likely to suffer from a stroke [O’Donnell, 2010]. Modifiable risk factors include hypertension, smoking, atrial fibrillation (AF), diabetes, diet, physical activity, alcohol consumption, blood cholesterol and obesity [Rodgers, 2004].

3.4.3 Types of stroke

Strokes can be classified as either ischaemic or vascular in origin. Ischaemic strokes are the most common and are caused by atherosclerosis or an embolus from the heart, for example. They are responsible for around 80% of all new strokes [O’Donnell, 2010; EROS, 2009]. Less common are strokes of vascular origin, caused by haemorrhage. Time is brain, and with each passing minute 1.9 million neurons, 14 billion synapses and 12 km (7.5 miles) of myelinated fibres are destroyed. This equates to the premature ‘ageing’ of the brain to the tune of 3.6 years for each hour without reperfusion treatment [Saver, 2006].

3.4.4 Assessment and management of stroke

• Assess ABCDE as for all patients

• Determining the time of onset in stroke is very important for subsequent treatment. Find out when the patient was last free of stroke-like symptoms

• Oxygen is not recommended unless the patient is hypoxic

• Record a blood sugar if trained to do so; hypoglycaemia is a common stroke mimic.

3.5 Meningococcal disease

Meningococcal disease is an umbrella term for a systemic bacterial infection caused by Neisseria meningitidis (meningococcus). It presents as meningitis (inflammation of the meninges), septicaemia or a combination of both [PHE, 2014a].

Although uncommon, of those affected around 10% will die (increasing to 50% in patients with septicaemia without meningitis), and over 10% of those who survive will suffer long-term effects, such as convulsions. It is most common in children under 4 years of age, with a smaller peak in incidence in teenagers aged 15–19 years [PHE, 2014b].

3.5.1 Pathophysiology

Meningococci inhabit the nasopharynx in around 10% of the population, although it is less common in infants (under 5%) and most common in 19-year-olds (over 23%). If the meningococci manage to penetrate the protective mucosa of the nasal passages and enter the bloodstream they rapidly multiply, doubling in number every 30 minutes.

In some people, meningococci cross the blood–brain barrier, where the bacteria are free to multiply inside the cerebrospinal fluid. This leads to inflammation and swelling in the meninges and brain tissue, raising intracranial pressure (ICP), which can result in nervous system damage and even death. Surprisingly, patients with meningococcal meningitis do better than those who go on to develop septicaemia. This is thought to be because the body’s immune response has prevented the bacteria from causing an overwhelming sepsis [Ninis, 2010].

3.5.2 Signs and symptoms

A major issue in the recognition of meningococcal disease is the non-specific nature of the signs and symptoms in the initial stages of the disease. These include [NICE, 2010b]:

• Fever

• Nausea/vomiting

• Lethargy

• Irritable/unsettled

• Ill appearance

• Refusing food/drink

• Headache

• Muscle ache/joint pain

• Respiratory signs and symptoms.

However, the diagnosis window is short. Many children will have non-specific signs and symptoms in the first 4–6 hours, but can be close to death after 24 hours [Thompson, 2006a].

3.5.3 Sepsis and shock

The first specific clinical signs to appear are likely to be those of sepsis and shock and include leg pain, abnormal skin colour, cold hands and feet and, in older children, thirst. Parents of younger children may also report drowsiness and difficulty in breathing (described as rapid or laboured) [Thompson, 2006a]. Don’t forget to enquire about how much urine a child has been passing or if they have had a wet nappy recently. Oliguria (low output of urine) is an early sign of shock [Ninis, 2010].

3.5.4 Fever

Many children with septicaemia will become acutely ill with a fever. This can be complicated by a trivial viral illness that precedes this, but look for a sudden change in the history. Remember that not all children with meningococcal disease have fever, and you should not dismiss a fever responsive to antipyretics (such as paracetamol and ibuprofen) as of viral origin [Ninis, 2010]. Rather counter-intuitively, infants can actually develop hypothermia in sepsis [Wells, 2001].

3.5.5 Rash

The classic sign is a petechial non-blanching rash (Figure 13.7). However, only 10% of children presenting with the rash will have meningococcal disease. The remainder will have a viral infection. On the other hand, febrile and ill children with a purpuric rash (a non-blanching rash of greater than 2 mm in diameter) are very likely to have meningococcal disease [Wells, 2001]. Care needs to be taken with blanching rashes, such as a maculopapular rash, as up to 30% of children may initially present with this, although careful examination will generally yield some non-blanching elements (Figure 13.8) [Hart, 2006]. On dark skin, you may have to check the soles of the feet, palms of the hand, abdomen or conjunctivae and palate. You must fully undress the child and be thorough in your search. Petechial rashes may not be widespread initially and can be easily missed.

Figure 13.7 Petechial non-blanching rash. Note how this does not blanch under the pressure of a glass

Courtesy Meningitis Research Foundation www.meningitis.org

Figure 13.8 Maculopapular rash with scanty petechiae

Courtesy Meningitis Research Foundation www.meningitis.org

3.5.6 Management

Patients with meningococcal disease need to be transported to hospital as soon as possible [AACE, 2016]. While you wait for an ambulance you should:

• Ensure a patent airway

• Administer high levels of oxygen to all patients via a non-rebreathe mask

• Assist ventilations if necessary.

3.6 Paralysis

In medical terminology, paralysis is typically represented by the suffix -plegia. This is not to be confused with paresis, which is used to refer to muscle weakness, or incomplete loss of muscle function [Porth, 2003]. Four common terms that you will hear used are [Douglas, 2005]:

• Monoplegia: Paralysis in a single limb

• Hemiplegia: Paralysis of both limbs on the same side of the body

• Quadriplegia (also tetraplegia): Paralysis of all four limbs

• Paraplegia: Paralysis of both the lower limbs.

3.7 Coma

Coma is the absence of consciousness (i.e. unconscious) and is often referred to as a loss of consciousness (LOC). This presents as a completely unaware patient unresponsive to external stimuli, with only eye opening to pain and no eye tracking or fixation, and limb withdrawal to a noxious stimulus (usually pain) at best (often with reflex motor movements) [Wijdicks, 2010].

Full consciousness is an awake state in which one is aware of oneself and the environment, including the ability to perceive and interpret stimuli and to interact and communicate with others in the absence of motor deficits [Young, 2014].

Common causes of coma include:

• Stroke – ischaemic and haemorrhagic

• Cardiac arrest

• Alcohol abuse

• Substance abuse and overdose

• Carbon monoxide poisoning

• Sepsis

• Bacterial meningitis

• Syncope (faint)

• Convulsions

• Traumatic brain injury

• Hyper-/hypoglycaemia.

Uncommon causes of coma include:

• Subarachnoid haemorrhage

• Brain abscess or tumour

• Burns

• Hypo-/hyperthermia.

It may not always be possible to determine the cause of coma and the management of the patient may just be supportive. However, for reversible causes, such as hypoglycaemia, convulsions and overdose, it is important to recognise these conditions as the patient can then receive the appropriate treatment out-of-hospital [AACE, 2016].

Chapter 14: Exposure/Environment

1 Extremes of temperature

1.1 Learning objectives

By the end of this section you will be able to:

• State the normal temperature range for an adult

• Explain the terms ‘hypothermia’ and ‘heat-related illness’

• Describe the appropriate management for a patient with signs of hypothermia and heat-related illness.

1.2 Introduction

Despite being exposed to a wide range of environmental temperatures, the human body maintains a stable temperature of around 37°C and is maintained in the range 35.8–38.2°C. Normal fluctuations of about 1°C occur over a 24-hour period, with highest temperatures recorded in the afternoon and early evening, and lowest temperatures in early morning [Marieb, 2013].

Thermoregulation is primarily the job of the hypothalamus, which receives sensory information from peripheral and central thermoreceptors. This is necessary because the different body regions have differing temperatures [Tortora, 2008]:

• Core: Consisting of organs within the skull, thorax and abdomen

• Shell: The skin.

By controlling the flow of blood to the shell, the hypothalamus can control the amount of heat generated and lost.

1.2.1 Heat-promoting mechanisms

When the external temperature falls, the heat-promoting centre is activated. This maintains core body temperature by [Marieb, 2013]:

• Constricting peripheral cutaneous blood vessels

• Causing shivering: Involuntary contractions of skeletal muscle, which generates heat

• Increasing the body’s metabolic rate.

In addition, there are a number of behavioural changes that can be promoted:

• Putting on warmer clothes

• Drinking hot fluids

• Increasing physical activity.

1.2.2 Heat-loss mechanisms

Most heat loss occurs via the skin by dilation of cutaneous blood vessels and/or enhanced sweating, allowing for heat loss to occur by [Marieb, 2013]:

• Radiation: Infrared waves (thermal energy)

• Conduction: Direct contact with cooler objects (such as cold water)

• Convection: Since warm air expands and rises, warm air around the body is constantly replaced with cooler air, which absorbs the heat. This process can be enhanced by moving air more rapidly across the body surface, for example by the use of a fan

• Evaporation: As water absorbs heat from the body, it becomes energetic enough to escape the body as a gas, called water vapour.

1.3  Assessment of temperature

There are a range of different thermometers on the market and you may need to use a different type of thermometer depending on the age of the patient, as shown in Table 14.1 [AACE, 2016; NICE, 2013].

Out-of-hospital, a peripheral temperature is gained to provide an estimation of what the temperature is in the core of the patient.

Table 14.1 Thermometers according to age

Infants under 4 weeks of age

• Electronic thermometer in the axilla

4 weeks to
5 years of age

• Paediatric infra-red tympanic thermometer

• Electronic thermometer in axilla

• Chemical dot thermometer in the axilla

Over 5 years

• Infra-red tympanic thermometer

• Electronic thermometer in axilla

Temperature readings are broadly accurate, but they can be impacted by factors including:

• Build-up of ear wax

• Patient lying on one side for a prolonged period

• Wearing of ear defenders or muffs prior to temperature being taken

• Stood outside for a prolonged period

• Water or snow in the ear

When taking a series of temperature measurements, always use the same site and procedure to try and improve accuracy. For example, if you are using the tympanic thermometer and you take the first reading from the right ear, you should use the right ear for all further temperature assessments.

Procedure: Electronic thermometer in axilla

1. Turn on the thermometer, check it is clean and functional and apply a fresh cover to the probe. Once you have turned it on, the thermometer will be able to perform any self-checks.

2. Place the tip of the thermometer high in the axilla, in the fold where the arm meets the chest. Get the infant to bring their arm down to the side so the thermometer is covered.

3. Leave in place until the thermometer has finished measuring. Usually there will be a visual or audible indication that this has happened.

4. Remove and read the temperature.

Procedure: Infra-red tympanic thermometer

The below is a general description on how to use an infra-red tympanic thermometer. You may need to vary this procedure based on different models available.

1. Turn on the thermometer, check it is clean and functional and apply a fresh cover to the probe. Once you have turned it on, the thermometer will be able to perform any self-checks.

2. The thermometer works by taking an infra-red reading of temperature directly from the tympanic membrane. As the ear canals are not straight, you should first try to just straighten the canal slightly.

a. For children under one, gently pull the pinna of the ear directly backwards.

b. For children over one and adults, pull the ear gently upwards and backwards.

3. Place the probe into the ear. It should be placed straight down in the canal so the tip of the device is facing the tympanic membrane. At this point some devices will ‘pre-warn’ the tip of the measuring probe to help ensure the results are accurate. They will emit a beep and the screen display will change when they are ready to use.

4. Push the button that measures temperature and hold the probe still until it has completed; this can take a few seconds.

5. Remove from the ear and read the temperature.

1.4 Hypothermia

Hypothermia is defined as a core body temperature of less than 35°C. It is classified into three categories, based on temperature [AACE, 2016]:

• Mild: 32–35°C

• Moderate: 28–32°C

• Severe: Less than 28°C.

However, without a low-reading thermometer, it can be difficult to record accurate core body temperature. Therefore, it is important to suspect that hypothermia might be a factor in the following [AACE, 2016]:

• Older patients (over 80 years of age)

• Children

• Some medical conditions: For example, hypothyroidism and stroke

• Intoxicated patients: Alcohol and/or recreational drugs

• Drowning

• Patients suffering from exhaustion

• Injured and immobile patients

• Decreased level of consciousness.

As patients succumb to hypothermia, they move through five stages [Durrer, 2003]:

1. Conscious and shivering

2. Decreased level of consciousness and not shivering

3. Unconscious

4. Not breathing

5. Death due to irreversible hypothermia.

1.4.1 Management

The mainstay of treatment is to prevent further heat loss. In the mildly hypothermic patient, this is likely to be enough, but severely hypothermic patients will require active rewarming, which realistically can only be performed in hospital [Nolan, 2016]. Adopt the following principles when managing a patient with hypothermia [AACE, 2016]:

• Move the patient to a warm environment and remove wet clothes

• Administer oxygen if the patient is hypoxaemic

• If using a foil blanket, ensure that you wrap the patient in a fabric blanket first and place the foil blanket over the top

• Give the patient hot drinks/food if they are conscious, but NOT alcohol

• Do not rub the patient’s skin: As with alcohol, this leads to peripheral vasodilation, which worsens hypothermia

• Avoid rough handling as it can cause arrhythmias and cardiac arrest

• Patients with a decreased level of consciousness should not be encouraged to walk, but managed horizontally.

1.5 Heat-related illness

Heat-related illnesses can occur as a result of external factors such as the sun, or internal factors such as drugs and exercise. It presents on a continuum, with heat stress the least serious heat-related illness, through to multi-organ dysfunction and even death at the other extreme [AACE, 2016]:

• Heat stress

• Heat exhaustion

• Heat stroke

• Multi-organ dysfunction.

1.5.1 Heat stress

This is a mild form of heat-related illness and is characterised by [Truhlar, 2015]:

• Normal temperature or mild temperature elevation

• Heat oedema: Swelling of feet and ankles

• Heat syncope: Vasodilation causes hypotension

• Heat cramps: Depletion of salts leads to muscle cramps.

1.5.2 Heat exhaustion

This is a more severe form of heat-related illness, with symptoms mostly as a result of fluid loss and electrolyte imbalances [Truhlar, 2015]:

• Systemic reaction to prolonged heat exposure (hours to days)

• Core body temperature over 37°C and less than 40°C

• Headache, dizziness, nausea and vomiting, tachycardia, hypotension, sweating, muscle pain, weakness and cramps

• Can progress quickly to heat stroke.

1.5.3 Heat stroke

Heat stroke is a systemic inflammatory response to a core body temperature of 40°C or higher, and is associated with altered level of consciousness and organ dysfunction [Truhlar, 2015]. It comes in two types: non-exertional heat stroke, which is caused by high external temperatures and/or high humidity; and exertional heat stroke, which is caused by excess heat production. Non-exertional heat stroke tends to occur in the elderly, very young and chronically ill, whereas exertional heat stroke is more typical in active groups such as athletes, manual workers and military recruits [AACE, 2016].

Clinical features include [Truhlar, 2015]:

• Core body temperature of 40°C or more

• Hot dry skin (although sweating is present in around half of all cases)

• Early signs and symptoms: Extreme fatigue, headache, fainting, facial flushing, vomiting and diarrhoea

• Arrhythmias and hypotension

• Respiratory distress

• Liver and kidney failure.

1.5.4 Management

Heat stress and exhaustion

The management of patients with heat-related illness broadly consists of cooling the patient and replacing lost fluid and electrolytes. For patients with signs and symptoms of heat stress consider the following [Lipman, 2013]:

• Remove the patient from the heat source

• Passively cool: Move the patient into the shade or an air-conditioned room. Loosen or remove tight-fitting clothing

• Provide oral isotonic fluid replacement

• Elevate oedematous extremities.

If the patient has developed heat exhaustion, similar management principles apply, except that depending on the patient’s level of consciousness, fluid rehydration may have to be intravenous. In addition, cooling should be active, using conductive, evaporative and convective methods. Cold-water immersion is ideal for the ambulant, co-operative patient, but may not be practical otherwise. Alternatives include removing the patient’s clothes and spraying or dousing the patient with water. Air movement can be augmented by fanning the patient [Lipman, 2013].

Heat stroke

While supporting the patient’s airway, breathing, circulation and disability, begin rapidly cooling the patient [Truhlar, 2015]. Ice water immersion is useful, but not practical, so consider the same techniques as for heat exhaustion to cool the patient. Ice packs are useful if they cover the body, not just the neck, axillae and groin, but should not be applied directly to the skin [Lipman, 2013]. Rehydration is safest intravenously as an altered level of consciousness increases the chance of aspiration [Soar, 2010].

2 Drowning

2.1 Learning objective

By the end of this section, you will be able to:

• Explain the pathophysiology and management of drowning.

2.2 Introduction

The definition of drowning has been complicated in the past and so in 2002 (at the World Congress on Drowning, held in Amsterdam) a single definition was agreed. As a result, drowning is now defined as a process resulting in primary respiratory impairment from submersion/ immersion in a liquid [Idris, 2003]. Whether the victim lives or dies after this process is not important, they have still drowned. If they do not survive, then they have fatally drowned [Szpilman, 2012].

2.3 Pathophysiology

When a drowning victim is unable to keep water (the most common liquid in drowning incidents) from their mouth, it is spat out or swallowed. If still conscious, victims will then attempt to hold their breath, but this is likely to continue for less than a minute, depending on levels of panic and the temperature of the water. Once the inspiratory drive is too high to resist, the victim will take a breath and water will be aspirated into the airways [Szpilman, 2012]. Laryngospasm may occur, but this is rapidly terminated by cerebral hypoxia, and active ventilation, with aspiration of water, will resume. It was once thought that laryngospasm might be responsible for drowning victims who were found not to have aspirated (so called dry-drowning). The theory was that the victim died due to hypoxic cardiac arrest because of laryngospasm or breath-holding [Layon, 2009]. However, autopsy studies have concluded that this is unlikely, as water does not passively seep into the lungs [Modell, 1999; Piette, 2006]. To drown therefore requires active ventilation while the victim is submerged (i.e. under the water and still alive).

Whether due to laryngospasm or breath-holding, with no gas exchange the victim becomes increasingly hypoxaemic. Unless they are rescued, the victim will succumb to hypoxaemia, leading to loss of consciousness and apnoea [Layon, 2009]. The cardiac rhythm deteriorates, usually following a sequence of tachyarrhythmias, bradyarrhythmias, pulseless electrical activity (PEA) and asystole [Szpilman, 2012].

2.4 Management

Try to avoid getting wet. You should only go into the water to rescue a drowning victim as a last resort and only if you are adequately trained and equipped. Many victims who are drowning can help themselves with firm coaching, or will have already been rescued by bystanders or professional rescuers, who can have a dramatic impact on the victim’s outcome. On beaches with a lifeguard, for example, less than 6% of victims will require hospital treatment and only around 0.5% will require cardiopulmonary resuscitation (CPR) [NWSF, 2012]. This is in stark contrast to the 30% of victims requiring CPR when rescued by untrained bystanders [Venema, 2010].

If you need to rescue the victim, remember to ‘call, reach, throw, wade and row’. As previously mentioned, encourage victims to self-rescue first. Next, try to reach them with an object such as a pole, tree branch or even items of clothing. Consider throwing something that is buoyant, ideally a rescue ring with a lifeline attached. Wading into the water is the next possibility as long as someone on the shore has hold of you, the water is shallow enough to stand in and the victim is within reach. Alternatively, use a boat, if available.

Get the victim out of the water as soon as possible and place them supine, with head and torso at the same level, and check for breathing. If they are breathing but unconscious, provide high-flow oxygen via non-rebreathe mask as per clinical guidelines and place them in the recovery position. They are at high risk of gastric regurgitation, so ensure that you have suction available [AACE, 2016].

Victims of prolonged immersion in water (typically 30 minutes or more, but less as water temperature decreases) may also suffer the added complication of circum-rescue collapse [Golden, 1997]. This is due to the increased hydrostatic pressure from the water on the victim’s legs and torso increasing venous return and cardiac output. Central baroreceptors mistake this for hypervolaemia resulting in increased diuresis. In addition, peripheral vasoconstriction will occur as the water is cold relative to the body, which magnifies this response [Lord, 2005]. Once the victim is removed from the water, the hydrostatic pressure is lost, exacerbating the hypovolaemia. This can also be compounded by hypothermia and physical effort (if the victim attempts to remove him- or herself from the water, for example). The sudden drop in venous return can reduce coronary perfusion enough to induce cardiac arrest. For this reason, it is advised to remove victims horizontally from the water if possible [Szpilman, 2012].

Hypothermia is likely to occur and wet clothes should be cut off to minimise movement. Hypothermic patients are at risk of cardiac arrhythmias, including ventricular fibrillation, even with minor movement [Althaus, 1982]. Get the patient covered with blankets and in a warm environment as soon as possible.

2.4.1 Cardiac arrest management

Resuscitation is difficult while in the water and should consist of ventilations only. Chest compressions are futile in deep water, so wait until the patient is on a firm surface, such as the shore or the deck of a boat [Szpilman, 2004]. The incidence of spinal injuries is very low (around 0.5%) and immobilising the spine delays effective resuscitation, so only immobilise the spine when there is a clear mechanism of injury that could cause spinal injury (such as diving into shallow water or water skiing) [Watson, 2001; Truhlar, 2015].

Get the victim out of the water as soon as possible and place them supine, with head and torso at the same level, and check for breathing.

If your patient is not breathing, or is breathing abnormally, administer five rescue breaths via a bag-valve-mask connected to high-flow oxygen. Note that this is different from the usual ABC approach that the current resuscitation guidelines advocate for adults, but reflects that correction of hypoxia is the most important aspect in the management of the drowned patient (see the Cardiac Arrest chapter). It can be difficult to differentiate post-arrest gasping from initial respiratory efforts of the drowning patient, so if you are unsure, administer ventilations and start CPR. Pulse checks are unreliable, so if in doubt, commence chest compressions with ventilations at a ratio of 30:2. Compression-only CPR is not advocated [Truhlar, 2015].

Large amounts of foam can be generated by the mixing of moving air with water and surfactant from the lungs. If this occurs, do not waste time trying to suction it, continue to provide ventilations until an appropriate clinician can intubate the patient.

Resuscitation efforts should not be stopped unless it is clear that it would be futile to continue (e.g. due to the patient sustaining massive traumatic injuries). There are no completely accurate prognostic indicators in drowning, although duration of submersion is correlated with risk of death or severe neurological impairment [Szpilman, 2012]. In water above 6°C, survival after submersion for more than 30 minutes is unlikely. At 6°C or below, survival time can be extended up to 90 minutes, although this is more likely to apply to children immersed in ice-cold water [Tipton, 2011]. As with hypothermia, the general rule is that your patient is not dead until they are warm and dead [Truhlar, 2015].

Chapter 15: Medical and Surgical Emergencies

1 Anaphylaxis

1.1 Learning objectives

By the end of this section you will be able to:

• Explain the term ‘anaphylaxis’ and its common causes

• Describe signs and symptoms that a patient with anaphylaxis may present with

• State the management of anaphylaxis including the administration of adrenaline using the patient’s own auto-injector.

1.2 Introduction

Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death [Sampson, 2006]. Its hallmark is rapidly developing life-threatening airway/breathing/circulation (or any combination of the three) problem(s) and it is usually associated with skin and mucosal changes [Soar, 2008].

The exact incidence of anaphylaxis is unknown. Approximately 3000 people a year are admitted to hospital in England [DoH, 2006b] (600–700 in Scotland [SG, 2009]) with anaphylaxis, and it is estimated that there are 10–20 deaths per year in England and Wales [DoH, 2006b].

The most common causes (triggers) are food, medication and insect stings [Lee, 2011]. In children, food is the most common cause of allergy, whereas in adults, it is medication [Capps, 2010]. Death is unlikely more than 6 hours after exposure to a trigger, but cardiac arrest can occur in minutes, particularly if the trigger is medication that has been administered intravenously. Envenomation typically causes cardiac arrest within 15 minutes, and food takes a little longer on average, at around 30 minutes [Pumphrey, 2000].

1.3 Signs and symptoms

Anaphylaxis is highly likely when any one of the following criteria is fulfilled [Sampson, 2006]:

  1. Acute onset of an illness (minutes to several hours) with involvement of the skin and/or mucosal tissue (e.g. generalised urticaria, pruritus or flushing, and swollen lips-tongue-uvula, also known as angioedema) and at least one of the following:

• Respiratory compromise (e.g. difficulty breathing, bronchospasm, stridor)

• Reduced blood pressure or associated symptoms of end-organ dysfunction (e.g. collapse)

  2. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours):

• Involvement of the skin/mucosal tissue

• Respiratory compromise

• Reduced blood pressure or associated symptoms

• Persistent gastrointestinal symptoms (e.g. crampy abdominal pain, nausea, vomiting, diarrhoea)

  3. Rapid onset of reduced BP after exposure to a known allergen for that patient (minutes to several hours):

• Infants and children: Low systolic BP

• Adults: Systolic BP of less than 90 mmHg.

Note: Up to 20% of anaphylaxis cases do not have skin and/or mucosal changes, particularly reactions that occur intraoperatively in adults and food/insect sting-induced reactions in children. Patients with severe anaphylaxis resulting in significant hypotension may not exhibit any cutaneous symptoms until their blood pressure is restored [Lee, 2011].

1.4 Management

Having conducted your standard ABCDE assessment and determined that your patient is likely to be suffering from anaphylaxis, you should identify the trigger and remove it if possible (e.g. stop any drug infusions, remove bee stings). However, if this is not possible, then do not delay treatment. If you suspect food-induced anaphylaxis, encouraging the patient to vomit is NOT recommended [Soar, 2008].

Lay patient flat where possible with legs raised. Note that patients with A or B problems are likely to be more comfortable sitting up, but do not allow patients to sit or stand if they feel faint as this can cause cardiac arrest.

Give intramuscular (IM) adrenaline immediately to prevent cardiorespiratory arrest [AACE, 2016]. Where possible, administer adrenaline into the anterolateral thigh as there is a greater margin of safety, it is quick to administer and the peak plasma concentration is higher when adrenaline is administered in the thigh compared to the deltoid [Simons, 2001]. Doses of adrenaline can be repeated every 5 minutes depending on patient condition.

Administer high-flow oxygen at 10–15 litres per minute initially. If local guidelines allow, consider administering nebulised salbutamol (Figure 15.1) [Truhlar, 2015; AACE, 2016].

Note: Adrenaline is also known as epinephrine, particularly in American texts.

1.4.1 Auto-injectors

Patients who are known to have anaphylactic reactions may have been provided with their own adrenaline auto-injector. Common systems in the UK include Jext® and Epipen® and are typically available as 300 microgram adult and 150 microgram child doses.

Figure 15.1 Emergency management of anaphylaxis

Procedure for Jext® auto-injector

Take the following steps to administer adrenaline with a Jext® auto-injector [ALK-Abello, 2013]:

1. Grasp the Jext® injector in your dominant hand (the one you use to write with) with your thumb closest to the yellow cap

2. Pull off the yellow cap with your other hand

3. Place the black injector tip against your outer thigh, holding the injector at a right angle (approximately 90°) to the thigh

4. Push the black tip firmly into your outer thigh until you hear a ‘click’ confirming the injection has started, then keep it pushed in. Hold the injector firmly in place against the thigh for 10 seconds (a slow count to 10) then remove. The black tip will extend automatically and hide the needle

5. Massage the injection area for 10 seconds

2 Sepsis

2.1 Learning objectives

By the end of this section you will be able to:

• Explain what sepsis and septic shock are and how they occur

• State how you would recognise a patient with sepsis or septic shock

• Describe the out-of-hospital management of sepsis.

2.2 Introduction

Sepsis is a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs. It leads to shock, multiple organ failure and death if not recognised early and treated promptly [Czura, 2011]. Sepsis is estimated to cause 36,000–64,000 deaths a year and is responsible for more deaths than lung, bowel and breast cancer [Daniels, 2011a]. Around 90% of patients with sepsis arrive by ambulance, most commonly presenting with a respiratory tract infection [Gray, 2013; Daniels, 2011b] and 35–40% of these patients will die in hospital [Daniels, 2011a; Vincent, 2006; Levy, 2010]. Septic shock is a subset of sepsis which has a higher risk of mortality than with sepsis alone [Singer, 2016]. Septic shock causes particularly profound circulatory, cellular, and metabolic abnormalities. Since determining the presence of septic shock can be difficult out-of-hospital, a pragmatic alternative is to treat any patient who is hypotensive despite fluid resuscitation as if they have septic shock. These patients are high risk, as are others with any of the ‘red flag’ signs/ symptoms shown in Figure 15.2. To ensure that these patients receive urgent attention, it is important the term ‘Red flag sepsis’ is used when communicating with other healthcare professionals [UKST, 2016].

2.3 Recognition and management

To simplify the identification of sepsis (particularly red flag sepsis), a screening tool has been developed for pre-hospital use (Figure 15.2) [UKST, 2016]. Since use of the National Early Warning Score (NEWS) is widespread, this has been included in the screening tool. However, it is perfectly acceptable for you to use the tool if the patient looks sick. Next, you should consider whether there is an infection present; it is not necessary for you to identify the exact source of the infection. Finally, the presence of any red flag signs/symptoms should be sought out to determine the presence of red flag sepsis. Patients who do not meet the criteria for red flag sepsis but have sepsis still require further assessment and appropriate management to prevent their clinical condition deteriorating. Identifying sepsis before arrival at the ED and, even more importantly, ambulance crews stating that they suspect the patient has sepsis reduces patients’ time to receive antibiotics and the sepsis care bundle in the ED [Studnek, 2012; Band, 2011].

3 Endocrine system disorders

3.1 Learning objectives

By the end of this section you will be able to:

• Describe the relevant anatomy and physiology of the endocrine system

• Describe the types and causes of diabetes

• Describe two diabetic emergencies

• Explain how to record a blood sugar measurement.

3.2 Introduction

The endocrine system consists of a collection of glands located throughout the body (Figure 15.3) that are responsible for the secretion of hormones: molecules that are released from endocrine glands and regulate the activity of cells in other parts of the body. The endocrine system works alongside the nervous system to help co-ordinate the function of all of the body’s systems [Tortora, 2008].

Figure 15.2 Pre-hospital sepsis screening tool

The endocrine system consists of the pineal, pituitary, thyroid, parathyroid and adrenal glands. In addition, there are a number of organs and tissues that are not strictly endocrine glands, but do secrete hormones. These include the pancreas, ovaries, testes, liver and heart.

Figure 15.3 The endocrine system

3.3 Anatomy and physiology of the pancreas

The pancreas is a mixed endocrine and exocrine gland, situated posterior to the stomach, and extends across the posterior abdominal wall from the duodenum on the right to the spleen on the left (Figure 15.4). It is retroperitoneal, apart from its tail [Drake, 2005].

Around 99% of the cells in the pancreas are involved in the production of pancreatic enzymes. The cells are organised into clusters called acini. Among the acini are collections of endocrine tissue called pancreatic islets, or islets of Langerhans after the German scientist Paul Langerhans, who first described them [Jolles, 2002].

Figure 15.4 The pancreas

There are five types of cells in the pancreatic islets, which have a range of functions, including regulation of blood glucose (Table 15.1).

3.3.1 Blood sugar regulation

Falling blood glucose levels normally activate a series of glucose counter-regulatory processes to prevent, or quickly correct, hypoglycaemia. This is crucial, given that the brain’s demand for glucose is fairly constant and the intake of (exogenous) glucose from eating is intermittent. This is accomplished by the dynamic control of endogenous production of glucose by the liver (and to a lesser extent, the kidneys) and reduction of glucose consumption by non-neural tissue, such as muscle [Briscoe, 2006].

Table 15.1 Cells of the pancreatic islets

Cell

Hormone

Action

Alpha

Glucagon

Increases blood glucose

Beta

Insulin, amylin

Insulin: reduces blood glucose

Amylin: delays gastric emptying, inhibits insulin

Delta

Somatostatin

Inhibits glucagon and insulin release

PP (or F)

Pancreatic polypeptide

Inhibits somatostatin secretion, gallbladder contraction and secretion of pancreatic digestive enzymes

Epsilon

Ghrelin

Stimulates hunger

Hormonal control of blood glucose is largely dependent on the endocrine pancreas via the hormones insulin and glucagon. Insulin increases transport of glucose across cell membranes and is released by the beta cells. It targets the muscle, fat and liver cells causing gluconeogenesis and synthesis of triglycerides, fatty acids and proteins [Jenkins, 2007].

Glucagon targets the liver, promoting conversion of glycogen into glucose and the creation of glucose from lactic and amino acids. This results in increased glucose release by the liver, into the blood. Glucagon release is inhibited by insulin and increased by falling blood glucose levels.

Insulin and glucagon are inhibited by somatostatin, which acts as a local negative feedback mechanism, to prevent uncontrolled insulin and glucagon release. Amylin also inhibits insulin and glycogen, but also somatostatin release as well [Quesada, 2008].

Defence against hypoglycaemia (also called glucose counter-regulation) can be broadly classified into physiological and behavioural responses [Briscoe, 2006]. As blood glucose falls (although still within ‘normal’ limits), insulin secretion from the beta cells is reduced, leading to increased glucose production by the liver and virtual cessation of glucose use by tissue sensitive to insulin.

When blood glucose falls below 4 mmol/l, glucagon release is increased from the alpha cells, further increasing glucose production and decreasing insulin release. In addition, adrenaline release from the adrenal medulla is increased by the sympathetic nervous system (SNS). Adrenaline has similar effects on the liver as glucagon, but can also stimulate renal production of glucose and plays a role in reducing insulin-stimulated glucose uptake [Elliott, 2011].

If blood glucose continues to fall, a more intense sympathetic-mediated adrenaline release causes a behavioural response in the form of hunger, as well as other autonomic symptoms, such as palpitations, sweating and pallor [Graveling, 2009].

3.4 Diabetes

Diabetes mellitus is a common metabolic disorder typified by chronic high blood sugar (hyperglycaemia). It is a major cause of morbidity and premature death due to long-term complications such as heart attacks, stroke, kidney failure and blindness [Holt, 2010]. There are around 3.2 million people in the United Kingdom known to have diabetes, 6% of the population [Diabetes UK, 2014].

3.4.1 Diabetic emergencies

Blood sugar is typically maintained within a narrow range of 3.0–5.6 mmol/l [AACE, 2016]. Diabetic patients are generally encouraged to keep their blood sugar at 4.0 or higher, with a target range of 4.0–8.0 mmol/l for children and 4.0–7.0 mmol/l for adults [NICE, 2004].

There are two main types of diabetic emergency that you will encounter:

• Hypoglycaemia

• Severe hyperglycaemia, which can be further divided into diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HHS).

3.4.2 Types and causes of diabetes

There are two types of diabetes [WHO, 1999]:

• Type 1: Previously referred to as insulin-dependent diabetes (IDDM). Patients with type 1 diabetes are unable to produce any insulin, usually due to autoimmune disease which destroys the insulin-producing beta cells in the pancreas [Holt, 2010]. Insulin is a hormone that increases transport of glucose across cell membranes and is released by the beta cells. It targets the muscle, fat and liver cells to promote the creation of glucose [Tortora, 2008]

• Type 2: Previously referred to as non-insulin dependent diabetes (NIDDM). Patients with type 2 diabetes have a relative insulin deficiency due to varying degrees of insulin resistance. This is by far the more common type of diabetes, accounting for around 90% of all people with diabetes in the UK.

Causes/risk of diabetes

Underlying causes of diabetes generally fall into four categories [Holt, 2010]:

• Genetic: A family history of type 1 diabetes or other autoimmune disease is linked to a higher risk of developing type 1 diabetes in the family. Likewise, type 2 diabetes also has a familial component, although this connection is rather more complicated

• Obesity: This increases the risk of developing type 2 diabetes, particularly in people with a body mass index over 25 kg/m² or large waist circumference

• Age: People are living longer and beta cell function declines with age, leading to a chance of developing diabetes in old age

• Ethnicity: Some ethnic groups are at higher risk of developing diabetes, particularly those of South Asian and Afro-Caribbean origin.

3.5 Hypoglycaemia

Hypoglycaemia in diabetics commonly occurs due to a relative excess of insulin in the blood and a compromised physiological and behavioural response to falling blood glucose levels. Since injected insulin and hypoglycaemic drugs, such as sulphonylureas, are not perfect pharmacokinetically, there are typically periods where there is an excess of insulin in the blood and falling blood glucose levels. The performance of the counter-regulatory defences is crucial in determining whether the patient will develop significant hypoglycaemia.

3.5.1 Signs and symptoms

Although diabetic patients are generally encouraged to keep their blood sugar at 4.0 mmol/l or higher, some will experience symptoms of hypoglycaemia at blood sugar levels higher than this, making recognition important. Some signs and symptoms of hypoglycaemia include [Deary, 1993]:

• Sweating

• Palpitations

• Shaking

• Hunger

• Confusion

• Drowsiness

• Odd/aggressive behaviour

• Speech problems

• Headache

• Nausea.

3.5.2 Management

If the patient is still conscious and able to take oral glucose, then administer 10–20 g of glucose. You can find 10 g of glucose in [BNF, 2014; AACE, 2016]:

• 55 ml Lucozade Energy Original

• 100 ml Coca-Cola

• 18 ml Ribena Blackcurrant (diluted to taste)

• NB: none should be diet/sugar-free varieties!

• 2 teaspoons of sugar

• 3 sugar lumps.

In addition, commercial preparations of glucose are available including GlucoGel, Dextrogel and Hypo-Fit. Administration of oral glucose can be repeated after 10–15 minutes, if required.

If the patient is unable to take oral glucose due to impaired consciousness, is unco-operative or there is a risk of aspiration, then either IM glucagon or IV glucose is usually administered by ambulance staff.

3.6 Severe hyperglycaemia

Severe hyperglycaemia (sometimes referred to as hyperglycaemic crisis) manifests as two conditions: diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state or syndrome (HHS, previously known as hyperosmolar non-ketotic coma, HONK) [Van Ness-Otunnu, 2013].

3.6.1 Diabetic ketoacidosis

DKA is a complex metabolic state characterised by:

• Hyperglycaemia

• Acidosis

• Ketonaemia.

It is a common and potentially life-threatening complication of type 1 diabetes mellitus (T1DM) mainly, compared to HHS, which typically only affects patients with type 2 diabetes mellitus (T2DM).

3.6.2 Hyperosmolar hyperglycaemic state

HHS does not have a universally agreed definition, but it is generally accepted that the following must be present for the patient to be diagnosed with HHS [Scott, 2015]:

• Hypovolaemia (secondary to severe dehydration)

• Blood sugar > 30 mmol/l without signs of hyperketonaemia or acidosis

• Blood osmolality > 320 mOsmol/kg (not measured out-of-hospital).

3.6.3 Pathophysiology

Diabetic ketoacidosis

DKA and HHS share the complications of severe hyperglycaemia, but early mechanisms are different. In DKA, insulin production is absent or severely reduced. This, coupled with increased levels of insulin counter-regulatory hormones (e.g. cortisol, glucagon, growth hormone and catecholamines), enhances hepatic gluconeogenesis (glucose creation) and glycogenolysis (breakdown of stored glucose in the form of glucagon). This leads to severe hyperglycaemia that is exacerbated by simultaneous reduction in glucose take-up by the peripheral tissues because of the lack of insulin. Although blood glucose is high, there is a glucose famine inside the cells, so body fat (adipose tissue) is used to create energy by increasing lipolysis and decreasing lipogenesis.

Hyperosmolar hyperglycaemic state

Although HHS is also caused by a decrease in insulin and increase in counter-regulatory hormones, the fundamental difference between HHS and DKA is that there is still sufficient insulin production to prevent significant ketosis but not the severe hyperglycaemia that is a key feature of the condition. As before, hyperglycaemia is caused by increased gluconeogenesis, accelerated conversion of glycogen to glucose and inadequate utilisation of glucose by the peripheral tissues, particularly muscle.

3.6.4 Signs and symptoms

DKA and HHS typically present in different groups of patients and over differing time periods. DKA most commonly occurs in T1DM (although advanced/severe T2DM patients are also at risk). HHS on the other hand is almost exclusively seen in T2DM and is more common in the elderly [Lupsa, 2014], although its incidence in teenagers and young adults is on the rise [Scott, 2015]. DKA typically presents within hours to days of onset whereas HHS does not occur for many days to weeks, which explains why the metabolic derangement and dehydration in HHS are so much more severe than in DKA [Savage, 2011].

Typical signs and symptoms of severe hyperglycaemia are common to both DKA and HHS (except where highlighted in the list below) [Lupsa, 2014; Corwell, 2014]:

• Polyuria

• Polydipsia

• Blurred vision

• Fatigue

• Weakness

• Weight loss

• Vomiting and abdominal pain (DKA): Probably due to delayed gastric emptying and ileus because of electrolyte abnormalities and/or acidosis

• Fruity breath odour (DKA)

• Kussmaul breathing (DKA)

• Focal neurological signs such as hemiparesis (HHS)

• Altered mental state: Although this can range from confusion to coma

• Signs of dehydration: Dry mucous membranes, poor skin turgor, long furrows on tongue.

3.6.5 Management

Out-of-hospital management of hyperglycaemic crisis is limited and consists of assessing and managing ABCD problems [AACE, 2016; Skellett, 2016]:

• Ensure airway patency, with patient positioning, suction and adjuncts, as required, particularly in patients with a reduced level of consciousness

• Adults need supplemental oxygen if the patient’s SpO₂ is < 94%. Children should receive high-flow oxygen titrated to a target range of 94–98%. Patients can expire CO₂ with spontaneous breathing far more effectively than with artificial ventilation, so avoid assisting/ interfering unless the patient is in respiratory failure or arrest.

3.7  Blood sugar measurement – extended skill

You will obtain blood glucose measurements as part of your clinical assessment, but as with all diagnostic tests, they are not perfect and are prone to error if the correct technique is not used. Common causes of error include [Lunt, 2010]:

• Incorrect calibration chip used to read the test strips

• Contamination of the test finger with glucose-rich foods or dilutional error due to inadequate hand drying or the patient licking their finger clean

• Expired strips or strips stored in adverse environmental conditions such as heat, humidity or extreme cold

• Patient conditions such as anaemia and hypoxia. Shocked patients may have a reduced capillary blood glucose reading compared to a venous blood sample

• Aspirin, paracetamol and vitamin C can all raise blood glucose, although this may not be clinically significant.

3.7.1 Procedure

Take the following steps to record a blood sugar measurement with an Accu-Chek® Aviva blood glucose meter:

1. Wash and dry your hands or use alcohol gel and put on gloves. Select an appropriate site, which is typically the side of a finger in an adult or older child and the heel of the foot in a younger child or infant. Clean the area with water or a water-soaked gauze and dry thoroughly. Insert the test strip into the meter and check that the meter turns on automatically
Alcohol swabs do not remove traces of glucose as effectively as water, so hand-washing is preferable. Failing that, simple cleansing wipes are almost as effective

2. Ensure that the code number of the display matches the code number on the test strip container

3. On the screen, an icon showing the test strip and a flashing blood drop will appear. Ask the patient to dangle their arm down at their side to encourage blood flow to their fingertips

4. Prick the target area with a lancet, disposing of it in a sharps bin after use

5. With the patient’s hand facing downwards, gently squeeze their finger to assist the flow of blood

6. Touch the blood drop to the front edge of the yellow window of the test strip. When you have enough blood, you will see an egg timer icon flash

7. The blood sugar result will appear on the display. Note this value on the patient’s clinical record

Chapter 16: Trauma

1 Major trauma services

1.1 Learning objectives

By the end of this section you will be able to:

• Define trauma and major trauma

• Define mechanism of injury and outline the different types

• Define the mechanisms that can cause injury to the head, spine, chest, abdomen and pelvis.

1.2 Introduction

Trauma is the acute physiological and structural change (injury) that occurs in a patient’s body when an external source of energy transfers to the body faster than the body’s ability to sustain and dissipate it [Pilbery, 2013]. The mechanism of injury (MOI) is defined as the physical forces that act on the body to cause damage [Pilbery, 2013]. Since human tissue, organs and systems can only withstand a limited range of physical, environmental and physiological stress, when the energy delivery to the body exceeds these limits, injury occurs. This tolerance to external energy delivery is dependent on which type of tissue(s) have been targeted, the age and physical health of the patient, and the type, magnitude and duration of the energy that has been transferred [Greaves, 2008].

1.2.1 Types of trauma

Trauma is generally divided into two types [NAEMT, 2014]:

• Blunt: Injuries that do not cause penetration of the skin by an external object. Typical mechanisms of blunt trauma include road traffic collisions (RTC) involving vehicles, pedestrians, motorcyclists etc., fall from height, serious sports injuries and blast injuries (although this mechanism often also causes penetrating trauma, the other type). This is the most common type of trauma in the UK [NAO, 2010]

• Penetrating: Injuries caused by projectiles penetrating the skin. Examples include stab and gunshot wounds and blast injuries involving shrapnel and secondary projectiles.

1.3 Mechanisms that cause injury

There are many mechanisms that can result in a host of isolated and multiple injuries to the human body. Some of the more common mechanisms and the injuries they cause to the head, spine, thorax, abdomen and pelvis are covered in this section.

1.3.1 Head

If the head is travelling ahead of the body, such as during a headfirst fall, it is the first structure to receive the force of the impact and energy transference. The continued movement of the rest of the body results in compression, which can damage the scalp and skull. If the skull fractures, bony fractures can end up damaging the brain. The same damage can also be caused by the application of an external force, such as occurs as a result of a blow to the head during an assault [NAEMT, 2014].

The brain is soft and compressible and can move following the application of external forces. This can lead to shearing of brain tissue as well as rupture of the blood vessels surrounding the brain, leading to intracranial haemorrhage.

If a projectile penetrates the skull, the damage can be very severe as the kinetic energy is distributed within the confines of the skull. Small calibre bullets, for example, may not have enough energy to exit the skull, but instead contour around it, leading to extensive damage [NAEMT, 2014].

1.3.2 Spine

The main mechanisms that cause spinal injury can be divided into abnormal flexion, extension, rotation and compression. Extension or flexion with rotation are the main causes of injury to the cervical spine [Greaves, 2008; Pilbery, 2013; NAEMT, 2014].

Flexion

Hyperflexion injuries are typically caused by RTCs where lap-belts (rather than three-point belts) are used, direct blows to the occiput and rapid deceleration in flexed positions such as diving and contact sports like rugby. Hyperflexion on its own is uncommon in the cervical spine, since the chin abutting the chest limits flexion.

Flexion with rotation

The design of the first two cervical vertebrae allows for significant rotation. Injuries due to this mechanism are considered unstable as there is little in the way of bony or soft-tissue support. Not surprisingly, this mechanism is much more likely to produce significant cervical injury and is often caused by lateral impact RTCs or direct trauma. Note that rotation rarely occurs in isolation.

Extension

These injuries are generally only found in cervical and lumbar regions and can be caused by hanging, striking the chin on a steering wheel during a collision or a rear impact collision where the headrest is improperly positioned [NAEMT, 2014].

Compression

Wedge fractures are the most common type of fracture of the lumbar and thoracic spines, but if a weight falls on the head or if the patient lands on their head after a fall, then the cervical vertebrae can be fractured and/or ligaments ruptured. Most fractures caused by compression are stable, but spinal cord injury can occur if the vertebral body is shattered and fragments of bone become embedded in the cord [Pilbery, 2013].

1.3.3 Thorax

Severe blunt thoracic trauma most commonly occurs as a result of RTCs (about 70–80%) where high speeds are involved, leading to rapid deceleration. This causes shearing forces that can rupture large blood vessels, tear the bronchial airways and damage the lungs, causing pneumothoraces, for example. Even with lower velocity mechanisms, such as direct blows to the chest, fractures of the rib cage and sternum as well as bruising to the underlying structures including the heart and lungs can occur [NAEMT, 2014].

In penetrating trauma, the most serious consequences arise as a result of rupture of the major blood vessels, which can lead to serious haemorrhage. Projectiles penetrating the chest wall can also cause open pneumothoraces [Greaves, 2008].

1.3.4 Abdomen

Abdominal injury is most commonly caused by blunt trauma, usually due to RTCs, and often as part of a multi-system pattern of injuries. If the abdomen comes into contact with the steering wheel during rapid deceleration, crush injuries can occur. Compression of the abdominal organs increases the intra-abdominal pressure, which in turn can rupture the hollow organs and/or the diaphragm. Penetrating trauma is less common, and in the UK is more likely to be a result of a stab wound than gunshot. Fortunately, less than half of all stab wounds actually penetrate the peritoneum (the lining of the abdominal cavity) [Greaves, 2008].

1.3.5 Pelvis

As with any trauma patient, you should consider the MOI to provide an indication as to possible underlying injuries. Pelvic ring fractures usually require high forces, so it is no surprise that the most common cause is RTCs. Front-seat passengers in head-on collisions, and those on the side of impact in T-bone type collisions in cars, are most common. These are closely followed by motorcyclists, pedestrians and falls from heights [Gabbe, 2011; Papadopoulos, 2006]. However, a significant sub-group are the elderly, who will typically fall from standing and may have osteoporosis [Garlapati, 2012].

2 Integumentary system anatomy and physiology

2.1 Learning objective

By the end of this section you will be able to:

• Describe the anatomy and physiology of the integumentary system.

2.2 Introduction

The integumentary system (or skin) is the largest organ in the human body, in terms of both surface area and weight. In adults, skin has a surface area of 2 m² and weighs 5 kg [Tortora, 2008]. It is composed of two main layers, the epidermis and dermis. Under the skin is a supportive subcutaneous layer, known as the hypodermis or superficial fascia (Figure 16.1) [Dykes, 2002].

Figure 16.1 Cross-section of the skin

2.3 Epidermis

This is the outermost layer and consists of five sublayers. Most of the cells (90%) are keratinocytes, which produce a tough, fibrous protein (keratin). This helps protect the skin and tissues from heat and microbes. Keratinocytes also produce lamellar granules which decrease water entry and loss, and prevent entry of foreign material. Around 8% of the cells are melanocytes, which produce melanin. This is taken up by keratinocytes, protecting the cell’s nucleus from the harmful effects of ultraviolet (UV) light. Keratin is either a yellow-red or brown-black pigment and contributes to skin colour. The remaining cells consist of Langerhans cells, which help in the body’s immune response, and Merkel cells, which are involved in touch perception [Tortora, 2008].

It takes around 2–3 weeks for a cell starting at the lowest layer of the epidermis to become a keratinocyte and migrate up to the top layer (stratum corneum) and slough off [AAOS, 2011].

2.4 Dermis

This deeper layer of skin mostly consists of connective tissue, elastin and an extracellular matrix, which provides strength and pliability. However, it also contains blood and lymphatic vessels, nerve fibres, hair follicles and sebaceous and sweat glands. The dermis is divided into two regions, the papillary and the reticular. The papillary region consists of connective tissue that anchors the epidermis and a dense network of capillaries and small blood vessels, in nipple-like projections called dermal papillae. These play an important part in temperature regulation. In addition, the dermal papillae also contain free nerve endings, which act as pain and fine touch receptors (Meissner corpuscles) [Tortora, 2008].

The reticular region makes up 80% of the dermis and consists of dense, irregular connective tissue. Interlocking collagen fibres run in various planes, forming ‘lines of cleavage’. Surgeons try to make incisions parallel to these lines, since the skin does not gape as much, resulting in less scarring [Thompson, 2008].

2.5 Hypodermis

Also known as the superficial fascia, this layer contains subcutaneous fat, connective tissue, sweat glands, muscle and bone. It helps to insulate the body, absorbs shocks to the skeletal system and enables the skin to move easily over underlying structures [AAOS, 2011].

2.6 Physiology

The skin provides a range of functions, which any damage can impair [Tortora, 2008; Thompson, 2008]:

• Protection against infection by forming a physical barrier to microbes and foreign material

• Sensory perception of pain, pressure, heat and cold

• Thermoregulation using nerves, blood vessels and sweat glands to control body temperature

• Excretion of trace amounts of water and body waste, while helping to prevent dehydration

• Maintenance of mineralisation of bones and teeth and synthesis of vitamin D

• Absorption of lipid-soluble substances such as fat-soluble vitamins and drugs through the skin.

3 Wounds and bleeding

3.1 Learning objectives

By the end of this section you will be able to:

• Describe the types of bleeding

• Explain how to appropriately assess and manage bleeding

• Explain how to detect concealed bleeding

• Describe various types of wounds and how to manage them

• Discuss the implications of foreign objects in wounds

• Explain complications associated with bleeding and wounds.

3.2 Introduction

Wounds and bleeding are a common reason for an emergency call. Even in the emergency ambulance service, these calls will vary in their severity, from wounds and bleeding that require basic first aid only, through to life-threatening wounds and bleeding that require prompt and more advanced intervention in order to prevent death.

3.3 Bleeding

Bleeding is the loss of blood from a damaged blood vessel. You will often hear the term ‘haemorrhage’ used, which is bleeding, but in medical circles is usually reserved for severe bleeding. Bleeding is often classified by the type of vessel involved (i.e. artery, vein or capillary) or whether it is external or internal [SJA, SAA, BRC, 2014].

3.3.1 Assessment

Sources of bleeding

Bleeding can be defined by whether it is visible on the outside of the body and/or which type of vessel is responsible [Gregory, 2010a; SJA, SAA, BRC, 2014]:

• Internal: This bleeding is concealed within the body and can be hard to detect [Greaves, 2008]. The thorax, abdomen, pelvis and long bones provide good hiding places for significant volumes of blood. The mechanism of injury and the presence of shock without signs of external haemorrhage can help with diagnosis. These patients need to be in hospital to stop the bleeding

• External: This bleeding is visible and should be detected during your primary and/or secondary survey. This bleeding can usually be controlled

• Arterial: Blood inside the arteries is under relatively high pressure and so bleeding can lead to significant blood loss. It is characterised by bright red (oxygenated) spurting, in time with the heart beat

• Venous: Since veins carry blood back to the heart, they typically carry deoxygenated blood and so bleeding is a darker red. Since the pressure is lower, blood does not spurt but flows freely. However, blood loss can still be severe, particularly from veins in the neck and legs

• Capillary: These are the smallest blood vessels in the body and carry a mixture of oxygenated and deoxygenated blood, so the colour of bleeding will vary. Blood loss tends to be small as blood oozes from wounds.

Estimating blood loss

Estimating blood loss accurately is very difficult and ambulance staff (and doctors/nurses/ midwives) generally do not do this well [Frank, 2010; Bose, 2006; Tall, 2003; Moscati, 1999]. Fractures can cause significant blood loss, depending on the bone(s) affected and whether the fracture is open or closed [NAEMT, 2014]. Remember to check for signs and symptoms of shock (this was covered in the Circulation chapter).

3.3.2 Management

The mnemonic ABC has been in use for many years, identifying the patient management priorities in the primary survey. However, in the military, there has been a change of priorities, to include early control of catastrophic haemorrhage (<C>) before the airway, when both cannot be managed simultaneously [Hodgetts, 2006].

Once the scene assessment has been completed, you need to check for, and manage, any actual or potential catastrophic haemorrhage. Only once this has been completed can you return to the normal AcBC (i.e. airway with consideration of the cervical spine, breathing and circulation) approach.

During the assessment of circulation (the second C), any interventions to manage catastrophic haemorrhage must be reassessed to ensure that bleeding is being controlled appropriately. Don’t forget the bleeding you cannot see. ‘Blood on the floor plus four more’ is a good way to remember the areas where significant blood loss can accumulate, i.e. the thorax, abdomen, pelvis and long bones [Greaves, 2010].

Most external haemorrhage can be controlled with simple first-aid measures such as direct pressure and elevation of the bleeding extremity. In some cases, additional interventions are required, but these should be introduced in an incremental fashion, as shown in the haemostasis escalator (Figure 16.2) [Lee, 2007b; Moorhouse, 2007].

Figure 16.2 The haemostasis escalator

Catastrophic haemorrhage management

If you suspect the bleeding is likely to cause death in minutes (i.e. is a catastrophic haemorrhage), you are likely to ascend the haemostasis escalator rather faster than for non-catastrophic haemorrhage. If the haemorrhage involves a limb, then a tourniquet should be immediately applied. Should the first tourniquet not adequately control the bleeding, then a second tourniquet should be applied above the first. If bleeding continues, pack the wound with a haemostatic gauze and apply a fresh dressing. Apply firm direct pressure [AACE, 2016].

In other body areas, such as the head, neck and torso, it will not be possible to use a tourniquet. In this instance, you should apply a wound dressing to the site of bleeding and apply firm pressure directly over the wound. Elevation is unlikely to be appropriate with these types of bleeds. If direct pressure fails to stem the bleeding, then wound packing should be undertaken and may be supplemented with haemostatic agents. This is achieved by inserting a sufficient quantity of gauze into the wound to create mechanical pressure on the injured vessel and provide a structure for coagulation. Where haemostatic agents are used, they should be placed as close to the bleeding point as possible and then direct pressure should be applied for at least three minutes. Ideally, constant pressure should be applied with a suitable elastic bandage. If this fails to control bleeding, apply further dressings and more direct pressure.

Assess limb positioning and consider whether the use of splinting may help to reduce bleeding. Straightening angulated fractures and applying a pelvic binder may help to reduce blood loss [NICE, 2016].

Non-catastrophic haemorrhage

For other, non-catastrophic external haemorrhage, you can move up the haemorrhage escalator. Start by applying direct pressure, with or without a dressing and, if the injury is below the knee or elbow, consider elevating the affected limb above the level of the heart, if practicable. If this does not control the bleeding, consider applying further dressing while continuing to apply firm direct pressure [AACE, 2016].

If bleeding continues, you should treat the haemorrhage as a potential catastrophic bleeding event. For limbs, this means applying a tourniquet and in the case of head, neck or torso wounds, packing with haemostatic dressing. As with catastrophic haemorrhage, consider whether the use of splinting of a limb or applying a pelvic binder would help reduce blood loss.

3.3.3 Tourniquets

The use of tourniquets (Figure 16.3) has caused controversy, but they do have a place in civilian ambulance services for use in specific circumstances [Lee, 2007b]:

• Extreme life-threatening limb haemorrhage, or limb amputation/mangled limb with multiple bleeding points, to allow immediate management of airway and breathing problems. Following treatment of any airway or breathing problems, the need for a tourniquet can be reassessed in the circulatory assessment and may be converted to a simple method of haemorrhage control

Figure 16.3 A tourniquet

• Life-threatening limb haemorrhage not controlled by simple methods

• Point of significant haemorrhage from limb is not peripherally accessible due to entrapment (and therefore it is not possible to initiate simple methods of haemorrhage control such as direct pressure)

• Major incident or multiple casualties with extremity haemorrhage and lack of resources to maintain simple methods of haemorrhage control.

However, incorrectly applied tourniquets can actually increase blood loss if venous, but not arterial, vessels are occluded. This is a risk for tourniquets sited below the knee and elbow joints, which may not be successful in controlling haemorrhage, as the arteries can run or slip between the tibia/fibula and radius/ulna and thus not be compressed by the tourniquet. Even correctly applied tourniquets, if used when not clinically indicated, can cause local tissue injury from direct contact with the tourniquet, and, when left in place for more than two hours, can lead to muscle and skin damage [Walters, 2005]. In addition, tourniquets cause severe pain and patients must receive adequate analgesia.

Procedure – Tourniquet application

The following steps are a suggested method for applying a tourniquet. As yet, there is no consensus on the most appropriate location to place a tourniquet, so follow local guidance [SWAST, 2013]:

1. Identify the need for a tourniquet during the primary survey, assessing for catastrophic haemorrhage

2. Apply the tourniquet as close to the injury as possible, leaving a gap of at least 5 cm between the injury and the tourniquet, except when injuries are close to the knee and elbow joints. In this case, apply the tourniquet above the joint

3. Tighten the tourniquet until the bleeding stops

3. Record the time of tourniquet application

4. Reassess during the assessment of circulation. If bleeding continues, apply a second tourniquet proximal to the first and over a single bone (i.e. humerus or femur)

5. Frequently reassess and tighten tourniquet as required. Provide analgesia.

3.4 Wounds

A wound is an injury to living tissue, breaking its continuity. There are seven basic categories [Dougherty, 2011; Gregory, 2010b; Pilbery, 2013]:

• Contusion (bruises): Caused by bleeding from damaged blood vessels under the skin. They cause a bluish/purple discolouration beneath the skin and are typically caused by blunt trauma

• Abrasion (grazes): Injuries caused by friction shearing the skin away. These usually involve the superficial layers of the skin, but can go much deeper. They can be very painful and are often dirty, with embedded grit and mud

• Laceration (tear): Tearing or splitting of the skin due to blunt trauma. These cause a ragged wound, which can extend through the skin surface to the underlying structures

• Incision (cut): A break in the continuity of the skin by a sharp implement, such as broken glass or a knife. These are usually clean wounds (unless the implement is dirty) with neat edges

• Puncture (stab): A penetrating wound caused by an object that is pointed and narrow, such as a nail or knife. Although these wounds are typically small, they can be deep, causing serious damage to vessels and other body structures below the skin

• Burn: An injury caused by energy transfer to the body’s tissues, causing necrosis and an associated inflammatory reaction (covered in the burns lesson later in this chapter)

• Gunshot: A complicated wound caused by a projectile moving at speed. The wound consists of an entry point, with varying amounts of tissue destruction and cavitation underneath the skin, and, if there is sufficient energy left, an exit wound.

There are a range of external and internal factors that can lead to wound formation [Thompson, 2008]:

• External: Mechanical (friction), chemical, electrical, temperature extremes, radiation and microorganisms

• Internal: Circulatory system failure, endocrine (e.g. diabetes), neuropathy, haematological, malignancy (cancer).

3.4.1 Management

Wound management will be determined by the size and nature of the wound and the presence of complicating factors. The main initial problems are bleeding, pain and the risk of infection [Purcell, 2010]. Always enquire about tetanus immunisation in any patient who has a wound with a higher risk of infection, such as a dirty wound, or a wound caused by a bite (human or animal) or involving a puncture by a dirty object [SJA, SAA, BRC, 2014]. In addition, consider whether there has been damage to other structures such as blood vessels, nerves, tendons and ligaments, which can have life-changing consequences if not managed appropriately. For example, consider a pianist who damages her hand causing damage to ligaments. Although the external wound may be minor, without prompt management of the ligamentous injury, her fingers may not function properly in the future.

If the wound is small and bleeding easily controlled, clean the wound:

• Use a wet gauze to clean the edges of open wounds, wiping away from the wound to avoid contaminating it further. Continue until all visible dirt and blood has been removed

• Irrigate wounds with tap water as rubbing or scrubbing can cause tissue damage and swabs or cotton wool can leave fibres in the wound.

Once cleaning is complete, cover with a sterile, non-adherent dressing. If the wound is suitable for treatment at home, or at a minor injuries unit, the clinician may advise that a wet dressing be applied over the wound, although this is typically reserved for wounds where treatment will commence promptly (for example within 30–90 minutes) [Pilbery, 2013].

If there is a foreign object in the wound, it should not be removed but left in place, and a sterile, non-adherent dressing applied. Focus your efforts on controlling bleeding and preventing further contamination.

4 Assessment and management of the trauma patient

4.1 Learning objectives

By the end of this section you will be able to:

• Explain the assessment and management of patients with a range of traumatic injuries

• Describe the complications associated with a range of traumatic injuries.

4.2 Introduction

The approach to the trauma patient is similar to that of all patients, with an initial scene assessment, followed by a primary survey. However, there are some aspects of this process that are specific to trauma and they are going to be covered in this lesson. In addition, there are a range of complications that can arise as a result of traumatic injury to specific regions and a number of these are going to be covered in this lesson, specifically injuries to the head, spine, thorax, abdomen and pelvis.

4.3 Scene assessment

The SCENE mnemonic can be used to ensure that you cover all aspects of an initial trauma scene assessment [AACE, 2016]:

• S: Safety. A dynamic risk assessment should highlight current as well as potential dangers. If you are not equipped in terms of kit and expertise to deal with the scene, withdraw and request specialist help, for example from the hazardous area response team (HART). Remember to continually reassess safety as the situation can change quickly. Make sure you are wearing appropriate personal protective equipment (PPE)

• C: Cause, including mechanism of injury (MOI). Finding out what happened is important in order to appreciate likely injuries and energy transfer. However, ensure that the scene matches the story you are being told, as you may have come across a crime scene or case of abuse

• E: Environment. Consider whether there are any environmental factors that need to be taken into account. These may complicate your extrication by affecting access to and from the scene and/or increase the risk of harm to the patient, due to increased risk of hypothermia, for example

• N: Number of patients. Determine the number of patients early on in your assessment to help you determine whether you can manage the scene on your own. It may also help to identify patients who have either wandered off from scene or who have been ejected from a vehicle, for example, and are currently hidden from view

• E: Extra resources needed. Depending on the number of patients, the severity of their injuries and the nature of the incident, you may need additional help from other emergency services, such as the police to keep a scene safe, or additional ambulances, including the air ambulance, for patient transport.

4.4 Primary survey

The aim of the primary survey is to identify threats to life promptly and intervene as soon as they are found. The steps of the primary survey should be undertaken sequentially, unless there are enough personnel to allow for simultaneous assessment and treatment [Greaves, 2008].

4.4.1 Procedure

Take the following steps to undertake a primary survey in the trauma patient:

  1. General impression: As you approach the patient, perform a global assessment. Are they sitting up and watching you approach, with well-perfused skin, or are they lying unresponsive, pale and clammy with an expanding pool of blood leaking from a wound?

  2. Catastrophic haemorrhage: This is bleeding that is likely to cause death within minutes, so cannot wait until airway and breathing have been addressed. Typically, bleeding can be controlled with direct pressure and elevation of the bleeding site, but may require the use of a tourniquet (see the section on WOUNDS AND BLEEDING previously)

  3. Airway with cervical spine consideration: If a patient has suffered significant blunt trauma or the MOI suggests that the cervical spine may have been damaged, provide prompt manual in-line stabilisation. Assess the airway by looking for obvious obstruction, listening for noisy airflow (snoring or gurgling) and feeling for air movement

  4. Manage the airway using appropriate airway manoeuvres, such as:

• Jaw thrust–chin lift

• Suction

• Naso- and oropharyngeal airways

  5. Breathing: Administer high-flow oxygen to patients to obtain a target saturation of 94–98%, even if they have COPD

  6. Examine the neck for:

• Tracheal deviation

• Wounds and swellings

• Emphysema (surgical/subcutaneous)

• Laryngeal crepitus

• Veins

  7. If you have enough personnel, a cervical collar can be applied, if appropriate

  8. Look for obvious chest injuries, wounds, bruising or flail segments. Assess the rate, depth and quality of respiration:

• Ventilate with a BVM if respirations absent or less than 10 breaths/min

• If respirations are greater than 30 breaths/ min it may also be clinically appropriate to ventilate the patient. Follow the advice of the clinician

• If respirations 10–30 breaths/min monitor closely

  9. Feel for equality of chest movement and note any instability

10. Manage breathing problems as you find them. This may include (depending on local guidance):

• Applying non-occlusive dressings to sucking chest wounds

• Insertion of a cannula into the chest by a clinician to decompress a tension pneumothorax

• Positioning to support a patient with a flail segment (not possible if the patient has a suspected spinal injury)

11. Circulation: If a catastrophic haemorrhage was encountered at the start of the primary survey, reassess this now

12. Assess both central and distal pulses (carotid and radial, typically), noting rate, rhythm and volume. Note the skin colour, temperature and the presence of clamminess. If additional personnel are available, the blood pressure can also be measured

13. Assess for signs of blood loss, remembering the phrase ‘blood on the floor plus four more’:

• Externally: Don’t forget to consider bleeding into clothing, splints and dressings

• Chest: Completed during assessment of breathing

• Abdomen: Look for bruising or external marks and feel for rigidity and to elicit tenderness

• Pelvis: This should not be manipulated or ‘sprung’ to assess for instability. The MOI is sufficient to immobilise the pelvis

• Long bones: Assess long bones, particularly the femurs, but do not be distracted by fractures that are not angulated

14. Manage bleeding appropriately. Ideally splint pelvic fractures prior to moving the patient. Limb fractures can wait until you are en route if the patient is critically injured

15. A clinician on scene may wish to gain intravenous access now if fluids and/or tranexamic acid (TXA) are required

16. To minimise clot disruption, patient movement should be kept to a minimum

17. Disability: Assess level of consciousness with AVPU, and pupil size, equality and reaction to light. Don’t forget to check the blood glucose if authorised

18. Exposure/environment: Take care to prevent hypothermia as this can dramatically increase their chances of dying (up to 3 times higher if core body temperature drops below 35°C [Ireland, 2011]). It may be more appropriate to remove patients to a heated ambulance before completing this step.

4.5 Head injuries

Common causes of traumatic brain injury (TBI) include road traffic collisions, direct blows to the head, falls from heights and sports-related injuries. The worst outcomes are associated with [Moppett, 2007]:

• Penetrating injuries

• Non-accidental injury in children aged under 5 years

• Pedestrians and pedal cyclists

• Ejection from a vehicle.

4.5.1 Recognition

Suggestive signs and symptoms of TBI include [Pante, 2010]:

• Lacerations, contusions or haematomas to the scalp

• Boggy areas when palpating the scalp

• Visible fractures or deformity of the skull

• Battle’s sign or ‘panda eyes’ (not apparent for several hours)

• Cerebrospinal fluid and/or blood leaking from the nose or ears

• Cushing’s Triad: Rising blood pressure, reducing heart rate and irregular respirations

• Dizziness

• Nausea and vomiting

• Abnormal pupils and/or pupil reaction

• Visual disturbances (double or blurred vision, seeing ‘stars’)

• Severe headache

• Altered level of consciousness

• Perseveration (repeatedly asking the same questions)

• Amnesia

• Paraesthesia/paralysis of the extremities

• Convulsions

• Posturing

• Abnormal respirations.

4.6 Spinal injuries

Spinal injuries, or more specifically spinal cord injuries (SCI), are rare, with around 1000 new cases per year [Harrison, 2007]. In adult major trauma, approximately 10% of patients will sustain a spinal fracture/dislocation, but less than 2% will sustain an SCI. The most common cause is a fall (46%), although, significantly, a third of these are falls of less than 2 m in height. Falls are closely followed by road traffic collisions (RTCs, 40%) and the other, much rarer, causes, such as sports injuries (under 3%), stabbings (1%) and shootings (0.6%). SCIs most commonly occur at the cervical level (45%), followed by thoracic (29%), lumbar (24%) and multi-level injuries (2%) [Hasler, 2011].

Risk factors for SCI include [Hasler, 2011]:

• Male sex

• Under 45 years of age

• Reduced Glasgow Coma Scale score

• Accompanying chest injury

• Dangerous mechanism (falls greater than 2 m, sports injury, RTC, shooting).

4.6.1 Management

All patients who are suspected of having a spinal injury should be manually immobilised as soon as possible. Patients with isolated penetrating trauma to the head or limbs do not require immobilisation, but if, in torso or neck trauma, it is possible that the projectile could have passed near or through the spinal cord and there are signs of spinal cord injury, then immobilisation is appropriate.

4.7 Thoracic injuries

Thoracic trauma accounts for 25–50% of all trauma and is a contributing factor to around half the deaths through injury. Major causes are road traffic collisions, industrial accidents and domestic and sporting injuries [Greaves, 2008]. The most common problem associated with severe thoracic injury is hypoxia [AACE, 2016].

4.7.1 Pneumothorax

The lungs are surrounded by a pleural membrane. The outer layer (parietal pleura) lines the chest wall, and the inner layer (visceral pleura) covers the lungs. Between them is the pleural space, which is lubricated to ensure that the surfaces glide smoothly over one another as well as creating a surface tension that results in the surfaces ‘sticking together’.

Pneumothorax, or air in the pleural space, is generally classified as being spontaneous, if there is no obvious causal factor, or traumatic, if there is an external cause [Noppen, 2010].

In the event that air within the alveoli can escape into the pleural space, or there is an external breach of the thoracic cavity allowing atmospheric air to enter the pleural space, the normal physiology of ventilation is disrupted and the lung collapses [Ryland, 2014].

Traumatic pneumothoraces are caused by penetrating trauma, such as stab and gunshot wounds or impalements; blunt trauma that leads to rib fractures and increased intrathoracic pressure; and bronchial rupture and barotrauma, where changes in pressure of the air delivered to the lungs leads to expansion. This phenomenon has been reported in air crew and SCUBA divers [Sharma, 2008].

Assessment

Arguably, the most important type of pneumothorax to recognise is one under tension. However, the clinical course of a tension pneumothorax is not the same for all patients, with the progression of clinical deterioration for an awake, spontaneously breathing patient likely to be considerably longer than for those who are being ventilated with positive-pressure ventilation [Leigh-Smith, 2005].

Signs and symptoms of a tension pneumothorax in awake patients include:

• Pleuritic chest pain (sharp pain, worse on breathing in and out)

• Air hunger

• Respiratory distress

• Tachypnoea (rapid breathing rate)

• Tachycardia (rapid heart rate)

• Falling oxygen saturations (SpO₂)

• Agitation

• On the same side as the injury:

• Hyper-expansion

• Hypo-mobility

• Decreased breath sounds

• Pre-terminal (near death):

• Decreasing respiratory rate

• Hypotension

• Decreasing level of consciousness.

Management

Patients with a simple pneumothorax with no signs of cardiovascular compromise, suggesting tension, can be managed conservatively out-of-hospital, but should be closely monitored en route to hospital [Lee, 2007a]. All patients with a pneumothorax should receive oxygen at the appropriate target range (usually 94–98%, except for patients at risk of carbon dioxide retention, who should be managed at either 88–92% or their usual range [AACE, 2016]). If there is an open pneumothorax, leave the wound open or apply a non-occlusive dressing [Zideman, 2015].

4.7.2 Haemothorax

Haemothorax, or blood in the thoracic cavity, usually occurs as a result of penetrating trauma. Life-threatening haemorrhage can occur in cases of severe lacerations of the lung, large vessels in the mediastinum and the heart. Each hemithorax (literally, half of the chest) can easily accommodate half of the patient’s circulating blood volume before the physical signs are obvious [Greaves, 2008].

However, this amount of bleeding will lead to the signs and symptoms of shock, and since blood occupies space usually reserved for the lung, lung collapse occurs, leading to absent or decreased lung sounds and reduced chest wall expansion on the injured side [Greaves, 2008].

There are few treatment options available outside of hospital; usually, expedient transport to the nearest major trauma centre (MTC) is indicated.

4.7.3 Flail chest

Blunt chest trauma can lead to multiple rib and sternal fractures. In the event that two or more ribs are broken in two or more places, the chest wall will lose the rigid structure that usually supports the chest. A flail segment will start to move paradoxically, that is, it will move inwards during inspiration and outwards on expiration. If this area is large enough, it results in compromised ventilation. However, it is usually bruising of the underlying lung that leads to hypoxia and there can also be significant blood loss, with each rib fracture causing around 100 ml of blood loss [Greaves, 2008].

The flail segment is not always obvious as muscular spasm can support the segment until the muscles are exhausted. Do not attempt to splint the flail segment as this is likely to further impair ventilation [NAEMT, 2014].

Figure 16.4 The abdominal cavity

4.8 Abdominal injuries

The abdominal cavity extends from the diaphragm to the pelvic bones and from the vertebral column to the muscles of the abdomen and flanks (Figure 16.4). Organs are classed as peritoneal if they are covered by a lining called the peritoneum. These include the spleen, liver, stomach, gallbladder, the tail of the pancreas, parts of the large intestine and most of the small intestine, and the female reproductive organs [NAEMT, 2014]. The retroperitoneal space is the area behind the peritoneum. This area contains the kidneys, ureters, pancreas (except the tail), parts of the small and large intestine and the aorta and inferior vena cava [AACE, 2016].

In blunt trauma, the spleen, liver and structures that are firmly fixed, such as the retroperitoneal organs, are most commonly injured due to shearing forces associated with rapid deceleration. Penetrating trauma can also cause serious damage and severe bleeding. Depending on the angle at which the penetrating object enters, thoracic injury is also possible, particularly in upper abdominal stab injuries [NAEMT, 2014].

Patients suffering from abdominal trauma may not exhibit many symptoms initially, although you should suspect internal injury in any shocked patient with a suggestive mechanism of injury. Look at the abdomen for signs of injury, such as bruising, abrasions and seat-belt marks. Gently feel the abdomen for signs of tenderness, but don’t be reassured by a normal examination [AACE, 2016].

There is no specific management of blunt abdominal trauma, but in penetrating trauma, if the injury has caused the bowel to protrude out of the abdomen, you should not push it back in. Instead, cover it with a dressing soaked in warm saline [NAEMT, 2014].

If the penetrating object is still in place in the patient’s abdomen, do not attempt to remove it. Instead, secure it appropriately, although if it is pulsating, allow some movement of the object, but not its removal [AACE, 2016].

4.9 Pelvic injuries

Fractures of the pelvic ring are uncommon, with around 20–37 per 100,000 people suffering a fracture, about 2–8% of all skeletal injuries [Garlapati, 2012; McCormack, 2010]. However, pelvic fractures are found in up to 20% of injuries involving a significant mechanism of injury resulting in multiple injuries. The major cause in the younger population is road traffic collisions (RTCs), with around 44–64% of pelvic ring fractures due to the patient being involved in an RTC. Vehicle speed and compartmental intrusion are important factors [Adams, 2002]. The overall mortality rate is around 12%, although it can be as high as 50% for open pelvic fractures [Lee, 2007c].

All pelvic fractures cause some bleeding, although the source can vary. Bleeding from cancellous bone that has been fractured is common, but bleeding can also occur from lacerations to retroperitoneal veins and the internal iliac arteries. Arterial bleeding accounts for up to 25% of haemodynamically unstable pelvic ring fractures [McCormack, 2010], but most bleeding is actually low-pressure bleeding (i.e. not arterial) and usually responds well to appropriate stabilisation (such as with a pelvic binder or external fixator) and tamponade [Abrassart, 2013].

Associated abdominal injuries

As well as the potential vascular damage that pelvic ring fractures can cause, the soft tissues are also vulnerable, and injuries to the anorectum, vagina, urethra and nerves can occur. The most common is bladder injury, typically caused by compression or tearing of the bladder wall. Urethral and anorectal injuries are more common with straddle injuries, for example when a motorcyclist straddles the fuel tank during an RTC, resulting in the separation of the two pelvic bones and severe tearing of the pelvic floor [Luke, 2010].

4.10 Fractures and dislocations

A fracture is a break (or breaks) in a bone. There are a number of types [Pilbery, 2013]:

• Transverse: A single horizontal break through the bone, splitting it into two parts

• Comminuted: A fracture that results in the bone being split into more than two parts

• Oblique: The bone is broken diagonally along its shaft

• Spiral: Caused by a twisting force

• Open: Sometimes called a compound fracture. A fracture with a wound at the site of the injury caused by bone pushing through the skin

• Closed: Sometimes called simple fracture. A fracture where no puncturing of the skin has occurred

• Greenstick: An incomplete fracture where only one side of the periosteum fractures. This fracture is common in children because their bones are soft and porous.

A dislocation is an abnormal separation of joint surfaces. They can occur in isolation, or be associated with a fracture (or fractures). Since joints are kept in place by soft tissues such as ligaments, these will have been injured for a dislocation to have occurred. Prompt reduction of the dislocation to its original anatomical position is required, following analgesia and/or a local anaesthetic. A competent clinician is required for this procedure.

The management of fractures and dislocations follows the standard primary and secondary survey for the trauma patient, but specifically consider:

Figure 16.5 Types of fractures.

• Splinting the affect limb

• Providing analgesia: These injuries can be very painful

• Cover open fractures with a sterile dressing.

4.11 Sprains and strains

Sprains are ligamental injuries, that involve a partial or complete (depending on severity) tear of the ligament, whereas strains are tears in muscles. Their management is essentially the same, and consists of [MoM, 2012]:

• Protect from further injury

• Rest the injured limb

• Ice wrapped in a damp towel should be applied to the injury for 15–20 minutes

• Compress with a simple elastic bandage or elasticated tubular bandage, which should be snug, but not tight

• Elevate the limb above the level of the heart.

5 Spinal immobilisation

5.1 Learning objective

By the end of this section you will be able to:

• Describe how to perform manual in-line stabilisation.

5.2 Introduction

Spinal immobilisation should be considered for any trauma patient with [EEAST, 2014]:

• A mechanism of injury consistent with spinal injury (mechanism may be minimal in the elderly or those with fragility conditions, e.g. osteoporosis)

• Glasgow Coma Scale score of less than 15

• Complaints of neck or back pain

• Signs or symptoms of spinal cord injury

• Drug/alcohol intoxication.

5.3 Manual in-line stabilisation

Manual in-line stabilisation (MILS) with adequate back support is one of two acceptable methods of immobilisation. The other requires the use of several items of equipment [AACE, 2016]. Therefore, MILS will almost always be the first form of spinal immobilisation to be applied to a patient with a suspected spinal injury.

5.3.1 Procedure

Take the following steps to apply manual in-line stabilisation [NAEMT, 2014; Pilbery, 2013]:

1. Use appropriate PPE as required. Advise the patient not to move their head, explain that you are about to hold their head, and gain their consent if possible

2. If the patient is supine (lying on their back) either kneel or lie on the ground behind the patient’s head. If seated, move behind the patient. Hold the head firmly with both hands. Support the lower jaw with your fingers and support the head with your palms. Try to rest your lower arms on a surface (such as the ground or the back of a seat) as maintaining MILS can be tiring

3. If the patient’s head is not facing forwards and the patient is conscious, ask them to slowly move their head into a neutral, in-line position (eyes looking straight ahead and nose in line with umbilicus). If the patient is unconscious, gently move the head into a neutral position. If there is any pain or resistance to this manoeuvre, stop immediately

4. Do not let go until instructed to do so by a clinician.

6 Burns

6.1 Learning objectives

By the end of this section you will be able to:

• Explain what is meant by the term ‘burn’

• Describe the types of burn and their causes

• Explain the safety considerations when dealing with burns

• State the rules associated with estimating the size of burns

• Explain time-critical factors that affect the management of burns

• Explain the complications associated with burns

• Explain the treatment of burns

• Explain why burns patients are transported to definitive care.

6.2 Introduction

A burn is an injury caused by energy transfer to the body’s tissues, causing necrosis and an associated inflammatory reaction [Greaves, 2008].

It is estimated that there are 250,000 burn injuries a year in the United Kingdom, resulting in 175,000 visits to an emergency department [NBCRC, 2001]. In England and Wales, serious burn injury (defined as requiring at least a 72-hour stay in hospital) is responsible for 5.4% of all serious trauma [Kalson, 2012].

Burn injury most commonly occurs in the home (over 30%) with the kitchen being the favoured location. The most common sources of injury are [NBCG, 2008]:

• Cup of tea in children

• Petrol ignition in adults

• Bathing, kettle spills and central heating radiators in elderly people.

Burns are commonly split into a number of types [AACE, 2016]:

• Chemical

• Cold

• Electrical

• Friction

• Radiation

• Thermal.

Note: Cold injury was discussed in the Exposure/ Environment chapter.

6.3 Assessment of burns

6.3.1 History

It is important to identify the mechanism, including the cause of the burn, how it came into contact with the patient, and any first aid undertaken. Note when the injury occurred, how long the patient was exposed to the source and the duration of any cooling. Don’t forget to be alert for signs of non-accidental injury.

6.3.2 Assessment

Pre-hospital estimation of total body surface area (TBSA) of burn injury is poor, with the ‘rule of nines’ (Figure 16.6) underestimating burns of less than 20% and overestimating burns over 40%; also, it is not suitable for children under 14 years of age [Hettiaratchy, 2004; AACE, 2016].

The whole hand (palm and fingers) represents about 0.82% TBSA in adults and 0.77% in children, making accurate calculations tricky. However, the palm alone is 0.5% TBSA [Muehlberger, 2010] and is suitable for estimating burns less than 15% or greater than 85% TBSA. Note that these methods will generally underestimate %TBSA in obese patients [Berry, 2001].

Figure 16.6 The ‘rule of nines’

Lund and Browder charts are more accurate, but these are cumbersome to complete in the back of an ambulance. An alternative that has been advocated is serial halving [Allison, 2004]. This involves determining whether greater than or less than 50%, 25% and finally 12.5% of the TBSA is burnt. This approximation is sufficient to determine whether the patient requires referral to a burns unit (if direct access is an option) and the need for intravenous fluids. Erythema (reddening) should not be included when calculating TBSA of burn injury [Enoch, 2009].

6.3.3 Classification

Although important for subsequent burns management, the depth of a burn does not affect pre-hospital treatment, but may provide some indication as to the cause (Table 16.1) [NZGG, 2007].

6.3.4 Burns requiring transport to hospital

The National Network for Burn Care (NNBC) has set out a suggested minimum threshold for patients who may require specialised burn care services. These patients will usually require transport to hospital, but check with your own ambulance service’s local arrangements [NNBC, 2012]:

Table 16.1 Burns classification

• All burns $ 2% TBSA in children or $ 3% in adults

• All full thickness burns

• All circumferential burns

• Any burn not healed in 2 weeks

• Any burn with suspicion of non-accidental injury

• All burns to hands, feet, face, perineum or genitalia

• Any chemical, electrical* or friction burn

• Any cold injury

• Any unwell/febrile child with a burn.

*May not apply to low (domestic) voltage injury

6.4 Thermal burns

The most common type of thermal burns (sometimes referred to as thermal injuries) are flame, scald and contact. Flame burns are more common in adults and are often associated with smoke inhalation and other traumatic injuries. These are more likely to result in deep dermal or full-thickness burns.

Scalds are the most common cause of burn in children, usually due to spillages of hot drinks or immersion in hot bath water. They generally cause epidermal or superficial dermal burn injury [Hettiaratchy, 2004].

Direct contact burns are caused by brief contact with a very hot object, or (more commonly) prolonged contact with a cooler object. Typical patient groups include epileptics and those who misuse alcohol or drugs.

Irreversible damage to the epidermis can be caused by exposure to 44°C heat for 6 hours, or 65°C for 1 second [Moritz, 1947]. Burns injuries are characterised by a local response and, if the total body surface area (TBSA) burnt is greater than 20%, a systemic response [Greaves, 2008].

6.4.1 Acute smoke inhalation injury

Smoke inhalation is a killer. Between 80% and 90% of fire-related fatalities are attributed to smoke inhalation, and it has a greater contribution to overall mortality and morbidity of burn injuries than either %TBSA or age [Kimmel, 1999]. Naso-oropharyngeal and mucosal burns are common [Toon, 2010], but thermal injury below the vocal cords is rare since heat is effectively exchanged in upper airway passages [Prien, 1988]. When air, steam and/or smoke are at sufficiently high temperatures to cause thermal injury to the lower airways, rapid oedema of the glottis develops, resulting in fatal airway obstruction.

Systemic toxins are the products of incomplete combustion and include carbon monoxide (CO) and hydrogen cyanide. CO is an odourless, colourless gas that binds to haemoglobin with 250 times the affinity of oxygen. This results in a decrease in the oxygen-carrying capacity of the blood. Cyanide adversely affects internal respiration by preventing aerobic production of adenosine triphosphate (ATP, the energy source for cells) [Toon, 2010].

6.4.2 Friction burns

Although friction burns are strictly speaking a thermal burn, they are the result of heat production caused by friction between the skin and another object. This can result in not just a burn, but abrasions too (see the lesson on WOUNDS AND BLEEDING) [Gregory, 2010b].

6.4.3 Management

Safety first! The patient needs to be removed from the source of the burn if it is safe to do so, but don’t get burnt yourself. Clothing should be removed unless it is sticking to the patient, as should jewellery, which may become constrictive as tissues swell.

Follow the <C>ABC approach for burns as you would any traumatic injury. However, inhalation injury is a particular concern and occurs in around 22% of all burns, 60% if facial burns are present [Toon, 2010].

Signs of inhalation injury include [Singer, 2010]:

• Full-thickness or deep dermal burns to face, neck or upper torso

• Singed nasal hair

• Soot in sputum or oropharynx

• Dyspnoea, hoarseness, cough or stridor

• Cyanosis

• Altered level of consciousness.

Administer high-flow oxygen via a non-rebreathe mask. CO poisoning may make pulse oximetry readings unreliable [AACE, 2016].

Cooling

Thermal burns should be cooled for 20 minutes [Bartlett, 2008], preferably with running water (between 8°C and 15°C) [NZGG, 2007]. There is little evidence that ice causes damage to underlying tissues, but it runs the risk of making the patient hypothermic so is not recommended [Cuttle, 2008, 2009]. Cooling should commence immediately after the burn has occurred, but there is limited evidence to suggest that cooling up to an hour after the burn has occurred is still beneficial [Cuttle, 2010]. If running water is not available or practicable, then gel-based body blankets can be used without causing hypothermia [NZGG, 2007; Singer, 2006; Martineau, 2006].

Covering/dressing

Patients with burns lose heat from nonepithelialised areas of skin due to evaporation. With the thermoregulatory function of the skin disrupted, patients are at risk of hypothermia, even on a warm day [AAOS, 2011]. Hypothermia is part of the lethal triad in trauma, and for each 1°C reduction in body temperature the mortality rate increases significantly [Lonnecker, 2001], although there is no evidence currently to suggest that pre-hospital cooling causes hypothermia [Lonnecker, 2001; Singer, 2010]. Once cooling has been completed, cover the burn with a clean sheet or Clingfilm, but take care not to apply it circumferentially as it can become constrictive as oedema develops [NZGG, 2007].

Time-critical features

If a burns patient has any of the following signs, they are considered to be time-critical and will require blue light transport to an appropriate facility [AACE, 2016]:

• Any major ABCD problems

• Airway burns

• History of hot air or gas inhalation

• Respiratory distress

• Evidence of circumferential (completely circling the neck, torso or limb) burns

• Significant facial burns

• Burns more than 15% TBSA in adults or 10% TBSA in children

• Presence of other major injuries.

6.5 Chemical burns

Chemical burns generally result from exposure to acids, alkalis and other corrosive materials. Alkali burns are generally more serious as they penetrate more deeply than other chemicals [ATLS, 2008]. Their severity depends on the concentration of the chemical, the duration of exposure and the speed in applying first-aid measures [Greaves, 2008].

6.5.1 Management

Safety first! It is important that you do not become exposed to the chemical. If in doubt, do not approach the scene but wait for the Hazardous area response team (HART) or the fire and rescue service to attend.

Speed is of the essence when treating chemical burns so flush the exposed area with copious quantities of water as soon as possible. However, brush off any chemical powder from the patient first. In industrial settings, decontamination showers may be available, but at home, the shower or a hosepipe is an alternative. While flushing, contaminated clothing should be removed, although do not pass anything over the patient’s head; cut it off [Pilbery, 2013].

Chemical burns should be irrigated for at least 15 minutes, and ideally for up to an hour (although alkali burns may require much longer periods of irrigation), but watch for hypothermia [NZGG, 2007].

6.6 Radiation burns

Radiation burns are most commonly caused by ultraviolet radiation from the sun or sunlamps (sunburn). However, in rare cases, it can be caused by exposure to radioactive materials [Gregory, 2010b].

Approximately 80% of skin cancer is preventable, and avoiding sunburn is key [Simon, 2010]:

• Take care not to burn

• Cover up with loose cool clothing, a hat and sun glasses

• Seek shade during the hottest part of the day

• Apply high-factor sunscreen (at least sun protection factor 15) to sun-exposed body parts

• Take extra care to protect children in the sun.

6.6.1 Management

Safety first! If the burns are due to exposure to radioactivity, do not approach but wait for the Hazardous area response team (HART).

Sunburn

Basic first-aid measures are usually sufficient [SJA, SAA, BRC, 2014]:

• Cover the patient’s skin with light clothing or a towel. Move them out of the sun, preferably indoors

• Encourage them to drink frequent sips of cold water while cooling the affected area with cold water. If the area of sunburn is large, it may be more practical for the patient to soak the area in a cold bath for 10 minutes

• If burns are mild, calamine or an after-sun lotion may help. Patients should be advised to stay inside or in the shade.

Most sunburn will manifest as reddening of the skin (erythema), but blistering is evidence of a partial thickness burn and transport to hospital should be considered if it meets the criteria for review by specialised burns care services [NNBC, 2012].

6.7 Electrical injuries

Electrical injuries are thankfully uncommon, but they cause significant damage and even death when they occur. The majority of electrical injuries in adults occur in the workplace and involve high voltages, whereas in children most injuries occur in the home with domestic voltage. Electrocution from lightning strikes is very rare, leading to around 1000 deaths each year worldwide [Nolan, 2016].

Electrical burns arise when a source of electrical power makes contact with the patient’s body. They are frequently more serious than they appear, since rapid heat loss from the surface of the skin may leave it relatively undamaged, whereas the underlying tissues may have sustained serious injury, particularly between the entry and exit points (don’t forget to look for both!) [ATLS, 2008].

6.7.1 Management

Safety first! Do not approach the patient until you are certain that the source of electricity has been cut off.

When dealing with electrical injuries, the thermal burns sustained may not be your highest priority. The patient may be in cardiac arrest, have airway or facial burns and be traumatically injured (fractures, serious internal injuries); this will need addressing first. Associated thermal burns can be managed as previously described.

6.8 The problem with burns

Without appropriate intervention and management, patients with serious burns can die due to [Sheridan, 2012]:

• Burn shock due to excessive fluid loss in the first 24 hours

• Respiratory failure in the subsequent 3–5 days

• Burn wound sepsis in the following few weeks.

Thankfully, because of prompt transfer by ambulance staff to burn centres and the subsequent specialised management that patients receive, this is less common. However, it does underline the importance of transporting patients to definitive care.

There are four general phases of burn care, with the ambulance service only playing a small part in the initial management stage [Sheridan, 2012]:

• Initial evaluation and resuscitation (0–72 hours)

• Initial surgery and temporary closure of wounds created by removal of full-thickness burns (days 1–7)

• Definitive wound closure (weeks 1–6)

• Rehabilitation and reconstruction (up to 2 years).

Chapter 17: Children and Infants

1 Why paediatric patients are different

1.1 Learning objective

By the end of this section you will be able to:

• Explain how paediatric patients are anatomically, physiologically and developmentally different from adults.

1.2 Introduction

Paediatrics is a speciality of medicine that looks after people from birth to age 18 years. Children are generally divided into five main groups [Lissauer, 2007]:

• Infants: From birth to 12 months of age. In the first 4 weeks after birth, infants may also be called neonates

• Toddler: Approximately 1–2 years of age

• Pre-school: This is a young child aged 2–5 years

• School-age: Generally 5–12 years (or the onset of puberty)

• Teenager: Also called adolescents. Generally from onset of puberty to 18 years, when, in the UK, they become an adult. Some guidance (such as for resuscitation or the administration of some drugs) treats this group the same as adults.

Note that for the purposes of resuscitation, an infant is a patient under 12 months of age and a child is a patient who is 1 year to the onset of puberty (around 12 years) [Skellett, 2016].

1.3 Anatomy and physiology

As children get older, their bodies change anatomically and physiologically. This is important to remember when undertaking your assessment as you may need to modify your plan for their management.

1.3.1 Airway

Most of the changes in the infant and child airway have been covered in the Airway chapter. However, some extra points to consider are provided here.

Face and mouth

Infants’ faces are small. This makes sizing of a face mask for resuscitation important if a good seal is to be achieved. It is important that pressure on the eyes is avoided as this can result in damage and a reflex bradycardia. The floor of the mouth is also easy to compress, so care must be taken not to apply pressure to the soft tissues under the mandible during airway opening and positive-pressure ventilations (Figure 17.1) [Skellett, 2016].

Figure 17.1 Infant positive-pressure ventilation

Nose and pharynx

In the first 6 months, infants breathe through their nose, meaning that any nasal obstruction can result in increased work of breathing and respiratory compromise [AAP, 2013].

1.3.2 Breathing

Infants and small children have relatively small resting lung volumes, which means they have less oxygen capacity in reserve than adults and have a higher oxygen consumption. In cases of respiratory compromise, therefore, the blood oxygen levels in these infants and small children will rapidly decline, making the prompt administration of supplemental oxygen crucial [Skellett, 2016].

The ribs of infants are cartilaginous and so are very pliable. In addition, they have weak intercostal muscles, which means that the diaphragm is their main muscle of respiration. If the diaphragm is impeded in any way, such as by gastric distension, for example, their ventilation may become ineffective [AAP, 2013].

As children get older, their intercostal muscles become more developed, contributing more to mechanical ventilation. Their ribs ossify, hardening and acting as an anchor for the developing intercostal muscles, making them less likely to collapse during periods of respiratory distress. As a result, intercostal recession in any child over the age of 5 years should be seen as an ominous sign of severe respiratory distress [Skellett, 2016].

Infants have a relatively high metabolic rate, oxygen consumption and carbon dioxide production, requiring a higher respiratory rate than older children. This can be further increased by pain, fever and anxiety, resulting in changing ‘normal’ respiratory rates for infants and children (Table 17.1) [Skellett, 2016].

Table 17.1 Respiratory rate ranges in infants and children

Age (years)

Respiratory rate (breaths/min)

< 1

30-40

1-2

26-34

2-5

24-30

5-12

20-24

> 12

12-20

1.3.3 Circulation

The circulating blood volume in an infant is about 80 ml/kg, which means that in a newborn baby weighing 3 kg, their blood volume is only 240 ml, making small blood losses significant.

Another important point to note is that oxygen delivery to the tissues is dependent on the arterial blood oxygen content multiplied by the cardiac output. In respiratory failure, a reduction in arterial blood oxygen can be compensated by increasing cardiac output. However, in circulatory failure, it is not possible to increase arterial blood oxygen content so tissue oxygen delivery falls immediately [Fuchs, 2012].

The stroke volume at birth is small, only 1.5 ml/kg, so increasing cardiac output is mainly achieved by increasing heart rate. Thus heart rates in infants and small children are higher than in older children (Table 17.2). In addition, systemic vascular resistance increases as children get older, a change reflected by increased ‘normal’ blood pressures (Table 17.3) [Skellett, 2016].

Table 17.2 Paediatric heart rate ranges

Age

Awake (beats/min)

Deep sleep (beats/min)

0-3 months

85-205

80-140

3 months to 2 years

100-180

75-160

2-10 years

60-140

60-90

> 10 years

60-100

50-90

Table 17.3 Paediatric blood pressure ranges

Age

Systolic blood pressure (mmHg)

0-1 month

> 60

1-12 months

80

1-10 years

90 + (2 x age in years)

> 10 years

120

1.4 Cognitive development

Children are also challenging because their brain develops as they age. This means that during your assessment of a child, you will expect different levels of interaction and abilities in a 1-year-old compared to a 12-year-old child [Lissauer, 2007; AAP, 2013; Fuchs, 2012].

1.4.1 Infants

Under 2 months

Infants in this age group will spend the majority of their time feeding and sleeping. They are unable to tell the difference between their parents/carers and others, so do not display stranger anxiety. They will exhibit primitive reflexes such as grasping objects placed in the palm of their hand, or turning their head towards a gentle stimulation of the side of their mouth (rooting).

2–6 months

Infants become more active during this period, making assessment a little easier. They begin to make eye contact, will smile and follow the light of your pen torch or a toy with their eyes. They will also turn their head in response to a loud noise or the voice of their parent/carer. Their motor skills develop and they will start to roll over and reach for objects. They will vocalise with coos and laughs when spoken to.

6–12 months

Infants are much more socially interactive at this age. They may be able to say single words such as ‘mama’ or ‘dada’, but will also develop stranger anxiety in the latter stages (typically after 9 months), so keep the infant with their parent/ carer if possible. They will be able to feed themselves, sit unsupported, reach for objects and pass them between hands.

1.4.2 Toddlers

There is a rapid change in growth and cognitive development at this age. By 18 months, children will have a vocabulary of around 6–10 words, and will know the name of, and be able to point to, several parts of their body. They should be able to walk steadily and feed themselves with a spoon.

As they reach 2 years of age, children may be able to combine several words together to make a simple phrase. They will start to engage in symbolic play, feeding their teddy for example. Stranger anxiety may be extreme and they are typically illogical thinkers, learning by trial and error, but have no sense of danger. They are self-centred and will be able to label objects as ‘mine’. Toilet training may lead to children being dry during the day.

1.4.3 Pre-school

These children are creative and illogical thinkers, often confusing fantasy and reality. They are likely to have misconceptions about illness, injury and bodily functions. In addition, they may fear the dark, being left alone and the presence of monsters under the bed. They have good language skills and can participate in parallel play, taking it in turns with others, but their attention span is short.

1.4.4 School-age

Children at this age understand cause and effect and are capable of abstract thought. They can tell you about the progress of their current illness or injury but their ability to understand the seriousness of the situation is limited. They can be involved with their care if explanations are kept simple and clear. Peer-group support becomes important at this age, but they will still have separation anxiety from their parents/carers when ill, and fear pain and loss of control.

1.4.5 Teenagers

Teenagers (adolescents) are sometimes compared to toddlers: highly mobile but lacking common sense! However, they are able to rationalise and express themselves and their feelings in words. This is also a period of experimentation and risk-taking. Children at this age will typically transition from relying on their parents/carers for psychological support and development to their friends and peers. This typically leads to feelings of anxiety if they are ‘different’ from their peers. In addition, they may struggle with anxiety of independence, body image, sexuality and peer pressure.

2 Initial assessment and management of the paediatric patient

2.1 Learning objectives

By the end of this section you will be able to:

• Conduct an initial assessment of the paediatric patient

• Identify problems with a paediatric patient’s airway, breathing, circulation and neurological status

• Describe the principles that underpin the support of a seriously ill paediatric patient

• Demonstrate the procedures to support a clinician to manage a seriously ill paediatric patient.

2.2 Introduction

The assessment of the paediatric patient is much the same as for adults, and you will follow the standard procedure you learnt about in the Patient Assessment chapter. As before, the primary survey is a chance to identify and correct life-threatening problems. In infants and children, prompt recognition and intervention when there are signs of respiratory and/or circulatory failure can prevent the majority of paediatric cardiorespiratory arrests [Skellett, 2016].

2.3 Developmental approach to the paediatric patient

As you found out in the section on WHY PAEDIATRIC PATIENTS ARE DIFFERENT, a child’s cognitive development changes as they age, which requires modification to your method of assessment. In this section, you will be provided with some suggestions about how to conduct an assessment of the paediatric patient. Don’t forget that you will also need to manage and reassure an often anxious and distressed parent/carer.

2.3.1 Infants

Conduct your assessment by taking account of the following principles [AAP, 2013]:

• Keep the environment comfortable, in terms of temperature and security for the infant. Familiar toys and blankets can help

• Use the name of the patient while conducting your assessment

• Where possible, assess an infant in the arms of a parent/carer

• Approach the infant slowly and calmly. Loud voices and fast movements may scare them

• Do not stand over an infant, but sit or kneel at their eye level

• Look, listen and feel, in that order, to minimise infant distress

• Warm your hands, and tools such as stethoscopes

• Be flexible in your assessment. If the infant is calm, count the respiratory rate and listen to the chest first. This is not possible to do accurately when the infant is crying

• Observe the interaction between parent/carer and the infant. Consider if child abuse is a possibility

• Toys can be used to distract the infant

• Older infants may display stranger anxiety, so if you need to expose the infant, ask the parent/carer to do this. Don’t let the infant get cold, though

• Save painful procedures (such as blood sugar measurement) until last.

2.3.2 Toddlers

Conduct your assessment taking account of the following principles [AAP, 2013]:

• Use the name of the patient while conducting your assessment

• Approach slowly and don’t touch them until they are familiar with you

• Communicate using a firm, but friendly, tone of voice

• Do not stand over a toddler, but sit or kneel at their eye level

• Where possible, place the toddler on the lap of a parent/carer

• Use play and distraction to help you conduct your assessment

• If you need to use equipment, such as a stethoscope, let them hold it and become familiar and comfortable with it

• Communicate directly with the toddler. Admire their clothes or ask about pets. Remember they are self-centred at this age

• Provide limited choices. For example ‘Do you want me to listen to your belly or chest first?’

• Avoid questions that can be answered with a ‘No’

• Examine a toddler from toe to head

• Involve the parent/carer. For example, place the pulse oximeter probe on their finger first, and ask them to remove the toddler’s clothes or hold an oxygen mask near the toddler

• Do not expect toddlers to sit still and co-operate. Be patient and opportunistic.

2.3.3 Pre-school

Conduct your assessment taking account of the following principles [AAP, 2013]:

• Use the name of the patient while conducting your assessment

• Use simple terms to explain what you are going to do

• Choose your words carefully. Use age-appropriate language and avoid scaring the child

• Teddy or dolls can be helpful to explain what you are going to do

• Set limits on behaviour, if required. For example, ‘You can cry or scream, but not kick or bite’. Praise good behaviour

• Use games and toys to provide distraction. Ambulance bandages can be useful for this

• Focus on one thing at a time and minimise the time between explaining a procedure, especially a painful one, and carrying it out.

2.3.4 School-age

Conduct your assessment taking account of the following principles [AAP, 2013]:

• Use the name of the patient while conducting your assessment

• Privacy becomes important in this age group. Make sure the environment is appropriate, and if you need to expose the child to examine them, cover them up afterwards

• Speak directly to the child first, then include the parent/carer. Ask older children if they would like their parent/carer present

• Involve the child in their care if they want this. Feeling out of control can distress children in this age group. However, do not negotiate unless the child really does have a choice

• Anticipate the fears that the child has and address them straight away. Assure them that becoming ill or injured is not a punishment

• Explain in simple terms what is wrong and what is going to be done

• Explain procedures just prior to undertaking them. Don’t lie to the child, for example telling them a procedure won’t hurt, when it will

• Praise the child for being co-operative, but do not chastise them if they are not

• Physical assessments in this age group can usually be conducted head to toe.

2.3.5 Teenagers

Conduct your assessment taking account of the following principles [AAP, 2013]:

• Use the name of the patient while conducting your assessment

• Speak directly to the teenager and ask them first for information. If they do not know the answer, for example the name of their GP, check with them if it is okay to ask their parent/carer

• Respect their modesty and privacy. Be confidential unless you have a duty to report or pass on their disclosures

• Be honest and non-judgemental. Provide accurate information and allay fears, particularly concerns over body image or being ‘different’ as a result of their current illness or injury

• Do not mistake the size of the teenager as a measure of their maturity

• Avoid becoming frustrated or angry if the teenager does not want to communicate or is unco-operative

• Enlist the help of their friends to assist when the teenager is being unco-operative, although keep in mind the teenager’s right to confidentiality.

2.4 Recognising the sick infant and child

Unlike adults, infants and children generally have a cardiac arrest secondary to respiratory and/or circulatory failure. Outcome from cardiac arrest in infants and children is significantly worse than in adults, and intervening early on can prevent this from occurring.

2.4.1 Respiratory failure

Respiratory failure can be either compensated or decompensated. Compensated respiratory failure (sometimes known as respiratory distress) is characterised by increased work of breathing to overcome a respiratory problem, e.g. bronchiolitis. Respiratory failure is termed decompensated when the respiratory system can no longer maintain appropriate blood levels of oxygen (O₂) and carbon dioxide (CO₂). Since blood gases are not available out-of-hospital, a rough equivalent is a pulse oximetry (SpO₂) reading of less than 90% when breathing room air [Skellett, 2016].

Occasionally, respiratory failure can be present in the absence of increased work of breathing, e.g. due to a decreased level of consciousness or a morphine overdose.

2.4.2 Cardiac failure

As with respiratory failure, cardiac failure can also be compensated or decompensated. In compensated failure, vital organ (heart and brain) perfusion is maintained and blood pressure remains within normal limits. This is mostly achieved by peripheral vasoconstriction. Once there is insufficient circulation to deliver O₂ to the tissues (i.e. in shock), the infant or child will become hypotensive and their level of consciousness will reduce.

2.5 Primary survey

The primary survey in the infant and child is the same as for adults, except for the general impression component, which should include use of the paediatric assessment triangle (PAT). The PAT is advantageous in children because it can be undertaken without actually touching the child and be performed ‘across the room’ to avoid increasing a child’s anxiety, by getting too close initially [AAP, 2013].

2.5.1 General impression

It is important to gain a general impression of the health of an infant or child from ‘across the room’, before your presence has an adverse effect on their level of anxiety or distress. To help you achieve this, use the paediatric assessment triangle (PAT) [Dieckmann, 2010]. As the name suggests, it consists of three key components:

• Appearance

• Work of breathing

• Circulation to skin.

Appearance

The child’s general appearance is probably the most significant aspect of the PAT as it provides information about the perfusion of the brain. The parts of this component can be remembered using the mnemonic TICLS [AAP, 2013]:

• Tone: Is the infant/child moving spontaneously or are they floppy and listless?

• Interactiveness: Does the infant/child respond to people, objects and sounds or are they uninterested in their surroundings?

• Consolability: Can the infant/child be consoled by their parent/carer?

• Look/Gaze: Does the infant/child look at you or do they have a ‘glass-eyed’ stare into the distance?

• Speech/Cry: Is their speech or cry strong or weak, muffled or hoarse?

Work of breathing

In children, it is their work of breathing that provides a better indication as to the adequacy of oxygenation and ventilation, rather than the more traditional respiratory rate and/or auscultation in adults [AAP, 2013]. Look for signs of increased work of breathing as well as listening for abnormal airway sounds:

• Abnormal airway sounds: These include snoring, muffled or hoarse speech, stridor, grunting and wheezing

• Abnormal positioning: Children who can sit up may adopt a ‘sniffing the morning air’ position, tripod position and/or refuse to lie down

• Recession: Recession of the chest muscles provides an indication of increased work of breathing, as does head bobbing in infants. Beware the child over 5 years who has signs of recession, as this is a sign of serious respiratory compromise [Skellett, 2016]

• Flaring: Look for nasal flaring, an exaggerated opening of the nostrils during laboured inspiration.

Circulation to skin

When cardiac output is not sufficient to meet the body’s metabolic demands, the circulation to non-essential organs, such as the skin, reduces. This can manifest in children as [AAP, 2013]:

• Pallor: White or pale skin indicating a reflex shunting of blood away from the skin. This may be the only sign of compensated shock

• Cyanosis: This is blue discolouration of the skin caused by inadequate oxygenation. Note that blue hands and feet in newborns and infants under the age of 2 months (acrocyanosis) is a normal finding

• Mottling: This is caused by abnormal blood vessel tone in the capillary beds of the skin. There are patchy areas of pallor and cyanosis. This can be normal when the child is exposed to a cold environment.

2.5.2 Airway

Obstruction of the airway is common in seriously ill children, causing hypoxia, which can lead to unconsciousness and cardiorespiratory arrest (such as in cases of choking) [Skellett, 2016]. It is important to remember that chest movement does not imply a clear airway: you need to listen and feel for air movement.

Look for apparent difficulty in breathing or increased work of breathing. In conscious children, they may be in visible distress. Listen for additional noises, such as stridor, a high-pitched (usually) inspiratory sound [Skellett, 2016].

Management

Children who are conscious should be allowed to adopt a position of comfort, ideally one that they themselves adopt to maximise the efficiency of their airway, and supplemental high-flow oxygen via a non-rebreathe mask should be administered.

For unconscious children, their head needs positioning appropriately to open the airway and prevent the tongue from falling backwards and occluding the airway. This can be achieved in children using a head tilt–chin lift, or jaw thrust manoeuvre. Remember that in infants, their head should be placed in the neutral position, with padding under the shoulders to account for their proportionally larger head (Figure 17.2).

Figure 17.2 An infant, with their airway in neutral alignment

Care must be taken not to compress the soft tissues under a child’s jaw as this can also occlude the airway [Skellett, 2016].

Oropharyngeal airways (OPAs) can be used in children as for adults. For small children and infants, it is generally recommended that the OPA is introduced the ‘right way round’ and not rotated 180°. This is likely to require a tongue depressor [Gregory, 2010b].

2.5.3 Breathing

Assessment

The most effective way of determining whether the airway is obstructed is to look, listen and feel [Biarent, 2010]:

• Look for chest (and abdominal) movements

• Listen at the child’s mouth and nose for breath (plus added) sounds

• Feel for air movement on your cheek.

Note that the chest may move in children, even with an obstruction, making it important to listen and feel.

As part of gaining a general impression, you will already have considered the patient’s work of breathing, which includes [AAP, 2013]:

• Abnormal airway sounds

• Abnormal positioning

• Recession

• Flaring.

Other signs of increased work of breathing include elevated respiratory rates and accessory muscle use.

Abnormal airway sounds

Stridor is a high-pitched inspiratory sound which indicates an upper airway obstruction. This may be an object, or swelling due to infection. In severe cases, it can also occur on expiration. A wheeze, on the other hand, is usually an expiratory sound and is a sign of lower airway obstruction. You may be able to hear it with just your ears, but often it will only be heard on auscultation [AAP, 2013].

Grunting is usually heard in neonates and small infants, although it can occur in small children. It occurs when the infant exhales against a partially closed glottis. This generates a small amount of end-expiratory pressure, keeping the small airways from collapsing at the end of expiration. It is an indication of severe respiratory compromise [Skellett, 2016].

Abnormal positioning

Children in respiratory distress typically adopt a position that maximises their respiratory efficiency. In upper airway obstruction, this will be a ‘sniffing the morning air’ position. In lower respiratory problems they may adopt a ‘tripod’ position, sitting forward with their arms outstretched and resting on their knees [Skellett, 2016].

Recession

Recession can be sternal, subcostal and/or intercostal. Note that significant recession can be seen in infants and young children, even in mild respiratory distress, due to their compliant chest wall (Figure 17.3). However, as previously mentioned, it is a serious sign in children over 5 years of age [AAP, 2013].

Figure 17.3 A newborn with intercostal recession

By Bobjgalindo (Own work) [CC-BY-SA-3.0-2.5-2.0-1.0], via Wikimedia Commons

Flaring

Nostril flaring in infants and young children is a sign of increased respiratory effort.

Respiratory rate

An increased respiratory rate (tachypnoea) is often the first sign of respiratory problems, although it can be difficult to assess in the crying infant/child (see Table 17.1) [Skellett, 2016].

Accessory muscle use

Additional muscles are often recruited when the work of breathing increases. One group is the sternocleidomastoid muscles in the neck. These cause ‘head bobbing’ in infants, who will nod their head up and down with each breath. However, this is not an efficient method of breathing [Skellett, 2016].

Pulse oximetry

This can be unreliable when a child has poor peripheral circulation, but if obtainable, a reading of less than 90% on air, or 95% on high-flow oxygen, is a sign of decompensated respiratory failure and urgent intervention is required [Biarent, 2010].

Management

All seriously ill children should receive high-flow oxygen via a non-rebreathe mask, unless their ventilation is insufficient. In this case, assistance should be provided with bag-valve-mask ventilation. For children who are conscious, placing a mask over the child may be distressing. In this case, attempt administration using the least-threatening method, for example by asking the parent/carer to hold an oxygen mask close to the patient’s mouth and nose [AACE, 2016]. Watch for signs of decompensation, which include:

• Changes to respiratory rate: Increasing or sudden decrease

• Reducing level of consciousness/interaction with ambulance staff and parents/guardians

• Exhaustion.

Unconscious children and infants whose airway is clear, and who are breathing normally, should be turned on their side into the recovery position [Maconochie, 2015]. While the adult recovery position can be used in children, modification is required for infants. Adopt the following principles when placing an infant in the recovery position:

• Place the child in as near true lateral position as possible, with their mouth suitably positioned to assist in the free drainage of fluid

• The position needs to be stable. This may require a small pillow or a rolled-up blanket to be placed along the infant’s back to maintain the position, to prevent the infant from rolling on to their back or front

• Avoid any pressure on the infant’s chest that might impair breathing

• Whatever the position, it should be possible to turn the infant from their side on to their back (and vice versa) easily and safely.

2.5.4 Circulation

Assessment

When assessing circulation, look for signs of blood and other fluid losses, which are causing shock. Children can compensate very well, maintaining their blood pressure until they have significant fluid losses. However, you can spot the child in compensated circulatory failure by examining the following [Skellett, 2016]:

• Heart rate

• Pulse volume

• Capillary refill time.

Heart rate

Tachycardia is common in children and has a number of causes including pain, anxiety and fever. It is also often the first sign of circulatory failure. Bradycardia, defined in an infant as a heart rate less than 80 beats/min and in a child, a heart rate less than 60 beats/min, is a serious sign [Skellett, 2016]. A heart rate of less than 60 beats/min in infants and children is normally an indication to start chest compressions.

Pulse volume

When a child develops shock, peripheral pulses will become weak and thready. If central pulses (such as a carotid pulse) become weak and thready, the child is in cardiorespiratory failure and arrest is imminent [Skellett, 2016], so always ensure you compare central and peripheral pulses.

As children become peripherally vasoconstricted in response to shock, their extremities will become cool. Sometimes there is a clear demarcation line between cool skin and warm skin, that will either move towards the torso if shock progresses, or move distally if perfusion and circulation improve [AACE, 2016].

Capillary refill time

Capillary refill time can be a useful indicator of circulatory status, as was covered in the Circulation chapter.

Skin

Skin perfusion can provide valuable clues as to the infant’s or child’s circulatory status. Note the temperature of the skin, particularly the level of warm/cold demarcation lines on the limbs. Monitor this level frequently to see whether things are improving or heading to circulatory failure. The colour of the skin should also be assessed if it wasn’t covered in the PAT.

End-organ perfusion

Although you will conduct a formal assessment of level of consciousness (LOC) in the Disability chapter, consider if there are any signs of poor cerebral perfusion. Early signs of compromise include a loss of interaction with the infant’s or child’s surroundings and irritability and agitation. Late signs include a loss of consciousness and loss of tone (e.g. a ‘floppy’ baby).

The kidneys are an essential organ and one clue that they are not being adequately perfused is a reduction in urine output. A simple way of assessing this is to ask about the number of wet nappies or the number of times the child has passed urine.

Management

The principal method of maintaining circulation is to ensure that airway and breathing are adequately addressed and any life-threatening conditions, such as tension pneumothorax, are identified and treated. However, for seriously fluid-depleted children, intravenous access will be required and fluid replacement in 20 ml/kg boluses of normal saline will be required [AACE, 2016].

As with breathing, watch for signs of decompensation:

• Changes in heart rate: Increasing or sudden fall

• Increasing peripheral vasoconstriction:

• CRT increasing

• Warm/cold demarcation line moving up the limb towards the body

• Loss/reduction of peripheral pulses

• Reduced level of consciousness

• Hypotension (late sign).

2.5.5 Disability

Assessment

Often, you will already have an idea about the patient’s level of consciousness (LOC) from the general impression. Use the AVPU mnemonic to quickly gauge the child’s LOC:

• A: Alert

• V: Responds to voice

• P: Responds to pain

• U: Unresponsive.

As with adults, a more formal Glasgow Coma Scale (GCS) score can be calculated. For children under four years of age, a modified GCS has been proposed (Table 17.4) [AACE, 2016]. Children four years of age and older should be assessed using the adult GCS score (Table 17.4).

Pupils should be checked for dilation, equality and reactivity. Seriously ill children are typically hypotonic and floppy, but in cases of serious brain dysfunction, posturing (particularly in response to pain) such as abnormal flexion and extension may be seen [Skellett, 2016].

Management

Ensure that airway, breathing and circulation are managed adequately. Don’t forget to check blood glucose if you are authorised, and during the history determine whether there is a risk of poisoning or meningococcal septicaemia [AACE, 2016].

2.5.6 Exposure/Environment

In order to complete the primary survey it may be necessary to remove some of the child’s clothing, but be mindful that children lose heat rapidly, particularly infants. Use this time to thoroughly examine infants and children who are ill for rashes [Pilbery, 2013]. Keep in mind the possibility of a non-accidental injury, and check for bruises and other signs of injury.

Table 17.4 Modified Glasgow Coma Scale score for children under four years of age

Component

Level of response

  Score

Eye opening

Spontaneous

4

To speech

3

To pain

2

None

1

Best verbal response

Appropriate words or social smiles, fixes on and follows objects

5

Cries, but is consolable

4

Persistently irritable

3

Restless, agitated

2

Silent

1

Best motor response

Obeys commands

6

Localises

5

Withdraws

4

Abnormal flexion

3

Extension

2

None

1

Chapter 18: Learning Disabilities

1 Supporting the care of people with learning disabilities

1.1 Learning objectives

By the end of this section you will be able to:

• Define the term ‘learning disability’

• Explain the needs of a person with a learning disability in emergency care situations.

1.2 Introduction

A learning disability is a reduced intellectual ability and difficulty with everyday activities – for example household tasks, socialising or managing money – which affects someone for their whole life [Mencap, 2015a]. Learning disability includes the presence of [DoH, 2001]:

• A significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence), with

• A reduced ability to cope independently (impaired social functioning),

• Which started before adulthood, with a lasting effect on development.

It is thought that up to 350,000 people in the UK have severe learning disabilities and this figure is increasing [NHS Choices, 2013].

1.3 Learning disabilities legislation and rights

A number of pieces of legislation have already been reviewed in the Legal and Ethical Issues chapter; however, you should be aware how a number of pieces of legislation apply to people with learning disabilities.

1.3.1 Legislation

Equality Act 2010

According to the Equality Act 2010, a person is disabled if a physical or mental impairment has a substantial and long-term negative effect on their ability to carry out normal daily activities [HMG, 2015a]. This definition will apply to nearly all of those suffering from a learning disability.

The Equality Act extends certain rights to those recognised as suffering from a disability [HMG, 2015b], including:

• Employment rights: It is against the law for employers to discriminate against a person because of a disability. All employers must make reasonable adjustments so those with disabilities are not disadvantaged

• Education: It is unlawful for education providers to treat disabled students unfavourably. This may be due to direct, or indirect, discrimination, or forms of harassment or victimisation. As with employers, education providers must make reasonable adjustments to ensure disabled students are not discriminated against

• Police: A person with learning disabilities should only be interviewed when a responsible person is present. The responsible person, or ‘appropriate adult’, should not work for the police and should have experience of working with people with learning difficulties.

Consent and capacity

People with a learning disability aged 18 and over have the same legal rights and freedoms as anyone else [Mencap, 2015b]. Having a learning difficulty does not automatically mean a person lacks mental capacity; in fact the majority will have full capacity. As always, you must assess your patient as the individual they are and have no pre-conceived ideas as to their potential mental ability until you have completed a formal and structured assessment.

1.3.2 Rights

As we have outlined above, people with learning difficulties have the same rights as all other people; these rights are detailed within the Human Rights Act 1998.

People with learning difficulties have the same right to access healthcare as all other people; however, due to a number of factors, patients with learning disabilities find it far harder to access healthcare and therefore suffer the negative consequences, including earlier death and poor long-term condition management, as identified by Sir Jonathan Michael (2008) in his public inquiry into accessing healthcare for those with learning difficulties.

When responding, remember that patients with learning disabilities have the same rights and expectations of receiving healthcare as any other patient, and try to practise in such a way as to promote these rights and to assist with overcoming any barriers that stand in the way.

1.4 Causes of learning disabilities

There are four main causes that are responsible for learning disabilities [Holland, 2011]:

• Genetics

• Events before birth

• Events during birth

• Events after birth.

1.4.1 Genetics

Chromosomal conditions, such as Down’s syndrome or fragile X syndrome, are not in themselves learning disabilities, but they do frequently cause learning disabilities.

1.4.2 Events before birth

Infections that a mother suffers during pregnancy can be transmitted to the fetus, leading to developmental problems and learning disabilities. Other maternal factors, including dietary deficiencies, excessive alcohol consumption during the pregnancy, and endocrine disorders such as phenylketonuria, can also cause learning disabilities.

1.4.3 Events during birth

If during a traumatic or difficult delivery a baby’s oxygen supply is interrupted for a significant period of time, brain damage may occur which will cause a learning disability.

1.4.4 Events after birth

In the early years of life, a child is susceptible to many factors which may cause long-term impairment and learning disabilities as a result. Examples of this include infections, particularly meningitis or encephalitis, and traumatic injuries of the brain, sustained by falls, road traffic accidents or non-accidental injuries.

1.5 Categories of learning disabilities

Learning disabilities are categorised as mild, moderate, severe or profound [Holland, 2011]. As with all conditions, the way in which any individual is challenged by their disability will be unique to them. Many people diagnosed with learning difficulties will be able to lead largely independent lives, whereas others may need more significant help and support.

For people with mild learning difficulties, some occasional support for complex issues may be all that is required, whereas many people with profound and multiple learning disabilities will require more intense help, potentially through to round-the-clock care.

You must always assess any patient with learning difficulties as an individual. Understand how they would normally manage, and what level of support they require on a day-to-day basis. Do not assume, just because a person has a diagnosis of a learning difficulty, that they are incapable of making decisions about their own care needs.

2 Disabilities and healthcare

2.1 Introduction

By the end of this section, you will be able to:

• Describe how learning disabilities lead to inequality in healthcare

• Describe how you may need to adapt your methods of communication when assisting a person with a learning disability

• Give examples of sources of information, advice and guidance to support the well-being of people with learning disabilities

• Describe how learning difficulties influence a person’s vulnerability

• Define hate crime and what to do if you think your patient is a victim of disability hate crime.

2.2 Inequality in healthcare

People with learning disabilities tend to have poorer health than people without a learning disability, as they are more likely to have additional health problems. This includes a higher incidence of weight-related problems, mental health issues and respiratory diseases.

People with learning disabilities are also more likely to have poor health outcomes as a result of not receiving equal healthcare. This means that people with learning difficulties die younger and sometimes in situations where their death could have been prevented if they had received better-quality care [Mencap, 2015d].

In 2007, Mencap released the report ‘Death by indifference’ which detailed institutional discrimination within the NHS for people with learning difficulties [Mencap, 2007]. The main findings of that report were that:

• The NHS viewed people with learning disabilities as a low priority

• Those providing healthcare do not understand much about learning disability

• Families and carers of people with learning disabilities are frequently not properly consulted and involved

• Those providing healthcare often have a poor understanding of capacity and consent, particularly how this should be applied to those with learning difficulties

• Health professionals rely inappropriately on their estimates of a person’s quality of life

• The complaints system within the NHS is often ineffectual, time-consuming and inaccessible.

2.2.1 Tackling inequality

Further reports since the one published in 2007 have confirmed again that lives are being lost unnecessarily due to patients with learning disabilities not receiving the same standard of care as patients without learning difficulties. Over 200 hospitals are now signed up to the ‘Getting it right’ charter, a set of principles for providing patients with learning difficulties with the best care possible.

As a responder, you should make all reasonable adjustments necessary to ensure that patients with learning disabilities receive the same standard of care as any other patients. Modifications will be unique based on the situation, but very importantly you will need to adjust your communication techniques.

2.3 Communication

As discussed previously, every individual will be affected by their own disability in a unique way, so in order to be able to communicate effectively you need to first understand what is normal for your patient.

For a patient with mild or moderate learning difficulties, you may be able to communicate in a near to normal manner, with maybe just ensuring you use language that is not overly complex or difficult to understand. For patients with more severe or profound learning difficulties it is likely you will need to make more significant adjustments.

Patients with profound, multiple or severe learning difficulties frequently rely on non-verbal communication, including facial expressions, vocal sounds, body language and behaviour. Some may have a small range of formal communication including words, drawings, gestures or symbols. For others, they may not have reached any form of intentional communication and you may be relying on feedback from carers as to how changes in behaviour may be indicating pain or distress. In these situations you should seek out the advice of those who know the patient best, as they may be able to better interpret signs the patient is displaying.

You should also consider the use of specialist assessment tools, such as the Abbey pain scale, which is used to assess pain in patients who cannot verbalise, and be mindful that many people with profound learning difficulties also suffer from some degree of visual and/or hearing disability [Mencap, 2008].

Some further guidelines for communicating with people who have learning difficulties include [Mencap, 2015c]:

• Find a good place to communicate in, somewhere quiet without distractions.If you are talking to a large group be aware that some people may find this difficult

• Ask open questions

• Check with the person that you understand what they are saying, e.g. ‘The TV isn’t working? Have I got that right?’

• If the person wants to take you to show you something, go with them

• Watch the person. They may tell you things by their body language and facial expressions

• Learn from experience. You will need to be more observant and don’t feel awkward about asking parents/carers for their help

• Try drawing. Even if your drawing is not great it might still be helpful

• Take your time, do not rush your communication

• Use gestures and facial expressions. If you are asking if someone is unhappy make your facial expression unhappy to reinforce what you are saying. Do your best to do this in a natural way to avoid being patronising

• Be aware that some people find it easier to use real objects to communicate but photos and pictures can really help too.

2.4 Learning difficulties and vulnerability

People with learning difficulties are more vulnerable to harm due to their disability. As with other types of abuse, this harm could take the form of physical abuse, mental abuse, financial abuse or sexual abuse.

People with learning disabilities are also often victims of hate crimes. Disability hate crime is when a person is attacked, threatened or verbally abused as a result of their disability, or perceived disability [Disability Rights UK, 2015]. Staggeringly, as many as 88% of people with learning disabilities reported some form of bullying or harassment in the past year [Mencap, 2013], and there have been a number of tragic cases where people with learning disabilities have been murdered as a result of their disability.

It is thought that the vast majority of hate crimes go unreported at present. As with all vulnerable people, you should do all you can to tackle a person’s vulnerability and ensure their safety. Any activity that may be described as a hate crime should be reported to the police.

Refer to the Legal and Ethical Issues, and the Safeguarding Adults and Children chapters for more information on safeguarding and how to make a safeguarding referral.

2.5 Further support

In the management of an individual incident you should look to friends, family and carers to help support your patient where possible. You may also be able to get further advice and support from:

• Social workers

• Support agencies.

Also consider what local expertise may be available through specialist learning disability nurses or charities such as Mencap.

Chapter 19: Older People

1 Ageing

1.1 Learning objective

By the end of the section you will be able to:

• Describe the anatomical and physiological changes that occur as a person ages.

1.2 Introduction

Older people are generally defined as those aged over 65; however, ageing is a highly unique process and there may be patients at a lower age that suffer from the same conditions and vulnerabilities as those aged 65 and over. So, although being aged over 65 is still the most accepted definition of older people, you should also consider that those aged 50–64 may also suffer from the same issues, depending on the unique progression of their own disease, vulnerabilities or risk factors [NICE, 2013].

There are currently around 11 million people in the UK over the age of 65, a figure that is expected to increase by 50% by 2031 [Age UK, 2014a]. Although there are no national statistics relating to the number of older people who call the ambulance service, around 45% of the 4,374,611 people who attended an emergency department in 2012/13, and arrived by ambulance, were over the age of 65 [HSCIC, 2014b].

1.3 Anatomy and physiology of ageing

There is no single mechanism of ageing. Instead, there are a range of mechanisms that over time result in the worsening of cell function, causing cellular damage and impairing the body’s ability to repair itself. This results in a range of anatomical and physiological changes (Figure 19.1).

1.3.1 Musculoskeletal system

Bones, joints and muscles are all affected by ageing.

Bones

Bone formation is greatest in the period from birth to adolescence, but equalises with bone absorption in a person’s twenties, before bone absorption becomes more dominant. This leads to a reduction in body calcium, impairing the body’s ability to create bone matrix and increasing the risk of fracture. Cancellous bones, such as those found in the vertebral bodies, wrists and hips, are especially vulnerable. Calcium supplements are often prescribed, as absorption of calcium from the digestive system also declines with age [Farley, 2011].

Joints

The loss of fluid within the intervertebral discs results in kyphosis: the familiar stooped posture of older age, which also reduces the height of the person. With stooping comes a change in the person’s centre of gravity and changes to their gait, which becomes slower, shorter and more cautious [Knight, 2008d].

Figure 19.1 Changes related to ageing

Muscles

Muscles degrade (atrophy), leading to a reduction in muscle strength and mass. The rate of decline is variable, with some muscles, such as the diaphragm, remaining unchanged, whereas the lower limbs can experience noticeable wasting. Coupled with the decline in nervous system function, movement speed is reduced, and increased muscle rigidity results in limited movement in the neck, shoulders, hips and knees [Farley, 2011].

1.3.2 Respiratory system

The respiratory system is in steady decline from around the age of 25, following a functional peak at 20 years of age. There are a variety of external factors which adversely affect the respiratory system, including poor nutrition, lack of physical exercise and smoking [Farley, 2011]. Changes due to ageing are fairly insignificant compared to the external factors as there is usually sufficient spare capacity in lung function to offset any decline due to older age.

Ventilatory changes

Respiratory function does deteriorate with age, in tandem with the decline of the musculoskeletal system. The strength of the respiratory system declines from around 55 years of age, with intercostal muscle wasting, increasing the work of breathing and making the respiratory system more reliant on the diaphragm [Knight, 2008a]. Shortness of breath on exertion (SOBOE) is more common in older people due to [Farley, 2011]:

• Decreasing muscle strength

• Muscles being more prone to fatigue when work of breathing increases

• Muscle wasting

• Decreased blood supply to the muscles of respiration.

Most measurements of lung function decline with age, but in healthy patients this is mostly offset by a large reserve capacity of the respiratory system [Farley, 2011].

1.3.3 Cardiovascular system

Blood vessels

As the body ages, blood vessels (particularly the arteries) lose their elasticity and become less compliant. The arteries thicken, which makes the arteries more rigid, and the normally smooth inner layer (tunica interna) becomes roughened, which increases the resistance to blood flow [Knight, 2008b]. This contributes to a rise in systolic blood pressure.

Heart

In order to overcome the increase in systemic vascular resistance, the heart needs to pump with greater force; like all muscles that are exercised, it thickens (hypertrophies), particularly in the left ventricle.

There are also changes in the electrical conduction system, with the loss of around 50–75% of pacemaker cells by the age of 50 leading to an increased chance that the heart will go into an abnormal rhythm.

1.3.4 Nervous system

Brain and senses

In healthy people the ageing brain functions normally, and learning, for example, is still able to occur. However, brain weight does decline by approximately 5–10% over a lifetime with little change up to the age of 50 years. Indeed, it is not until 60 years of age and older that there is a significant reduction in weight [Farley, 2011].

About 10% of neurons are lost by the age of 75, but this does not result in significant loss of mental function. However, the loss of sensory neurons leads to impaired hearing, vision, smelling, temperature regulation and appreciation of pain. In addition, older people become increasingly reliant on visual, tactile and auditory cues to stay on their feet since their brain becomes less able to sense balance which increases the risk of falling, particularly if any/all of these senses are impaired [Knight, 2008c].

1.3.5 Immune system

From a functional peak around puberty, there is a gradual reduction in immune system capacity over a person’s lifetime of between 5 and 30%, but the immune system does continue to function even in very old adults. However, older people are more likely to die of infectious diseases such as pneumonia, influenza and gastroenteritis, for example. In addition, older adults respond differently to infection than younger adults, including [Farley, 2011]:

• Fewer microorganisms are required to cause symptomatic infection

• Confusion prior to a raised temperature is more common

• Symptoms can be masked and/or mistaken for other diseases

• There is increased risk from chronic diseases such as diabetes and chronic obstructive pulmonary disease.

1.3.6 Integumentary system

The skin is probably the most visible sign of older age and all layers are affected [Farley, 2011]:

• Epidermis: Loss of skin cells leads to decreased surface contact between the dermis and epidermis, which reduces the exchange of nutrients and other products of metabolism. In addition the epidermis degrades, causing roughened skin that takes longer to heal and provides less of a barrier

• Dermis: This layer also degrades, becoming thinner. The dramatic reduction in dermal blood vessels leads to pallor, decreased temperature and impaired thermoregulation compounded by a loss of sensory nerve endings, increasing the risk of injury

• Hypodermis: A reduction in subcutaneous fat leads to increased conductive heat loss, and the redistribution of the fat leads to bony prominences, which are vulnerable to pressure ulcers and fractures following trauma. Clinically, the skin looks dry, lax and wrinkly. The wrinkles are due to a combination of gravity, decreasing subcutaneous fat and, in the face, repeated traction by facial muscles. In addition photo-ageing caused by ultraviolet radiation from the sun increases the number of skin lesions, which are usually benign, although they can become cancerous later in life.

1.3.7 Digestive system

Food intake declines with age, with about a 10% reduction in calorific intake each decade after 50 years of age. Older people may experience altered taste, linked mainly to a decrease in the sense of smell and smell discrimination, as the appeal of foods is based on its smell and taste. In addition, they are more likely to have missing teeth and poorly fitting dentures, all of which contribute to weight loss and malnutrition becoming more common. Increased intake of sugar and salt can contribute to the development of diabetes and high blood pressure [Nigam, 2008].

Muscular contractions that initiate the swallowing reflex also decline with age, leading to an increased risk of choking. Lower down the gastrointestinal tract, there is impaired absorption of essential fats and other nutrients, while in the large intestine the process of moving the contents through (peristalsis) slows, increasing the transit time of bowel contents, which can cause constipation. This in turn can lead to the formation of haemorrhoids due to the increased straining required to defaecate [Nigam, 2008].

2 Caring for older patients

2.1 Learning objectives

By the end of this section, you will be able to:

• Identify a range of common conditions associated with ageing

• Describe the impact co-morbidities will have on your treatment plans

• Discuss attitudes towards ageing.

2.2 Age-related conditions

The following are a range of conditions commonly associated with older patients; however, these conditions are not necessarily unique to older patients and can be seen in younger people as well in certain circumstances.

2.2.1 Parkinson’s

Due to the death of cells in the brain, Parkinson’s patients don’t have enough of the neurotransmitter dopamine. One in 500 people in the UK suffer from diseases for which there is no cure and no known cause [Parkinson’s UK, 2015].

The main symptoms of Parkinson’s are:

• Tremor, rigidity and slowness of movement but may also include:

• Tiredness

• Pain

• Depression

• Constipation.

Parkinson’s is treated with a combination of medication, therapy and occasionally surgery to help alleviate symptoms and slow the progression of the disease.

2.2.2 Arthritis

Arthritis is defined as inflammation within a joint. There are many different forms of the condition, but the two main ones are inflammatory arthritis, and degenerative or mechanical arthritis [Arthritis Research UK, 2015].

Inflammatory arthritis

Inflammation is a normal response as part of the body’s healing process, but in patients with this form of arthritis the inflammation happens for no obvious reason. This is an autoimmune condition (the body’s own immune system is attacking the joints) and instead of helping to repair the body it causes damage to the joint, pain and stiffness. This type of arthritis often affects several joints at once and includes rheumatoid arthritis. As well as joint pain, other symptoms of rheumatoid arthritis include:

• Tiredness

• Depression

• Irritability

• Flu-like symptoms.

Degenerative or mechanical arthritis

A normal joint is covered at the ends of the bone in smooth cartilage, to allow bone ends to glide across each other. In degenerative forms of arthritis, these smooth cartilage ends have been worn away. The underlying bone tries to repair this, but often overgrows, altering the shape of the joint, known as osteoarthritis.

Osteoarthritis is particularly common in joints that get heavy use, including the hips and knees, base of the thumb and big toe (Figure 19.2).

Figure 19.2 Normal and arthritic joints

2.2.3 Osteoporosis

Osteoporosis occurs when the mesh-like structure within bones becomes thin, causing bones to become fragile and break easily [NOS, 2015].

Bones are constantly going through a process of regenerating themselves by breaking down old matter and replacing it with new.

Up to around the late twenties bone density increases slowly and from around 35 years onwards it starts (very gradually to begin with) to decrease as part of the natural ageing process; however, in certain people this can be accelerated and lead to weaker bones, which are more likely to fracture as a result.

Women are more susceptible to osteoporosis due to increased bone loss in the years following the menopause.

The main risk of osteoporosis is the increased risk of fractures, from just minor forces, rather than the significant force we would normally expect to cause a fracture. Broken hips and wrists are common injuries, as is a broken neck or back in a fall from standing height.

2.2.4 Elderly mental illness

It is thought by some that mental health problems are a normal part of ageing, but this is not necessarily the case with most older people developing no mental health problems, and many of those that do can be helped or treated, or the onset even prevented with the right action early on [MHF, 2015].

Dementia

Dementia is one of the most common causes of mental illness in older patients, and we will look at this in some detail in the next section of this chapter.

Depression

Depression is another common mental illness in later life that makes people feel sad and lack motivation [Age UK, 2015]. We all have these feelings at times, but depression occurs when these feelings are more intense and persist for weeks, months or longer. Depression is often linked to loss, which is common as people grow older. These losses can influence people’s self-esteem and feeling of value and include:

• Loss of job

• Loss of good health

• Loss of independence

• Loss of spouse or friends

• Loss of social network.

As with depression at any age, a number of treatment options, including medication and talking therapies, are available. It is also possible that certain things can be done to prevent the development of depression to begin with.

Many elderly people are isolated and spend prolonged periods of time on their own. Arranging for appropriate social interactions can help to alleviate these feelings of isolation and prevent the development of depression in the first place.

When treating elderly patients, make sure you consider the risk of depression as part of your holistic assessments. Mental and physical health are closely intertwined and you should be looking to always promote an individual’s mental well-being as well as their physical.

2.3 Attitudes to ageing

Attitudes towards ageing are fundamental for ageing well and current attitudes towards ageing in society and the media may be negatively impacting on the older population [AAA, 2015].

As has already been discussed, ageing is unique to every individual and age itself is no marker for a person’s independence, or ability to contribute to society. Some people will suffer from a range of age-related illnesses in their sixties whereas others will live long into their nineties with limited if any illness or disability.

Everyone, regardless of age, should be encouraged to live the best-quality life that they can and you must not judge anyone’s ability on purely their age, as doing so would not just lead to an inaccurate assessment, but would also be considered discrimination by the Equality Act.

2.4 Patients with co-morbidities

When treating elderly patients, it is often the case that they suffer from a number of simultaneous co-morbidities, for example, a patient suffering from cardiovascular disease and type 2 diabetes; both of these are serious long-term conditions that can be life limiting, especially if not managed correctly. They also interact with each other and can make the other disease worse. This makes caring for patients very challenging as a number of conditions may be interacting with each other and causing varied presentation.

Many of these patients will have specialist medical or nursing support and might be under the care of a chronic condition management team, or community matron.

When dealing with patients with a range of co-morbidities, be sure to consider all of the conditions that may be influencing the current presentation: do not become fixated on just one element of the patient’s illness. These cases are complex and in elderly patients, who may already have compromised immune systems or compensatory mechanisms, can represent significant dangers. Be prepared to seek additional help and support early on in such situations and recognise the limitations of your own scope of practice and knowledge where necessary.

3 Dementia

3.1 Learning objectives

By the end of this section you will be able to:

• Define dementia

• Explain the differences between dementia and delirium

• Describe a number of strategies that can assist when communicating with a patient with dementia

• Identify a number of causes of challenging behaviour

• Explain how to manage challenging behaviour.

3.2 Introduction

Dementia is a set of behaviours or symptoms which suggest difficulties with cognitive function. The most common symptoms include: memory loss, confusion, mood and personality changes, and problems with planning and performing tasks in the right order. Dementia is diagnosed when the symptoms cause such problems with the everyday tasks of daily life that the person affected can no longer carry on living independently, without care.

Dementia is an ‘organic’ disorder, meaning there is an associated physical deterioration of the brain tissue, which can be seen via a brain scan or, after death, at autopsy, though depending on the exact type of dementia different physical changes will be seen. Dementia is progressive – the damage and symptoms get worse over time. It is therefore not a normal result of ageing, but rather is the result of a disease [SCIE, 2013].

3.2.1 Dementia in context

It is estimated that 7.1% of people over 65 have dementia, which translates into around 850,000 people in the UK in 2015 [Age UK, 2014b]. One in 3 people over 65 will develop some form of dementia and two-thirds of people with dementia are women [NHS Choices, 2015b]. It is estimated that the current cost to the UK economy stands at £26 billion a year [Alzheimer’s Society, 2015c].

Dementia is an increasing challenge as people are living longer, and by 2021 it is estimated that the number of people in the UK living with dementia will have reached 1 million.

3.3 Dementia

Dementia tends to affect sufferers in three different ways:

• Cognitive: As the areas of the brain responsible for cognition are damaged and the number of cells are reduced, sufferers are less able to deal with complex thought processes or store memories so easily

• Behavioural: As different areas of the brain are affected a person’s behaviour may change. This is particularly seen in frontotemporal dementia where the sufferer may lose a sense of inhibition

• Neurological: Physical changes to the structure of the brain means that the brain of those with dementia is not able to function appropriately. A loss of brain cells and a change to the types and quantity of chemicals in the brain lead to a vast alteration in neurological function. In some forms, including dementia with Lewy bodies, physical signs such as shaking may develop, showing changes to the neurological system.

3.3.1 Different types of dementia

There are over 100 types of dementia, with Alzheimer’s disease being the most common single cause in the UK, making up around 66% of cases, and vascular dementia coming in second. However, multiple disease processes are even more common than single disease processes, with Alzheimer’s disease and vascular dementia, and Alzheimer’s disease and Lewy bodies dementia, being common combinations [NG, 2001].

3.3.2 Causes of dementia

Different forms of dementia have different underlying causes; here we will consider some of the most common types [Alzheimer’s Society, 2015e; NHS Choices, 2015c]. Dementia is normally caused by gradual changes in the brain, often associated with brain cells dying quicker than they should as part of the normal ageing process. It is thought that an abnormal protein present within the brain is responsible for a lot of this premature degeneration.

Alzheimer’s disease

In Alzheimer’s disease loss of brain cells leads to the brain shrinking. The cerebral cortex, the area of the brain responsible for processing thought and other complex functions including memory, calculation and some communication skills, is most affected.

Clumps of protein gather in the brain and it is thought that they are responsible for the increased rate of brain cell death. Connections between brain cells are also lost and the chemicals that normally carry signals, known as neurotransmitters, are greatly reduced, all of which leads to the cognitive impairment seen.

Vascular dementia

Vascular dementia occurs when cells are damaged due to a lack of blood and therefore oxygen reaching brain tissue. As people age their vessels tend to become narrower and harden where fatty deposits develop. This process called atherosclerosis means that less blood can get through the vessels and surrounding brain tissue is starved of oxygen.

Patients who have been diagnosed with small vessel disease or have previously suffered from a stroke or a TIA are at increased risk of developing vascular dementia.

Other causes include:

• Lewy bodies

• Frontotemporal dementia

• Infections, including encephalitis

• Some brain tumours

• Lack of thyroid hormone

• Head injury

• Long-term alcohol abuse.

3.3.3 Disease progression

Every sufferer will have a unique disease progression; however, the main forms of dementia are all progressive, i.e. they will all get worse with time. The speed at which any individual’s disease progresses will vary widely and is based on many factors, including their age at time of onset, genetics, and other physical and mental health [Alzheimer’s Society, 2015d]. Patients with a history of poorly controlled heart disease or diabetes are likely to experience a faster deterioration.

The Alzheimer’s Society (2015d) describes the progression of the disease in three broad stages:

Early (mild) stage

Dementia normally begins with mild subtle changes in a person’s abilities or behaviour. The changes are often incorrectly thought to just be part of a normal ageing process, and include:

• Loss of memory of recent events

• Mislaying items around the house

• Becoming confused easily

• Losing track of the day or date.

Middle (moderate) stage

As the disease progresses changes become more obvious and a greater degree of help is required in day-to-day life. Changes may include:

• Needing frequent reminders or help to eat, wash, dress and use the toilet

• Increasingly forgetful – especially of names

• Becoming confused about where they are, and may try to walk off to find somewhere else

• Experiencing difficulty with perception, and may start to have delusions.

Changes in behaviour are more commonly seen in this stage and sufferers can become easily upset, angry or even aggressive – perhaps because they are misinterpreting events or do not understand what is happening.

Late (severe) stage

At this stage sufferers will need increasing levels of help with daily activities and may gradually become totally dependent on others for nursing care. Loss of memory can become severe and they may not recognise people and their surroundings, though they may have occasional moments of clarity or recognition.

Behaviour changes can become very severe with restlessness, agitation and angry outbursts, occurring particularly during close personal care, usually because the sufferer does not understand what is happening.

This stage of the disease can be very distressing for both the sufferer and their family and carers and needs to be managed gently and tactfully.

3.3.4 Dementia and other diseases

When assessing a dementia patient, be careful not to attribute changes in their status to the on-going deterioration of the condition without good evidence to do so. Dementia normally progresses slowly and any sudden changes should trigger a search for a different cause. Many dementia patients will suffer from other co-morbidities (the presence of other diseases) and a detailed assessment will be required to identify any underlying illness.

Asking people who are familiar with the patient for detailed information on their condition is a good way to find out what is normal.

3.3.5 Treating patients with dementia

Responding for the ambulance service, it is likely that you will frequently meet patients with dementia, at various stages of the disease progression. Managing these patients may require some significant modifications to your usual approach and although every encounter will be unique, you should consider the following guidance:

• Approach all situations in a calm manner: Your patient may be confused, scared or not understand what is happening. A calm manner on your part can help to relax your patient and make them feel safe

• Communicate clearly and be patient: More details of communicating with dementia patients is included in the next section

• Use relatives, friends and carers wherever possible to aid communication and to help the patient feel more relaxed by having a friendly familiar face present

Be compassionate: Remember that every dementia patient is different and will need different management – there is no one way to manage ‘dementia patients’.

3.3.6 Dementia and pain management

Pain management for dementia patients remains a difficult issue, especially for dementia patients who are not able to communicate effectively. It is well recognised that dementia patients frequently receive inadequate pain relief [Chandler, 2014], and that is especially true of emergency care patients.

One of the key challenges is that patients are unable to express their pain, so healthcare staff tend to underestimate the amount of pain a patient is suffering and therefore not provide adequate pain management techniques.

It is likely that the ambulance crews that back you up will use specialist tools, to help determine whether or not a dementia patient is in pain. One such tool designed for use with late-stage dementia patients is the Abbey pain scale (Figure 19.3) [Abbey, 2004].

3.3.7 Dementia and discrimination

The Equality Act 2010 defines a disability as any physical or mental impairment that has a ‘substantial’ and ‘long-term’ negative effect on a person’s ability to carry out normal daily activities. Clearly, dementia meets these criteria, so those that suffer from dementia are protected by the Equality Act, which makes it illegal to discriminate against them on the basis of their disability. Nonetheless, The Alzheimer’s Society (2015b) identifies that dementia patients are frequently discriminated against for a broad range of reasons, including:

• Attitudes towards dementia which is still highly stigmatised and a failure to understand the broad nature of the disease

• Impaired mental capacity: An assumption that patients are unable to make even simple decisions for themselves so others decide for them, without having taken all reasonable steps to support the person in making the decision themselves

• Ageism: Dementia is generally an illness of older persons meaning that many symptoms are put down to ‘getting old’ rather than tackled and treated appropriately.

When caring for dementia patients remember that every patient is an individual, with a unique illness and unique needs. Therefore, you must tailor your treatment so it is uniquely appropriate for each patient you come into contact with.

3.3.8 Dementia vs delirium

If dementia can be thought of as chronic brain failure, then delirium is acute brain failure [Barrett, 2014]. It is a common and serious condition that is characterised by disruptions in thinking, consciousness, attention, cognition and perception. Unlike dementia, it comes on over a short period of time (typically hours to days). To complicate matters, patients with dementia can also develop delirium and this has been associated with serious complications and poor outcome, including death [Fick, 2002].

Differentiating between delirium and dementia can be difficult, so if in doubt, it is safer to assume delirium and ensure patients receive prompt medical attention [SAS, 2014]. Table 19.1 lists some of the differences between dementia and delirium to help with identification [Snyder, 2015].

Causes of delirium

Delirium can be the result of virtually any medical condition or drug treatment as well as having a number of other causes, including [SAS, 2014]:

• Infection: Examples include urinary tract infections, pneumonia or fever from a viral infection

• Medication: Such as anticholinergics, analgesics and corticosteroids

• Serious medical illnesses: For example diseases of the liver, kidneys, lungs and heart

• Sudden alcohol and/or drug withdrawal

• Major surgery

• Acute stress

• Epilepsy

• Brain injury or infection

• Terminal illness

• Constipation

• Urinary catheters

• Immobility.

3.4 Communication

Although the principles of communication have already been covered in the Communications chapter, there are some additional points to consider when you are caring for a patient with dementia:

Figure 19.3 The Abbey pain scale

Source: Abbey, Piller, De Bellis, Esterman, Parker, Giles and Lowcay (2004) ‘The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia’, International Journal of Palliative Nursing. 10:1, 6–13. Copyright © 2004 MA Healthcare Ltd. Reproduced by permission of MA Healthcare Ltd.

Table 19.1 The differences between dementia and delirium

Dementia

Delirium

Gradual (chronic) onset

Sudden (acute) onset

Impaired recent memory

Inattention

Regression

Disorganised thinking

At least two of the following:

Disjointed thinking

Reduced level of consciousness

Poor judgement

Perceptual disturbances, e.g. hallucinations

Loss of mental function

Increased/decreased psychomotor activity

• Get their attention: Approach the patient from the front so they can see you coming. Try to make eye contact and ensure they can see your face and body movements

• Use their name: Using their name can help them understand that you are not a stranger (although this may not be true), which can be reassuring

• Frequently remind them who you are: This can reduce anxiety and avoid the patient becoming alarmed at being treated by a stranger

• Keep ambient noise and activity to a minimum: Reducing distractions, activity and noise will help a patient with dementia (indeed most patients) to concentrate on what you are saying

• Do not rush: Take your time. Slowing your rate of speech can help, but increase the time spent speaking AND listening. It may help if you silently count to seven between short sentences, and then give the patient the same time to answer

• Keep calm: Adopt a calm tone and manner to reduce distress and make the patient feel more comfortable with you. Patients with dementia maintain the ability to determine your body language even after their ability to understand speech has been lost

• Keep things simple: Avoid jargon and speak in short and simple to understand sentences. When giving instruction, break down the task into simple stages. Give clear instructions; for example, rather than saying ‘sit there’ you could try saying ‘sit in this blue chair, please’

• Use the patient’s preferred method of communication: Establish this early on from the patient and others who know them. This includes speaking to the patient in their first language or using communication aids such as pictures or talking mats.

3.5 Challenging behaviour

Many patients with dementia are placid and sweet-tempered, but over 90% will exhibit some form of challenging behaviour. This includes [Barrett, 2014]:

• Sleeplessness

• Wandering

• Agitation

• Pacing

• Aggression (including spitting)

• Disinhibition

• Jealousy (especially sexual jealousy).

Challenging behaviour needs to be seen as a manifestation of unmet need, which the patient may not be able to express, such as boredom, frustration and/or annoyance.

3.5.1 Managing challenging behaviour

It is important to appreciate that each patient will be slightly different, so the best way of managing challenging behaviour will need to be tailored to them. Advice from carers and/or relatives may help, but general principles include [YAS, 2013]:

• Trying to find out what is the cause of the behaviour

• Reducing the stress and/or demands placed on the patient

• Explaining what is happening using the patient’s name and saying who you are. You are likely to have to repeat this process often

• Giving patients time to respond to your requests or questions

• Trying not to show criticism or irritation and avoiding confrontation with patients

• Watching for warning signs that they are becoming more anxious or agitated. Get help if the situation does not calm down quickly

• Including carers and/or relatives who know the patient and who will have experience in managing the patient’s challenging behaviour

• Not making sudden movements or using a sharp tone. Instead, remain calm and keep your voice low.

Aggressive behaviour

Patients with dementia may sometimes become aggressive, either verbally or physically. This can be very distressing for the person, carers, friends and family. You should understand why this happens and how to resolve it as part of your role [Alzheimer’s Society, 2015a].

Patients with dementia have the same needs as everyone else, including comfort, social interaction, stimulation, emotional well-being, and being free from pain. However, dementia patients may not understand their own needs or be able to communicate them. This can lead to frustration and in turn challenging or aggressive behaviour.

Guidance for responding to such situations includes [Alzheimer’s Society, 2015a]:

• Remain calm and avoid confrontation, as a heated response will make the situation worse

• Reassure the person and acknowledge any feelings they are able to express

• Listen to what they are saying

• Try to explore what is causing the behaviour

• Try to distract their attention if they remain angry

• Maintain eye contact, come down to their level and try to ensure your body language and positioning is not aggressive or restrictive in any way.

Chapter 20: Cardiac Arrest

1 Adult basic life support

1.1 Learning objectives

By the end of this section you will be able to:

• Explain the benefits of the chain of survival to basic life support

• Explain common types and causes of cardiac arrest in adults

• Explain the procedure for providing basic life support to adults.

1.2 Introduction

Cardiac arrest is the ultimate medical emergency, but you will have the ability to undertake the two most effective treatments for this: cardiopulmonary resuscitation (more commonly called basic life support in healthcare circles) and defibrillation. However, the role of the ambulance service is just one link in a chain which maximises the patient’s chance, not only of a return of spontaneous circulation (ROSC), but also of surviving to hospital discharge neurologically intact (i.e. with normal or near-normal brain function) [Perkins, 2015]. That chain is known as the chain of survival [Nolan, 2006].

1.2.1 Chain of survival

The chain of survival encompasses four key principles that are required if a resuscitation is to be successful in adults (Figure 20.1) [Perkins, 2015]:

• Early recognition and call for help

• Early bystander cardiopulmonary resuscitation (CPR)

• Early defibrillation

• Post-resuscitation care.

Figure 20.1 The chain of survival

Image reproduced by the kind permission of Laerdal Medical

Early recognition and call for help

This relies on patients and the public calling for help early and can be influenced by the ambulance service with public education and training sessions. Recognition of cardiac chest pain is particularly important as around 21–33% of patients with acute myocardial ischaemia will suffer a cardiac arrest in the first hour following onset [Müller, 2006].

Early CPR

Performing CPR immediately following cardiac arrest can double or triple the chance of the patient surviving [Perkins, 2015]. When someone calls 999 they will be given advice on how to perform chest compressions only, as this has been shown to produce higher survival rates in adults than conventional CPR (chest compression and mouth-to-mouth ventilation) [Hüpfl, 2010].

Early defibrillation

Providing good-quality CPR and defibrillating in the first 3–5 minutes of a cardiac arrest can produce a survival rate of 50–75%, but, conversely, the chance of surviving to hospital discharge falls by 10–12% for every minute of delay [Perkins, 2015].

Post-resuscitation care

Restarting your patient’s heart and palpating a pulse (return of spontaneous circulation = ROSC) is a great feeling, but the patient is not out of the woods yet. The true measure of success is returning the patient to their pre-cardiac arrest state, with brain function intact so that they can leave hospital. Providing post-resuscitation care on scene, en route and in hospital is crucial if this is to happen [Nolan, 2016].

Children

In stark contrast to adults, children usually suffer a cardiac arrest secondary to hypoxia. The outcomes from these secondary cardiac arrests are very poor and the emphasis with children is to intervene before their heart arrests [Skellett, 2016].

1.3 Adult BLS

Basic life support (BLS) refers to maintenance of airway patency, and supporting breathing and circulation, with artificial ventilation and chest compressions as required [AACE, 2016]. The procedure described is for a single rescuer, but tasks are usually shared when there is more than one rescuer on scene.

1.3.1  Procedure

Take the following steps to perform adult BLS [Perkins, 2015; AACE, 2016]:

1. Ensure the scene is safe for you, the patient and other bystanders. Check the patient to see if they are responsive by gently shaking their shoulders and asking if they are alright

2. If the patient responds, obtain a history and undertake a further patient assessment. If the patient does not respond, inform your colleague so they can assist. Turn the patient on to their back

3. Open the patient’s airway and look, listen and feel for breathing for no more than 10 seconds. Note that agonal breathing (occasional gasps) is common immediately following cardiac arrest and should not be confused with normal breathing or taken as a sign of life. If the patient is breathing, place them in the recovery position

4. If the patient is not breathing or there are no signs of life (not moving, no normal breathing or coughing), update the EOC and start chest compressions:

• Kneel beside the patient

• Place the heel of one hand in the centre of the chest (lower half of the sternum)

• Place the heel of your other hand on top of the first

• Interlock your fingers and ensure that pressure is NOT applied over the patient’s ribs

• Keeping your arms straight and with you positioned directly over the patient’s chest, apply downward pressure to compress the chest to a depth of 5 cm but not more than 6 cm

• After each compression release the pressure on the chest, but maintain contact with the patient’s skin

• Repeat at a rate of 100–120 compressions/min

5. After 30 compressions, open the airway (you can insert an oropharyngeal airway if available) and provide 2 rescue breaths with a pocket mask or bag-valve-mask. If your colleague is available, they may well have already assembled the equipment and be prepared to ventilate. Each ventilation should deliver a tidal volume of 500–600 ml, enough to cause the chest to rise, and take about 1 second to deliver. If you are performing BLS with another person, do not attempt to compress the chest while ventilation is being provided, but keep your hands in the correct position so that chest compressions can immediately resume once the ventilations have been administered

6. Continue with chest compressions and ventilations at a ratio of 30:2. If there is another person who can provide chest compressions, you should alternate chest compressions with them every two minutes, but keep the changeover time to a minimum

2 Paediatric basic life support

2.1 Learning objectives

By the end of this section you will be able to:

• Explain how the causes of cardiac arrest in children are usually different from adults

• Explain the procedure for providing basic life support to paediatric patients.

2.2 Introduction

You will recall from the Children and Infants chapter that paediatric patients are not small adults. This is true of cardiac arrest where, unlike adults, who experience a primary cardiac arrest typically due to a cardiac arrhythmia, infants and children usually suffer a secondary cardiac arrest [Maconochie, 2015]. This is not the sudden event experienced by adults, but a progressive worsening of the patient’s condition until they cannot continue to compensate. Outcome from secondary cardiac arrest is poor.

Paediatric basic life support (BLS) is different from that of adults, and there are also some differences between infants (paediatric patients under 1 year of age) and children (between 1 year of age and puberty) and so they are presented separately in this lesson.

2.3 Infant BLS

2.3.1  Procedure

Take the following steps to perform basic life support on an infant [Maconochie, 2015; AACE, 2016]:

  1. Ensure the scene is safe for you, the patient and other bystanders. Check for responsiveness by placing a hand on the infant’s forehead to stabilise it and tug their hair while calling their name. If they do not have hair, consider flicking the soles of their feet. Never shake an infant

  2. If the patient responds, assess the infant’s ABCDE, call for assistance and reassess regularly. If they do not respond, summon additional assistance

  3. Open the infant’s airway by placing one hand on their forehead and gently tilt it back until it is in a neutral position (Figure 20.2). Perform a chin lift by placing the fingertips of your other hand on the bony part of the lower jaw and lift upwards. Don’t compress the soft tissues under the jaw as this will occlude the airway. Placing a towel under the infant’s shoulders and upper body can help keep their head in a neutral position

  4. If a head tilt–chin lift is not effectively opening the airway, you can use a jaw thrust to open the airway:

• Position yourself behind the infant

• Place two fingers under both angles of the jaw

• Rest your thumbs on the infant’s cheeks

• Lift the jaw upwards

  5. Look, listen and feel for normal breathing by placing your face close to the infant’s face:

• Look for chest and abdominal movements

• Listen for airflow at the mouth and nose

• Feel for airflow at the mouth and nose

  6. If the infant is breathing normally, turn them on to their side and monitor their breathing

  7. If the infant is not breathing or there are no signs of life (not moving, no normal breathing or coughing), check for, and carefully remove, any visible airway obstruction and provide five rescue breaths:

• Ensure the head is in a neutral position and apply a chin lift

• Either place a bag-valve-mask over the infant’s mouth and nose (Figure 20.3), or take a breath and place your mouth over the mouth and nose of the infant

• Ventilate the chest steadily for 1 second, just enough to make the chest rise

• Maintain head tilt–chin lift and watch the chest fall

• Repeat this sequence five times

  8. If the infant’s chest is not rising and falling in a similar fashion to normal breathing, open the infant’s mouth and check for any visible obstruction. Do not blindly sweep in the infant’s mouth. Reposition the head to ensure it is in the neutral position, using a jaw thrust if the head tilt–chin lift manoeuvre is not effective. Make no more than five attempts to achieve effective ventilation before moving on to chest compressions

  9. Check for signs of life (movement, coughing or normal breathing). If you are confident in checking for a pulse, feel for a brachial pulse in the medial aspect of the infant’s arm. Unless you are sure you can feel a pulse, assume it is absent and start chest compressions. If there are signs of circulation, reassess airway and breathing and manage appropriately

10. If there are no signs of life and/or no pulse or a pulse rate of less than 60 beats/min, start chest compressions:

• If you are on your own, use the tips of two fingers (Figure 20.4), otherwise adopt the encircling technique by placing both thumbs side by side on the lower sternum and spreading the remaining fingers around to the infant’s back (Figure 20.5)

• Avoid compressing the abdomen, by placing your fingers one finger’s width above the xiphisternum

• Compress the sternum at least one-third of the depth of the chest (or by 4 cm) and then fully release the pressure while maintaining contact with the sternum

• Repeat the compressions at a rate of 100–120/min for 15 compressions and then give 2 ventilations

• Continue compressions and ventilations at a ratio of 15:2 unless you are on your own, in which case a ratio of 30:2 may be easier

• Continue until the infant shows signs of life or you become exhausted

Figure 20.2 Neutral alignment

Figure 20.3 Ventilating with a pocket-mask

Figure 20.4 Chest compressions using the two-finger technique

Figure 20.5 Chest compressions using the encircling technique

2.4 Child BLS

2.4.1  Procedure

Take the following steps to perform basic life support on a child [Maconochie, 2015; AACE, 2016]:

1. Ensure the scene is safe for you, the patient and other bystanders. Check for responsiveness by placing a hand on the child’s forehead to stabilise it and tug their hair while calling their name or telling them to wake up. Never shake a child

2. If the patient responds, assess the child’s ABCDE, call for assistance and reassess regularly. If they do not respond, summon additional assistance

3a. Open the child’s airway by placing one hand on their forehead and gently tilt it back until it is in a ‘sniffing’ position. Perform a chin lift by placing the fingertips of your other hand on the bony part of the lower jaw and lift upwards. Don’t compress the soft tissues under the jaw as this will occlude the airway. Do not use a head tilt–chin lift technique in children who you suspect have a cervical spine injury: use a jaw thrust instead

3b. If a head tilt–chin lift is not effectively opening the airway, or you suspect a cervical spine injury, use a jaw thrust to open the airway

4. Look, listen and feel for normal breathing by placing your face close to the child’s face:

• Look for chest and abdominal movements

• Listen for airflow at the mouth and nose

• Feel for airflow at the mouth and nose

5. If the child is not breathing or there are no signs of life (not moving, no normal breathing or coughing), check for, and carefully remove, any visible airway obstruction and provide five rescue breaths:

• Apply a head tilt–chin lift

• Either place a pocket mask or bag-valve-mask over the child’s mouth and nose, or take a breath and place your mouth over the mouth of the child and pinch their nose to prevent air escaping

• Ventilate the chest steadily for 1 second, just enough to make the chest rise

• Maintain head tilt–chin lift and watch the chest fall

• Repeat this sequence five times

6. Check for signs of life (movement, coughing or normal breathing). If you are confident in checking for a pulse, feel for a carotid pulse at the neck. Unless you are sure you can feel a pulse, assume it is absent and start chest compressions. If there are signs of circulation, reassess airway and breathing and manage appropriately

7. If there are no signs of life and/or no pulse or a pulse rate of less than 60 beats/min, start chest compressions:

• Position yourself at the side of the child

• Avoid compressing the abdomen, by locating the xiphisternum and placing the heel of one hand one finger’s width above this point

• Lock your elbows and position your body so that your shoulders are directly over the child’s chest

• Compress the sternum at least one-third of the depth of the chest (or by 5 cm) and then fully release the pressure while maintaining contact with the sternum. If this is difficult, use the two-handed technique as you would for adults

• Repeat the compressions at a rate of 100–120/min for 15 compressions and then give 2 ventilations

• Continue compressions and ventilations at a ratio of 15:2 unless you are on your own, in which case a ratio of 30:2 may be easier

• Continue until the child shows signs of life or you become exhausted

3 Defibrillation

3.1 Learning objectives

By the end of this section you will be able to:

• Describe the types of cardiopulmonary arrest

• Recognise when it is appropriate to use a defibrillator

• Explain the safety considerations when using a defibrillator.

3.2 Introduction

Heart rhythms associated with cardiac arrest are divided into shockable and non-shockable rhythms, depending on whether they should receive an electric current across the myocardium (heart muscle) to depolarise a sufficient amount of the heart muscle simultaneously and allow the normal heart pacemaker (the sino-atrial node) to resume control of the electrical conduction system. Delivering electricity to the heart in this way is known as defibrillation [Nolan, 2016].

In patients who have a shockable rhythm, the sooner they receive defibrillation, the greater the chance it will be successful and the patient will survive. However, it is equally important to ensure that defibrillation minimises the interruption of cardiopulmonary resuscitation (CPR). For each 5-second delay in CPR prior to delivering a shock, the chance of the shock being successful is halved [Nolan, 2016].

3.3 Shockable rhythms

There are two shockable rhythms: ventricular fibrillation and ventricular tachycardia. Ventricular fibrillation (VF) is a rapid and disorganised ventricular rhythm and is never associated with a palpable pulse (Figure 20.6). Your AED will always advise a shock with this rhythm.

Ventricular tachycardia (VT) is known as a broad- or wide-complex tachycardia, because the QRS complexes are > 0.12 seconds in duration (typically 0.16–0.20 seconds). It usually originates from the ventricles, is monomorphic (has one shape), and has a regular rhythm at a rate of 100–300/min (Figure 20.7) [Nolan, 2016; Garcia, 2004]. Most AEDs will shock VT as long as it meets certain criteria (such as heart rate > 150 for example).

3.4 Non-shockable rhythms

As with shockable rhythms, there are two non-shockable rhythms: asystole and pulseless electrical activity. As the name implies, these are patients who will not benefit from defibrillation.

3.4.1 Asystole

Asystole is the term given to the absence of electrical activity from the heart. On an ECG, you will see a flat (isoelectric) or almost flat line (Figure 20.8) [Garcia, 2004]. A variant of asystole is an agonal rhythm, which is characterised by a slow (a rate of < 10/min), broad, sinusoidal complex which interrupts the otherwise isoelectric line on the ECG [SWAST, 2014c].

Figure 20.6 Ventricular fibrillation

Figure 20.7 Ventricular tachycardia following a 200J shock. The patient was in VF prior to the shock

Figure 20.8 Asystole. Note the two complexes on the left-hand side of the ECG before the start of asystole. The baseline is not always completely straight in asystole

3.4.2 Pulseless electrical activity (PEA)

PEA is organised electrical activity in the absence of a palpable pulse. Typically, patients in PEA will have some mechanical myocardial activity, but it is not sufficiently strong to produce adequate cardiac output to lead to a detectable pulse or blood pressure [Nolan, 2016].

3.5 Defibrillators

There are many brands and types of defibrillator on the market and it is important that you are familiar with the equipment you work with. Broadly, they fall into two types: automated external defibrillators (AEDs) and manual defibrillators. You will be issued with an AED.

3.5.1 Automated external defibrillators (AEDs)

These ‘shock boxes’ are devices that provide voice and visual prompts to guide users to defibrillate safely. AEDs are now widely available in public places such as shopping centres, sports centres, airports and railway stations [BHF, 2013]. Despite their name, some AEDs can be manually overridden by healthcare providers capable of rhythm interpretation, but they are capable of recognising shockable and non-shockable rhythms [Nolan, 2016].

3.5.2 Difficult environment and defibrillation

You will frequently encounter challenging environments, which make resuscitation difficult. In terms of defibrillation, some of these can increase the risk of injury due to inadvertent electrocution. However, prompt defibrillation is life-saving and so it is important that you make a dynamic risk assessment and do not delay a shock unnecessarily.

Specific defibrillation scenarios include [Deakin, 2015]:

• Wet surfaces: This is safe as long as you are not in contact with the patient and the patient’s skin (if wet) is dried to ensure good contact is made by the self-adhesive pads to the patient’s chest

• Metal surfaces: As before, this is safe as long as you are not in contact with the patient. Metal surfaces actually conduct any current that leaks from the pads through the metal and away from the crew and bystanders

• In-flight: Defibrillation in aircraft and helicopters is safe, particularly if the patient is in contact with metal surfaces for the reason given above. Oxygen use in a confined cabin could potentially increase the risk of fire, although there are no reports of these occurring. Consider restricting oxygen use in aircraft cabins or confined spaces.

3.5.3 Safety

The only person who should receive a shock when a defibrillator is used is the patient. This can be achieved as long as members of the resuscitation team communicate well, so that everyone is well clear of the patient at the time of defibrillation.

Other ways of maximising safety include [Nolan, 2016; EEAST, 2014; Kerber, 2012]:

• Use self-adhesive pads, rather than paddles

• Do not defibrillate patients while they are in water or near an explosive or combustible environment

• Ensure that the rescuers do not hold intravenous infusion equipment or the ambulance trolley during defibrillation

• Wear gloves

• Shave the patient’s chest, if required, to obtain a good skin-to-electrode contact

• Avoid placing the pads over jewellery, piercings, medication patches, wounds and tumours

• Ensure that the pads are well away from pacemaker sites (8 cm in adults and 12 cm in children)

• Remove oxygen from the patient unless the ventilation bag is directly connected to an endotracheal tube or supraglottic airway device (SAD). It should be at least 1 m away from the patient’s chest [Deakin, 2015].

3.5.4 Adult defibrillation

Pad placement

The standard placement for defibrillator pads is to place one just below the right clavicle, to the right of the sternum, and the other in the left midaxillary line, about level with the nipple [Soar, 2015]. There are often illustrations on the pads to indicate correct placement.

AED procedure

Take the following steps to defibrillate using an AED [Perkins, 2015]:

1. Check for danger and ensure that you, the patient and bystanders are safe. Assess the patient’s responsiveness

2. If the patient is unresponsive and not breathing normally and there is another person who can provide chest compressions, instruct them to commence CPR at a ratio of 30 compressions to 2 ventilations (30:2)

Bare the patient’s chest and ensure that the pad sites are free from jewellery, piercings, medication patches, pacemakers, wounds and tumours. Shave the chest if required

3. Switch on the AED and attach the pads to the patient, ensuring they make a good contact

4. Follow visual/voice prompts, ensuring that no-one touches the patient while the AED is analysing the rhythm

5. Shock?

• If a shock is advised, make sure everyone is clear of the patient and push the shock button. Follow visual/voice prompts

• If a shock is not advised, restart CPR at a ratio of 30:2

6. Continue until the ambulance crew arrives and takes over, the patient shows signs of life or you become exhausted

3.5.5 Paediatric defibrillation

Pad placement

The standard placement for defibrillator pads is to place one just below the right clavicle, to the right of the sternum, and the other in the left mid-axillary line. Adult defibrillator pads can be used on children who are > 25 kg (about 8 years of age), but they must not touch each other. Use paediatric pads for children under 25 kg (under 8 years of age), if available, but adult pads can be used in smaller children if there is no alternative [Maconochie, 2015].

If a sufficient gap between the defibrillator pads is not possible due to patient size, place the pads in the anterior–posterior position, with one pad over the left precordium and the other on the back, just under the left scapula (shoulder blade).

AED paediatric procedure

Take the following steps to defibrillate a child with an AED [Maconochie, 2015]:

  1. Check for danger and ensure that you, your colleagues, the patient and bystanders are safe

  2. Start basic life support (BLS). If you are on your own, perform 1 minute of CPR before attaching the AED

  3. Bare the patient’s chest and ensure that the pad sites are free from jewellery, piercings, medication patches, pacemakers, wounds and tumours

  4. Switch on the AED and attach the pads to the patient, ensuring they make a good contact. Use paediatric pads on patients under 25 kg if available

  5. Follow visual/voice prompts, ensuring that no-one touches the patient while the AED is analysing the rhythm

  6. Shock?

• If a shock is advised, make sure everyone is clear of the patient and push the shock button. Follow visual/voice prompts

• If a shock is not advised, restart CPR at a ratio of 15:2 (30:2 if you are on your own)

  7. Continue until senior help arrives and takes over, the patient shows signs of life or you become exhausted

4 Cardiac arrest in special circumstances

4.1 Learning objectives

By the end of this section you will be able to:

• Explain the considerations for a pregnant patient in cardiac arrest

• Explain the considerations for a hypothermic patient in cardiac arrest.

4.2 Introduction

In this chapter, you have been introduced to the principles and techniques of resuscitation of a patient in cardiac arrest. However, in some circumstances, the techniques need to be modified and/or alternative techniques used. Note that cardiac arrest associated with drowning is covered in the DROWNING section within the Exposure/Environment chapter.

4.3 Cardiac arrest in pregnancy

The general procedure for resuscitating a pregnant patient is the same as for any other patient. However, for patients who are more than 20 weeks pregnant, there is a risk that their fetus-filled uterus can press down on the inferior vena cava and aorta, restricting venous return and leading to a reduction in cardiac output and uterine perfusion [Nolan, 2016].

To prevent this from occurring, the pregnant patient must not lie supine. In the conscious patient, the left lateral position is often used, but this is not practicable in a cardiac arrest when chest compressions need to be provided. Instead, the uterus should be manually displaced to the left, or the patient placed on an extrication board and tilted 15–30° to the left [ALSG, 2010].

The hand position for patients in advanced pregnancy (over 28 weeks) may need to be 2–3 cm higher on the sternum. In addition, you may not be able to place the defibrillator pads in their usual position, due to placing the patient in a left lateral tilt and/or their large breasts. In these cases, use alternative pad placement, such as an anterior–posterior, or bi-axillary placement [Deakin, 2015].

During the latter stages of pregnancy, the patient is more likely to regurgitate their stomach contents and aspirate them into the lungs, particularly with over-enthusiastic bag-valve-mask ventilation, so take care to provide just enough positive-pressure ventilation to see the chest rise [ALSG, 2010].

4.4 Cardiac arrest in hypothermic patients

In cases of moderate and severe hypothermia, signs of life can be difficult to identify. Unless there is a clear indication that the cardiac arrest has been caused by a lethal injury or fatal illness, patients should be resuscitated based on the principle that ‘no one is dead until warm and dead’ [Truhlar, 2015].

5 Post-resuscitation care

5.1 Learning objectives

By the end of this section you will be able to:

• State clinical signs that indicate an ROSC

• Explain the management of the post-resuscitation patient.

5.2 Introduction

A return of spontaneous circulation (ROSC) in a patient who you have resuscitated is a great feeling, but it is just the first step in the path to complete recovery from a cardiac arrest. A complex pathophysiological process occurs as a result of whole body ischaemia during a cardiac arrest and subsequent reperfusion when ROSC is achieved. This is known as post-cardiac arrest syndrome [Deakin, 2015].

During rhythm/pulse checks, if an organised rhythm is seen on the ECG that is compatible with a cardiac output, you should look for evidence of an ROSC [Soar, 2015]:

• Signs of life including purposeful movement, normal breathing or coughing

• Presence of a central pulse.

5.3 Management

The following steps should be taken once ROSC is achieved [EEAST, 2014; SWAST, 2014c; Deakin, 2015]:

• Reassess the patient’s airway and breathing:

• Provide ventilation, if required, at a rate of 10–12 breaths/min

• Oxygen therapy should be titrated to maintain an SpO₂ of 94–98%, except in trauma, where high-flow oxygen should continue to be administered

• Reassess the patient’s circulation:

• Perform frequent pulse and blood pressure checks

• Check blood glucose, if possible

• Aim for a core temperature no higher than 36.0°C. Do this by passively cooling the patient, i.e. don’t cover the patient in blankets.

6 Cardiac arrest decisions

6.1 Learning objective

By the end of this section you will be able to:

• Explain when a resuscitation attempt may be stopped or not commenced.

6.2 When to start and stop resuscitation

Whenever there is a chance that a patient may survive a cardiac arrest, resuscitation should be attempted unless a patient has stated, via an ‘advance decision to refuse treatment’ (ADRT), that this should not occur, or there is a valid ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) order [AACE, 2016].

However, there are certain patients who have an injury or presenting condition that is unequivocally associated with death, irrespective of age [AACE, 2016; SWAST, 2014c]:

• Massive cranial and cerebral destruction

• Hemicorporectomy (complete amputation of the body below the waist) or similar massive injury

• Decomposition/putrefaction: Tissue damage suggests that the patient has been dead for hours, days or even longer

• Incineration: Full thickness burns and charring covering more than 95% of the total body surface area (TBSA)

• Hypostasis: The pooling of blood in the dependent part of the body (i.e. below the level of the heart) after death

• Rigor mortis: Stiffness of the body and limbs following death

• Fetal maceration.

6.2.1 Conditions when resuscitation can be discontinued

Even if resuscitation has been commenced, this should be stopped if any of the following are present [AACE, 2016]:

• A DNACPR order

• An ADRT clearly states that the patient is not to be resuscitated

• The patient is in the final stages of a terminal illness and a clinician on scene determines that CPR would not be successful even if no formal DNACPR decision has been documented

• There is no realistic chance that CPR would be successful because:

• At least 15 minutes have elapsed since the onset of cardiac arrest

• No bystander CPR was provided prior to the arrival of the ambulance service

• There are no exclusion factors such as drowning, hypothermia, poisoning or pregnancy

• The AED advises no shock is required

• The patient has been submerged for more than 90 minutes.

6.3 End of life decisions

6.3.1 Advance care plan

In terminal conditions, death can often be anticipated, which provides patients with the opportunity to consider their wishes and preferences about future care, particularly as they are likely to be unable to do so when close to death. Unfortunately, only 5% of people put these wishes and preferences in writing by means of an advance care plan (ACP, sometimes also called a preferred priorities for care document) [NatCen, 2013]. The contents of an ACP are not legally binding, but any best-interests decision about patients must take into account the patient’s wishes and preferences [Watson, 2009].

6.3.2 Advance decision to refuse treatment (ADRT)

ADRTs (also known as living wills) are documents that outline specific aspects of care that the patient does not wish to receive. This is then typically referred to when the patient is unable to make these wishes clear. Examples of the interventions that a patient may refuse include being ventilated, being tube fed, receiving antibiotics and being admitted to hospital unless they are suffering from a complaint with a treatable cause.

Unlike the ACP, this is a legal document and, as long as the phrase ‘even if life is at risk’ is present, and the document is signed, dated and witnessed, the contents must be respected by healthcare staff. Note that treatment can only be declined and not requested, and the ADRT only comes into effect once the patient loses mental capacity [Henry, 2008].

6.3.3 Do not attempt cardiopulmonary resuscitation (DNACPR) decision

DNACPR decisions are made by a senior clinician, usually with involvement from the patient’s clinical team. This will normally be a consultant, GP or suitably experienced nurse [BMA, 2007]. There are four broad situations when a DNACPR decision will be made [Dimond, 2011]:

• A mentally competent patient refuses resuscitative treatment

• A valid advance directive clearly states that the patient does not want CPR

• CPR is unlikely to be successful

• Successful CPR is possible, but the length and quality of life following resuscitation is not in the patient’s best interests.

Ideally, this is written and agreed ahead of time and documentary evidence of the decision will be presented to you before you commence resuscitation.

Ultimately, if you are unsure about the validity of previously made decisions, then commencing resuscitation is defendable [AACE, 2016].

Glossary

Medical terminology can be rather overwhelming at first. This glossary will provide an explanation of various terms.

Anterior

The front surface of the body, or situated nearer to the front of the body (particularly if comparing the position of one structure to another).

Arrhythmia

A problem with the rate or rhythm of the heartbeat.

Aspiration

Fluid or solid entering the lower respiratory tract (larynx and below).

Aspirin

Aspirin has an anti-platelet action which reduces clot formation and has analgesic (pain-relieving), antipyretic (temperature reducing) and anti-inflammatory actions.

Auscultation

The technique of listening to sounds within the body using a stethoscope.

Autoimmune disease

Autoimmune diseases arise from an abnormal immune response of the body against itself, i.e. against substances and tissues that are normally present in the body.

Battle’s sign

Bruising behind the ears, which can indicate a skull fracture.

Body mass index

Body mass index (BMI) is defined as a persons weight divided by the square of their height in metres (kg/m²). This can be adjusted for age and gender, and supplemented with waist circumference measurements, if appropriate. A patient with a BMI of 2529.9 kg/m² is considered to be overweight, and if over 30 kg/m², obese.

Bradycardia

Slow heart rate.

Brittle asthma

Brittle asthma is a rare form of severe asthma which can result in very serious and often life-threatening attacks.

BVM

Bag-valve-mask.

Care Quality Commission

An independent health and adult social care regulator for England. Their job is to make sure health and social care services provide people with safe, effective, compassionate, high-quality care. They do this by monitoring, inspecting and regulating services to make sure they meet fundamental standards of quality and safety.

Cartilage

Cartilage is a flexible connective tissue found in areas of the body, including the joints between bones, the ribcage, the ear, the nose, the bronchial tubes and the intervertebral discs. It is not as hard and rigid as bone but is stiffer and less flexible than muscle. It does not contain blood vessels, so grows and repairs slowly.

Catastrophic haemorrhage

Bleeding severe enough to cause exsanguination, i.e. blood loss causing death, typically within minutes, or less.

Choking

A mechanical obstruction of the airway occurring anywhere between the mouth and carina.

Circadian rhythms

Circadian rhythms are physical, mental and behavioural changes that follow an approximate 24-hour cycle, responding primarily to light and darkness in a persons environment.

Cognitive function

A persons ability to process thoughts. It encompasses memories, perception, thinking and reasoning.

Connective tissue

Basic tissue type that binds, supports and separates other tissue and organs.

Crepitus

The grating, crackling or popping sounds and sensations experienced under the skin and joints, or a crackling sensation due to the presence of air under the skin. A type of crepitus, bone crepitus, can be heard and felt when two fragments of a fracture are moved against each other.

Distal

Further from the point of attachment of a limb.

Fetal maceration

Tissue degeneration that occurs once an undelivered fetus dies

Focal

Affecting a specific region of the body. For example, a focal neurological deficit may result in a weakness or paralysis of a limb following an impairment of nerve, spinal cord, or brain function.

Furosemide

A commonly used diuretic drug (water tablet) from the group known as loop diuretics.

Glasgow Coma Scale score

The Glasgow Coma Scale (GCS) was developed in 1974 as a way of objectively testing the level of consciousness in brain-injured patients and to improve communication between healthcare professionals. It was originally a 14-point score, but the division of limb flexion into withdrawal and abnormal flexion led to the 15-point score familiar today. Although designed for in-hospital use, it is now routinely used by the ambulance service and is an important marker for the early management of traumatic brain injury (TBI).

Haematoma

A blood clot that has formed outside a blood vessel (artery or vein).

Haemoptysis

Coughing up or spitting of blood from the lungs.

Humerus

The long bone of the upper arm

Ileus

A partial or complete blockage of the bowel

Intercostal

Between the ribs.

Ketonaemia

The presence of ketone bodies in the blood.

Korotkoff sounds

Turbulent blood flow that can be heard when using the manual auscultatory technique to record blood pressure. Named after a Russian surgeon, Nikolai Korotkoff, who first described them in 1905.

Kussmaul breathing

Breathing that is abnormally deep and rapid, sighing. Named after the nineteenth century Strasbourg physician Adolph Kussmaul.

Lateral

Of, at, towards, or from the side or sides.

Medial

Towards or at the midline of the body.

METHANE

The mnemonic METHANE is designed to provide the initial communication surrounding details of a major incident. It consists of:

• Major incident declared or standby. The person making the report should be explicit whether this is a major incident declaration or a standby in anticipation of the occurrence of a major incident

• Exact location of the incident. Where possible the grid reference or GPS co-ordinates should be included, along with any landmarks or iconic sites

• Type of incident. What is the exact nature of the incident? For example rail, chemical, road or terrorist

• Hazards. What hazards are known to be present or could potentially manifest themselves?

• Access and egress. What are the agreed or best routes to and from the scene?

• Number of casualties. How many casualties are there and, if possible to determine, what are the level and severity of injuries?

• Emergency services. Which emergency services are present and which are required? Include specialist resource request if known.

Microorganism

A very small organism that lives outside and inside larger organisms such as the human body.

Oedema

An abnormal build-up of fluid, mainly water, in the body. People with kidney failure are prone to fluid overload, leading to oedema.

Oliguria

Abnormally reduced production of urine.

OPA

Oropharyngeal airway. A curved plastic tube, with a reinforced flange at one end and designed so that it fits between the tongue and hard palate to help keep the airway open.

OPQRST

• O Onset. When did it (the presenting complaint) start?

• P Provocation/palliation. What makes it worse/ better? Include self-treatment such as taking analgesia

• Q Quality. How does the patient describe their symptom, particularly pain? Is it sharp or dull, for example?

• R Region/radiation/referral. Where is the symptom located? In the case of pain, does it stay in one place (can the patient point to it with one finger) or does it go elsewhere?

• S Severity. On a scale of 0 to 10, where 0 is no pain and 10 is the worst pain imaginable, what score does the patient give it now?

• T Time. How long has the patient had it and if it has been relieved, when did this occur? In the case of pain, also consider whether the pain is intermittent (comes and goes).

Panda eyes

Bruising around both eyes that can be a sign of skull fracture.

Partial pressure

In a mixture of gases, each gas has a partial pressure which is the hypothetical pressure of that gas if it alone occupied the volume of the mixture at the same temperature. The total pressure of the gas mixture is the sum of the partial pressures of each individual gas in the mixture.

Percussion

A method of tapping on a surface to determine the underlying structure. It is used in clinical examinations to assess the condition of the thorax or abdomen.

Pleuritic chest pain

Chest pain that is usually sharp and stabbing, localised to a specific area of the chest (the patient can often point to the pain with a finger) and made worse by coughing and deep inspiration.

Posterior

Further back in position; of or nearer the rear or hind end.

Primary assessment

A swift patient assessment and management process, which can be completed within 6090 seconds. It is designed to be a stepwise approach, meaning that any abnormalities identified in one step should be addressed before moving on to the next.

Precordium

The area over the heart and lower thorax.

Proximal

Located nearer to the centre of the body or the point of attachment.

Psychomotor

Physical behaviour that is the result of conscious mental processes.

Pulse oximetry

The technique of measuring the oxygen saturation of the haemoglobin in the blood.

Recession

In an anatomical context, the drawing away of a tissue (or part of a tissue) from its normal position.

Rigors

Shaking or exaggerated shivering which usually occurs in response to a high temperature.

SADs

Supraglottic Airway Devices. Airway devices that sit just above the glottis. The most common SAD is the laryngeal mask airway.

SAMPLE

An acronym for:

• S Signs and symptoms of the presenting complaint

• A Allergies (particularly to medication but food allergies might be relevant)

• M Medications

• P Past medical history

• L Last oral intake

• E Events that led to the current illness or injury

Scope of practice

The area or areas of a persons profession where they have the knowledge, skill and experience to practise safely and effectively.

SOCRATES

• S Site

• O Onset

• C Character. Same as Quality above

• R Radiation

• A Association. Are there any other signs and symptoms associated with the presenting complaint?

• T Timing

• E Exacerbating/relieving factors

• S Severity

Stridor

High-pitched (usually) inspiratory breath sound, indicating upper airway narrowing.

Superior

Located above or directed upward. In human anatomy, situated nearer to the top of the head (vertex). Opposite of inferior.

Supine

Lying face up, usually referring to a patient who is lying on their back.

Surfactant

A substance made up of lipids and proteins and produced in the lungs. It lines the surface of the alveoli and decreases the surface tension, making it much easier to inflate the lungs

Tachycardia

Rapid heart rate.

Tachypnoea

Rapid breathing rate.

TILEE

• Task. Consider if the lift:

• Involves holding the load away from the body

• Involves long distances

• Requires strenuous effort or twisting

• Individual. Consider whether the lift:

• Requires specialist training

• Presents a hazard

• If you and your colleagues are capable of performing the lift

• Load. Is the load:

• Heavy

• Difficult to get hold of

• Unstable

• Unpredictable

• Harmful

• Likely to grab out when alarmed at being carried down the stairs

• Environment. Determine the presence of:

• Constraints on posture, e.g. low ceiling, confined spaces

• Poor, uneven flooring

• Hot/cold/wet weather

• Poor lighting

• Noise.

• Equipment: Consider what equipment:

• Is available

• Will reduce the risk to you and the patient

• Is safe to use

• You are trained and competent in the use of.

Turgor

Condition of normal tension in a cell or group of cells, such as the skin.

Urticaria

(Also called nettle rash or hives.) Swelling of the superficial layers of the skin, usually as a result of an allergic reaction. The characteristic itchy lumps (called weals or hives) last for only a few hours.

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Van Ness-Otunnu R, and Hack JB, 2013. Hyperglycemic crisis. The Journal of Emergency Medicine, 45(5), 797–805.

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Venema AM, Groothoff JW and Bierens JJLM, 2010. The role of bystanders during rescue and resuscitation of drowning victims. Resuscitation, 81(4), 434–439.

Vincent, 2006

Vincent J-L, Sakr Y, Sprung CL, et al., 2006. Sepsis in European intensive care units: results of the SOAP study. Critical Care Medicine, 34(2), 344–353.

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Walls RM and Murphy MF (eds), 2012. Manual of Emergency Airway Management. 4th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health.

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Index

Abbey Pain Scale 212

ABC (mnemonic) 174

ABCD tool, Time Critical Risk Management (US Navy) 70–71

abdomen

assessment 83

trauma 172, 179, 181–182

abdominal thrusts

choking adult 97

choking child 99

abduction (movement) 49

abrasion 176

absence seizures 151

abuse 42–47

learning disabilities 203

management 45–46

psychological 44

AcBC (mnemonic) 174

accessory muscles, respiration 102, 197

Accu-Chek® Aviva blood glucose meter 169–170

accusations of abuse 46

acrocyanosis 195

acute coronary syndrome 142, 143

acute heart failure 143–144

adduction (movement) 49

adenoids 85

adolescents see teenagers

adrenaline (pharmaceutical) 161–163

adrenaline (secreted) 166

ADRT (advance decision to refuse treatment) 19, 226, 227

Adults with Incapacity (Scotland) Act 2000 19

advance care plans 227

advance decision to refuse treatment 19, 226, 227

AEDs (automated external defibrillators) 3, 222, 224

age discrimination 23, 208

ageing 204–206

aggressive behaviour 214

agonal rhythm 222

air, pressure 101–102

aircraft, in-flight defibrillation 223

airwaves pagers 14

airway 84–99

assessment 79–80, 86–92, 178

child 98, 190, 196–197, 217–218

convulsions 151

infant 98, 190, 196–197, 217–218

management 86–92

smoke inhalation 187

airway adjuncts 91–92

oropharyngeal airway 91–92, 229

alcohol, hypothermia and 157

alcohol handrubs 29–30

medical gases and 105

alkalis, burns 188

allergies, history-taking 81

alternative care pathways/providers 6

alveoli, lungs 101

Alzheimer’s disease 209, 210

Amber calls 5

ambulance service 5–9

Ambulance Trusts, role in NHS response to emergencies 73

amylin 166

anaphylaxis 160–163

anatomy 48–59

cardiovascular system 129–133

nervous system 146–149

pancreas 165

respiratory system 84–86

angina 141–142

angioedema 160

anisocoria 149

anterior (term) 48, 49, 228

aorta, physiology 132

appendicular skeleton 50, 51

aprons 33, 34

removing 35

arrhythmias 221–222, 228

arterial blood gases 121

arteries 132–133

ageing 205

bleeding from 174

brain 152

arterioles 132

arthritis 207

aspiration 228

aspirin 142–143, 228

on blood glucose 169

assisted ventilation 109–113

children 190, 197, 217, 218, 220

drowning 159

infants 190

pregnancy 225

trauma 178

associate ambulance practitioners 7

asthma 123–125

assessing severity 124

brittle 228

asystole 221, 222

atherosclerosis 141, 209

ATMIST model, handovers 14

atria, heart 130

atrial systole 133–134

atrioventricular node 131

auscultation 228

blood pressure 139

autoimmune disease 228

auto-injectors, adrenaline 161–163

automated blood pressure measurement 141

automated external defibrillators 3, 222, 224

autonomic nervous system 149

autonomy, personal 19

AVPU (level of consciousness) 80, 199

axial skeleton 50, 51

axilla, thermometers 156

Baby P (Connelly), abuse case 43

Bachmann bundles 131

back blows 97

infant 98

back injuries 60

see also spine

backup 72

bacteria 27

bag-valve-mask ventilation 110–111

balance, ageing 205

‘bare below elbows’ policy 34

barotrauma 180

basic life support see cardiopulmonary resuscitation

batch labels, gas cylinders 105, 106

Battle’s sign (panda eyes) 179, 228, 229

beclomethasone 123

‘best interest’ decisions 19

‘big bang’ incidents 72

biomechanics 62

bleeding 174–176

see also haemorrhage

blood 132

blood gases (arterial) 121

blood loss, estimation 174–175, 179

blood pressure 138–141

anaphylaxis 160

children 191

pulse oximetry and 122

blood vessels 132–133

ageing 205

blood volume, children 191

blood-borne viruses 38

blunt trauma 171

body fluids, splash contamination 38

body mass index 228

bones 48, 50–57

ageing 204

crepitus 228

trauma 179

Boyle’s law 101

brachial pulse 136

blood pressure measurement 140

bradycardia 137, 228

children 198

brain 147–148

ageing 205

arteries 152

children 191, 198, 199

dementia 208–209

haemorrhage 152

trauma 171, 179

brain stem 147

breach of duty 16

breath, smell of 83

breathing

ageing 205

assessment 80, 83, 87, 121–122, 178–179

cardiac arrest 216

children 190–191, 195, 196–198, 218, 220

control 102–103

infants 191, 218

Kussmaul breathing 229

physiology 100–103

tracheostomy 96

see also assisted ventilation; oxygen

British Standards, gas cylinders 104

brittle asthma 228

bronchi 86

rupture 180

bronchodilators

COPD 126

reliever inhalers 123

bronchopneumonia 127

budesonide 123

bullets see gunshot wounds

bullying, learning disabilities 203

bundle of His 131

burns 177, 184–189

certainty of death 226

classification 186

‘but for’ principle, negligence 17

buttons, laryngectomy 96

BVM (bag-valve-mask ventilation) 110–111

call handlers 5

capacity (mental) 18, 19–20

learning disabilities 200

capillaries 132

bleeding from 174

capillary refill time 137–138

carbon dioxide, partial pressures 103

carbon monoxide 187

pulse oximetry and 122

cardiac arrest 3, 215–227

anaphylaxis 160

basic life support 215–221

decisions 226–227

defibrillation 221–225

drowning 159

post-resuscitation care 225–226

pregnancy 225

cardiac cycle 133–134

cardiac failure 143–144

children 191

cardiac output 80

children 191

cardiogenic shock 145

cardiopulmonary resuscitation (CPR) 215–221

drowning 159

infants 217–219

paediatric 217–221

procedures 216–221

starting and stopping 226

see also defibrillation

cardiovascular system

ageing 205

anatomy 129–133

disorders 141–145

physiology 129, 133–135

Care Quality Commission 228

carotid pulse 136, 137

cartilage 228

cartilaginous joints 50

catastrophic haemorrhage 79, 175, 178, 228

catastrophic incidents 72

cauda equina 148

causation of harm, negligence 17

CD-sized oxygen cylinders 107

central nervous system 146

control of breathing 102–103

see also brain; spinal cord

cerebellum 147

cerebrospinal fluid 148

cerebrum 148

cervical spine, trauma 172, 178

chain of infection 28

chain of survival 215–216

chairs, use for moving 65–68

challenging behaviour 213–214

chemical burns 188

chemoreceptors, respiration 103

chest compressions

choking adult 97

choking infant 99

CPR vs 215

drowning 159

techniques 216–217, 218, 219, 220–221

chest pain 2–3, 141, 142

pleuritic 229

child abuse 43

children 190–199

asthma 124

basic life support 217–221

capillary refill time 138

cardiac arrest 215–216, 217–221

choking 97–99

defibrillation 224–225

Entonox 119

meningococcal disease 153

oxygen 113, 190, 197

temperature assessment 155–156

chin lift 217–218, 219

choking 96–97, 228

child 97–99

chordae tendineae 130

chronic bronchitis 125, 126

chronic obstructive pulmonary disease (COPD) 125–127

oxygen and 113, 115, 125

circadian rhythms 228

circle of Willis 152

circulation 129–145

assessment 80, 135–141, 179

children 191, 195–196, 198

post-resuscitation care 226

trauma 175

circum-rescue collapse, drowning 159

Classification, Labelling and Packaging Regulation 74

cleaning 36–38

Climbié, Victoria, abuse case 43

Clinell wipes 37

clinical risks, defined 25

clothing

contamination 34

hygiene 37

‘cloud on the horizon’ (impending incident) 72

cognitive development, children 191–192

cognitive function 228

cognitive impairment see dementia

colonisation, by pathogens 26

coma 154

see also Glasgow Coma Scale; unconsciousness

combustion, triangle of 39

command and control 7–8, 73

comminuted fractures 182, 183

communication 2, 10–14

barriers 12–13

confidentiality 21

consent 18–19

dementia 210, 211–213

of intentions (ABCD tool) 71

learning disabilities 202–203

at major incidents 73

community acquired pneumonia 127

community first responders 1

illnesses of 27

community responders 6

co-morbidities 208, 210

compensated cardiac failure, children 195, 198

compensated respiratory failure, children 194

compensation, haemorrhage 144

complaints 17–18

complex partial convulsions 151

compound fractures 182, 184

compression injuries, spine 172

conchae, nasal 53

conducting portion of respiratory system 100

see also specific structures

conduction pathway, heart 130–131, 133–135, 205

confidentiality 20–22

connective tissue 228

Connelly (Baby P), abuse case 43

consciousness, level of 80, 198, 199

consent 18–19

learning disabilities and 200

reporting abuse 46

to sharing information 21

constipation, ageing 206

contact dermatitis 33

contents gauges, gas cylinders 105, 106, 118

contusion 176

conus medullaris 148

convection 155

convulsions 150–151

cooling

heat-related illness 158

thermal burns 187

COPD see chronic obstructive pulmonary disease

coping strategies, stress 41

co-responders 6–7

coronary arteries 131–132

disease 141–143

corrosives, danger labels 76

coughing, choking child 98

CPR see cardiopulmonary resuscitation

crepitus 228

cricothyroid membrane, infant 98

critical care, specialist paramedics for 7

cruciate ligaments 55–56

cuffed tracheostomy tubes 93

Cushing’s triad 179

cyanide 187

cyanosis 195

cylinders (medical gases) 103–107

components and labels 104–105

oxygen 107

preparing for use 106–107

safety checks 105–106

storage 104

after-use procedures 117–118

damages, negligence 17

danger labels 74–76

Dangerous Preparations Directive 74

Dangerous Substances Directive 74

data protection 20–22

death

from burns 189

signs 226

Death by indifference (Mencap) 202

debriefing (ABCD tool) 71

decannulation caps, tracheostomies 94

decompensated cardiac failure, children 195, 198

decompensated respiratory failure, children 194, 197

decompensated shock 144

decompression sickness, Entonox and 118

decontamination 36–38

chemical burns 188

deep (anatomical term) 49

deep vein thrombosis 127, 128

defibrillation 3, 221–225

effectiveness 215

oxygen and 113, 223

defibrillators 3, 222, 224

degenerative arthritis 207

deliberate incidents 72

terrorist attacks 71

delirium 211, 213

demand valves, Entonox 119, 120

dementia 208–214

depression 207–208

dermatitis 33

dermis 173

ageing 206

burns 186

detergents, wipes 37

diabetes mellitus 166–170

type 1 166

type 2 166

diabetic ketoacidosis 167, 168

diaphragm 102

infants 191

diastole 134

diastolic blood pressure 138, 140

diencephalon 147

diffusion, gases 102

digestive system, ageing 206

direct contact burns 186

disability

assessment 149–150, 179

see also learning disabilities

disability (Equality Act 2010) 200

dementia as 211

hate crimes 203

disclosure of abuse 46

discrimination 22–23, 208

discriminatory abuse 45

discs, intervertebral 53–54, 60, 61

disinfection see decontamination

dislocations 182–184

dissociative shock 145

distal (term) 49, 228

distributive shock 145

diversity (of people) 22–23

diving, Entonox and 118

do and debrief (ABCD tool) 71

do not attempt CPR (DNACPR) 226, 227

documentation see record-keeping domestic waste 35

dorsal (term) 48

double-cannula tracheostomy tubes 94–95

Down’s syndrome 201

dressings 175, 177, 182

burns 187

drinking, last oral intake 82

drowning 158–159

dry-drowning 158

duty of care 16

dynamic risk assessments 26, 70–71

ears, assessment 83

eating, last oral intake 82

elastic recoil, rib cage 102

elderly people 204–214

electrical conduction pathway, heart 130–131, 133–135, 205

electrical injuries 188–189

electrocardiography 134–135

ST segment 135, 142

ventricular tachycardia 221

electronic communication devices 14

emboli, pulmonary 127–128

emergency calls 1–4

emergency operations centres 1–2, 5

communication with 14

emotional abuse 44

emotions, effect on communication 13

emphysema 125, 126

employers

health and safety regulations 24–25

structured risk assessments 26

encircling technique, chest compressions 218, 219

end of life decisions 227

advance decision to refuse treatment 19, 226, 227

endocardium 129

endocrine system disorders 163–170

enhanced triage 5

enteric nervous system 147, 149

Entonox 103, 118–121

temperature 106

environment

assessment 80

risks from 71

temperature 155–158

enzymes, COPD 125

epicardium 129

epidermis 173

ageing 206

burns 186

epiglottis, infant 98

epilepsy 150–151

epinephrine see adrenaline

equality (of people) 22–23

inequality in healthcare 201–202

Equality Act 2010 200, 203, 211

escalating safeguarding concerns 47

ethics 15–23

see also end of life decisions

events leading to illness, history-taking 82

evidence, of abuse 47

expiration (breathing) 102

explosives, danger labels 76

extension (movement) 49

spinal trauma 172

eye contact 12

eye protection 34

removing 35

face, arm, speech test 150

face masks (oxygen delivery) 108

children 197

infants 190

face masks (PPE) 33–34, 38

facial bones 52

facial shields, mouth-to-mouth ventilation 109–110

failures 17

falls, spinal trauma 179–180

fascia, superficial see hypodermis febrile convulsions 151

feedback, communication 11

female genital mutilation 43, 45

fenestrated tracheostomy tubes 94

Ferno stretcher 62

fetal maceration 228

fever, meningococcal disease 153

FFP3 masks 34, 38

fibrillation, ventricular 221

fibrous joints 50

filtering face piece masks 34, 38

financial abuse 45

fire 38–39, 104

thermal burns 186–187

fire marshals 39–40

fire safety 38–40

Firesafes 109

firtrees, gas cylinders 105, 107

fissures, lungs 100

flail chest 181

flame burns 186

flammable substances, danger labels 76

flaring, nose 195

flexion (movement) 49

spinal trauma 171–172

floor

getting up from 65–68

moving patient on to 68–69

flow selectors, gas cylinders 104, 107, 117

flowmeters, Schrader outlets 112–113

fluid replacement, children 198

fluticasone 123

foam, drowning patient 159

focal (term) 228

food, last intake 82

foot, anatomy 56, 57

foreign objects, wounds 177

fractures 182–184

fragile X syndrome 201

Francis report 15

friction burns 187

frontal bone 52

fulcrum 58, 59

full thickness burns 186

fungi 28

furosemide 228

gas exchange 100, 102

gases, danger labels 76

gases (medical) 103–121

gastric distension 109

gauges, gas cylinders 105, 106, 118

gauze

wound cleansing 177

wound packing 175

getting up from floor 65–68

Glasgow Coma Scale 228

paediatric modification 199

glass test, meningococcal disease 154

glottis, infant 98

gloves 33, 34

removing 35

glucagon 166

glucose

blood level 80, 165–166, 169–170

dosages 167

glyceryl trinitrate (GTN) 143

Green calls 5

greenstick fractures 182, 183

grooming for sexual abuse 44

grunting, infants 196–197

GTN 143

gunshot wounds 177

head 171

gurgling, airway 87

haematoma 229

haemoptysis 128

haemorrhage

airway management 91

assessment 179

brain 152

catastrophic 79, 175, 178, 228

shock 144–145

trauma 175

see also bleeding

haemostatic agents 175

haemothorax 181

hand, anatomy 54, 56

hand hygiene 29–33

blood glucose measurement 169

handling 48, 59–69

aids 64–65

see also manual handling

handovers 3, 14

handwashing 31–32

handwheels, gas cylinders 105, 106, 117, 120

harassment, learning disabilities 203

harm, negligence 16–17

hate crimes, learning disabilities 203

hazardous area response teams 7

hazardous manual handling operations, legislation 25

hazardous materials 73–77

hazards, defined 25

head, trauma 171, 179, 201

head bobbing 197

head tilt, jaw thrust manoeuvre with 88–89

head tilt–chin lift manoeuvre 87–88, 217–218, 219

‘headline news’ 72

head-to-toe assessment 82–83

health and safety 24–41

legislation on infections 27

Health and Safety at Work etc. Act 1974 24

personal protective equipment 27

Health and Social Care Act 2008 27

healthcare-associated infections 27

‘hear and treat’ responses 5

heart

ageing 205

anatomy 129–132

electrical conduction pathway 130–131, 133–135, 205

see also entries beginning cardiac...

heart failure 143–144

children 195

heart rate see pulse rate

heat, loss mechanisms 155

heat exhaustion 157–158

heat stress 157–158

heat stroke 157, 158

heat-related illness 157–158

helicopters, in-flight defibrillation 223

hemicorporectomy 226

hemiplegia 154

herniation, intervertebral discs 54, 60, 61

hip bones 54–55, 56

history of presenting complaint 82

history-taking 2–3, 80–82

asthma 124

hormones 164

hosts, infections 29

Human Rights Act 1998 23

humerus 229

hydrogen cyanide 187

hypercapnic respiratory failure 125

hyperflexion injuries, spine 171–172

hyperglycaemic crisis 167–168

hyperosmolar hyperglycaemic state 168

hyperoxia 125

hypertension, defined 138

hypodermis 173

ageing 206

hypoglycaemia 80, 166, 167

hypostasis 226

hypotension

children 195

defined 139

hypothalamus 147, 155

hypothermia 156–157, 179

burns patients 187

cardiac arrest 225

water immersion 159

hypovolaemic shock 144–145

drowning 159

hypoxia

cardiac arrest 215–216

COPD 126

ice packs 158, 184

ileus 229

immobilisation, trauma patients 180, 184

immune system, ageing 205–206

incision (trauma) 176

inclusion (of people) 22

inequality in healthcare 201–202

infants 190

airways 98, 190, 196–197, 217–218

assessment 193

basic life support 217–219

bradycardia 198

breathing 191, 218

choking 98–99

circulation 191

cognitive development 191–192

infections

mechanisms 28–29

older people 205–206

pneumonia 127–128

prevention and control 26–38

infectious substances, danger labels 76

inferior (term) 48, 49

inflammatory arthritis 207

in-flight defibrillation 223

information governance 20–22

infra-red tympanic thermometers 156

inhalation injury see smoke inhalation

inhalers, asthma 123

injections, waste disposal after 36

injuries

mechanism of (MOI) 71, 171

to staff 59, 60

see also physical abuse; trauma

in-line stabilisation (manual) 184

inner cannulas, tracheostomy tubes 94

insertions, muscles 58

inspiration 102

insulin 166

integrated valve cylinders 104, 105

integumentary system see skin

intercostal (term) 229

intercostal muscles, children 191

intercostal recession 191, 195, 197

internal bleeding 174

see also haemorrhage

internal incidents 72

inter-scapular blows, choking child 99

intervertebral discs 53–54, 60, 61

ipratropium bromide 123

irrigation of wounds 177

ischaemia, myocardium 141, 215

ischaemic strokes 152

islets of Langerhans 165

isovolumetric contraction, heart 134

J point, electrocardiography 135

jaw thrust manoeuvre 88, 218, 220

with head tilt 88–89

Jext® auto-injector 162–163

Joint Emergency Services Interoperability Programme 8

joints 49–50

ageing 204–205

arthritis 207

see also specific joints

judgements (prejudgements) 16

keratinocytes 173

ketoacidosis 167, 168

ketonaemia (term) 229

kidneys, children 198

knee 55–56, 57

Korotkoff sounds 139, 140, 229

Kussmaul breathing 229

kyphosis 204–205

labels

gas cylinders 105, 106

hazardous materials 74–76

laceration 176

lacrimal bones 53

languages 13

laryngectomy 93, 95–96

laryngopharynx 85

laryngospasm, drowning 158

larynx 85–86

last oral intake 82

lateral (term) 48, 49, 229

learning cultures 17–18

learning disabilities 200–203

left anterior descending artery (coronary) 132

left atrium 130

left bundle branch 131

left coronary artery 132

left ventricle 130

legal issues 15–23

health and safety 24

learning disabilities 200

manual handling 61–62

level of consciousness 80, 198, 199

levers 58–59

lifting see manual handling

lightning strikes 188

line managers 8

listening 12

living wills (advance decision to refuse treatment) 19, 226, 227

loads 60, 61, 62, 63–64

levers 58–59

see also manual handling

lobar pneumonia 127

lobes, lungs 100, 101

lobules, lungs 101

long bones 50

longevity, wealth and 22

lower limbs

assessment 83

bones 55–57

lumbar spine 61

Lund and Browder charts 185

lungs

anatomy 86

physiology 100–101

lying position

rising from 65–68

major incidents 72–74

terrorist attacks 71

maltreatment, defined 42

Management of Health and Safety at Work Regulations 1999 24–25

mandible 53

see also jaw thrust manoeuvre

manual airway manoeuvres 87–90

manual handling 48, 59–65

abusive 44

legislation on 25, 61–62

risk assessment 26, 60–62

Manual Handling Operations Regulations 1992 25, 61

manual in-line stabilisation 184

masks see face masks mass incidents 72

maxilla 53

mechanical ventilation 111–113

mechanically powered stretchers 62

mechanism of injury (MOI) 71, 171

medial (term) 48, 49, 229

mediastinum 86

medication

current 3

history-taking 81

medium concentration face masks 108

medulla oblongata 147

melanocytes 173

Mencap, Death by indifference 202

meninges 148

meningococcal disease 152–154

mental capacity 18, 19–20

learning disabilities 200

mental illness, older people 207–214

metal surfaces, defibrillation and 222–223

METHANE (mnemonic) 73, 229

microbial filters, Entonox 119

microorganisms 27–28, 229

midbrain 147

misunderstandings

avoidance 13

mitral valve 130

mobile phones 14

monoplegia 154

mottling, children 196

mouth

anatomy 84–85

assessment 83

infants 190

mouth-to-mask ventilation 110

mouth-to-mouth ventilation 109–110, 217, 218

movement

musculoskeletal system 49, 58–59, 205

spine 171–172

moving

getting up from floor 65–68

see also handling; manual handling

Munchausen’s syndrome by proxy 44

muscles 48, 58–59

ageing 205

respiratory 102

myocardium 129

infarction 142

ischaemia 141, 215

nail varnish, pulse oximetry and 122

nasal bones 52

nasal cannulae, oxygen delivery 108, 113

nasal conchae 53

nasopharynx 85

National Advisory Group on the Safety of Patients in England 15

National Health Service

ambulance services 6

standards of care 15–16

nature of illness (NOI) 71

nebulisers 108

neck

assessment 83, 178

trauma 172, 178

neglect 44–45

negligence 16–17

nervous system 146–154

ageing 205

control of breathing 102–103

neurons 146

ageing 205

999 calls

fire 39

response to 5–6

non-accidental injury 43–44

non-invasive blood pressure measurement 139–141

non-rebreathe masks 108

respiratory rate indicators 121

non-shockable rhythms 221–222

non-ST-segment elevation myocardial infarction 142

non-verbal communication 11–12

norovirus 27

nose

anatomy 52, 53, 84

flaring 195

infants 190

oxygen cannulae 108, 113

number of patients 71, 178

obesity

body mass index 228

burns assessment 185

diabetes mellitus 167

moving patient from scene 70–71

observations 13–14

obstructive shock 145

obturators, tracheostomies 94, 95

oedema 229

offensive waste 35

older people 204–214

oliguria 229

one-chair method, rising from floor 65–67

one-person ventilation, bag-valve-mask ventilation 111

OPA see oropharyngeal airways

open fractures 182, 184

operational commanders 8

OPQRST (mnemonic) 81, 229

origins, muscles 58

oropharyngeal airways 91–92, 229

children 196

convulsions and 151

oropharynx 85

osmolality, hyperosmolar hyperglycaemic state 168

osteoarthritis 207

osteoporosis 207

‘over-the-counter’ drugs 81

oxidising substances, danger labels 76

oxygen

administration 113–118

after-use procedures 117–118

bag-valve-mask ventilation 110

children 113, 190, 197

concentrations for combustion 39

convulsions 151

COPD and 113, 115, 125

defibrillation and 113, 223

delivery devices 107, 108–109

dosages 114, 115, 116

fire 104

hyperglycaemic crisis 168

partial pressures 102, 103

pneumothorax 181

post-resuscitation care 226

safety 103

saturations 121–122

tracheostomy 94, 95

P waves, electrocardiography 135

pacemaker, heart 130–131

pacemaker devices, defibrillation and 223

packaging, waste disposal 36

packing, wounds 175

pad placement, defibrillation 223–225

paediatric assessment triangle (PAT) 195

paediatrics see children

pagers 14

pain

Abbey Pain Scale 212

acute coronary syndrome 2–3, 142

angina 141

assessment 81

dementia 211, 212

learning disabilities 202

pleuritic 229

pallor 195

pancreas 165

panda eyes (Battle’s sign) 179, 228, 229

papillary dermis 173

paracetamol, on blood glucose 169

paralinguistics 11

paralysis 154

paramedics 6, 7

paraplegia 154

paraquat poisoning, oxygen and 116

parasites 28

parasympathetic nervous system 149

paresis 154

Parkinson’s disease 206

partial convulsions 151

partial pressures 102, 103, 229

past medical history 82

patient assessment 2, 78–83

burns 185

general impression 79

paediatrics 192–199

patient-identifiable information 20–21

Pelka, Daniel, abuse case 43

pelvic girdle 54–55, 56

assessment 83

trauma 172, 179, 182

penetrating injuries 171

abdomen 181–182

thorax 172

percussion 229

pericardium 129

peripheral nervous system 146–147

peritoneal organs 181

personal protective equipment 33–34

for decontamination 38

Health and Safety at Work etc. Act 1974 27

scene assessments for 2

for waste disposal 36

pharmacy medicines 81

pharynx 85

phones, mobile 14

physical abuse 43–44

physical responses, 999 calls 5–6

pictograms, danger labels 75–76

pilot balloon, tracheostomy tube 93

piriform aperture 52

plasma 132

platelets 132

pleura 86, 180

pleuritic chest pain 229

pneumonia 127–128

pneumothorax 180–181

Pneupac® paraPAC® ventilator 111, 112

pocket masks, mouth-to-mask ventilation 110

police

learning disabilities and 200

reporting abuse 46

pons 147

post-cardiac arrest syndrome 225

posterior (term) 48, 49, 229

posterior descending artery (coronary) 131–132

post-ictal phase 151

post-resuscitation care 225–226

posture

ageing 204–205

cardiac arrest in pregnancy 225

for manual handling 63

respiratory failure 87, 195, 197

power levers 58

PPE see personal protective equipment

PR segments, electrocardiography 135

precordium 229

pregnancy, cardiac arrest 225

prejudgements 16

pre-planned major events 72

pre-school children 190

assessment 194

cognitive development 192

presenting complaint 80

pressure (physical), air 101–102

pressure (psychological), stress vs 40

preventer inhalers, asthma 123

PRICE (mnemonic) 184

primary assessment 229

primary survey 78–80, 178–179

children 195–199

proximal (term) 48, 49, 230

psychological abuse 44

psychomotor (term) 230

pulmonary embolism 127–128

pulse oximetry 121–122, 230

children 195, 197

pulmonary embolism 128

pulse rate 137

children 191, 198

pulseless electrical activity 222

pulses 80, 135–137

children 198

pulmonary embolism 128

puncture (trauma) 177

see also stab wounds

pupils 80, 83, 149

Purkinje fibres 131

QRS waves and complexes, electrocardiography 135, 221

quadriplegia 154

radial pulse 135, 136

radiation burns 188

radioactive materials, danger labels 76

rashes 80

meningococcal disease 153, 154

‘reasonably practicable’ (term) 25

reassessment 83

recession 195, 197, 230

intercostal 191, 195, 197

record-keeping 12, 13–14

abuse and 46

information governance 20–22

personal 21–22

recovery position 69, 89–90

children 197–198

red blood cells 132

dissociative shock 145

Red calls 1, 5

red flag sepsis 163, 164

reflexes 148–149

infants 192

rehydration 158

relationships (working relationships) 9

relaxation period, cardiac cycle 134

reliever inhalers, asthma 123

removing PPE 35

rescue, from drowning 158–159

reservoirs of infection 28

respiratory centres 103

respiratory failure

children 194–198

hypercapnic 125

tripod position 87, 197

respiratory rates 121

asthma 124

children 191

pulmonary embolism 128

respiratory system

ageing 205

anatomy 84–86

physiology 100–103

responsiveness 79

resuscitation see cardiopulmonary resuscitation

reticular dermis 173

retroperitoneal space 181

return of spontaneous circulation (ROSC) 215, 225–226

rheumatoid arthritis 207

rhythm

for defibrillation 221–222

pulse 137

ribs 54

assessment 83

children 191

flail chest 181

motion 102

right atrium 130

right bundle branch 131

right coronary artery 131–132

right ventricle 130

rights, learning disabilities and 200–201

rigor mortis 226

rigors 230

rising from lying position 65–68

‘rising tide’ incidents 72

risk assessment 25–26

manual handling 26, 60–62

scene assessment 70–71

trauma 177–178

risks, defined 25–26

rotation, spinal trauma 172

rule of nines 185

SADs (supraglottic airway devices) 230

safeguarding 42–47

safeguarding referrals 46–47

safety

defibrillation 223

gas cylinders 105–106

oxygen 103

at scene 70–71, 177–178, 187, 188

see also health and safety

salbutamol 123

SAMPLE (acronym) 81, 230

scalds 186

scene assessment 2, 70–77, 177–178

SCENE risk assessments 26, 70–77, 177–178

school-age children 190

assessment 194

cognitive development 192

Schrader outlets 105, 112–113

after-use procedures 117

scope of practice 17, 230

Scotland, Adults with Incapacity (Scotland) Act 2000 19

secondary survey 82–83

security, patient-identifiable information 21

seizures 150–151

sepsis 163

meningococcal disease 153

screening tool 164

serial halving 185

sesamoid bones 50

severe sepsis 163

sexual abuse 44

sharps 35, 38

shields (facial), mouth-to-mouth ventilation 109–110

shock 144–145

children 198

drowning 159

meningococcal disease 153

septic 163, 164

shockable rhythms 221

shortness of breath on exertion, ageing 205

signs (clinical) 81

death 226

sildenafil, GTN contraindicated 143

sino-atrial node 130–131

situation awareness 70

skeleton 48, 50–57

injuries to 60

see also bones

skin 172–173

ageing 206

care 33

circulation in children 195–196, 198

trauma 172–173

skull 52–53

assessment 83

sleeve protectors 34

smoke inhalation 186–187

pulse oximetry and 122

smoking

COPD 125

fire prevention 39

snoring 87

social contexts, communication 12

social services, safeguarding and 46

SOCRATES (acronym) 81, 230

soft palate 85

somatic nervous system 148–149

somatostatin 166

spacers, inhalers 123

speaking valves, tracheostomies 94, 95

specialist paramedics 7

speech, stroke 150

speed levers 58–59

sphygmomanometers 139

spigots, Venturi masks 108

spinal cord 148

trauma 179–180

spine 53–54, 60, 61, 148

trauma 159, 171–172, 179–180, 184

splash contamination 38

sprains 184

sputum, pneumonia 127

ST segments, electrocardiography 135, 142

stab wounds

abdomen 172, 182

see also puncture (trauma)

stabilisation (manual in-line) 184

stable angina 141

Stafford Hospital 15–16

standards for responders 17

standards of care, National Health Service 15–16

Staphylococcus 27

status epilepticus 151

STEP 1-2-3 Plus method 71–72

stereotyping 16, 22, 23

sterilisation 37

stoma patency, laryngectomy 96

stomach, distension 109

storage

gas cylinders 104

medical records 21

straddle injuries 182

strains 184

stranger anxiety 192, 193

strategic commanders 8 Streptococcus 27

stress 40–41

communication and 11

stretchers 62

stridor 87, 196, 230

stroke 151–152

face, arm, speech test 150

stroke volume, children 191

structured risk assessments 26

ST-segment elevation myocardial infarction 142

sub-arachnoid space 148

sub-lingual sprays, GTN 143

suction, airway 90–91

sugar see glucose sunburn 188

superficial (term) 49

superficial fascia see hypodermis

superior (term) 48, 49, 230

supine (term) 230

support structures 8–9

assessing patient’s capacity 20

discrimination and 23

errors and 18

support workers 7

supraglottic airway devices (SADs) 230

surfactant 230

surgical face masks 33–34

susceptible hosts, infections 29

swallowing 85

sympathetic nervous system 149

symptoms 81

synovial joints 50

systemic inflammatory response syndrome 163

systole 133–134

systolic blood pressure 138, 140

T waves, electrocardiography 135

tachycardia 137, 230

children 198

ventricular 221, 222

tachypnoea 230

tactical commanders 8

teenagers 190

assessment 194

cognitive development 192

temperature

body 155

drowning 159

Entonox 106

environment 155–158

post-resuscitation care 226

tension pneumothorax 180

terrorist attacks 71

tetraplegia 154

thalamus 147

thermal burns 186–187

thermogenesis 48

thermometers 155–156

thermoregulation 155

thinking the unthinkable, on abuse 43

thorax 54

infants 191

trauma 172, 178–179, 180–181

thrombosis 127–128

TICLS (mnemonic) 195

TILE 230

TILEE 61

Time Critical Risk Management (US Navy), ABCD tool 70–71

time-critical features, burns 187

tiotropium bromide 123

toddlers 190

assessment 193

cognitive development 192

tongue 84–85

tonic-clonic convulsions 151

total body surface area 185

tourniquets 175–176

toxic substances, danger labels 76

trachea 86

child 98

tracheo-oesophageal puncture valves 95

tracheostomy 93–96

patency 94–95

tracheostomy tubes 93–95

transient ischaemic attacks 152

transmission of infections 28

transverse fractures 182, 183

trauma 171–189

brain 171, 179

head 171, 179, 201

primary survey 78–79

spine 159, 171–172, 179–180, 184

see also physical abuse

triage 5, 73

triangle of combustion 39

triangle of paediatric assessment (PAT) 195

tricuspid valve 130

tripod position 87, 197

tunica externa 133

tunica media 132

turbinates, nose 84

turgor 230

TWELV (mnemonic) 178

twisting, for manual handling 64

two-chair method, rising from floor 67–68

two-finger technique, chest compressions 219

two-person ventilation, bag-valve-mask ventilation 111

tympanic thermometers 156

unconsciousness

airway 196

see also coma

unstable angina 142

upper limbs

assessment 83

bones 54, 55

weakness 150

urgent care, specialist paramedics for 7

urgent concerns in safeguarding 46

urticaria 230

values-based healthcare 15

valves

Entonox 119, 120

heart 130

tracheostomies 94, 95

veins 132

vascular dementia 209

vehicles, fire 40

veins 132, 133

bleeding from 174

venous thromboembolism 127–128

ventilation (respiratory function) 100, 101–102

ageing 205

assisted see assisted ventilation

Ventolin (salbutamol) 123

ventricles, heart 130

ventricular fibrillation 221

ventricular systole 134

ventricular tachycardia 221, 222

Venturi masks 108

venules 132

verbal communication 11

vertebral column see spine

vicarious liability 17

viruses 27–28

blood-borne 38

vital signs 82

vitamin C, on blood glucose 169

volume

air pressure vs 101

pulse 137

volunteers, health and safety responsibilities 24

vomer 53

vomiting

airway management 91

diabetic ketoacidosis 168

from gastric distension 109

vulnerability to abuse 43

waste disposal 35–36

wealth, longevity and 22

weight, maximum safe handling 64

wet surfaces, defibrillation and 222

wheeze 87, 196

white blood cells 132

Winterbourne View hospital, abuse in 42–43

wipes 37

work of breathing, children 195, 196

working relationships 9

wounds 171, 172, 174–177

written communication 12

zygomatic bones 53