What is the purpose of exposure/environment assessment?
Look for any life threatening conditions - not to be confused with secondary survery
How would you expose a patient?
Cuts are made in a clamshell fashion; this allows the clothes to be laid back onto the patient with the aim to reduce exposure to the environment
What is a log roll?
A method to move a patient without flexing the spinal column. The manoeuvre
aides assessment, transfer and extrication of a patient while maintaining spinal
When may log rolling be detrimental to patient care in a pre-hospital setting?
Pelvic fractures - can dislodge a clot, and cause extreme pain shich can cause sympathetic overactivity, leading to increased BP
How many individuals/responders are required to perform a safe log roll?
Minimum of 4 - one person for the head, 3 for the body. However, it may be the case that there are less than the required number, meaning you have to make do with the number of helpers you have
Assuming there are 4 individuals available for a log roll, how should they position themselves in order to perform an effective manoeuvre?
- Head - maintaining MIS to prevent/protect c-spine injury
- Chest - one hand across the patient’s body at the shoulder and one hand on the greater trochanter
- Pelvis - one hand on the anterior superior iliac spine and one hand on the proximal thigh
- Legs - one hand under the knee and one hand under the ankle
What can a log roll be useful for in terms of assessing a patient?
Secondary survey of back and spine
Should spinal boards be used for spinal immobilisation?
No - only for extrication
What are negative effects of spinal boards?
- Pressure sores
- Inadequate immobilisation
- Pain and discomfort - which can lead to unnecessary radiographs
- Decreased respiratory capacity
What is a scoop stretcher useful for?
Transferring patients with c-spine injury
What technique would you use when using a scoop stretcher?
- Size the scoop stretcher - Lie the stretcher beside the patient to adjust the length as appropriate
- Split the blades and lie either side of the patient
- Log roll to 10° and slip the blade in beside the patient
- Clip the blades together - clip the blades at the head first, as it is easier to adjust the length at the feet
- Secure the body with straps
- Secure head with head blocks and tape
What is the single movement principle?
Describes how an early single movement can prevent excessive handling of the patient later on. This aims to maintain haemostasis, minimise spinal movement and dislodging of the ‘first clot.’ During this single movement all assessment and interventions should be carried out before placing the patient back down on a transfer stretcher
What are advatnages of a vacuum mattress?
- Spinal immobilisation
- Comfortable transport
- Moldable to different shapes
- Can have X-rays taken through it
- Can be used in water
- Rigid support for pelvic injuries
What is the technique for using a vacuum mattress?
- Log roll onto scoop stretcher
- Place patient onto vacuum mat and remove blades
- Mould vacuum mattress around body
- Remove air pump
- Strap patient in and ensure triple immobilisation of the head
When does hypothermia occur?
When core temperature falls below 35oC
What is classed as mild hypothermia?
What is classed as moderate hypothermia?
What is classed as severe hypothermia?
What is the mortality rate associated with severe hypothermia?
Between 30% and 80%
How is heat lost from the body?
- Conduction – direct contact with a cooler object
- Convection – due to air currents over the body
- Radiation – heat transfer from a area of high temperature to an area of low
- Evaporation – water evaporating from the skin or lungs in breathing
What physiological responses does exposure to cold cause?
- Sympathetic activation
- Endocrine activation - ACTH, TSH
- Muscle stimulation
- Adaptive behavioural actions
What effect can hypothermia have on the brain and cognition?
Can affect decision making, cause confusion and apathy, and over time, lead to coma
Why can the brains response to hypothermia be regarded as protective?
Can decrease cerebral oxygen demand, resulting in lower metabolic requirements
What effects does hypothermia have on the heart?
- Decreased CO
- Arrythmias - AF, VF
In terms of clinical presentation, what cardiovascular features indicate someone has mild hypothermia?
- Peripheral vascoconstriction
What are cardiovascular manifestations of moderate hypothermia?
What features can appear on ECG in someone with moderate hypothermia?
What cardiovascular rmanifestation can occur in severe hypothermia?
- Extreme bradycardia
Below what core body temperature does asystole occur?
Usually below 24oC
What Are neurological manifestations of mild hypothermia?
What are neurological manifestations of moderate hypothermia?
- Loss of fine motor skills
- Slurred speech
What are neurological manifestations of severe hypothermia?
- Fixed dilated pupils
- Decreased metabolism
What are clinical features of mild hypothermia?
- Mood change/irritable/confused/drowsy
- Decreased co-ordination
- Cold diuresis
What is cold diuresis?
Vasoconstriction raises MAP inducing diuretic like effect on the kidneys via renal resistance to ADH
What are clinical features of moderate hypothermia?
- Uncontrolled shivering
- Increased confusion
- Incoherent speech
- Bradypnoea/decreased ventilation
- Arrythmias - AF, atrial/ventricular rhythms
- Paradoxical undressing
- J-waves on ECG
- Unreactive dilated pupils
What are features of severe hypothermia?
- Muscle stiffness and rigidity, apparent rigor mortis
- Fixed dilated pupil
- Loss of consciousness
- No shivering
- Cold skin, blue coloration
- Irregular heart beat
- Pulmonary oedema
- Cardiac arrest
Why is a hypothermic patient not regarded as being dead until they are "warm and dead"?
Due to the decreased metabolic rate secondary to the low core temperature hypoxia can be tolerated for a longer period of time due to increased ischaemic tolerance of the brain. This means that in severe hypothermia resuscitation can be successful even after a period of hours.
If a person was found to be hypothermic, what would you assess for intiially to determine how to manage them?
Are they conscious or not
If someone who was hypothermic was found to be conscious, what things would you assess for to determine how to manage them?
- SBP < 90 mmHg
- Ventricular arrythmias
- Temp < 28oC
If a conscious hypothermic patient was found to have an SBP > 90, a temperature of 30oC, and mild bradycardia, how would you manage them?
Actively rewarm and transfer to local ED
If a hypothermic patient was found to have an SBP of 83 mmHg, and was in VF, how would you manage them?
Consider direct transfer to ECLS centre for consideration of ECMO/CPB. Contact hypothermia centre
If a patient who you suspected had hypothermia was in cardiac arrest and had significant trauma, how would you manage them?
Confirm death or continue life support and transfer to local ED
What are important things to assess in terms of submersion in cold water?
- Time submerged
- Water temperature
- Time from when head seen to go underwater or from time search started
What conditions are regarded as unsurvivable in terms of submersion in cold water?
- Water temp >/= 6oC + 30 minutes of head underwater
- Water temp < 6oC + 90 minutes head under
Would you attempt to re-warm someone who is in cardiac arrest due to hypothermia?
No - just prevent further heat loss
If someone has been buried in an avalanche, was in cardiac arrest and their airway was obstructed with snow/debris, how would you proceed?
Wht clinical staging system can be used to clinically assess hypothermia to determine managing someone with hypothermia?
Clinical swiss staging system
What are features of stage I hyperthermia as per Swiss staging system?
- Clear consciousness
What are features of Stage II hypothermia as per Swiss clinical staging system?
Impaired consciousness, without shivering - 28-32oC
What are features of stage III hypothermia as per Swiss clinical staging system?
Unconsciousness - 24-28oC
What are features of stage IV hypothermia as per Swiss clinical staging system?
Apparent death - 13-24 oC
What is classed as stage V hypothermia as per Swiss clinical staging system?
Irreversible death due to hypothermia - < 13oC
How would you manage someone with mild/stage I hypothermia?
- Warm sweet drinks
- Remove wet clothing - if others available
- If uninjured/alert - no need for hospitalisation
How would you manage someone with moderate/stage II hypothermia?
- Active warming - heat packs, forced-air
- IV/IO access
- Fluid replacement – saline heated to 40-42°C
- Transfer to hospital - if haemodynamically unstable then ensure an ICU and CPB if available.
How would you manage someone with Severe/stage III hypothermia?
CAREFUL HANDLING IS NEEDED
- Active warming- heat packs, forced-air
- IV/IO access
- Fluid replacement – saline heated to 40-42°C
- Intubation or use a supraglottic device followed by ventilation
- CPR if no signs of life
- Transfer to hospital preferably with cardiopulmonary bypass
How would you manage stage IV hypothermia?
- Start CPR as soon as diagnosis confirmed - continue throughout and do not terminate early
- Intubate and ventilate
- Transfer ASAP
When can CPR be done intermittently, and why?
When you have a hypothermic patient in cardiac arrest - only when continuous CPR is impossible
What is afterdrop, and why is it important to take into consideration when managing a hypothermic patient?
A continued fall in the core temperature after removal from the cold environment due to an increase in conductive heat loss from when the peripheries reperfuse. This is important to remember during medical care as a further drop can increase the risk of ventricular fibrillation (VF).
How can you prevent afterdrop occuring?
- Reducing limb movement
- Managing in the horizontal position
- Thorough active rewarming
What methods can be used to actively rewarm someone?
- Encouragement to shiver
- Warm, sweet drinks
- Calorie support
- Heat pack - not direct skin contact
- Warm, humidified oxygen
Why is moving someone with moderate to severe hypothermia as little as possible so important?
Excessive movement can precipitate life-threatening dysrythmias, particularly VF
Why is fluid therapy needed in hypothermia?
To prevent hypovolaemic shock occuring when the patient is warmed due to peripheral vasodilation
What fluids would you give a hypothermic patient?
Normal saline - warmed to 40-42oC
What intervals for intermittent CPR would you use if someone had a core body temperature of < 20oC?
Perform at least 5 mins CPR, followed by <10 minutes without
What intervals for intermittent CPR would you use if their core body temperature was between 20-28oC?
5 minutes of CPR, followed by < 5mins no CPR
What intervals for intermittent CPR would you use if a patients temperature was unknown?
5 mins CPR, followed by < 5 mins no CPR
How long can CPR be delayed in a hypothermic patient?
Up to 10 minutes to allow rescuers to move the casualty
What are the two main clinical presentations of meningococcal disease?
- Meningococcal Septicaemia
What is meningococcal septicaemia?
What are features of meningitis?
- Severe headache
- Neck stiffness
- Focal neurological defecit
What are feautres of meningococcal septicaemia?
- Limb/joint pain
- Clod hands/feet
- Pale/mottled/blue skin
- Abdo pain
- Impaired consciousness
When should fluids and oxygen therapy be started in someone with meningococcal septicaemia?
- Signs of shock
What two situations would parenteral antibiotic therapy with IM or IV benzyl-penicillin be started in a pre-hospital environment?
- High clinical suspicion of meningococcal disease with non-blanching rash
- If urgent transfer not available and meningococcal disease is suspected without a non-blanching rash
What would you assess for as part of your exposure assessment?
- Expose and assess for other signs of injury - Look, feel move