ABC of Prehospital Emergency Medicine E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: ABC Series
- Sprache: Englisch
In the newly revised second edition of ABC of Prehospital Emergency Medicine, a team of experienced prehospital practitioners deliver a comprehensive up-to-date guide to the rapidly evolving field of prehospital emergency medicine. The book includes evidence-based practice and expert opinion to meet the needs of the PHEM training curriculum covering operational, clinical and system considerations. An international team of expert editors and contributors have also provided readers with: * A thorough introduction to prehospital emergency medicine, including activation and deployment, personal protective equipment, and scene safety and assessment * Comprehensive exploration of the primary survey, airway, breathing, and circulation assessments * Practical discussions of prehospital anesthesia, analgesia, sedation, monitoring and ultrasound * The prehospital management of medical, trauma and psychiatric emergencies * How to care for special groups, including the elderly, obstetric, pediatric, and bariatric patients * Considerations in mass casualty and chemical, biological, radiation, and nuclear incidents. ABC of Prehospital Emergency Medicine is essential reading for paramedics, doctors, nurses and other prehospital practitioners. The text is ideal for those undertaking subspecialty PHEM training, those studying for postgraduate prehospital degree modules, or practitioners undertaking PHEM exams.
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Veröffentlichungsjahr: 2023
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Prehospital Emergency Medicine
SECOND EDITION
EDITED BY
Tim Nutbeam
Lead Doctor for the Devon Air AmbulanceHonorary Professor of Prehospital Emergency Medicine (PHEM), University of PlymouthConsultant in Emergency Medicine at University Hospitals Plymouth NHS TrustPlymouth, UK
Matt Boylan
Consultant in Military Emergency Medicine and PHEMUniversity Hospitals Birmingham NHS Foundation TrustBirmingham, UK
Caroline Leech
Deputy Clinical Lead for The Air Ambulance Service, Rugby, UK
Consultant in Emergency MedicineUniversity Hospitals Coventry & Warwickshire NHS TrustCoventry, UK
Clare Bosanko
Critical Care Doctor for the Devon Air AmbulanceConsultant in Emergency Medicine, University Hospitals Plymouth NHS TrustPlymouth, UK
This edition first published 2023
© 2023 John Wiley & Sons Ltd
Edition History
1e © 2013 John Wiley & Sons Ltd
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
The right of Tim Nutbeam, Matt Boylan, Caroline Leech and Clare Bosanko to be identified as the authors of the editorial material in this work has been asserted in accordance with law.
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The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.
Library of Congress Cataloging-in-Publication Data
Names: Nutbeam, Tim, editor. | Boylan, Matthew, editor. | Leech, Caroline (Consultant in emergency medicine), editor. | Bosanko, Clare, editor.
Title: ABC of prehospital emergency medicine / edited by Tim Nutbeam, Matt Boylan, Caroline Leech, Clare Bosanko.
Description: 2nd edition. | Hoboken, NJ : John Wiley & Sons, 2023. | Includes bibliographical references and index.
Identifiers: LCCN 2022057616 (print) | LCCN 2022057617 (ebook) | ISBN 9781119698326 (paperback) | ISBN 9781119698340 (pdf) | ISBN 9781119698333 (epub)
Subjects: MESH: Emergency Medicine--methods | Emergency Medical Services--methods
Classification: LCC RC86.8 (print) | LCC RC86.8 (ebook) | NLM WB 105 | DDC 616.02/5--dc23/eng/20230221
LC record available at https://lccn.loc.gov/2022057616
LC ebook record available at https://lccn.loc.gov/2022057617
Cover Image: © Gorodenkoff/Adobe Stock Photos
Cover Design: Wiley
Set in 9/12pt MinionPro by Integra Software Services Pvt. Ltd, Pondicherry, India
Contents
Cover
Title Page
Copyright
Contributor list
Foreword
Preface
1 Prehospital Emergency Medicine
Part 1 Operational Practice
2 Activation and Deployment
3 Responder Safety
4 Extrication
5 The First Five Minutes and the Primary Survey
6 Airway Assessment and Management
7 Breathing Assessment and Management
8 Circulation Assessment and Management
9 Prehospital Monitoring
10 Prehospital Ultrasound
11 Analgesia and Sedation
12 Transfer and Retrieval
Part 2 Providing Prehospital Trauma Care
13 Abdominal Injury
14 Pelvic Injury
15 Head Injury
16 Spinal Injuries
17 Extremity Injury
18 Burns
19 Suspension and Crush Injury
20 Ballistic and Blast Injury
21 Cardiac Arrest
Part 3 Providing Prehospital Medical Care
22 Acute Medical Emergencies
23 Overdose and Poisoning
Part 4 Special Groups
24 The Paediatric Patient
25 The Obstetric Patient
26 The Bariatric Patient
27 The Older Patient
28 Mental Health Crisis
29 Capacity
Part 5 Environmental
30 Environmental Injuries
31 Drowning
32 Diving Emergencies
33 Altitude Illness
Part 6 Emergency Preparedness
34 Mass Casualty Incident Management
35 Chemical, Biological, Radiation, and Nuclear Incidents
36 Mass Gatherings
Part 7 Clinical Governance and Professional Skills
37 Clinical Governance
38 Medicolegal and Ethical Aspects
39 Human Factors, Ergonomics, Safety, and Culture
40 Human Performance
41 Research and Development
Index
End User License Agreement
List of Tables
CHAPTER 02
Table 2.1 Summary of NHS Pathways...
CHAPTER 03
Table 3.1 Health and Safety...
Table 3.2 Example risk...
CHAPTER 04
Table 4.1 Types of entrapment
CHAPTER 05
Table 5.1 <C> ABC
Table 5.2 Life-threatening...
Table 5.3 Life-threatening...
CHAPTER 06
Table 6.1 Causes of airway obstruction
Table 6.2 Prediction of...
Table 6.3 Clinical assessment...
Table 6.4 Equipment needed for...
Table 6.5 Commonly used...
CHAPTER 11
Table 11.1 Pharmacological...
Table 11.2 Local Anaesthetic...
Table 11.3 Sedation
CHAPTER 12
Table 12.1 Characteristics...
Table 12.2 Comparison of...
Table 12.3 An example of...
Table 12.4 Effects of transfer...
Table 12.5 Flight physiology
Table 12.6 Preparation of a...
Table 12.7 Example of a patient...
Table 12.8 Key considerations...
Table 12.9 Simple oxygen...
CHAPTER 16
Table 16.1 The regional...
Table 16.2 Incomplete...
Table 16.3 Advantages...
Table 16.4 Patients...
CHAPTER 21
Table 21.1 Indications for...
Table 21.2 Relative contraindications...
Table 21.3 Minimum requirements...
Table 21.4 Additional items which...
CHAPTER 22
Table 22.1 Initial assessment...
Table 22.2 Chemical sedation...
CHAPTER 23
Table 23.1 ECG changes
Table 23.2 Oral activated...
Table 23.3 Toxidromes
Table 23.4 Toxins and...
CHAPTER 24
Table 24.1 Example weight...
Table 24.2 The primary...
CHAPTER 26
Table 26.1 Body mass index chart
Table 26.2 Broca formula...
Table 26.3 Drug dosing in obesity
Table 26.4 Examples of...
CHAPTER 28
Table 28.1 Sections in the...
Table 28.2 List of physical...
Table 28.3 Examples of common...
CHAPTER 30
Table 30.1 Environmental...
Table 30.2 Signs and symptoms...
Table 30.3 Frostbite classification
Table 30.4 Management of hypothermia
Table 30.5 Management of local cold injury
Table 30.6 Prevention strategies...
Table 30.7 Heat illness types/traditional...
Table 30.8 Risk factors for cold...
Table 30.9 Rewarming strategies...
CHAPTER 31
Table 31.1 Categorisation...
CHAPTER 33
Table 33.1 Aids to...
Table 33.2 AMS symptoms...
Table 33.3 HACE prevention...
Table 33.4 HAPE prevention...
Table 33.5 Essential drugs...
CHAPTER 34
Table 34.1 Examples...
Table 34.2 CSCATT
Table 34.3 Incident types...
Table 34.4 METHANE mnemonic
Table 34.5 Categories of triage
CHAPTER 35
Table 35.1 Therapeutic...
CHAPTER 39
Table 39.1 Advantages and...
Table 39.2 Checklist classification...
CHAPTER 40
Table 40.1 Examples of...
List of Illustrations
CHAPTER 01
Figure 1.1 Pre-hospital...
CHAPTER 02
Figure 2.1 Computer-aided dispatch...
Figure 2.2 GoodSAM instant-on-screen...
Figure 2.3 Ground-based...
Figure 2.4 Fire tenders...
Figure 2.5 Urban...
Figure 2.6 Example of helicopter...
CHAPTER 03
Figure 3.1 Level 2 and Level 3...
Figure 3.2 Powered respirator...
Figure 3.3 Responder in PPE.
Figure 3.4 HEMS Practitioner...
Figure 3.5 Practitioner in...
Figure 3.6 Run – Hide...
Figure 3.7 Drysuit/Flood response.
Figure 3.8 PPE for operating...
CHAPTER 04
Figure 4.1 Division of...
Figure 4.2 Car anatomy...
Figure 4.3 Rapid extrication...
Figure 4.4 Rapid extrication...
Figure 4.5 Roof-off extrication.
Figure 4.6 Roof fold-down.
Figure 4.7 Access through...
Figure 4.8 Access after...
Figure 4.9 Access after...
Figure 4.10 Chain cabling.
Figure 4.11 Accessing the...
CHAPTER 06
Figure 6.1 Airway management...
Figure 6.2 Lateral trauma...
Figure 6.3a Head tilt and chin...
Figure 6.3b Jaw thrust manoeuvre.
Figure 6.4 Oropharyngeal...
Figure 6.5 Nasopharyngeal...
Figure 6.6 Combined use of...
Figure 6.7 Examples of supraglottic...
Figure 6.8 PHEA setup.
Figure 6.9 Pre-PHEA checklist...
Figure 6.10 Video laryngoscopy...
Figure 6.11 Thirty-second drills.
Figure 6.12 Failed intubation plan.
Figure 6.13 PHEA overview.
Figure 6.14 Surgical airway anatomy.
Figure 6.15 Age related laryngoscope...
Figure 6.16 Needle cricothyroidotomy...
CHAPTER 07
Figure 7.1 Penetrating wound to axilla.
Figure 7.2 Nasal capnography...
Figure 7.3 Oxygen delivery devices.
Figure 7.4 Improving the mask...
Figure 7.5 Patient positioning.
Figure 7.6 Tension pneumothorax.
Figure 7.7 Needle decompression.
Figure 7.8 Simple thoracostomy.
Figure 7.9 Intercostal drain...
Figure 7.10 Open pneumothorax...
Figure 7.11 Flail chest...
CHAPTER 09
Figure 9.1 Modern multimodality...
Figure 9.2 All monitoring...
Figure 9.3 Pulse oximetry.
Figure 9.4 Normal (rectangular)...
Figure 9.5 Abnormal capnography...
Figure 9.6 ECG electrode placement.
Figure 9.7 Invasive blood pressure...
CHAPTER 10
Figure 10.1 Prehospital focused ultrasound.
Figure 10.2 (a) Ultrasound scan...
Figure 10.3 Chest ultrasound...
Figure 10.4 Chest ultrasound...
Figure 10.5 Chest ultrasound...
Figure 10.6 Chest ultrasound...
Figure 10.7 Subcostal view...
Figure 10.8 Pericardial effusion...
Figure 10.9 The inferior vena...
Figure 10.10 COACHRED protocol...
Figure 10.11 The eFAST examination...
Figure 10.12 Free fluid in Morrison...
Figure 10.13 Free fluid in the pelvis...
Figure 10.14 Aortic aneurysm...
Figure 10.15 Ultrasound of the...
Figure 10.16 The measurement of optic...
Figure 10.17 Ultrasound can clearly...
CHAPTER 11
Figure 11.1 Transduction, transmission...
Figure 11.2 Penthrox inhaler device...
CHAPTER 12
Figure 12.1 Transport from...
Figure 12.2 Road ambulance.
Figure 12.3 Rotary transfer.
Figure 12.4 Fixed wing...
Figure 12.5 Space and configuration...
Figure 12.6 Space and configuration...
Figure 12.7 Space and configuration...
Figure 12.8 Dedicated critical...
Figure 12.9 Neonatal transport...
CHAPTER 13
Figure 13.1 Extent of the...
Figure 13.2 Seat belt mark...
Figure 13.3 Bowel evisceration...
Figure 13.4 Impalement on...
CHAPTER 14
Figure 14.1 X-ray showing anteroposterior...
Figure 14.2 X-ray showing...
Figure 14.3 X-ray showing...
Figure 14.4 Indications for pelvic...
Figure 14.5 Commercial pelvic...
CHAPTER 15
Figure 15.1 Cross-section...
Figure 15.2 Intracranial...
Figure 15.3 Herniation...
Figure 15.4 Abnormal...
Figure 15.5 Signs of base...
Figure 15.6 Prehospital...
CHAPTER 16
Figure 16.1 Dermatomes.
Figure 16.2 Helmet removal
Figure 16.3 Ferno Pedi-Pac...
CHAPTER 17
Figure 17.1 The Kendrick...
Figure 17.2 Severe limb...
Figure 17.3 Surgical equipment...
Figure 17.4 Dressing and...
CHAPTER 18
Figure 18.1a Flame burn.
Figure 18.1b Scald.
Figure 18.1c Contact burn.
Figure 18.1d Frostbite.
Figure 18.2 Chemical burn.
Figure 18.3 Electrical burn.
Figure 18.4 Sunburn.
Figure 18.5 Lund...
Figure 18.6a Superficial dermal burn.
Figure 18.6b Deep dermal burn.
Figure 18.6c Full thickness burn.
Figure 18.7 Inhalational injury.
Figure 18.8 Escharotomy.
Figure 18.9 Examples of non-accidental...
CHAPTER 20
Figure 20.1 Cavitation.
Figure 20.2 Secondary blast injury...
Figure 20.3 Tertiary blast injury...
Figure 20.4 Staged care.
Figure 20.5 Facial blast injury...
Figure 20.6 Ballistic airway management.
Figure 20.7 Gunshot entry wound to the...
CHAPTER 21
Figure 21.1 European resuscitation...
Figure 21.2 Defibrillator pad...
Figure 21.3 European resuscitation...
Figure 21.4 Prehospital resuscitative...
CHAPTER 22
Figure 22.1 Capnogram traces...
Figure 22.2 V4R ECG lead...
Figure 22.3 Prehospital...
CHAPTER 24
Figure 24.1 Length-based assessment...
Figure 24.2 The paediatric airway.
Figure 24.3 Correct mask size...
Figure 24.4 Handlebar bruising...
Figure 24.5 Seatbelt bruising...
Figure 24.6 Advanced paediatric...
Figure 24.7 Encircling technique...
Figure 24.8 One handed compressions...
CHAPTER 25
Figure 25.1 Aortocaval compression.
Figure 25.2 Fundal height (weeks gestation).
Figure 25.3 Placental abruption...
Figure 25.4 The second stage of...
Figure 25.5 (a–d) Breech delivery.
Figure 25.6 McRoberts manoeuvre.
Figure 25.7 Suprapubic pressure.
Figure 25.8 Bimanual compression...
Figure 25.9 Aortic compression...
Figure 25.10 Manual reduction...
Figure 25.11 (a–d) Perimortem...
Figure 25.12 Newborn life support...
CHAPTER 26
Figure 26.1 Consequences...
Figure 26.2 Ideal positioning...
Figure 26.3 Patient on Rapid...
Figure 26.4 Intraosseous access...
Figure 26.5 Stryker bariatric...
Figure 26.6 Specially adapted...
CHAPTER 27
Figure 27.1 Clinical frailty...
Figure 27.2 Trauma assessment...
CHAPTER 29
Figure 29.1 Flowchart for the...
CHAPTER 30
Figure 30.1 Hypothermia ECG...
Figure 30.2 Frostbite.
Figure 30.3 Regional estimates...
Figure 30.4 Tiger snake bite.
Figure 30.5 Pressure-immobilisation...
CHAPTER 31
Figure 31.1 Water rescue...
Figure 31.2 Decision-making...
CHAPTER 33
Figure 33.1 Neurological...
Figure 33.2 CXR and PoCUS...
Figure 33.3 Portable altitude...
Figure 33.4 Retinal Haemorrhages...
Figure 33.5 UV Keratitis...
CHAPTER 34
Figure 34.1 Typical organisation...
Figure 34.2 Modified sieve...
Figure 34.3 CBRN triage sieve British...
Figure 34.4 Paediatric triage...
Figure 34.5 Ten Second Triage...
Figure 34.6 NHS Major Incident...
CHAPTER 35
Figure 35.1 The STEP...
Figure 35.2 Chemical, biological...
Figure 35.3 The PRISM ‘Rule...
Figure 35.4 Dry decontamination of non-ambulatory...
Figure 35.5 Dry decontamination of ambulatory...
Figure 35.6 Basic flow chart for...
Figure 35.7 Nerve agent...
Figure 35.8 Biological...
CHAPTER 36
Figure 36.1 A seated audience...
Figure 36.2 Temporary medical...
Figure 36.3 A helicopter emergency...
CHAPTER 37
Figure 37.1 Components of...
Figure 37.2 Balancing clinical...
CHAPTER 39
Figure 39.1 Work as imagined...
CHAPTER 40
Figure 40.1 Baddeley’s...
Guide
Cover
Title Page
Copyright
Table of Contents
Contributor list
Foreword
Preface
Begin Reading
Index
End User License Agreement
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Contributor list
Peter AitkenJames Cook University, Townsville, QLD, Australia
Keith P. AllisonConsultant Plastic Surgeon, James Cook University Hospital, Middlesbrough, UK
Tracy-Louise AppleyardSouthmead Hospital, Bristol, UK
Jennifer Bard J.D.University of Florida Levin College of Law, Gainesville, FL USA
Ed BarnardMilitary Consultant in Emergency Medicine (Prehospital Emergency Medicine)Cambridge University Hospitals NHS Foundation Trust, UKEast Anglian Air Ambulance, UK
Ewan BarronWest Midlands Deanery, Birmingham, UK
Hannah BawdonSandwell and West Birmingham Hospital, Birmingham, UK
Clare BosankoDevon Air Ambulance, UKUniversity Hospitals Plymouth NHS Trust
Martin BothaUniversity of the Witwatersrand, Johannesburg, South Africa
Matthew BoylanWest Midlands Ambulance Service MERIT, Birmingham, UKRoyal Defence for Defence Medicine, University Hospitals Birmingham, Birmingham, UK
Richard BrowneQueen Elizabeth Hospital, Birmingham, United KingdomACCOTS Adult Critical Care Transfer Service, Birmingham, UK
Adam BystrzyckiAlfred Hospital, Melbourne, VIC, Australia
William CharltonAcademic Department of Military General Practice, UKKent Surrey Sussex Air Ambulance
Tudor A. CodreanuState Health Incident Coordination Centre, Western AustralianDepartment of HealthEmergency Department, Critical Care Directorate, Busselton HealthCampus, Busselton, West Australia
Rob ColeWest Midlands Ambulance Service, UK
Richard CorrallWest Midlands Ambulance Service, UK
Stephanie CowanWest Midlands CARE TeamThe Air Ambulance Service, UK
Iwan DaviesWest Midlands CARE TeamThe Air Ambulance Service, UK
Tim DraycottSouthmead Hospital, Bristol, UK
Dave DungayDevon Air Ambulance, UK
Tom EvensAmbulance Service of New South Wales, Australia
Rob FenwickConsultant Nurse, Emergency Department, Wrexham Maelor Hospital, UK
Chris FrerkConsultant Anaesthetist at Northampton General Hospital, Trustee ClinicalHuman Factor Group, UK
John GlasheenHigh Acuity Response Unit, Queensland Ambulance Service, Queensland, AustraliaLifeflight Retrieval Medicine, Queensland, Australia
Surpreet GrewalBirmingham School of Anaesthesia, Birmingham, UK
Scott GrierSouthmead Hospital, Bristol, United KingdomRetrieve Adult Critical Care Transfer Service, UK
Ian GurneyDefence Consultant Advisor in Emergency Medicine, Academic Dept of Military Emergency Medicine, UK
Clare HammellLeighton Hospital, Crewe, UK
Tim HarrisRoyal London Hospital, London, UK
Jeremy HenningThe James Cook University Hospital, Middlesbrough, UK
Tim HooperRaigmore Hospital, NHS Highland, Inverness, Scotland
Jonathan HulmeSandwell and West Birmingham NHS Trust, City Hospital, Birmingham, UKWest Midlands Ambulance Service (WMAS) University NHS FoundationTrust, West Midlands, UKMidlands Air Ambulance Charity, West Midlands, UK
Tom HurstLondon’s Air Ambulance, Bart’s Health, UK
Per Kristian HyldmoSorlandet Hospital, Kristiansand, NorwayFaculty of Health Sciences, University of Stavanger, Stavanger, Norway
Neil JeffersLondon’s Air Ambulance, UK
Philip KeaneWye Valley Hospitals NHS Trust, Hereford County Hospital, Hereford, UK
Damian KeeneDepartment of Military Anaesthesia and critical care, Birmingham, UK
University Hospitals Birmingham, Birmingham, UK
Walter KloeckUniversity of the Witwatersrand, Johannesburg, South Africa
David KloeckUniversity of the Witwatersrand, Johannesburg, South Africa
Craig M. KlugmanDePaul University, Chicago, IL USA
Ben LawtonEmergency Department, Logan Hospital, Queensland, AustraliaQueensland Children’s Hospital, Queensland, AustraliaDon’t Forget The BubblesSchool of Medicine, University of Queensland, Queensland, Australia
Caroline LeechDeputy Clinical Lead for The Air Ambulance Service, Rugby, UKConsultant in Emergency Medicine, University Hospitals Coventry &Warwickshire NHS Trust, Coventry, UK
Christopher J. LewisConsultant Burn Surgeon, Royal Victoria Infirmary, Newcastle upon Tyne, UK
Mark LittleJames Cook University, Townsville, QLD, Australia
David LockeyNorth Bristol NHS Trust, Bristol, UKLondon’s Air Ambulance. Barts Health NHS Trust
Adam LowUniversity Hospitals Birmingham NHS Foundation Trust & Midland AirAmbulance Charity, UK
Fionna LoweDerriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
Carly LynchLondon Ambulance Service, UK
Rod MackenzieCambridge University Hospitals NHS Foundation Trust, Cambridge, UK
Assiah MahmoodMagpas Helimedix, St. Ives, UK
Kristyn ManleySouthmead Hospital, Bristol, UK
Suzanne MasonUniversity of Sheffield, UK
Niall Aye MaungAcademic Department of Military General Practice, UK
Stefan MazurMedSTAR, South Australian Emergency Medical Retrieval Service, SA, Australia
Jamie MilesUniversity of Sheffield, UK
Keniesha MillerDerriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
Paddy MorganExtreme Environments Laboratory, School of Sport, Health & Exercise Science, University of Portsmouth, Portsmouth, UKEmergency Medical Retrieval and Transfer Service (EMRTS) Cymru, CymruNorth Bristol NHS Trust, Bristol, UK
Lucas A. MyersMayo Clinic Medical Transport, Mayo Clinic, Rochester, MN, USA
Ian NortonRoyal Darwin Hospital, Darwin, NT, Australia
Tim NutbeamDerriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
Matt O’MearaUniversity Hospitals of North Midlands, UK
Lucy ObolenskyGP, Programme Lead Global and Remote Healthcare Masters Universityof Plymouth, UK
Andrew PearceRoyal Adelaide Hospital, Adelaide, SA, Australia
Keith PorterUniversity Hospital Birmingham, UK
Harvey PynnConsultant in Emergency Medicine and Critical Care doctor, Bristol, UK
Marius RehnFaculty of Health Sciences, University of Stavanger, Stavanger, NorwayDivision of Prehospital Services, Air Ambulance Department, OsloUniversity Hospital, Oslo, NorwayNorwegian Air Ambulance Foundation, Oslo, Norway
Tom RenninsonNorth Bristol NHS Trust, Bristol, UKEmergency Medical Retrieval and Transfer Services, Wales, UK
Keith RobertsUniversity Hospitals Birmingham, UK
Malcolm RussellEmeritus Medical Director, Air Ambulance Kent, Surrey & SussexClinical Governance Lead, Midlands Air Ambulance Charity, MedicalDirector UKFire & Rescue Services International Search and Rescue (UK ISAR) Team, Mercia Accident Rescue Service – responding BASICS doctor
Christopher S. RussiMayo Clinic Medical Transport, Mayo Clinic, Rochester, MN, USA
Mårten SandbergDivision of Prehospital Services, Air Ambulance Department, OsloUniversity Hospital, Oslo, Norway
Alison SandersBarts Health NHS Trust, Imperial College Healthcare NHS Trust, UK
Chris ShambrookPlanetK Performance Systems, UK
Peter ShirleyRoyal London Hospital, London, UK
Tony SimWye Valley Hospitals NHS Trust, Hereford County Hospital, Hereford, UK
Niroshan SiriwardenaUniversity of Lincoln, UK
Wayne SmithUniversity of Cape Town, South Africa
Willem StassenUniversity of Cape Town, South Africa
Omar TayariInstitute of Naval Medicine, Gosport, UK
Mike TiptonExtreme Environments Laboratory, School of Sport, Health & ExerciseScience, University of Portsmouth, Portsmouth, UK
Jake TurnerNottingham University Hospitals NHS Trust, Nottingham, UKThe Air Ambulance Service, Rugby, UKWest Midlands Ambulance Service MERIT, Birmingham, UK
Jamie VassalloAcademic Department of Military Emergency Medicine, Royal Centre forDefence Medicine, Birmingham, UK
Jason van der VeldeCork University Hospital, Cork, Ireland
Lee WallisUniversity of Cape Town, South Africa
Peter Welby-EverardSpecialty Trainee, Emergency Medicine, Defence Medical Services
Foreword
Dominique Jean Larrey, a French surgeon and military doctor practicing in the late 1700s, is often cited as the father of modern-day Prehospital Emergency Medicine (PHEM). His vision and commitment to provide care at the point of wounding, triage his patients on the basis of clinical need and transport them to battlefield hospitals in his flying ambulances was the blueprint of present-day PHEM practice. In the face of adversity, he provided contemporary medicine where patients needed it most, and at the same time created innovative practices such as triage.
Such achievements remain inspirational today. The ‘roots’ of PHEM by this measure are admittedly short, especially when compared to those of hallowed medical establishments that can trace their practices and buildings back nearly 1000 years. With this comes a need for PHEM to make up for lost ground. It is therefore with huge pride for our sub-speciality I see the efforts of the contributors in this second edition of the ABC of Prehospital Emergency Medicine making such significant strides in bringing together our modern-day understanding of the diseases we treat and defining modern PHEM practice.
The content of the first edition has been re-structured with the addition of new chapters such as Human Performance and Human Factors. In keeping with Larrey’s desire to innovate, our modern-day understanding of bleeding mimics are described, as well as, impact brain apnoea, and the interventions of REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) and e-CPR (Extracorporeal Membrane Oxygenation Cardiopulmonary Resuscitation). Our understanding of our patient’s pathologies and physiology is forever evolving: as are the complexities of interventions we can deliver. The second edition of the ABC of Prehospital Emergency Medicine reflects this evolution and will give any practitioner of PHEM a modern bedrock of understanding that will undoubtedly help the patients they tend. I would recommend it to all.
Dr Gareth Davies
Consultant in Emergency Medicine & Prehospital Care, Barts Health Trust
Emeritus Medical Director London’s Air Ambulance
Consultant in Emergency Medicine & Prehospital Care
Nobles’ Hospital, Isle of Man
Chief Medical Officer Isle of Man TT
Preface
The first edition of this book was conceived 15 years ago in recognition of the paucity of resources available for practitioners in the growing field of Prehospital Emergency Medicine.
Then the project had two clear aims:
To present accessible, cutting edge, expert opinion on core PHEM topics
To provide the reader with the practical knowledge and resources to put this knowledge into clinical practice
Published in 2013, the first edition brought together an international field of experienced prehospital practitioners to share their knowledge and expertise in the accessible ABC format.
Since then Prehospital Emergency Medicine has grown and evolved; with postgraduate qualifications and training available to clinicians from a variety of professional backgrounds, an increasing number of commissioned prehospital services alongside the voluntary agencies, and increased scrutiny and governance of practice. Our knowledge has grown too, and much of what was contained in the first edition has been superseded.
This second edition has been in development for several years, hampered by the COVID-19 pandemic, when our contributors were required to focus on clinical care. However, we are now proud to share this updated and expanded ABC of Prehospital Emergency Medicine. It is our hope that this text will serve as a useful educational tool for all those in prehospital training, as well as a useful revision aid for the seasoned practitioner.
We must thank the team at Wiley Blackwell, our supportive (and tolerant) families, and our expert team of authors without all of whom this project would never have happened. Finally, we would like to dedicate this text to the hundreds of prehospital practitioners who have dedicated many hundreds of thousands of hours of their own time to make the specialty what it is today.
Tim NutbeamMatthew BoylanCaroline LeechClare Bosanko
CHAPTER 1 Prehospital Emergency Medicine
Introduction
‘Prehospital care’ is the term given to the provision of medical care outside of the hospital or alternative fixed healthcare setting. In the developed world, the provision of prehospital care is usually the responsibility of a regional ambulance or emergency medical service (EMS). A number of agencies may operate in support of the ambulance service including air ambulance charities, private ambulance companies, rescue organisations (e.g. mountain rescue, coastguard), the voluntary aid societies (e.g. St John’s or Red Cross) and volunteer immediate care practitioners (e.g. British Association of Immediate Medical Care, BASICS). Medical cover of sporting and mass gathering events, extreme and wilderness medicine, disaster and humanitarian medicine, and transfer and retrieval medicine all involve the provision of prehospital medical care.
Prehospital emergency medicine
Prehospital emergency medicine (PHEM) is a field within prehospital care. PHEM’s evolution has been triggered by the demand to meet new challenges imposed by the regionalisation of specialist medical and trauma services. Many of the critically injured or unwell patients that prove to benefit most from these new systems of care are paradoxically those less likely to tolerate extended transfer without advanced critical care support. As a result, there is a need to provide prehospital practitioners capable of advanced clinical assessment and critical care intervention at the scene of an incident, together with safe retrieval to an appropriate centre of definitive care. In most continents the enhanced skill set required to provide this level of care falls outside that deliverable by the ambulance service or its supporting bodies, and therefore requires the deployment of specially trained physician – led teams. The role of the PHEM practitioner or team is to augment the existing prehospital response, not replace it. Their function is to provide an additional level of support for those patients with higher acuity illness and injury, both on scene and during transfer. In doing so they are also well placed to educate and enhance the skills of the prehospital providers they work alongside.
Training in PHEM
An important advancement within prehospital care in the UK has been the recognition of PHEM as a new medical subspecialty led by the Intercollegiate Board for Training in Pre-Hospital Emergency Medicine (IBTPHEM). IBTPHEM has produced a curriculum that outlines the knowledge, technical skills, and non-technical (behavioural) skills required to provide safe prehospital critical care and transfer. Links to the IBTPHEM and the curriculum can be found in the further reading section. The key themes of the curriculum are shown in Figure 1.1.
Figure 1.1 Pre-hospital emergency medicine curriculum themes.
Similar prehospital training programmes exist across Europe (e.g. Germany) where they are firmly integrated into medical training and the emergency medical services. In Australasia, geography has been the driving force behind the development of retrieval medicine as a specialisation. A number of retrieval services (e.g. Greater Sydney Area HEMS) have recognised the commonality between PHEM and retrieval medicine and have moved towards delivering a combined model that provides both inter-facility secondary transfer and primary prehospital retrieval. The experiences of many of these systems has helped to develop the PHEM subspecialty within the UK.
Summary
PHEM is a challenging and exciting development within the field of prehospital care. This book aims to provide some of the underpinning knowledge required for effective PHEM practice.
Further reading
www.ibtphem.org.uk
PART 1 Operational Practice
CHAPTER 2 Activation and Deployment
Stephanie Cowan2,3, Iwan Davies2,3, and Matthew Boylan1,2
1 West Midlands Ambulance Service MERIT2 West Midlands CARE Team3 The Air Ambulance Service
OVERVIEW
By the end of this chapter you should:
Understand how emergency calls are handled and prioritised
Understand the different types of dispatch
Understand the risks and benefits of deployment by road
Understand the risks and benefits of deployment by air.
Introduction
The first step in delivering high-quality prehospital care is the timely activation and deployment of prehospital resources. The initial aim is to get the right resource to the right patient in the right time frame. This process requires efficient call handling, robust call prioritisation, and intelligent tasking of resources. Prehospital practitioners may deploy to the scene using a variety of different transport modalities. The choice of modality will be determined by the system in which they work and by the nature and location of the incident.
Activation of prehospital services
It is important for the prehospital practitioner to understand how emergency calls are processed and resources dispatched.
Call handling
In most developed countries there is a single emergency telephone number that members of the public may dial to contact the emergency services. The emergency number differs from country to country but is typically a three-digit number that can be easily remembered and dialled quickly, e.g. 911 in the USA, 999 in the UK and 000 in Australia. In the 1990s the European Union added 112 as the Global System for Mobile Communications (GSM) approved common emergency telephone number.
In the UK, emergency calls from telephone and mobile phones pass to operators within Operator Assistance Centres (OACs). OACs can now also receive emergency calls via third party service providers such as motor vehicle collision detection systems or public access defibrillator cabinets. The role of the OAC is to connect the call to the appropriate emergency service (Police, Fire, Ambulance, Coast Guard) and provide caller and location details to the emergency service call centre (ECC). The Enhanced Information Service for Emergency Calls (EISEC) provides service subscriber details and address, termed the Caller Line Identification (CLI) for every fixed line call. For emergency calls made by mobile, the Advanced Mobile Locations (AML) system automatically sends the caller’s GPS co-ordinates via an SMS to the emergency call centre. The data then appears automatically as an incident on the dispatcher’s Computer-Aided Dispatch (CAD) screen in the ECC (Figure 2.1). At the same time, the caller is connected to a call taker at the ECC who will begin the process of call prioritisation. Location finding services such as what3words are being used by some ambulance services to augment the above systems and allow more accurate location finding.
Figure 2.1 Computer-aided dispatch in the emergency control centre.
Call prioritisation
There are several systems available by which calls can be prioritised including NHS Pathways, Advanced Medical Priority Dispatch System (AMPDS), and Criteria Based Dispatch (CBD). NHS Pathways uses a solely symptom-based approach to call assessment, whereas AMPDS and CBD use a combination of symptom (e.g., chest pain, unconsciousness), specific condition (e.g. diabetes, pregnancy) or incident type (e.g. fall, road traffic accident) as prompts for assessment. Regardless of the system used, the aim is to match severity with the response time and in some systems direct patients to other community services. As an example, the priority categorisation and corresponding response targets for the NHS pathways system are shown in Table 2.1.
Table 2.1 Summary of NHS Pathways dispatch priorities and response targets
Category
Colour
Type
Response
Response target
90th percentile response target
1
Purple
Life threatening injury and illness, particularly cardiac arrest
Immediate dispatch and often auto-allocation of nearest resource.
7 minutes
15 mins
2
Red
Time-critical emergency calls such as stroke patients
Resources dispatched, could be diverted to a Category 1 call.
18 minutes
40 mins
3
Amber
Urgent calls such as abdominal pains
Includes treatment by resources in their own home. Some services will interrogate Category 3 calls further.
None
Mean indicator 60 mins
120 minutes
4
Green
Less urgent calls such as back pain and vomiting
Some of these patients will be given advice over the telephone or referred to another service such as general practice or the pharmacist.
None
180 minutes
The process of call prioritisation used by these systems is known as systematised caller interrogation and they incorporate protocolised pre-arrival first-aid instructions that are relayed by the call taker to the caller while they await the emergency response. In addition, each injury and injury mechanism can be allocated a unique code for audit purposes.
Activation of enhanced care assets
Although effective in prioritising an ambulance service response, the forementioned systems have been shown to lack the sensitivity and specificity required to select calls that would benefit from enhanced prehospital emergency medicine (PHEM) intervention. To identify these cases, an additional tier of enhanced caller interrogation and dispatch criterion is required. The method by which this is achieved varies across different enhanced care services.
In many services this is undertaken by active PHEM practitioners (e.g. critical care paramedics or doctors) as they are felt to be best placed to make accurate judgements about the likely need for advanced interventions. The use of non-clinical dispatchers in this role has previously been associated with high rates of over-triage, although there is some emerging evidence to suggest that the use of bespoke algorithms in combination with non-clinical dispatchers can increase tasking accuracy.
One example of enhanced call prioritisation and dispatch is that used by London Air Ambulance in the UK. A dedicated Air Ambulance dispatch desk within the Emergency Control Centre is manned by an operational air ambulance paramedic. They are responsible for scanning all the incoming cases and identifying those that would benefit from enhanced intervention. A set of evidence-based criteria known to be associated with severe injury are used to trigger the ‘immediate dispatch’ of the helicopter or car-based team (Box 2.1). Certain other cases undergo direct caller interrogation by the paramedic to assess whether enhanced intervention would be beneficial (Box 2.2). This is termed ‘interrogated dispatch’. The clinical knowledge and experience of the air ambulance paramedic is critical in ensuring rapid and accurate identification and prioritisation of these cases. The third form of dispatch is the crew request, which is treated as an immediate dispatch.
Box 2.1 Immediate dispatch criteria (London Air Ambulance)
Fall from greater than two floors (>20 feet)
Fall or jumped in front of a train
Ejected from vehicle
Death of a same vehicle occupant
Amputation above wrist or ankle
Trapped under vehicle (not motorcycle)
Request from any other emergency service
Box 2.2 Incident categories for interrogation (London Air Ambulance)
Shooting
Stabbing
Explosions
Road traffic collisions
Industrial accidents/incidents
Hanging
Drowning
Entrapments
Amputations
Burns/scalds
Building site accidents
Falls from height less than two floors
Impalement
Obtaining accurate information from the scene of an incident is complex and represents a significant challenge to personnel interrogating emergency calls. Bystanders are often not medically trained, and the emotional effect of the incident may render them incapable of accurately describing the scene or clinical condition of the patient, causing inaccurate and delayed dispatch of appropriate resources. The time critical nature, severity of injury and scarcity of critical care teams necessitates accurate, early, and careful allocation of resources. The recent utilisation of a secure live video feed from bystander mobile phones (e.g. GoodSAM Instant-On-Screen function™ – Figure 2.2) allows visual as well as auditory triage in order to improve triage accuracy. Improved mobile and artificial intelligence technology that allow the remote assessment of vital signs and audio analysis of emotions are now being trialled to see whether they can improve the accuracy and speed of the standard interrogation process and lead to earlier deployment of enhanced care teams and less over triage.
Figure 2.2 GoodSAM instant-on-screen function (Courtesy of GoodSAM).
Dispatch
While the call is being prioritised by the call taker, the dispatcher is responsible for allocating appropriate resources to the incident. Most modern CAD systems have an integral automatic vehicle location system (AVLS) which will automatically populate a list of the nearest available resources. The choice of resource will depend on the location, mechanism of injury, number of patients involved, and the perceived severity of injury. Many ambulance services have moved from VHF radio to digital data transmission (e.g., Airwave in the UK) as their primary mode of communication enabling the incident details to be sent directly to the radio handset. The details are also sent directly to vehicle-mounted data terminals with integrated satellite navigation systems that will automatically plot the route to the incident. Alternative modes of dispatch include activation via a base telephone landline, mobile phone or pager system.
Deployment of prehospital services
Ambulance services may choose to deploy their resources to the scene of an incident by foot, bicycle, motorbike, car, ambulance, helicopter, or fixed wing aircraft. The decision to deploy a particular asset will be determined by the distance the asset is from the incident, the accessibility by road, known congestion, and the required skill set of the responders. PHEM practitioners deployed to augment the ambulance service response will usually deploy by land vehicle or by helicopter.
Deployment by land vehicle
Many systems deploy their prehospital practitioners by rapid response vehicle (Figure 2.3). Land-based deployment is not restricted by weather or daylight hours in the same way that helicopter deployment is. They are ideal for operations in built-up urban areas as they are not limited by the need for an appropriately sized landing site. Over relatively short distances they also offer similar response times to helicopters because of the additional time taken by helicopters for take-off and landing.
Figure 2.3 Ground-based enhanced care team. (Courtesy of the West Midlands CARE Team).
Response vehicles must be roadworthy. A daily vehicle check is important and should include fuel and oil levels, water coolant, screen wash, electrics, lights, and tyres (tread depth, inflation, and damage). Medical equipment should be appropriately restrained and a lockable box available for controlled drug storage. The vehicle should have visual and audible warning devices, as well as high-visibility markings. Drivers must be appropriately trained and insured for emergency response driving.
Activation may be via radio or mobile phone. If activation occurs while the vehicle is mobile, the driver should pull over at the next safe opportunity before further details of the incident are taken. Progression to scene should be made rapidly but safely with the full use of visible and audible warning devices. Parking at scene will usually be under the direction of the police. If the prehospital practitioner is first on scene at a road traffic accident, the fend-off position may be used to protect the incident scene (Figure 2.4). The vehicle should be positioned approximately 50 meters back from the incident and positioned to afford maximum use of rear visual devices and reflective high-visibility markings. The front wheels should be turned in a safe direction to reduce the risk of the vehicle being pushed into the incident if another vehicle collides with it. Keys should be left in the ignition and the engine left running to prevent the battery draining flat. Once parked in a fend-off position, no one should return to the vehicle unless necessary.
Figure 2.4 Fire tenders protecting the scene in the ‘fend-off’ position. (Courtesy of Shane Casey).
Deployment by helicopter
Helicopter Emergency Medical Services (HEMS) provide extended range and rapidity of advanced critical care team deployment over a large geographical area. These assets are particularly advantageous when covering remote and rural regions, allowing bypass of local hospitals, delivering patients to their definitive care site directly and quickly. They can also be utilised effectively in the urban setting where traffic congestion may limit rapid deployment by road (Figure 2.5). Deployment by helicopter provides a unique, ‘birds-eye’ view of the incident which can be useful to appreciate the complexity of a scene, access and egress routes, and any potential risk; particularly valuable at large or major incidents.
Figure 2.5 Urban HEMS. (Source: Adam Calaitzis/Adobe Stock).
Restrictions on the use of helicopter platforms occur due to environmental conditions, including poor weather conditions (high wind speeds, low cloud levels, and freezing temperatures) and an inability to identify a suitable landing site. Some aircraft are able to fly in low light conditions or hours of darkness if equipped with a Night Vision Imaging Systems (NVIS). Each service will determine the benefit of a 24-hour service, versus the added cost and risks associated with flying at night.
Helicopter operations within Europe are regulated by the European Aviation Safety Agency (EASA), formerly known as JAR-OPS. Similar national regulations are in place in the USA and Australasia. EASA defines a HEMS flight as a ‘Flight by a helicopter, operating under a HEMS approval to facilitate emergency medical assistance, where immediate and rapid transportation is essential, by carrying:
medical personnel,
medical supplies (equipment, blood, organs, drugs), or
ill or injured persons and other persons directly involved’.
The HEMS designation for flight operation is important as this allows exemptions from normal weather limits and other certain rules of air, relating to flying and landing in congested areas and special sites such as nuclear power stations, prisons, and some restricted airspaces/areas. Incidents that do not meet EASA definition of HEMS are classified as air ambulance missions and do not confer the same exemptions.
Medical personnel carried on HEMS flights fall into one of two categories:
HEMS crew member
– an individual who has been specifically trained and assigned to the HEMS flight to provide medical assistance to the patient and assist the pilot during a mission with such roles as navigation or radio management.
Medical passenger
– an individual who is carried during a HEMS flight whose primary role is patient care. No specific training other than a pre-flight briefing is required, but they must be accompanied by a HEMS crew member.
During start-up and shut down, the rotors blades are less stable and more susceptible to sail. The inherent dangers of the moving rotor blades necessitate tight control of entrance and exit from the aircraft by the pilot. The crew should hold outside of the rotor disc space until a confirmatory thumbs up signal is passed from the pilot to the crew confirming that it is safe to enter the disc space. The crew will approach the aircraft in the appropriate safe direction avoiding the main hazard areas of the aircraft e.g., engine exhausts and rotor blades (Figure 2.6). It is important to note that hazard areas and direction of safe approach may differ between aircraft types and so local familiarisation is essential. When landing on scene care should be taken on sloping ground to avoid walking uphill into the rotor disc – always exit in a downhill direction under the guidance of the pilot or a HEMS crew member. Any passengers should also have received a brief from the pilot or a HEMS crew member before being escorted onto and off the aircraft. Take-off and landing are the most hazardous periods of a HEMS flight therefore talking and noise should be kept to a minimum during this phase unless a hazard is noted.
Figure 2.6 Example of helicopter zones of safe approach for the AW109SP.
Landing sites during daylight hours need to be twice the diameter of the rotor blades and should be flat, free of debris and clear of any wires. The surrounding area of the site needs to be considered (people, animals, potential risks) including the access and egress routes for the crew and other emergency services personnel. These requirements change substantially at night.
Tips from the field
Use of PHEM practitioners for enhanced prioritisation of emergency calls minimises over-triage
Always pull over safely before taking incident details or programming the sat-nav
Always carry a set of maps as a back-up in case of electronic failure
Take advantage of the bird’s-eye view of the scene afforded by helicopter deployment – assess for hazards, mechanism and casualty locations.
Further reading
Avest et al. Live video footage from scene to aid helicopter emergency service dispatch: a feasibility study.
Scand J Trauma Resuscitation Emerg Med
2019;
27
;55:1–6.
Brown JB, Forsythe RM, Stassen NA, Gestring ML. The national trauma triage protocol: can this tool predict which patients with trauma will benefit from helicopter transport?
J Trauma
2012;
73
:319–325.
Lin G, Becker A, Lynn M. Do pre-hospital trauma alert criteria predict the severity of injury and a need for an emergent surgical intervention?
Injury
2012;
43
:1381–1385.
Munro S, Joy M, de Coverly R, Salmon M, Williams J, Lyon RM. A novel method of non-clinical dispatch is associated with a higher rate of critical Helicopter emergency medical service intervention.
Scand J Trauma Resuscitation Emerg Med
2018;
26
;84:1–7.
Ringburg AN, de Ronde G, Thomas SH, et al. Validity of helicopter emergency medical services dispatch criteria for traumatic injuries: a systematic review.
Prehosp Emerg Care
. 2009;
13
:28–36.
Sherman G.
Report on Operating Models for NHS Ambulance Trust Control Rooms in England
, 2007. Manchester: Mason Communications Ltd.
