PRE-HOSPITAL CARE

Margareta Burell 2008

 The stages of prehospital care
• Survey the scene - check for hazards to the
rescuers or patient – call for back-up
• Primary survey - rapid assessment to identify
and treat conditions the involve immediate threat
of life – initiate airway management , check
breathing and circulation
• Secondary survey - close look at the scene –
more history and physical assessment
• Definitive field management – wound care,
stabilization of fractures – packaging for transport
• Ongoing reevalution of the patient´s condition
 To think about ….
• Dead heroes can´t save lives, injuried heroes
are a nuisance. So check the scene for
hazards before you lurch in …..

• The people who can shout and scream - they

can also breath - and have open airways…..
• Look more for the silent ones ……
 TRIAGE
Sorting of patients based on the need for
treatment and the available resources to
provide that treatment
• Airway
• Breathing and ventilation
• Circulation
• Diasability – neurological status
• Exposure/environmental control
 Airway
Physiology
• The respiratory system is composed of an
upper and lower airway from the nose to the
alveoli in the lungs.
• About 250 ml of the breating volume is ”dead
space” and will not be chanced
• Normal volume when we breath is about
500 ml
 Anatomy of airway
• Trachea
• Epiglottis wiht vocal folds
• Bronchi
• Bronchioli
• Alveoli – surrounded by capillaries – it is here
the respiratory system meets the blood
system and gas exchange occurs
 Breathing - ventilation
• Hypoxi (reduced oxygen in the blood) will
occur when it is inadequate oxygenation of
the patient´s tissues

• Observations of breathing : look – listen – feel

• Normal respiratory rate is 12 – 20 per minute
• Normal minute volume about 500 ml
 Gas exchange in the alveolus
• Oxygen is taken up from the alveolus
• Carbon dioxide is released into the alveolus

• Hypoventilation - carbon dioxide elimination is

reduced and CO2 accumulates in the blood -
respiratory acidosis = pH lower than normal 7,35 -7,45

• Hyperventilation - when carbon dioxide elimination is

increased – the level of CO2 in the blood falls –
respiratory alkalosis = pH higher than normal
(concentration of hydrogen ions)
 Respiratory insuffience
• A feeling of shortness of breath
• Rapid breathing
• Very deep breathing
• Use of accessory muscles in the neck and
abdomen to assist respirations
• Flaring of the nostrils on inhalation
• Bluish tinge to the lips and nail beds (cyanosis)
• If the respiratory center is depressed -- slow,
shallow respirations
 Oxygen administration
• Catheter in the nose (nasal catheter)
• Face mask

• Flow rate can be up to 12 liter /minute

 Causes of respiratory arrest
Airway obstruction
• Tongue (in the unconscious patient)
• Foreign body (choking)
• Swelling (edema or spasm in larynx/troat)
• Trauma to the airway

Depression or damage to the respiratory center

• Drugs (narcotics, medicaments ex barbiturates )
• Head injury
• Stroke
• Electric shock

Primay cardiac arrest

 Recognition of respiratory problems
To diagnose respiratory arrest
look, listen and feel for breathing

• Help for free airway - tilt the patient´s head

back – chin lift
• Mouth- to-mouth ventilation
• Ventilation with a pocket mask
 Circulation and bleeding
Circulatory system is just life-
threating as failure of the respiratory
system
Evaluation of pulse for presence,
quality, regularity
 Pulsation
• Tachycardia - rapid pulse
• Bradycardia - slowly pulse
• Arytmia – irregular rhytm

• Normal pulse rate is about 60 -80

Blood volume is about 5 000 ml adult person
Arteria – venous - capillary
 Palpation for pulse
• At the neck beside the muscles (carotis)
• At the wrist (radialis)
The pulse can be rapid, weak for example

• When you have low blood pressure - under

about 70 mm Hg you cannot feel much of
pulsation at the wrist
Blood pressure about 120 mmHg /70 normally
but depending on age, illness etc etc
 Fluids and electrolytes
• Body fluids total body water about 60 %
of body weight

• Cations are Sodium (Na) Potassium (K)

Calcium (Ca) Magnesium (Mg)

• Anions are Chloride (Cl) and bicarbonate

(HCO3)
 Buffer systems
• The bicarbonate buffer system

• The lungs

• The kidneys
 Types of Shock
• Hypovolemic -- loss of volume fluid, blood
or plasma
• Cardiogen - - heart pump function problem
• Neurogenic - - vascular system problem with
dilatation of perifer blood vessels - or
spinal cord problem
• Mixed types pump and tubing (volume in
blood vessels/other places)
 Symptoms and signs of shock
• Restlessness and anxiety
• Thirst
• Nausea – sometimes also vomiting
• Cold, clammy, pale (ev mottled) skin
• Weak, rapid pulse
• Shallow, rapid breathing
• Changes in the state of consciousness (confusion,
disorientation, coma)
• Fall in blood pressure
 Treatment of shock
• Maintain an airway
• Give oxygen
• Control bleeding
• Fluid - intravenous (avoid drinking)
• Keep the patient warm
• Legs elevated
 Disability
• Disability is a direct measurement of cerebral
function and also measurement of cerebral
oxygenation
Level of consciousness
• Alert
• Responds to Verbal stimulus
• Responds to Painful stimulus
• Unresponsive
 Expose
• Physical examination - undress the patient if
it helps - partly if nescessary

Depends on the situation and where and

how many causualties …..
 Fahrenheit
• Temperature - cold ground often – prevent
risk for cold injuries

• Shock also get cold - give the patient a sheet

or something
 Get vital signs
• Pulse rate
• Breathing rate – sound etc
• Bloodpressure
• Warm – cold – wet?
• Colour – pale -cyanotic?
 History
• What happened?
• What hurts?
• What else is wrong?

• The scenario and mechanisms of injury

(position in the train, car, bus etc etc )
• History of the patient – resourses etc etc
 To think about ….

Never assume that it is

impossible to talk to a
patient until you have tried
Head anatomy
 Injuries to the Head, Neck and Spine
• The scalp with skin, hair etc
• The skull ( a hard inflexible box that encloses
the brain) consists of 29 bones
• Inward the skull are the meninges situated
dura mater a strong fibrous wrapping
arachnoid, a delicate transparent membrane
pia mater, a thin highly vascular membrane and
firmly adherent to the brain
Head injuries
 Bleedings in the skull
• Above the dura - epidural hematom is an
arteriell bleeding
• Under the dura - subdural hematom is a
venous bleeding
 Medulla – lower brainstream and
verterbral column

• Medulla - control centre for regulating

respiration and heart beat

• After medulla - the vertebral column with

7 cervical spines, 12 thoracic spines, 5 lumbar
spines, sacrum and coccyx with fused
vertebrae spines
 Assessment of the Head-Injuried
Patient

• Any patient wiht significant head injury also

has cervical spine injury until proved
otherwise
 General Appearance
• Position in which the patient was found
• Level of consciousness
• Behavior and degree of distress
• Skin condition
• Obvious wounds or deformities
 Glasgow Coma Scale
• Eye opening - speech and pain (score 1-4)

• Best motor response –commands and pain

(score 1-6)

• Verbal response - confused or disoriented

(score 1-5 )
 Reaction Level Scale -85
• Awake – can get contact ?
• Follow movements with the eys
• Can lift arms etc on demand
• Avoid pain
 Examination of the Pupils
• Dilatated pupils
• Constricted pupils
• Unequal pupils
 Signs of increasing intracrainiell
pressure - Summary
• Detoriating level of consciousness
• Hemiplegia (one side pares)
• Vomiting
• Unilateral pupillary reaction
• Rising blood pressure wiht slowing pulse
• Abnormal respiration or no respiration (apne)
 Treatment
• Establish an airway
• Assist breathing
• Administer Oxygen
• Control bleeding
• Cover wounds
• Infusion – saline
• Do not overheat the patient
• Check for neurological and vital signs – chancing state
of consciousness?
• Immobilize the spine (collar)
• Transportation - carefully
 Chest Anatomy
• Esophagus
• Trachea
• Clavicle
• Sternum and ribs
• Heart
• Aorta
• Lung
• Pericardium
• Pleura a smooth slippery membrane and
a similar membrane nest to the lung – pleura space
• Diaphragm
• Liver
• Stomach
 Chest injuries
• Esophageal and trachea injuries
• Pneumothorax
• Hemothorax if blood in the pleura space
• Rib Fractures - flail chest if many ribs are broken
• Pulmonary Contusion
• Diafragmatic and mediastinum injuries
• Aorta injury
• Heart injury
• Liver and spleen can be involved and cause
bleedings
 Treatment
• Check for how the patient can breath in the
best position – maybe half sitting – maybe on
the best side – not injuried
• Assessment – rapid rate? sound? pain? pulse?
• Assist ventilations
• Oxygen
 Abdominal anatomy
• Spleen
• Stomach
• Liver and pancreas
• Diafragm
• Large and small bowel (thin and thick bowel)
• Bladder
• Kidneys
• Bloodvessels – aorta and inferior vena
• For female also reproductive organs
• Pelvis bones
 Treatment
• Check for ABC
• Anticipate vomiting
• Immobilize the spine
• Think of bleeding - not to much of infusion –
open the bloodvessels in abdomen even
more……..
• Check for pain – where and how? – maybe no
medicament against the pain
 Fractures, Dislocations and Sprains
• Fractures - open and closed
• Transversed – greenstick – spiral - oblique –
comminuted – impact spiral
 Signs and Symptoms of Fractures
• Deformity – an unnatural position
• Shortening ex hip fracture
• Swelling – blood or/and edema fluid
• Guarding and loss of use -motion
• Tender to palpation
• Grating or crepitus over the broken bone-end
• Exposed bone ends
• Pain
 To think about
• Always check pulses, strenght and sensation
distal to a musculoskeletal injury

• Treat every severe sprain if it were a fracture

 Symptoms of Disclocations and/or
Sprains
• Pain
• Loss of motion
• Deformity
• Numbness or weakness
• Abscence of distal pulse
 Treatment
• Immobilisation - fixation
• Keep the injuried part of the body high to
avoid more swelling
• Release pain with medicament
• Check circulation and sense of feeling and
touch beyond the injuried part of the body
(foot – hand/fingers)
 Priorities for evacuation
• Priority I thoracic injuries, airway problems, shock
• Priority II stabilized patients in danger of shock,
abdominal trauma, widespread burns, closed head
injury and deteriorating level of cnsciousness
• Priority III patients with spinal cord injuries, eye
injuries, hand injuries, compound fractures or injuries
to large area of muscle
• Priority IV patients with lesser fractures and soft
tissue injuries
• Priority V walking wounded