FPHC consensus statements Flashcards
How does the FPHC consensus statement divide airways burns? (2)
- Supraglottic (nose/oropharynx and larynx) - most common
- Infraglottic
How can infraglottic burns be caused? (5)
Steam inhalation
Aspiration of scalding liquid
Blast injury
Flammable gas under pressure
Aerosolised chemicals
What are the features of infraglottic burns? (5)
- Impaired ciliary activity
- Hypersecretion
- Oedema
- Mucosal ulceration
- Bronchial spasm
What 3 considerations should be made with intubation in patients with airway burns?
- Largest size tube that will be placed (bronchoscopy on ITU)
- Uncut (airway will swell)
- Careful with tube tie
What features have been shown to correlate with need for RSI (FPHC)? (6)
- Full thickness facial burns
- Stridor
- Resp distress
- Swelling on larygnoscopy
- Smoke inhalation
- Singed nasal hairs
When does FPHC recommend using cyanide antidote?
Suspected smoke inhalation AND:
- altered mental status
- CV instability
What 3 categories of burns severity does FPHC recommend using pre-hospital?
< 20%
20-50%
> 50 %
What does FPHC say about water cooling of thermal burns? (3)
- Water < 20 degrees (12 ideal)
- 20 mins
- Not ice water secondary to risk of tissue necrosis
What does FPHC recommend with regards to first aid for chemical burns? (3)
- Treat any chemical burn ASAP regardless of delay to presentation
- Use amphoteric solution as first line
- Irrigate for as long as possible
When does FPHC state fluid resus should be commenced pre-hospital in burns:-
- adults
- paeds
> 20%
What analgesia should be avoided in burns?
NSAIDs if requiring fluid resus
When does FPHC recommend chest escharatotomy?
Circumferential or near circumferential eschar with imprending or established respiratory compromise to to thoraco-abdominal burns
Describe the 3 parts to the FPHC extrication decision tool for non-medical personel
- Can the casualty self extricate
- Is a snatch rescue indicated?
- Deliver quickest appropriate extrication
What is the FPHC recommended first line extrication method?
Self/minimally assisted
What is the acronym USTEP, what is it used for and who recommends it?
FPHC
Non-clinicians for helping self extricate
Understanding (get patient understand)
Support (emotionall)
Try moving (if unable then can’t self extricate)
Egress (clear route out)
Plan - where will they go next (chair/trolley)
Under what circumstances does FPHC state MILS is not needed inside the vehicle?
Fully conscious and no neurology
If patients have neurology what extrication measure does FPHC recommend
Rapid extrication with gentle handling
When does the FPHC recommend using a hard collar in extrication? (2)
- Suspected serious neck injury
or
- GCS <15 + evidence of significant injury to any body compartment
When should a binder be placed during extrication according to FPHC?
After extrication
What does the FPHC consensus statement recommend with respects to airway in pregnancy? (4)
- NP relatively c/i due to increased friability of mucosa in pregnancy
- Use smaller ETT due to swelling
- Use second generation SGA
- Use vertical incision for front of neck as increased tissue oedema seen in pregnancy makes landmarking more challenging
What does FPHC recommend for pregnancy trauma patients with respects to breathing? (2)
- High flow oxygen in all trauma patients
- Thoracostomies/chest drains should be 3rd or 4th IC space
What does FPHC recommend with respects to circulation in pregnant trauma patients? (7)
- Limited reliance on BP as marker of hypovolaemia
- Examination of uterus and external genitalia mandatory in evaluation of haemorrhage
- Tilt/manual displacement recommended at all times for pregnant trauma patients
- IV access above diaphragm
- Early blood products as fluid will exacerbate pre-existing haemodilution that occurs in pregnancy
- TXA
- Pelvic binders
What does FPHC recommend in pregnant patients being resusitated? (2)
- Supine with manual displacement of uterus
- RH within 15mins of witnessed arrest with ongoing CPR
What does FPHC recommend for all pregnant trauma patients in terms of conveyance/destination? (3)
- All trauma patients should be seen in the ED not maternity
- If >20/40 should go to nearest TU with maternitry (if trauma negative) or MTC with maternity (if positive). If <20/40 can go to hospital without maternity
- All MTCs should have co-located obstetrics
In a self ventilating patient with suspected PTX/tension PTX what does FPHC recommend as:
1. First line
2. Second line
3. Third line
- Needle decompressoin 2nd IC space mid clavicular
- 5th IC space mid-axillary line
- Thoracostomy followed up by CD if level 6 practitioner
What does the FPHC say about chest drains pre-hospital in their consensus statement
Should be avoided where possible due to:
- prolongation of on-scene time
- risks of kinking
- blocking or falling out during transfers
- long-term infection risks with non-sterile insertion techniques.
It is accepted that chest
drain insertion will be necessary in some circumstances eg high-altitude aero-medical retrieval.
What is the complication rate of pre-hospital thorocostomy?
10-15%
What does FPHC recommend with respects to abx and thoracostomy?
Should be considered
for pre-hospital thoracostomy, especially in cases of penetrating chest trauma, or with transport times >3 hours
What does FPHC recommend for treatment open PTX? (2)
- Commercial chest seal, vented preferably (3 sided dressing no longer recommended)
- IV abx prophx
What is the FPHC consensus statement on massive HTX? (3)
- If no respiratory compromise then drainage should be delayed until ED
- Where thoracostomy has shown significant haemorrage then a chest drain maybe beneficial to monitor blood loss, however should not significantly impact of scene time.
- Clamping chest drain for exsanguinating chest trauma can be considered, however caution needed as high chance of co-existing PTX which could tension with PPV etc.
What is the FPHC consensus statement recommendations on flail chest? (4)
- Where possible, sit up
- Patient may find holding their ribs helps with pain
- Pain score and suitable analgesia
- No entonox a 1/3 patients with >3 rib #s have PTX as well
What factors associated with ribs #s have been shown to lead to worse outcomes and trigger clinicians to convey to centre with CTS? (8) (FPHC consensus statement)
- age 65 years or more
- three or more rib
fractures - bilateral flail chest
- chronic lung disease
- co-existent underlying lung injury
- anticoagulant use
- BMI >25
- oxygen saturation <90% in the Emergency Department.
What does FPHC consensus statement say about pre-hospital pericardiocentesis? (3)
- No evidence for its use
- Can cause damage
- Unlikely to be able to aspirate clotted blood from needle
What are the 4 things needed for to indicate pre-hospital thoracotomy according to FPHC?
- Stab wounds to the chest or upper abdomen
- Cardiac arrest with loss of vital signs ≤ 15 minutes
- The suspected injury is suitable for temporary repair and control
- A chain of survival exists for definitive management following Resuscitative Thoracotomy
What does the FPHC define exertional heat illness as?
A syndrome associated with:
- raised core temperature
- disordered thermoregulation
- which occurs on a spectrum of severity
- during or immediately after
physical activity
What does FPHC require alongside a raised temperature during or immediately after exercise to diagnose EHI?
Symptoms
What does FPHC define as mild EHI?
core body temperature from
38.5°C to 40°C associated with signs or symptoms of heat illness other
than CNS during or immediately after exercise
What does FPHC define as severe EHI?
A life-threatening condition of:
Disordered thermoregulation
+ central nervous system dysfunction
+ core body temperature above 40°C
during or immediately after physical activity
What are the signs/symptoms of severe EHI? (12)
Temp > 40 degrees + CNS dysfunction (less than A on AVPU) +/-
- Confusion
- Agitation or agression
- Behavioural changes
- Stumbling gait/ataxia
- Seizures
- LOC + coma
- Vomiting
- Urinary/faecal incontinence
- Flushed/pale skin
- Collapse
- Hypotension
- Arrhythmias
What does FPHC recommend with regards to temperature measurement in EHI? (5)
- Core temperature should be measured with flexible rectal probe (rigid can cause injury)
- Oesophageal temp probe acceptable if I+V
- Core body temperature measurement should not be delayed, priority
- Peripheral temprature measurement is unreliable and may lead to false reassurance, not recommended
- Cooling recommended if not able to measure core body temp if EHI suspected until core temp can be measured
What does FPHC state about transfer before cooling in EHI?
Shown increase mortality, transfer should be delayed until cooling
How quickly should we aim to cool patients with EHI?
0.15 degrees C / min
What does FPHC recommend for cooling in EHI?
Cold Water Immersion (CWI) up to neck with continous core temp monitoring
What are the main relative contraindications to cold water immersion in EHI? (2)
- Hypotension
- Arrhythmia
If cold water immersion is c/i or not available in severe EHI what does FPHC recommend?
Shade, strip and spray
What temperature should we aim for in cold water immersion post EHI and why?
38.5 to 39 degrees to prevent hypothermia
How long should patients core temp be measured following cold water immersion ?
30 mins
What should be done if patients become hypothermic post cold water immersion?
Gentle rewarming with coretemp measurement
What patients with EHI should be 1. conveyed and 2. who can be discharged?
- Anyone with severe EHI (will need bloods)
- Mild EHI with resolution of symptoms post cooling wth robust safety netting
How and to what temp should patients with mild EHI be cooled?
- Shade, strip and spray
- 37.5 degrees as low risk of hypothermia post cooling
What does FPHC not recommend in management of EHI in pre-hospital setting? (6)
- Anti-pyretics
- Dantrolene
- Steroids
- Depolarising neuromuscular blockers
- Abx
- IV fluids unless clinically indicated (caution with ? hyponatreamia)
Under what time has tourniquets beens shown to be safe and over what time should they not be removed until hospital)
< 2 hours shown to be safe
> 6 hours leave in place (unlikely in civilian setting) but will need amputation likely and will lead to reperfusion etc.
What are the contraindications (2) for self extrication and what are not? (4)
- an inability to understand or follow instructions and/ or
- injuries or baseline function that prevents standing on at least one leg.
Self-extrication is appropriate for:
1. children who can understand and follow instructions
2. patients who are experiencing neck or back pain
3. patients experiencing soft neurological signs (e.g.non-dermatomal tingling)
4. patients with signs of central cord syndrome.
Following crush syndrome, how much urine should be maintained?
8L/day or 300ml/hr
How does FPHC recommend maintaining diuresis 8L/day?
Mannitol 20% 1-2 mg/kg over first 4 hours, in combination with IVI
Not >200g/day and not if anuric
Which patients does the FPHC consensus statement suggest may not need a binder? (5)
- Mechanism not suggestive of pelvic injury and
- Haemodynamically stable (HR<100, SBP >90)
- GCS >13
- no distracting injury
- no pain in pelvis
What does FPHC consensus statement say about type of pelvic binder used? (2)
- No good evidence for one device over another
- Best evidence currently is for SAM Splint or T-POD device
What is the FPHC consensus statement with regards to femoral fractures and suspected unstable pelvic fractures and haemodynamically unstable patients?
- if traction of legs will delay transfer +/- worsen instability of patient (via pelvic disruption), they should be pulled to length and then tied together at knees and a figure of 8 around ankle
How quickly following injury can crush syndrome develop?
1 hour
What does the FPHC receommend for the fluid management of crush injuries?
2L warmed crystalloid (not Hartmanns) prior to extrication if possible followed by 1.5L/hr following this
What is the FPHC definition of
1. Crush injury
2. Crush syndrome
A crush injury is a direct injury resulting from crush.
Crush syndrome is the systemic manifestation of
muscle cell damage resulting from pressure or crushing
Shock in crush is multifactoral, what are 3 contributing factors?
- Blood loss from injuries
- Shift of fluid out of IV compartment
- Acidosis/low Ca2+/high K+ lead to negative ionotropy
Aside from hyperkalaemia, what is the other common electrolyte imbalance in crush syndrome?
Hypocalcaemia
What role does the FPHC suggest using mannitol for in crush injury?
Diuresis - more in the hospital phase to augment alkaline diuresis
Some evidence it may help avoid fasciotomy in compartment syndrome
What chest seal does the FPHC recommend for open PTX?
Asherman chest seal
