Operational Practice Flashcards
Which agency regulates helicopter operations in Europe?
European Aviation Safety Agency (EASA)
What does the EASA define as a HEMS flight? (4)
A flight:
1. by helicopter
2. operating under a HEMS approval
3. to facilitate emergency medical assistance
4. where immediate and rapid transportation is essential
To be a HEMS flights the EASA states you need to be carrying one of what 3 things?
- Medical personnel
- Medical supplies
- Ill/injured persons or other persons directly involved
If not meeting HEMS criteria what is a AA flight called?
Air ambulance mission
How large should a landing zone be for a helicopter?
Over twice size of discs
What regulates PPE in the UK?
Health and Safety Executive in the PPE at Work Regulations
Describe the JESIP hierarchy of control measures?
ERICPD
Eliminate
Reduce
Isolate
Control
PPE
Discipline
What should be the standard of helmet?
Fire fighting standard
= EN443
What is the European standard for High vis?
EN471
What is the minimum class of garment for working on motorways/dual carriageways?
Class 3
What specifications make a ‘class 3’ garment? (2)
- Mimimum 0.8m2 flourescent background
- Minimum 0.2m2 retro-reflective materials
What should flight suits be made of and what type of fire do they protect from?
- Nomex or Kermel
- Flash fire (4-5 secs flame)
What proportion of major trauma have SCI and of these how many have severe, time critical injuies?
- 0.7%
- 50%
What is the benefit of self extrication?
Shown to reduce movement of cervical and lumbar spine, improved further with a collar
Describe a ‘rapid extrication?’
Lateral extrication via closest apperture (usually door). Rescue board slid into car seat and patient rotated then laid down and pulled up board, MILS ideally
Describe a B post rip
Rear doors opened and cut lower then upper B-post, then entire side of vehicle can pivot on front hinge of A post
What is a ‘roof off extrication’?
Historial gold standard
Roof removed, board placed behind patients back and seat lowered (if poss). Patient then pulled up board with MILS
Slow
What can FRS do to improve access to a vehicle on its side?
Roof fold down:
- upper supporting posts cut
- roof folded down
What 2 things can FRS do to improve access to a vehicle on its roof? (2)
- B-post rip
- Roll back onto wheels
What is a dashboard roll used for?
Footwell entrapment
Describe chain cabling and what it is used for?
Chains to front and rear posts, winch used to apply traction.
Reverses vehicle damage forces associated with frontal collision
How long does chain cabling take?
12.5 mins
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?
- Who recommends it?
1.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)
- Non-clinicans to helpe extricate
- FPHC
.
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 are the components of HAVNOT and what is it used for?
Predicting difficult airway
Hx of difficult airway
Anatomical abnormalities
Visual clues (beard, BMI etc)
Neck immobility
Opening mouth <3cm
Trauma
What acronym is used to predict difficult BVM?
Mask seal difficulty
Obesity, Obstructed airway
Age >55yrs
No teeth
Snorer, Stiff lungs
What acronym is used to predict difficult SAD insertion?
RODS
Restricted mouth opening < 3 fingers
Obstruction at larynyx or below
Distorted airway
Stiff cervical collar, Stiff lungs
What is the acronym SHORT?
Predicting difficult cricothyroidotomy
Surgery, Scars, Short neck
Haematoma
Obesity, Oedema
Radiotx
Trauma, Tumour
What are the sizes of OP airway and who are they used for? (7)
000 - neonate
00 - infant
0 - small child
1 - child
2 - small adult
3 - medium adult
4 - large adult
How are OPAs measured?
Incisors to angle of jaw
What size NPA is used usually for:
1. Men
2. Women
- 7.0
- 6.0
How should NPAs be measured?
Nostril to tragus of ear
Describe the IGel sizes
Why do paediatric patients become bradycardic when SATs drop?
Dominant parasympathetic system
When does DAS recommend using needle cricothyroidotomy?
< 8 years old unless previous ENT experience
How should a needle cricothyroidotomy be performed?
-14 to 16G cannula inserted angled 45 degrees caudally
- syringe attached and when loss of resistance flatten angle of cannula and advance further 2-3mm
- remove needle and attach pre-prepped 3 way tap with all ports open with 02 tubing
- set oxygen to rate L/min (patients age)
- occlude 3 way tap for 1 sec, open for 4 secs, 1:4 (if not completely obstructed should be some passive exhalation via airway)
What blades should be used for:
- pre-term
- term
- 1 year (infant)
- 2 year
- > 2 years
- pre-term = Miller 0
- term = Miller 1
- 1 year (infant) = MAC 1
- 2 year = MAC 2
- > 2 years = MAC2 or 3
How much oxygen Fi02 is delivered via NC?
4% per 1L/min (up to 4L)
When should a NRB be used?
If need Fi02 >50%
How much oxygen does each venturi allow?
Blue = 24 %
White = 28%
Yellow = 35%
Red = 40%
Green = 60%
What are the different oxygen cylinders capacities?
What are the 3 receptor types involved in shock physiology?
- Arterial baroreceptors
- Cardiac C-fibres
- Arterial chemorecptors
Which receptor triggers the baroreceptor reflex?
Arterial baroreceptors
Describe the baroreceptor reflex in shock
- Pressure receptors within aortic arch and carotid sinus that respond to stretch
- decreased volume activates these leading to an increased HR and peripheral vasoconstriction
Where are cardiac c-fibres located and what reflex do they initiate?
- Left ventricle
- Depressor reflex
Describe the Depressor Reflex in shock?
- cardiac c-fibres are mechanorecptors in the LV that respond to excessive cardiac activity in context of hypovolaemia
- leads to bradycardia and peripheral vasodilation
Where are arterial chemoreceptors located?
Carotid and aortic body
Describe arterial chemoreceptors role in shock?
- in carotid and aortic body that responds to acidosis and hypoxia
- increased minute volume and surpresses cardiac c-fibre mediated reflex
- leads to ‘air hunger’ and acts to augment venous return via thoracic pump
Describe the physiology involved in shock associated with blunt trauma
- Baroreceptor and arterial chemoreceptor predominate. Therefore tachycardia and peripheral vasonstriction and increased minute volume
- Tissue injury and pain suppress c-fibres therefore depressor reflex less common
Describe the physiology involved in shock and penetrating trauma
- Major vascular and haemorrhage can occur without significant tissue injury/pain
- At a critical right atrial pressure cardiac c-fibre medicated depressor reflex causes vagal mediated bradycardia and decreased peripheral vasoconstriction.
- Results in drop in cardiac output and worsened shock
- biphasic response
Describe the physiology of shock in arterial injury shock
- Sudden loss of elastic arterial diastolic recoil due to major arterial vascular injury
- decreased arterial diastolic pressure leads to impaired LV coronary pressure and immediate/profound shock
- more common in penetrating trauma
Desrcibe TBI related shock
- Catecholamine surge and sympathetically mediated local noradreanline affects myocardium
- Concurrently increased ventricular afterload, hypoxia, hypercapnia and other shocked sates leads to myocyte injury and acute onset cardiomyopathy
What is in the ‘hateful 8’ signs/symps shock?
- Diaphoresis
- Pallor
- Venous collapse
- Abnormal HR
- Hypotension
- Air hunger
- Decreased ETC02
- Altered mental status
Describe te pre-hospital haemostatic ladder (5 parts)
- Wound dressing
- Direct pressure and elevation
- Indirect pressure
- Haemostatics
- Tourniquets
What are the 2 types of haemostatic gauze and give an example of both?
1.Factor concentrators - Quickclot
2. Mucoadhesive agents - Celox
How do factor concentrator haemostatic gauze work?
Granules absorb water, concentrate coag factors, promotes clotting
How do mucoadhesive haemostatic gauze work?
Chitosan based
Anionic attraction of red cells, increases adherences to wound surface
Where does a proximal tibial IO go in an:
1. adult
2. child
- 1 finger medial to tibial tuberosity
- 1 finger below and 1 finger medial to tibial tuberosity
Where does a distal tibial IO go in an:
1. adult
2. child
- 3 fingers above tip of medial malleolus
- 2 fingers above tip of medical malleolus
Where is a femoral IO placed?
2 fingers above patella just off midline (medially)
When is a femoral IO useful?
Infants
How is resp rate measured using monitoring
Small AC current via ECG lead 1 (adult) or II (paeds) measures change in thoracic impedance
What are the flow rates through each cannula size?
How does a pulse oximeter work?
- measures absorption of red (660nm) and infrared light (940nm) using 2 light emitting diodes
- oxy and deoxy haemoglobin have differing absorptions and the proportion is measured around 50 x / sec
What is the issue with CO poisoning and oximetry?
Most oximeters unable to differentiate between carboxyhaemoglobin and oxyghaemoglobin therefore will interpret patients saturation as incorrectly high
Why do patients with methaemoglobinaemia have low saturations?
Pulse oximeter doesn’t measure methaemoglobin and therefore will show low SATs for given Pa02
What is a normal range for ETC02
4.0-5.7 kPA
Describe the sections of a normal capnography waveform
What values of causes the colormetric capnography to be:
- yellow
- purple
Yellow = ETCO2 >15mmHg
Purple = ETC02 <4mmHg
What size should the optic sheath measure on US?
<5mm when measured 3mm away from optic disc
What does an optic sheath size >6mm suggest?
ICP >20cm H20
Where are the 3 areas of increased risk with HEMS flights and why?
- Enroute (decreased height and visibility restrictions)
- Landing (decreased site and performance restrictions)
- Elevated hospital landing (deck edge strike)
In terms of aviation, which aircraft has right of way?
Aircraft on the right
What should aircrafts do if facing head on head collision?
Avoid collision to right
Under what circumstances to HEMS flights not have priority? (2)
- Aircrafts declaring emergency
- Non powered aircraft
What size landing site are needed:
1. in daylight
2. at night
D = dimension = max length of aircraft with rotors running (from tips of rotor in 12 o’clock to tip of tail blade)
- 2D x 2D
- 2D x 4D
What 4 criteria should be looked for in a landed site?
- Flat
- Clear of debris
- No wires
- < 10 degree slope
What requirements are there of a HEMS TCM? (3)
- Specifically trained
- Must be front left seat facing forward
- Complete EASA regulation compliance very 12 months
What is required for medical passengers to fly? (2)
- Pre flight briefing
- Accompanied by HEMS TCM
What is the responsibility of medical passengers? (4)
- Primary = patient care
- Medical equipment - present and stored correctly
- Gain approval for certain medical equipment from pilot
- Assist with look out
Who decides whether a flight is a HEMS mission? (potentially life/limb threatening)
Medical team, not pilot
What is the cloud base height limit during:
1. Day
2. Night
- 300m (but practically 500ft due to ‘rule 5’)
- 1200m
What is the visibility limit to fly:
1. day
2. night
- 1500m
- > 3000m
Aside from the size requirement, what else is needed to allow a HEMS landing at night?
Landing zone must be lid from ground or helicopter
What is rule 5?
Have to be at least 500m above person/vehicle or structure (can be lower to the ground)
What is the minimum level above person/vehicle/structure HEMS flights need to be at night?
1000m (this is normal aviation rules)
If visibility is <5000m what should we ensure forward visibility is greater than?
Distance travelled in 30 secs
What should be in the medical passenger brief? (8)
- Familiarisation of helicopter type
- Entry/exit under normal and emergency conditions
- Use of specialist medical equipment
- Need for commanders approval prior to use of specialist equipment
- Method of supervision of other medical staff
- Use of intercomm
- Location of fire extinguishers
- CRM
What are the wind limits for HEMS flights? (2)
- 40 knots on rotor starts
- 70 knots in flight
When can HEMS fly in icy conditions?
Can’t fly if ice
What is the TAF?
Terminal Aerodrome Forecast
What is the METAR?
Meteorological Aerodrome Report
For landing sites at night what are the 2 conditions that will allow a landing?
- Pre-surveyed and lit landing sites (either from ground or aircraft)
- Full briefing and identification of site prior to land with 500m recce above scene with NVG
What is performance class 1?
- Able to land or fly away safely in even of engine failure at all stages of flight.
- must be able to clear obstacles safely by 35ft during take/off or landing if engines fail
What is performance class 2?
- Have a limited period of exposure in which safe recovery not assured in event of engine failure.
- aircraft may be damaged but crew uninjured
When is performance class 1 and 2 required respectively?
- Hospitals, pre-surveyed night sites
- HEMs mission landing sites and base
What 3 things are in place to mitigate increased risk of HEMS flying?
- Pilot experience - only HEMS requires experience minimum
- Instrument ratings for all pilot
- Need for TCM/second pilot
What is the law that governs blue light driving?
No specific rule but multiple exemptions in other laws - driver must justify the need for exemption
What Act governs the need for training specifically to use speed exemptions?
2006 Road Safety Act
What are the blue light exemptions? (7)
- Speed limit (police/fire/ambulance only)
- Red lights - treat as give way
- Keep left/rigtht bollards
- Motorway regulations - can use hard shoulder even against direction of traffic
- Stopping in clearway (no stopping zone), entering bus lane or pedestrian zone
- Parking on crossings, double white/yellow lines, parking offside at night, parking footway/central reservation
- Keeping engine running whilst parked
What is not exempt in terms of blue light driving (6)?
- Careless/dangerous driving
- Not stopping if involved in RTC
- No seatbelt
- Ignoring no entry/stop or give way signs
- Ignoring flashing sights at level crossing/bridge/fire station
- Crossing solid lines to overtake
Who can use:
1. blue lights
2. red front light
3. constant blue light
4. green light
5. amber lights
- Emergency vehicles only
- FRS
- Police
- Doctors
- Indicators/reflectors/road clearance/dangerous goods vehicles
How often should warning lights flash on emergency vehicles?
1-4 x / second and spend equal time on/off
What are the EU standards for ambulances?
CEN 1789 EU Standards
What are the different class of ambulances?
A1 = carries single patient and does not have lights/sirens
A2 = Carries 1 or more patients on either stretchers/chairs and may have lights/sirens
B = normal ambulance
C = mobilie intensive care unit
What are the regulations set out by CEN 1789? (12)
- Exterior painted in sulphur yellow (RAL 1016)
- Green/yellow Battenburg markings (Scotland are white not yellow do have the markings)
- Star of life on roof and side: must be >500mm diameter
- Ambulance >100mm height + in capital letters
- 2000L stationary oxygen and 400L portable oxygen
- DC to AC converter
- Needs brake assist (not predictive breaking)
- 3-pin earthed plug socket
- Lockers capable of withstanding 10G force
- Straps capable of withstanding 10G force
- Lights and sirens complying with European regulations
- Offside and rearmost window must be tinted to 5% light transmission
One stretcher preferable but not mandated
Where is the CLEAR acronym used and what does it stand for?
NARU traffic guidelines:
Collision - closed carriage
Lead - establish effective leadership to co-ordinate
Evaluate to ensure proportionate response
Act in partnership, recognising differing priorities
Re-open ASAP
What do the following stand for?
1. DHS
2. VMS
3. ALR
4. LBS 1
- Dynamic hard shoulder (can open to ease congestion)
- Variable message sign (can change as needed)
- All lanes running (no hard shoulder)
- Lane below sign 1 (smart motorway)
Who is responsible to requesting changes to smart motorway signs (VMS)?
First police officer on scene, then incident commander
If unable to access accident via normal flow, what needs to happen to allow reverse access?
- Police/fire or Highways England operational commander has control of head of scene
- Confirmed no vehicles downstream of incident
- RVP will be chosen (usually 1 junction down) where wait until confirmation lane closure +/- escort
At an RTC on motorway who is responsible for safety?
Police/highway England
If not present then fire
At an incident on the motorway where should the following park:
1. Police/HE
2. FRS
3. Ambulance
- 50m behind incident
- 25m behind incident + fend off
- Beyond incident to allow safe loading and protection
What needs to happen for HEMS to land on motorway?
Lanes closed both directions therefore only land when ready to load
How often should distance marker posts be placed and what are they for?
- Every 100m
- For maintenance/emergency purposes and to show nearest phone
Describe a distance marker post
Number with no units = distance from reference datum (e.g city centre)
On motorway has arrow pointing to direction of nearest phone
Describe a driver location sign
What do the following represent in terms of carriageway identifiers?
1. A
2. B
3. C + D
4. J
5. K
6. L
7. M
A - ‘away from London’ (usually, not always
B - ‘back to London’
C + D - service road adjacent to A +B
J - slip road off A
K - slip road onto A
L - slip road off B
M - slip road onto B
What is the global emergency number?
112
What are the initial 3 stages of a 999 call?1.
- Emergency caller
- Phone provider (determines which service)
- Operator Assistance Centre (OAC)
Describe how a call ends up generating a CAD (3)
- Information passed electronically in form of Caller Line Identification (CLI)
- Via system called Enhanced Information Service for Emergency Calls (EISEC)
- Data then automatically appears as incident on dispatchers Computer Aided Dispatch (CAD)
What do the following stand for?
1. CLI
2. EISEC
3. CAD
- Caller Line Identification
- Enhanced Information Service for Emergency Calls
- Computer Aided Dispatch
What is the most common prioritisation systems used in UK?
Advanced Medical Priority Dispatch System (AMPDS)
Describe what AMPDS is and how it works
Advanced Medical Priority Dispatch System
- Structured question/answer logic tree to allocate dispatch priority
- ‘systemised caller interrogation’
What are the 2 advantages and one disadvantage of AMPDS?
- Incorporates pre-arrival first aid instructions
- Each illness/injury given unique code for audit
- Not sensitive for HEMS dispatch which therefore requires additional tier of interrogation
Describe the 4 categories of dispatch and the time target
Cat 1 = life threatening - 7mins avg
Cat 2 = emergency calls - 18mins avg
Cat 3 = urgent calls = <120 mins at least 90% time
Cat 4 = less urgent <180mins at least 90% of time
Describe the ‘fend off’ position?
Safe distance from incident with an angle of 40 degrees into the safest direction for the vehicle to go, wheels can be angled in same direction.
When arriving first on scene in a vehicle, what should be done? (6)
- Park safe distance away
- Leave visible warning lights on
- Leave engine running to prevent flat battery
- Secure responders vehicle
- PPE
- Update control
With respects to HAZCHEM codes (1 number followed by 2 letters) , what does the number mean?
1.
2.
3.
4.
- Coarse water spray
- Fine water spray
- Normal foam (protein based foam that is not alcohol resistant)
- Dry agents, water should not be used/come in contact with substance
If the second character (first letter) of the EAC is:
1. S,T,Y or Z
2. P,R,W, or X
what does it mean?
- normal fire fighting equipment fine
- Needs liquid tight chemical protective clothing (CPC), with breathing apparatus
(Please Remember Wearing Xtra kit)
What does the 3rd character of the EAC code being an ‘E’ mean?
May be a public safety hazard outside the immediate area. People should stay indoors and close windows, ignition sources eliminated and ventilation stopped.
What does ATMISTER mean?
Handover tool:
Age
Time of injury
Mechanism of injury
Injuries
Signs inc. vitals
Treatment given and neede
ETA
Requests
What conditions mean resusitation should not be commenced? (8)
- Decapitation
- Massive IC/cerebral destruction
- Hemicorporectomy
- Decomposition/putrification
- Incinerations (>95% full thickness)
- Hypostasis
- Rigor mortis
- Foetal maceration in newborn
What is the SCREAMER mnemonic?
For scene assessment
Safety
Communicate
Read the wreckage
Everyone accounted for?
Assess casualties
Method of extrication
Evacuation route
Right facility
What colour is the collar of entonox cylinders?
Blue and white
What can cause entonox to seperate into its constituent parts (nitrous oxide and oxygen) and what can be done to reverse it?
- Temp < 6 degrees
- Repeated invert to mix
How much of the arm should a BP cuff be?
40% of mid arm circumference (usually 12.5cm)
Where should a BP cuff be placed?
Level of heart
What are the European regulations for blue lights and what is not allowed?
- Minimum output 120cd during day and 50cd at night, measured at a vertical angle of 0 degrees and a horizontal angle of 360 degrees.
- front and rear facing light bas of 58 inches in length
Individual lights no longer acceptable.
What is the European requirement for how loud a siren should be?
120dB at a distance of 1m from the centre of the front bumper
What is the universally recognised format for the following signs:
1. Hazard warning
2. Mandatory instruction
3. Prohibition sign
4. Exit/Safe condition sign
5. Fire equipment location sign
- Black lettering on yellow background
- White lettering on blue background
- White lettering on red background
- White lettering on green background
- Red sign with white lettering
What are the advantages and disadvantages of the Franco-German vs Anglo-American approach to EMS
Adv: Reduced hospital admissions, can be admitted directly to ward/specialty
Disad: Longer on scene times
What are the immediate HEMS dispatch criteria? (7)
- Ejection from vehicle
- Death of occupant in same vehicle
- Trapped under vehicle (not motorbike)
- Fall from > 2 storeys
- Fall/jump in front of train
- Amputation above ankle/wrist
- Emergency services request
What are the minimum cloud bases for HEMS flights depending on the differing visibilities?
- 300ft with visibility of 3000m
- 400ft with vis of 2000m
- 500 ft with vis 1500m
What is the minimum cloud base and visibility for night HEMS missions?
1200ft cloud base with visibility of 3000m.
What is the definition of:
1. Fog
2.Mist
3. Haze
- Visibility <1000m due to suspension of water droplets
- Visibility 1000m or more and therefore a lower density of waters droplets suspended in the surface layers of the atmosphere
- Suspension of small, dry particles within the air causing an opalescent appearance
What are Instrument Flight Rules?
Allows pilots to navigate using instruments as opposed to vision
(visual flight rules)
What are the 4 legal requirements for a medical passenger?
- Helmet (only legally required for landing)
- Self certification of being fit-to-fly
- Certification in a medical role or completion of HEMS crew member course
- Safety briefing
When can a HEMS flight be reduced to one pilot? (4)
Must be in the day + one of:
- Pilot/TCM required to stay and give assistance to ill/injured persons
- After arriving at operating site, installation of stretcher prevents TCM from occupying front seat
- Medical passenger requires assistance from TCM
What is the minimum rest period for pilots between shifts?
11 hours
How many consecutive days can HEMS pilots work, and then how many mandatory days off must they have?
Up 7 consecutive days, then minimum 2 consecutive days off
How many days off must pilots having in every consecutive 4 weeks?
7
In terms of HEMS pilots rest, what does a single day rest include?
2 nights and 36 hours
Describe the FPHC competency framework (A-H)
A - First aider, certified by non-national organisation
B - First level responder nationally certified and qualified to meet statutory requirements within the workplace (first aider at work)
C - Nationally certificated pre-hospital responder (use of airway
adjuncts & oxygen) eg Community First Responder
D - Nationally certificated non health care professional pre-hospital provider caring for patients as a secondary role eg Police Officers in
Specialist Roles, Fire Service IEC, equivalent UKSAR trained personnel, Enhanced Community First Responder
E - Nationally certificated non health care professional pre-hospital provider caring for patients as a primary role eg UKSAR, some military personnel and specialist certificated police officers and firefighters.
F - Non-registered health care professional eg Ambulance Technician,
CMT1.
G - Registered pre hospital care practitioner
H - Advanced registered pre hospital care practitioner
What is different between level A-B and C-H with regards to the FPHC competency framework?
Levels C-H must operate within a governance structure and CPD
What can a D13 (firearms/tactical) police officer provide in terms of patient care? (8)
= 1 A + 2B + 3C + 2 D/E
- Airway suctioning
- I-Gel with BVM
- Chest seal application
- Pelvic binder
- Tourniquet
- KTD
- Spinal immobilisation
- Penthrox and entonox
When can children who have expected deaths be left in community?
Needs formal care plan and named clinician available - if no care plan should go to ED
When can children suffering unexpected death be left in community?
- Unequivoval evidence of death and evidence of crime scene once ambulance
+ - Police control contacted
+ - Child death detective inspector agrees then can be left at home
What are the conditions that do not require resusitation being commenced? (9)
- Massive cranial/cerebral destruction
- Hemicorporectomy
- Decapitation
- Decomposition/ putrefaction
- Incineration (>95% full thickness burns)
- Hypostasis
- Rigor mortis
- Foetal maceration
- Submersion for >90 mins
How must the UN number be displayed on a vehicle? (2)
- 150mm in height
- On both side and rear of vehicle
What does an orange Hazchem sign without characters or a hazard diaomond indicate?
Dangerous load e.g. multi-loaded tanker of seperately packaged items
What do these signs mean?
Red: Flammability hazards
Blue: Health hazards
Yellow: Instability hazards
White: Special hazards, such as oxidizing chemicals
Top left to bottom right
- Explosive substance
- ?
- Flammable gas
- Flammable solids
- Substances liable to spontaneous combustion
- Miscellaneous dangerous substance
- Infectious substances
- Corrosive substances
- Non-flammable and non toxic compressed gas
- Subtstances flammable when in contact with water
- Radioactive subtances
- Oxidising substances
When accessing using ‘reverse access’ on motorway which lane should be used?
Lane closest to central reservation
What is considered a ‘fast’ road?
40mph or more
What is the exception to normal PPE rules on motorbikes?
Sikhs wearing a turban don’t need to wear a helmet
What are the rules re: riding pillion? (5)
- One pillion passenger per motorbike
- Must sit astride bike, facing forwards with both feet on footrests
- Only if bike designed for pillion passenger
- Cannot carry a pillion if only have provisional license
- No legal age
Who governs paramedics?
Health and Care Professions Council (HCPC)
What are the following non-medical gas cylinder colours representing?
1. Red
2. Orange
3. Blue
4. Yellow
5. Red and Yellow
6. Bright green
7. White
- Propane (v. flammable)
- Propane (Calor specific brand)
- Butane (oxidising substance)
- Chlorine
- Carbon monoxide
- Argon (inert but can affect nervous system)
- Compressed oxygen
What is needed to be able to use blue light exemptions? (3)
- Complete high speed driving course
- Entered High Speed Driving register
- Have assessment every 5 years
What is the Emergency Workers (Obstruction) Act 2006 and who does it cover (5) and who is not covered?
Makes it an offence to obstruct, physically or otherwise, emergency personel whilst they are responding:
- Fire
- Ambulance
- Coastguard
- RLNI
- Personel transporting blood organs
(not police as this is covered in the Police Act 1996)
What are the 4 clinical quality indicators for the ambulance service?
- Outcome from acute STEMI: proportion receiving PPCI within 150mins and the proportion of patients receiving the appropriate care bundle
- Outcome following CVA: Proportion arriving at HASU within 1 hour and proportion receiving appropriate care bundle
- Outcome from OOHCA: ROSC rate
- Outcome from OOHCA: survival to discharge
Who is responsible within the ambulance service of ensuring there is enough provision at public events and minimum impact on core duties?
Emergency Preparedness, Resilience and Response lead
What are the legal car restraint requirements for:
1. < 3yrs
2. 3-12 years or 135cm or less
3. >12 years or >135cm
- Child seats in private vehicles (taxis do not need to provide them, children should not wear seatbelt in this case)
- Child in booster seat in the rear of the vehicle with standard seat belt
- Child can sit in front seat with standard seat belt
How do conducted energy devices (CEDs) lead to neuromuscular incapacitation?
0.1J/pulse via nitrogen metal prongs
What are the common superficial (2) and rare but serious injuries (5) from CEDs?
Common: Retained probes/ superficial burns
Rare: #/dislocation/ VF/ seizure/ miscarriage/ rhabo
What are the indications for ED review following discharge of CEDs? (5)
- Retained probe near large vessel
- Chest pain/palpitations/arrhythmia
- ABD
- Head injury
- Those presenting as ‘drunk’
What current does a defib use and why?
DC because it is less arhythmogenic
What are the component parts of a defib circuit?
2 circuits
- Charging circuit
- Step up transformer
- Inductor
- Capacitor
- Rectifier - Patient circuit
- switch
- inductor
- pads
How does a defibrillator circuit leading to a shock? (5)
2 separate circuits : charging and patient
- Step up transformer increases the standard UK current (240V AC to around 5000V AC)
- This flows through the inductor which produces a magnetic field, storing energy and opposes direction of current.
- A rectifier then converts the AC current to DC by only allowing it to flow in one direction
- This current is stored in a capacitor (2 conducted plates seeparated by an insulator)
- Once the switch is set to discharge current flows through patient
- This current is prolonged by the presence of an inductor on the patient side of the circuit as well
What is the difference between monophasic and biphasic defibs?
Monophasic older - current passes through pads in one direction
Biphasic - second impulse in the opposite direction meaning ca use lower energies.
When does a synchronised shock deliver?
R wave
When should paeds pads be used instead of adult pads?
Patients < 8 yrs or 25kg
What size are adult and paeds defib pads?
Adult = 22cm
Paeds = 12cm
If having to use adult defib pads for a child, what should be done? (2)
AP placement
Dose attenuator (if not available use adult dose)
What size should a BP cuff be? (3)
- Bladder should be 80% of arms circumference
- Bladder should cover 40% of distance between acromiom and olecranon
- Entire cuff should be 20% wider than the diameter of the limb
What are the size (L) of the following:
1. C
2. CD
3. D
4. ZD
5. E
6. HX
7 ZX
- 170
- 460
- 340
- 605
- 680
- 2300
- 3040
What are collar colours of the following medical gases?
1. Oxygen
2. Helium
3. Helium/02 (heliox)
4. Nitrogen
5. Entonox
6. Carbon dioxide
7. Air
- White
- Brown
- Brown and white
- Blue
- Blue and white
- Grey
- Black and white
What is the principle behind pulse oximetry?
Beer-Lambert Law - intensity of light transmitted through a transparent substance decreases as concentration of substance and distance it travels through increases.
Under what value is pulse oximetry unreliable?
< 85%
What affect does hyperbilirubinaemia have on pulse oximetry?
Prevents transmission of light so gives falsely low readings
What is the main c/i to a KTD?
Lower leg or ankle fractures
How far past the foot should the KTD pole be extended?
> 8cm
Apart from C02, what else can change colorimetric devices?
Gastric contents
What colour do colorimetric devices go in the presence of C02?
Yellow - ‘good as gold’
How does waveform capnography work?
- Infrared light absorbed by C02
- Measure in a single chamber made of sapphire (glass doesn’t allow infrared to pass through)
- Photodetector measures how much emitted light is absorbed and calculates C02
How is capnograhy calibrated?
Using air and a known concentration of C02
What is the appoximate difference bewtween ETC02 and PaC02?
1.0 KPa
What are the flow rates for
1. Humeral
2. Tibial
IOs
- 80ml/min
- 15ml/min
Once an IO is felt to go into the medullary space how much should it be advances in adults and paeds
Adult 1-2 cm
Paeds - none
How much of an IO needle should be visible once it hits bone, before drilling?
5mm
How large are IO needles?
15G
How do US probes work?
- 2-15MHz ultrasound waves
- Emited by passing electromagnetic waves through piezoelectric crystals
- Probe switches between transmitter and receiver mode to interpret images (99% receiver mode)
How do US waves lead to different images?
Fluid = black and anechoic/ no sound waves reflected
Dense structures = echogenic and bright
In terms of US what is ‘attenuation’ and ‘scatter’
Attenuation = waves passing through tissues of body lose energy and reduce in amplitude and intensity
Scatter = sound waves hitting air and scattering in all directions
What do factor concentrating haemotatics (Quickclot/Combat Guaze) use and how does it work?
Kaolin - hydrated aluminium silicate crystalline mineral
Activates factor XII
Which haemostatic agent is c//i with shellfish allergy?
None of them
What is the evidence for Heliox use in asthma? (BTS)
None
In cardiac/resp arrest how much 02 should be given? (BTS)
As much as possible
In critically unwell patients how much 02 should be given with COPD and non-COPD, and what are examples of ‘critically unwell? (6) (BTS guidelines)
100% NRB regardless - target SATs should be 94-98% untill ABG
- Major trauma
- Sepsis
- Shock
- Status
- Anaphx
- Major pulmonary haemorrhage
How should 02 be delivering in patients with: (BTS)
1. No risk hypercapnia SATs >85%
2. No risk of hypercarpnia SATS <85%
3. Risk of hypercapnia and SATS <88%
- 2-6L NC or 5-10L simple FM
- 10-15L NRB
- Target SATs with venturi 24-28% or NC 1-2L initially and titrate pending ABG
What conditions do not routinely require 02 if not hypoxic? (4)
MI
Stroke
Pregnancy/obstetric emergenciees
Most poisonings
What are the component parts of a Mapleson C (Waters circuit) ? (3)
1
What must be ensured in order to be able to use a Waters circuit and why is this an issue?
- Needs fresh gas flow rate at least equal to patients peak inspiratory flow to prevent rebreathing (can be >30L/min if unwell)
- Means needs large amounts of oxygen and therefore inappropriate for transfers etc.
What is the size of an adult BVM and the resevoir?
Bag = 1600ml
Resevoir at least same size
In order to provide 100% 02 using BVM what does the flow rate need to be?
At least the minute volume of patient
Why is a BVM not ideal for self ventilating patients and how could this be improved?
- Air inlet valve is one way to allow delivery of oxygen from reservoir but prevents exhaled gas re-entering the bag
- Needs a significant inspiratory pressure to open and if poor seal or poor inspiratory effort this valves may not open leading to air entraining rather than oxygen delivery
Breathing can be augmented by squeezing the bag.
What is the size of a Mapleson F (Ayre’s T piece with Jackson-Rees modification)
500ml
When is a Mapleson F ineffective and why?
Mask ventilated or sponteously breathing patients because it requires oxygen flow rates 2-3 x their MV
What is the universal donor type for FFP?
AB
How often should equipment used for lifting persons/equipment be checked?
Every 6 month
What is the recommended length of CVC?
1. Right IJV
2. Left IJV
3. Right subclavian
4. Left subclavian
5. Femoral
- 15cm
- 20cm
- 20cm
- 24cm
- 24cm
What is a complication of CVC placement with congenital left sided SVC?
SVC drains into coronary sinus leading to increased risk of systemic air embolism
re: FFP3
- What size particles is IT tested for?
- what is the recommended maximum wearing time ?
- what is its filtering efficiency?
- 0.3 micrometers
- 4 hours
- > 95%
When should FFP3 be donned?
Aerosolizing procedures (droplet covered by simple masks)
Describe the 4 LSU device tests
- Checks for occlusion - passes if lights <100mmHg
- Checks vacuum build up efficiency within 3 secs - passes if >300mmHg
- Checks maximum achievable vacuum level within 10 secs - passes >500mmHg
- Checks for leaks in system - passes if lights >450mmHg
How does a heat and moisture exchange (HME) filter work? (3)
- Moisture absorption: As you exhale, the air passes through the HME filter, where the hygroscopic material absorbs the moisture from your breath, causing condensation on the filter’s surface.
- Heat retention: Simultaneously, the filter also traps heat from the exhaled air.
- Release on inhale: When you inhale, the previously captured moisture and heat are released back into the air you breathe in, warming and humidifying it.
How effective are HME filters at filtering bacteria and viral particles and what have they been proved to reduced?
99% effective
Reduce VAPs
How much does an adult HME filter increase dead space?
40ml
What are ambulance service guidelines for when to wear gloves?
If risk of:
- contact with blood/bodily fluids
- sharps/contaminated instruments being used
- likely to be in contact with non-intact skin/mucous membranes
Should be donned immediately before procedure and not left on unecessarily
Where should clean gloves be disposed off?
Clinical waste
What material are clinical gloves usually made out of?
Nitrile (latex free)
Describe level A HAZCHEM PPE
Highest level of respiratory, skin, eye and mucous membrane protecion
- Positive pressure breathing apparatus or self-contained breathing apparatus.
- Fully encapsulated chemical protective suit
- Gloves: inner + outer chemical resistent
- boots; chemical resistant, steel toe with over boots
Describe level B HAZCHEM PPE
Required when highest level of respiratory protection is needed, but a lesser level of skin and eye protection
- minimal level recommended on initial site entries until hazards have been further identified
- Positive pressure breathing apparatus or self-contained breathing apparatus.
- chemical resistant clothing
- gloves, inner and outer, chemical resistant
Describe level C HAZCHEM PPE
Required when type of airborne substance is known, concentration is measured, the criteria for air purifying respirators met and skin/eye exposure unlikely
- Periodic measuring of air must be performed
- Full face mask
- Chemical resistant clothing (coverall including hood)
- Gloves inner and outer, chemical resistant
Describe level D HAZCHEM PPE
Work uniform and used for nuisance contamination only
Coveralls and safety boots only
How do Powered Respiratory Protective Suits (PRPS) work and when can they not be used?
Chemical protective clothing with 2 battery powered filters on rear than draw in air from the outside.
Therefore cannot be used in oxygen poor enviroments
What agents do PRPSs protect from?
Chemical and biological
How do staff know when the battery life is lower inside and PRPS?
Visual and auditory alarm inside the hood
What are the time restrictions on wearing PRPSs? (3)
- Can’t wear > 60mins for operational use
- Additional 15 mins for decon
- Cannot re-don for 60 mins
How are the gas-tight suits used by FRS different to PRPSs?
- Self contained breathing apparatus - no filter
- Can be used in oxygen poor enviroments
What is the recommended time for the FRS gas-tight suits to be worn?
Guidelines:
- 15 mins for deliberate reconnasissance
- additional 30 mins for rescue activities
Describe the EH20 escape hood (5)
- Single use hood to allow non-trained people to escape a suspcted CBRN hazard
- One size fits all
- Gives at least 20 mins protection
- Filter ineffective in smoke filled enviroments
- Can’t be used in oxygen poor environments
What is not covered in the PPE regulations 2002?
Anything covered elsewhere e.g respirators
What are the key points of the PPE regulations of 2002?
(5)
- It must be worn according to the instructions
- It must be visibly examined before use
- It is the employers responsibility to provide/train and ensure appropriate use of PPE
- All PPE must be marked ‘CE’ and the mark must be >5mm
- It must be designed to provide the maximum protection without causing limitation of the chosen activity
What is the name of the footwear requirements?
EN345
What does EN345 state? (7)
Safety footwear must be:
1. Slip resistant
2. Oil/acid resistant
3. Heat resistant sole
4. Water repellent
5. Metatarsal guard
6. Anti-static
7. Toe cap providing minimum 200J protection
With regards powered respirator protective suits (PRPS) what is the maximum time?
1. They should be worn for operational use
2. Time for decontamination
3. Minimum time should not return to PRPS work?
- 60 mins
- 15 mins
- 60 mins
How can electric vehicles be identified?
From 2020 will have green band on number plate
When might an EV be more unstable than a standard car and why?
When on its side because the battery is in the floor and therefore it has a lower centre of gravity
What are the voltages in an EV?
Up to 650V DC
What is the colour of the high voltage cables in an EV?
Orange
In an incident involving an EV what should happen with regards to the high voltage system and what is a good way of confirming this?
High voltage system isolated from chassis and should switch off in event of an incident but can be difficult to know. If airbags have been deployed this is a good indicator that it has been.
Battery fires in EVs are rare, if they occur what is the risk? (3)
- Can lead to a thermal runaway reaction leading to a vapour cloud explosion
- Battery fires can cause a ‘jet like’ directional flame that can release toxic chemicals
- Hydrofluric acid can be generated by the combination of water used to extinguish the fire and hydrogen fluoride gas released from the battery during a thermal event
What are the exclusion zones for the following voltage power pylons?
1. 275kV / 400Kv
2. 132kV
3. 11kV or 33kV
4. Low voltage = 230/400 V
- 7m
- 6m
- 3m
- 1m
How can oxygen deplete enviroments occur in enclosed spaces/building collapse?
- Large amounts of gases released into confined spaces
- Gases with higher densities than oxygen which accumulae in poorly ventilated areas and displace oxygen
- Fire/chemical releases and confined spaces can create asphyxiant hazards in building collapses
With regards to oxygen deficient enviroments, what levels of oxygen concentration lead to:
1. symptoms
2. Severe symptoms
3. Death
- < 17% = poor night vision, SOB and tachycardia
- < 10% = n/v, confusion, LOC
- < 6%
- How large should the collapse zone be around a structure at risk of collapsing?
- Why
- Who determines this?
- 1.5 x height
- In case of 90 degrees collapse (worst case)
- FRS commander
How is working in confined spaces regulated?
Working in Confined Spaces Regulations 1997
How does the Confined Space Regulations 1997 recommend reducing risk? (4)
- Avoid entry when possible:
The primary principle is to avoid entering confined spaces if at all possible, and to perform work from outside where feasible. - Safe system of work: if entry is unavoidable, a detailed safe system of work must be developed and followed, including rescue procedures.
- Rescue plan requirements:
This plan should include details like identifying potential hazards, designated rescue personnel, rescue equipment, communication procedures, and emergency response protocols. - Competent rescue team:
A trained rescue team should be readily available to perform a rescue operation in case of an emergency.
What is the definition of a confined space according to the Health and Safety Executive?
Under these Regulations a ‘confined space’ must have both of the following
defining features:
(a) it must be a space which is substantially (though not always entirely) enclosed;
and
(b) one or more of the specified risks must be present or reasonably foreseeable.
What are the risks laid out by the Working in Confined Spaces Regulations that must be present to be classified as such? (5)
Is there a risk of one or more
of the following?
■ Serious injury due to fire
or explosion
■ Loss of consciousness
arising from increased
body temperature
■ Loss of consciousness or
asphyxiation arising from
gas, fume, vapour, or lack
of oxygen
■ Drowning from an
increase in the level of a
liquid
■ Asphyxiation arising from
a free-flowing solid or
being unable to reach a
respirable environment
due to being trapped by
such a free-flowing solid
What is the minimum space required for safe working with full rescue equipment in an enclosed space?
575mm
How big should a sewer be to be judged as safe to enter?
0.9 high by 0.6 wide
- What are ‘self rescue’ breathing apparatus?
- How long can they be used for?
- Give 2 examples of this equipment
- Carried by the user or stationed inside the confined space, but are only used for
emergency escape. - Short duration (up to 15 minutes).
- (a) the rebreathable type which consists of a tube and mouthpiece (and may also
contain a mask and hood);
(b) the ‘escape set’ which consists of a cylinder-fed positive pressure face mask or hood.
How are respirators regulated?
Control of Substances Hazardous to Health Regulations 2002 (COSHH).
In the case of a shaft containing a ladder or step irons, what is the clear space is recommended between the ladder/steps and the back of the shaft?
900mm
How often should any working platform used for construction work and from which a person could fall more than 2 metres be inspected (3)
■ after assembly in any position;
■ after any event liable to have affected its stability;
■ at intervals not exceeding seven days.
What is the definition of working from height?
Work in any place where, if there were no precautions in place, a person could fall a distance liable to cause personal injury
Under what duration of work does the WFH regulation recommend okay to use a ladder?
30 mins
What does the WFH regulation recommend for safe use of ladders? (7)
- Don’t overreach – make sure your belt buckle (or navel) stays within the stiles
- 1-in-4 rule = ladder should be one space or unit of measurement out for every four spaces or units up (a 75° angle)
- Ladder extends at least 1 metre / three rungs above where you are working
- < 6 m horizontally of any overhead power line
( unless it has been made dead or it is protected with insulation). Use a non-conductive ladder (eg fibreglass or timber) for any electrical work - Maintain three points of contact when climbing and wherever possible at the work position.
- Where you cannot maintain a handhold, other than for a brief period (eg to hold a nail while starting to knock it in, start a screw etc), you will need to take other measures to prevent a fall or mitigate the consequences if one happened
- Secure the ladder
Where does the WFH recommend is safe to place a ladder? (7)
- on firm ground
- on level ground
- Clean, solid surface that are not slippy
- where it will not be struck by vehicles
- where it will not be pushed over by other hazards e.g. doors/ windows,
- where the general public are prevented from using it (use barriers, cones or, as a last resort, a person standing guard at the base)
- where it has been secured
How should a ladder be secured according to the WFH legislation? (4)
- Tie the ladder to a suitable point, making sure both stiles are tied
- Where this is not practical, secure the ladder with an effective ladder stability device
- If this is not possible, securely wedge the ladder (eg wedge the stiles against a wall)
- If you cannot achieve any of these options, foot the ladder. Footing is the last resort
Which regulations cover lifting equipment?
Lifting Operations and Lifting Equipment Regulation (LOLER)
How should a working platform/scaffolding be inspected?
If:
(a)used for construction work; and
(b)from which a person could fall 2 metres or more,
Should be inspected daily befor use and formally every 7 days (and not used in any position that it was not inspected in)
What is the WFH regulation heirarchy of control measures ? (3)
- Avoid Work at Height – Use alternative methods if possible.
- Use Collective Protection – Guardrails, netting, or scaffolding.
- Use Personal Protective Equipment – Harnesses and fall arrest systems.
How high should the guardrails on scaffolding be?
950mm
What is
1. Physical entrapment
2. Medical entrapment
- Require intervention to vehicle/surroundings to extricate
- Would be able to physically leave vehicle immediately, but needs extrication for medical reasons e.g.pain/spinal immobilsation
NB: can be both e.g dashboard trapping fracture legs
In terms of entrapment, what types of injuries and how common is it in:
1. Men
2. Women
- 9.4% = > common head/face/chest/limb
- 15.8% = > common pelvis and spine
How common is SCI in entrapped patients?
< 1%
In the EXIT project which method resulted in the least spinal movement?
Spinal collar and no insructions
Who has overall responsibility at an RTC and who works in the inner and outer cordons?
Police overall in charge and will place an outer cordon
Only FRS and ambulance in inner cordon
What are the six stages of extrication?
- Safety and scene assessment
- Stability and initial access
- Space creation
- Glass management
- Full access
- Immobilisation and extrication
What has been shown to positively (3) and negatively (5) impact on extrication experience?
- Positive communication
- Companionship
- Planned post incident follow up
1, Poor communication
2. Loss of autonomy
3. Unmanaged pain
4. Delay communication with remote family
5. Onlooker use of social media
Describe the 3 stages of escape and rescue from mines set out in the UK Mines Regulations 2014
- Primary - owner must provide self rescuer for each person
- Secondary - provide extra escape provisions including:
- safe havens where can wait in a safe atmosphere before rescue
- changeover facilities where can exchange self-rescuer for fresh one. - Tertiary - provision of mine rescue service for those unable to self rescue
What is the responsbility of mine operators in terms of rescue/safety? (4)
- Rescuing trapped people either themselves or via specialist rescue service (not local authority FRS)
- Escape routes
- Safe havens including ensure 2 separate methods of communication
- Alarms
How does a self rescue device work?
Polluted air drawn through filter with hopcalite + either drying agent or noble metal catalyst. Turns CO into c02 which is safer to breathe in
What is the definition of a quarry according to the Quarries Regulations 1999? (3)
- An excavation made for the purpose of extraction of minerals, being neither a mine nor a well
- Any reclamation site where minerals are being extracted from
- Any disused tip, which is not a mine, and where minerals are being extracted from
What examples of rescue equipment does the Quarries Regulations 1999 outline? (8)
1 Breathing apparatus
2. Rope
3. Ladders - rigid or rope
4. Tripods/winches
5. Tools -pickaxe, crowbar, shovel and cutters
6. Stretchers
7. Buoyancy aids
8. Rescue boats
In a quarry which is the most likely flammable gas to accumulate?
Methane
What level should the flammable gas alarm be set to in a quarry?
If level >25% of their lower limit
What dies the Health & Safety at Work Act (HSWA) 1974 set out in:
1. Section 2
2. Section 3
3. Section 4
- Safe equipment standards and systems of work. Appropriate use and storage of dangerous goods, supervision and training in relation to safety, safe health work environment.
- Avoiding exposing employees or service users to risk
- States that those in control must not endanger staff- facilitating safe entrance and exit plus providing safe equipment and PPE.
Describe the parts of the Working at Height heirachy of control measures:
1. Avoid
2. Prevent
3. Minimuse
- Avoid working at height where possible
- Barriers, MEWPS, harness with short lanyards
- Safety nets, harness, air bags
What does the Purple Guide state about when to act in terms of lightening?
If time between thunder and lightening < 30 secs as this approximates 6 miles away (speed of sound 1mile/5 secs)
Should stay sheltered until 30 mins after last thunder claps
