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Surgery and Surgical Procedure

Prehospital retrieval and management

The aim should be for rapid and smooth transfer of patients from the scene of the accident to a hospital that is well equipped and adequately staffed, with trained personnel to deal quickly and efficiently with all of the injuries encountered.

A ‘scoop and run’ policy is best where transfer time to hospital is short. A ‘stay and play’ policy may be required in the face of entrapment but prehospital personnel must be properly trained and equipped (to PHTLS standards, for example). In all cases, attention is first paid to securing an adequate airway. Gloves are worn and a two-finger ‘sweep’ is used to clear solid material from the mouth and pharynx combined with good suction under direct vision to remove fluid and debris. Airway patency is then maintained by chin lift or jaw thrust maneuvers, lifting the mandible forwards and, if appropriate, inserting an airway device (oropharyngeal/nasopharyngeal or endotracheal according to clinical

judgement and expertise available). If unable to open the airway by the above, a surgical cricothyroidotomy may be performed in patients over the age of 12 years by inserting a 6-mm paediatric cuffed tracheostomy tube through the cricothyroid membrane. Under the age of 12 years the cricoid membrane is very narrow and the cricoid cartilage is the only complete ring preventing airway collapse. Under these circumstances, a needle crico­thyroidotomy may buy some time (20 minutes) provided that a means of jet-insufflating oxygen through the needle is available. Proprietary mini-tracheostomy sets should not to be used. These have a very narrow internal diameter and do not allow spontaneous ventilation. They are indicated only in critical care environments for bronchial toilet. Finally, access to the trachea should not be attempted under these conditions — tracheostomy is time-consuming and fraught with danger.

Meanwhile, attention is paid to protecting the cervical spine by the use of a well-fitting semirigid neck brace, sandbags and forehead strapping. Modern spine boards incorporate neck restraint pads and straps, and may be used in lieu of sandbags and forehead strapping.

Other measures include ensuring adequate ventilation and oxygenation, covering and sealing open ‘sucking’ chest wounds, controlling external bleeding by direct pressure and monitoring the neurological status. The ‘AVPU’ method is recommended in the prehospital setting.

Prehospital mini-neurological examination

• A-Alert

• V — Responds to Voice

•  P — Responds to Pain

•  U — Unresponsive

• Pupils — Size and reaction

If there is any obvious long bone fracture of an extremity with gross deformity, the limb should be gently drawn into alignment and a traction splint applied.

Controversy exists regarding the prehospital role in resus­citation by intravenous fluid infusion. Vascular access in a cold, shocked injury victim is often difficult and time-con­suming, and there is emerging evidence that a degree of hypotension (systolic blood pressure 80—85 mmHg) may be safely tolerated (see later). If circumstances dictate that trans­fer time will be prolonged, or when entrapment and diffi­culty in extrication is encountered, then more sophisticated and advanced life-support measures may be instituted with the caveat made at the beginning of this section.


April 5, 2009 - Posted by | Accident and emergency | ,

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