Chapter 33. Overview of trauma resuscitation
On arrival at an accident, identify yourself to the other emergency services
Safety
The first priority at all times is to be safe: are you safe, is the scene safe, is the casualty safe? It is important to remember that the Fire service has overall responsibility for the safety of an accident scene.
Safety – self, scene, casualty
Assessment
The first role of the paramedic, particularly if the Ambulance service is the first emergency responder to arrive, is a brief assessment of the scene:
• Safety
• Hazards
• Casualties – numbers
• Mechanisms of injury
• Emergency services – present and required.
Communication
Report to ambulance control your arrival (if this is not automatic) and the situation as soon as you have made your assessment.
Patient management
The first and most important part of the management of any trauma victim is the primary survey. This must be performed rapidly, carefully and in a standard manner; it is the basis of all good trauma care.
Primary survey = identification of life threatening problems + treatment
On approaching the patient, an introduction is essential (and good manners), as is an explanation of what is about to happen.
The primary survey
<C> – Catastrophic haemorrhage must be addressed if present
A – Airway with cervical spine control
B – Breathing with ventilation
C – Circulation with control of overt haemorrhage
D – Disability with neurological assessment
E – Exposure and environment
Management of catastrophic haemorrhage
Obvious heavy external bleeding should be immediately controlled with direct pressure and elevation, pressure dressings, pressure point control and if necessary a tourniquet or haemostatic dressing.
Airway with cervical spine control
Maintain in-line cervical stabilisation from the outset.
If the patient is breathing quietly and comfortably, no other action may be necessary other than to apply oxygen at 12–15 L/min via a face mask with reservoir.
If the patient can speak, however incoherently, it means that the airway is clear and the patient is breathing; otherwise the first step is to assess the airway.
If the airway is at risk, either the insertion of an airway (nasopharyngeal or oropharyngeal) or putting the patient in the recovery position should be considered (remembering the possibility of a cervical spine injury).
If the airway appears obstructed or partially obstructed, any obvious removable obstruction should be removed digitally or by suction and simple airway manoeuvres should applied. These are chin lift and jaw thrust.
All trauma victims require high-flow oxygen
The airway takes precedence over the cervical spine and if it is absolutely necessary to compromise the cervical spine (e.g. by performing a head tilt) in order to achieve a patent protected airway, then this must be done.
Airway takes precedence over cervical spine
1. Airway clearance – manual and aspiration
2. Manual airway opening manoeuvres:
• Chin lift
• Jaw thrust
3. Oropharyngeal airway
4. Nasopharyngeal airway
5. Oral tracheal intubation
6. Cricothyroid ventilation.
Breathing with ventilation
When – and only when – the airway is patent and protected, it is possible to move on to the assessment of breathing. Assessment of breathing begins with the neck, look for:
• Tracheal shift
• Wounds
• Emphysema (surgical)
• Laryngeal crepitus
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