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J R Army Med Corps 2000; 146: 232-242
ADD ON...PRE HOSPITAL CARE
Equipment for Immediate Medical Care
R Mackenzie, I Greaves, RC Sutcliffe
Introduction
The task of compiling and maintaining
equipment for immediate medical care can
be difficult. Potential clinical challenges
vary from acute medical emergencies to the
management of multiple victims of major
trauma. Whilst some guidance is available
on the broader aspects of equipment
selection (1-4), there is little clear guidance
as to what equipment is most appropriate in
the trauma setting and how it should be
packed. This third article in the pre-hospital
care series reviews some of the principles of
equipment selection and packing and
provides practical advice on the
development of a trauma bag. This is
equally relevant to the provision of medical
cover in the barracks setting and to the
provision of civilian pre-hospital care by
service medical personnel. It should be
noted that the Army is currently reviewing
equipment for pre-hospital care in the
operational setting (Deployable Medical
Modules Review) and that this article
focuses on generic equipment issues. The
equipment required for acute medical
emergencies in general practice is described
elsewhere(5-7).
Maj R Mackenzie PhD,
MRCP, Dip IMC
RCSEd, RAMC
254 (City of
Cambridge) Field
Ambulance (V), 450
Cherry Hinton Road,
Cambridge, CB1 8HQ
Maj I Greaves MRCP,
FFAEM, Dip IMC
RCSEd, DTM&H,
DMCC, RAMC
MDHU Peterborough,
Thorpe Road,
Peterborough, PE3 6DA
Maj RC Sutcliffe MA,
MRCGP, Dip IMC
RCSEd, RAMC
254 (City of
Cambridge) Field
Ambulance (V), 450
Cherry Hinton Road,
Cambridge, CB1 8HQ
Box 1. Factors to be considered
• Who is going to use the equipment ?
CMT, paramedic, doctor, nurse, medical team
• What types of casualty are likely ?
Age group, type of injury, numbers
• Where are they likely to occur ?
Training area, sports field, main road, wilderness
• What conditions can be expected ?
Terrain, environment, day or night
• How long is medical care expected to be provided for ?
1/2 hour, 4 hours, 24 hours
General principles
Before starting to select equipment, it is
important to consider the circumstances in
which it is likely to be used and for whom
the equipment is intended (both in terms of
the casualty and the immediate care
provider) (box 1). Trauma bags are often
assembled with only one seriously injured
casualty in mind. What if there are two or
more? Certain items of equipment may
need to be duplicated and others added if
multiple casualty incidents are likely.
Similarly, most trauma scenarios focus on
adults.
Although
the
emergency
management of children follows the same
basic principles as that of injured adults,
additional equipment will also be needed if
paediatric care is required.
With regard to the type of injury, the
trauma bag for the sports field will have very
different equipment from that used for rifle
ranges, road accident work or cave rescue.
Thus it is important to consider on whom
the equipment is expected to be used and
their potential injuries. The probable
location of any casualties and the terrain
and weather conditions that may be
expected to prevail will also influence
equipment selection. Equipment designed
to be carried across open country will need
to be lighter and more compact than that
which remains in a vehicle. It may be a long
walk to reach the fallen rider or parachutist.
Specialist rescue aids may be required for
road accident, mountain, confined space
and water rescue and each of these
environments poses particular equipment
problems. In addition to the terrain,
environmental hazards such as water and
extremes of heat and cold may influence the
storage and usefulness of some equipment.
Operating in the dark, regardless of the
weather, can be extremely difficult without
good knowledge of the contents of a
carefully packed bag. Even if the most
appropriate equipment is chosen, careless
initial packing or inadequate maintenance
may render the contents of a bag ineffective
in any but the most benign environment. It
is essential that the packaging is so designed
that the practitioner can locate any piece of
equipment by feel in the dark.
A further factor to consider is the level of
intervention expected of anyone who might
need to use the equipment and the
likelihood of them obtaining early
additional medical support. The rapid
availability of a fully equipped paramedic
ambulance will obviously influence
equipment choices. So too will delayed
evacuation or evacuation by other means
such as helicopters. In most circumstances,
additional support will be available well
within 30 minutes but 4 to 12 hours may be
more realistic in mountainous or remote
areas.
The practitioner also needs to be
confident that they will be able to access
and use any particular item of equipment
when indicated. A key principle is that the
equipment should be simple, immediately
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233
Pre Hospital: Equipment for Immediate Medical Care
accessible and, where possible, selfcontained. For example, the practitioner
should be able to progress step wise (if
necessary) through airway management
options without having to rummage
through separate sections of a bag.
Cricothyroidotomy kits and military chest
drain sets are good examples of pre-packed
self-contained equipment packs which
contain most items required to perform the
procedure. Any omitted items (local
anaesthetic, syringe, needle, forceps etc)
should be identified and packed with these
kits.
Box 2. General principles
• Durability
• Flexibility
• Compatibility
• Safety
• Accountability
Having identified the circumstances in
which the equipment is going to be used,
some broad general principles should also
be considered (box 2). The equipment
needs to be durable and robust. It may need
to be packed in crushproof and waterproof
containers rather than water resistant softpacks depending on the circumstances. The
equipment needs to be flexible to the extent
that it can be readily adapted to the range of
incidents that might be expected. Modular
packing systems facilitate flexibility and
may allow practitioners to choose the
modules relevant to the incident (e.g. search
and rescue vs. road accident). Compatibility
refers to the ease with which the equipment
is interchangeable with that used by other
providers such as the ambulance service,
A&E departments or other receiving
medical facilities. Compatibility facilitates
use of equipment by other professionals
who may arrive to offer assistance and aids
re-supply (“one for one” swaps). If the
receiving medical facility is not familiar with
extrication or immobilization equipment,
the casualty may come to further harm
during its removal. Measures to ensure that
the equipment will be used safely are under
emphasised. Safety is ensured by regular
training sessions and the inclusion of an
aide memoire within the equipment sets.
This is especially important if the
equipment is being used infrequently,
contains drugs or may be used for children.
Finally, the responsibility for the
maintenance and checking of the
equipment needs to be made clear, together
with any obligations regarding controlled
drugs or accountable items.
Once all of these issues have been
addressed, a decision on the broad
composition of the equipment can be made.
For the remainder of this article, a generic
trauma bag designed for the resuscitation of
one paediatric or adult casualty will be
Box 3. Categories of equipment
• Protection
• Communications
• A: Airway management
• B: Chest injuries and ventilatory support
• C: Bleeding and circulatory support
• D: Head and spine injuries
• E: Environment and extremity trauma
• Drugs
• Additional equipment
described under several headings (box 3). It
is assumed that further assistance will be
available within 30 minutes and that rapid
evacuation is possible. Although this may
not be representative of the demands faced
by some immediate care providers in the
military setting, the principles of equipment
selection and packing still apply. A good
discussion of the interventions that may be
usefully performed in the tactical
environment is provided by Butler et al
(8,9) and is a valuable reference for those
packing medical equipment for tactical
medical support. A discussion of equipment
for wilderness medicine can be found at the
Wilderness EMS Institute web site
(www.wemsi.org)
and
in
standard
wilderness and mountain rescue texts.
(10,11).
Protection
Protect yourself, protect the casualty and protect
the scene.
These basic principles of immediate care
have equipment implications. It is essential
that all personnel who may routinely be in
contact with potentially infective blood
borne agents are immunised against
hepatitis B and utilise universal precautions
(box 4).
Box 4. Equipment implications of employing
universal precautions
• Protection of existing wounds and the prevention
of puncture wounds, cuts and abrasions
Protective gloves and first aid (self aid)
equipment to protect own wounds
• Simple
protective
measures
to
avoid
contamination with blood or body fluids
Jackets and/or overalls, latex gloves and eye shields
• Control of work surface and equipment
contamination
Clean up material and disinfectant spray
available
• Safe handling and disposal of sharps
Low risk sharps (eg Safelon TM) and sharps
boxes
The most common contributing factor in
injury amongst rescue personnel is lack of
personal protective equipment (PPE). Thus
when working in a rescue environment,
particularly when alongside the civilian
emergency services, appropriate boots,
gloves, helmets, eye protection and high
visibility clothing must be available. The
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R Mackenzie, I Greaves, RC Sutcliffe
234
protective clothing worn should adhere to
the same standards of visibility and safety as
that worn by the emergency services.
Jackets for road accident work must meet
BS-EN 471 class 3 standards. These are
described in detail in the British Association
for Immediate Care (BASICS) equipment
directory (4) (updates available at
www.basics.org.uk) and advice can be
obtained from local Fire and Ambulance
Services.
Wilderness
and
tactical
environments clearly place different
constraints on PPE. Whether the need is for
foul weather protection or motorway traffic
protection, deliberate decisions need to be
taken about PPE and whether it is to be
issued on an individual basis or available for
whoever is expected to provide the
response.
Communications
There
are
two
key
aspects
to
communication equipment. The first
concerns the means by which the
immediate
care
responder
will
communicate with their own control facility
and the other emergency services. It does
not matter what system is in place but it is
essential to ensure that facilities to
communicate are appropriate to the
circumstances and readily available. The
second aspect concerns communicating the
details of injuries and interventions to the
receiving medical facility. This is
particularly important when the providers
are not travelling with the casualty and
drugs have been administered. This
communication is best done using
dedicated ‘patient report forms’ as used by
the civilian ambulance services. Polaroid
photographs may seem impractical but can
Table 1. Equipment for airway management (see text for details)
Equipment
Notes
Nasopharyngeal airways (3 sizes)
Unwrapped and prepared
(tracheal tubes cut to size may be used)
Oropharyngeal airways (4 sizes)
Unwrapped
Suction pump
Prepared for use
Rigid and flexible suction catheters
Sizes appropriate for other airway adjuncts
Wide bore suction tube
Laryngoscope handle
Laryngoscope blades (3 sizes)
Blade type according to experience
Batteries and bulbs
Laryngeal Mask Airway (3 sizes)
50 ml syringe
For tracheal tube and LMA
Anaesthetic drug pack
With syringes etc.
Tracheal tubes
Sizes 3,5 and 7 (mm internal diameter)
as minimum (ready for use but uncut)
Magills forceps
Bougie
Intubation accessories
Tie, lubricating jelly, gauze, catheter
mount etc.
Cricothyroidotomy kit
Needle and surgical
Size 6.0 tracheostomy tube
Packed with scalpel if not with
cricothyroidotomy kit
Jet insufflation apparatus
Prepared for use
communicate an enormous amount of
information about the mechanism of injury.
Airway management
Airway obstruction and hypoxia is a
contributing factor in up to 85% of trauma
deaths (12) and may be the sole cause of
death in patients with transient loss of
consciousness but no other injury(13). The
full range of basic (14) and advanced (15)
airway management equipment should
therefore be available to the immediate care
practitioner (within the limitations of their
training) (table 1).
Airway management equipment is
traditionally packaged as separately
wrapped items. Oropharyngeal and
nasopharyngeal airways do not need to be
sterile. Some argue the same for tracheal
tubes: those required for immediate use
should be packed in such a way that the cuff
is protected from damage but the tube is
immediately to hand. Nasopharyngeal
airways which require a safety pin through
the flange (Portex®) should have this fitted
at the packing stage. Ideally nasopharyngeal
airways with a bigger flange and which do
not require a safety pin (Argyle®) or Linder®)
should be used. An appropriate range of
sizes of both airway adjuncts is needed.
Effective suction is essential to airway
management. A number of hand, foot and
battery operated suction pumps are
available. Whichever is used, the device
should be packed ready to use. Thus it
needs to be packed with a range of sizes of
rigid and flexible suction catheters to match
the variety of airway adjuncts and tracheal
tubes carried. With foot operated pumps, it
may be necessary to pack an extra length of
suction tubing to ensure that it will reach
the casualty (particularly for road
accidents). Suction should always be
performed in a controlled way and wherever
possible under direct vision. A laryngoscope
is an invaluable aid to suction and airway
toilet even if tracheal intubation equipment
is not carried. Whenever laryngoscopes are
carried, appropriate spares (batteries and
bulbs) should also be available. If the
laryngoscope is only required to facilitate
suction then simple plastic disposable types
usually suffice. Direct laryngoscopy is often
better achieved with a metal laryngoscope
and an appropriately sized and shaped
blade. It is usually possible to use a larger
blade on a smaller patient (by limiting
insertion) but the converse is not true. Thus
large, intermediate and small blades should
be carried. Whether to carry straight
(Miller), curved (MacIntosh) or other
specialist blades depends on the
predominant trauma population and the
experience of the providers. Straight blades
are of value in small children only and the
standard curved blades are most commonly
used in adults.
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235
Pre Hospital: Equipment for Immediate Medical Care
Endotracheal intubation is a complex skill
that requires training and practice.
Although it is of particular benefit to
casualties with head or chest injuries (12),
there is evidence that inappropriate
attempts to intubate may also cause
harm.(16) Furthermore, casualties with a
Glasgow Coma Score higher than 3 cannot
usually be intubated without the use of
sedatives and muscle relaxants. Finally, the
intubated patient requires close supervision
and, when anaesthetic agents have been
used, maintenance of anaesthesia. If there is
any doubt about the availability of the skills
and experience required to intubate
casualties at the scene, intubation
equipment should not be included in the
pack.
The Laryngeal Mask Airway (LMA) is an
alternative that is gaining acceptance in prehospital use. (12,15,17) Single use devices
are available and the training is easier to
obtain and assimilate than for tracheal
intubation. Less equipment is required and
the casualty’s level of consciousness does
not need to be as low. Although the LMA
does not provide the same degree of
protection from aspiration as an
endotracheal tube, there seems to be little
evidence of this problem in clinical
practice (12,15,18). LMAs should also be
available for when laryngoscopy is
impossible (due to the position of the
patient) or intubation attempts have failed.
They should be packed close to any
intubation equipment along with a large
syringe to inflate them (40 ml required for
size 5). The Combitube is often
recommended as an alternative. Unlike the
LMA, this device is not routinely used in
anaesthetic practice in the UK and it is
therefore very difficult to obtain any
practical training or experience in its use.
Although the Combitube has been used in
pre-hospital care (15,18), any advantages it
may have over the LMA are probably lost
due to lack of training opportunities. The
relative advantages and disadvantages of
the LMA and Combitube have been well
reviewed (12,18).
If intubation and anaesthetic equipment
is to be provided, then the full range of
equipment should be available, including
Fig 1. Improvised device for insufflation of oxygen via a needle cricothyroidotomy. Oxygen
tubing is secured to one port of a three way tap (with 10 cm extension) by a cable tie. The
extension is connected to the hub of the cannula and the spare port is used to control flow.
difficult airway alternatives. The methods
and drugs chosen will depend to a large
extent on the practitioner’s training and
expertise. The minimum equipment is a
laryngoscope (with appropriate blades and
spares), a range of cuffed and uncuffed
endotracheal tubes, lubricant, a syringe to
inflate the cuff, a method of securing the
tube in place (ties are more secure than
adhesive tape), a stethoscope and a bagvalve-mask device. A gum elastic bougie, a
catheter mount and appropriately sized
Magill’s forceps may also be of particular
value in the pre-hospital environment.
Tracheal tubes should be packed ready for
use but should remain uncut to allow
nasotracheal intubation if necessary.
A later article in the pre-hospital care
series will focus on the specific issues
regarding anaesthesia. There is a wide
range of drugs which may be used to
facilitate intubation. One of the most
commonly used combinations for prehospital rapid sequence induction is
etomidate
and
suxamethonium.
Maintenance of anaesthesia is then
commonly achieved with intravenous bolus
doses of midazolam or propofol and a nondepolarising muscle relaxant such as
atracurium or pancuronium. For the
purpose of the equipment bag, a suitable
container will be required to carry
sufficient quantities of anaesthetic drugs
along with syringes, drawing up needles,
saline or water, syringe caps and some form
of labeling system. Although pre-printed
labels are available, an indelible pen can be
used to write on the syringe barrel. The
importance of storing all of this equipment
in the same place cannot be over
emphasized. In many cases, it is safer if all
drugs are stored separately and collected
prior to departure. It is not advisable to
store drugs in a vehicle if there is any risk of
the vehicle being broken into. The
anaesthetized casualty will need to be
accompanied and the right equipment for
the transfer should be readily available.
Needle and surgical cricothyroidotomy
are the surgical airway techniques which
are routinely taught. Pre-packed sets are
available for both and the decision about
which to carry depends both on the likely
clinical circumstances and the availability
of insufflation apparatus. In adults, needle
cricothyroidotomy should only be seen as a
temporizing measure pending further
attempts at tracheal intubation, progression
to a surgical airway or rapid transfer to
hospital. Surgical cricothyroidotomy is
contra-indicated in small children. Jet
insufflation via a needle cricothyroidotomy
requires high flow oxygen and a syringe,
three way tap and oxygen tubing assembly
or equivalent (figure 1). It should also be
recognised that the minimum tube size that
will allow effective ventilation is 6 mm
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R Mackenzie, I Greaves, RC Sutcliffe
236
Chest injuries and ventilatory
support
Fig 2. Airway management equipment as packed in a
trauma bag. Oropharyngeal and nasopharyngeal airways
are arranged by size and are immediately accessible. LMAs
and intubation equipment is protected within an additional
bag. Not on the picture are the cricothyroidotomy set,
improvised connector and 6.0mm tracheostomy tube. Note
that none of the airway devices remain in their original
packaging.
Table 2. Equipment for chest trauma and ventilatory support (see text for details)
Equipment
Notes
Lightweight oxygen cylinder
With regulator and key if necessary
Non-rebreathing masks
Adult and paediatric sizes
Bag-valve-mask apparatus with reservoir bag
Adult and paediatric sizes
-with disposable bacterial filter if re-usable
Oxygen tubing
Chest drain kit
Including scalpel, introducer, chest drain,
suture and drainage bag.
Pneumothorax kit
Including long cannula, syringe, tape and
flutter valve
Asherman chest seal
Only has 1 gauze swab included
Gauze swabs
Forceps
Unless included in chest drain kit
Hand held sutures
To secure drains
Adhesive tape role
Pulse oximeter / Capnometer
Pocket size (with spare batteries and probes)
therefore cricothyroidotomy kits should be
supplemented with a 6 mm ID cuffed
tracheostomy tube.
Effective management of the airway may
have the greatest impact on mortality and
morbidity of all pre-hospital interventions.
The airway management equipment
therefore needs to be comprehensive and
accessible. It is surprising how little space
this may take (figure 2). The clinical
management of the traumatized airway has
been reviewed elsewhere (19).
The equipment required for managing
chest injuries and providing ventilatory
support includes all the airway management
equipment and the specific equipment
shown in table 2. All casualties should have
high inspired oxygen concentrations
delivered by a system which best meets their
ventilatory pattern and needs. In the
spontaneously breathing patient, a nonrebreathing mask with a reservoir bag and
oxygen flow rate sufficient to meet peak
inspiratory demands will provide maximal
oxygenation. These masks usually come in
adult and paediatric sizes and are packed
with short lengths of oxygen tubing. It may
be necessary to pack an additional length of
spare tubing to increase the reach. Oxygen
cylinders have been until relatively recently
made of steel and restricted in volume by
pressure limitations on the cylinders. It is
traditionally taught that a D size oxygen
cylinder will contain 340 litres of oxygen.
Newer carbon-fibre / aluminium composite
cylinders are stronger and lighter. The same
cylinder size can be pressurized to a higher
degree and will contain more oxygen. These
lightweight cylinders are ideal for prehospital trauma bags.
Casualties
who
require
assisted
ventilation may obtain this via mouth to
mask or bag-valve-mask (BVM) apparatus.
Single use BVMs in a variety of sizes are
now available but are much more expensive
than simply adding a disposable bacterial
filter to a reusable BVM. If oxygen is
available, a reservoir bag and length of
oxygen tubing will also be required.
Otherwise, the BVM can be used without a
reservoir.
The most important pre-hospital
interventions in casualties with thoracic
trauma are ventilation and decompression
of a tension pneumothorax (12,20). Open
chest wounds should be sealed and
flail segments stabilised. Although
decompression of a tension pneumothorax
can be achieved by insertion of an
intravenous cannula in the second
intercostal space, mid-clavicular line, there
are few cannulae which are of sufficient
length to ensure that the pleural cavity is
reached. The minimum length should be
4.5cm on the basis of studies of chest wall
thickness (21). Pre-packed emergency
pneumothorax kits (which are essentially
mini-chest drains) are available which
contain long, wide bore cannulae with skin
fixing devices and one-way flutter valves.
Either tube (22) or open (23) thoracostomy
may be indicated for delayed evacuation or
prolonged entrapment. Both techniques
have been shown to be safe in the prehospital environment and are associated
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237
Pre Hospital: Equipment for Immediate Medical Care
with significant improvements in oxygen
saturation, blood pressure and pulse rate
(20). Tube thoracostomy kits are available
which contain a scalpel, chest drain, flexible
introducer, hand held suture and drainage
bag. Additional local anaesthetic, needles,
syringes, alcohol swabs, gauze, tape and,
perhaps most importantly, forceps may be
regarded as luxuries but will make the
procedure easier and more comfortable for
the patient. Open thoracostomy can only be
performed on ventilated patients. Only a
scalpel and gauze dressing are required.
Open chest wounds can be closed with
traditional three sided dressings using, for
example, the wrapper of a first field dressing
and some tape. More recently however, the
Asherman chest seal has been introduced.
This pack contains a self adhesive disc with
a one way flutter valve and a gauze swab and
is designed simply to be placed over an
open pneumothorax once the skin has been
dried. Little further equipment is required
to manage chest trauma (figure 3).
Capnometry (the analysis of carbon
dioxide in exhaled air) and pulse oximetry
are now used routinely in hospital practice
and have become a basic standard of
monitoring for inter-hospital transfers.
Many advocate this level of monitoring in
pre-hospital care, particularly in the context
of entrapment and pre-hospital anaesthesia
(24). Pocked sized pulse oximeter,
capnometry or combined units are now
available and should certainly be considered
in the
trauma bag if anaesthesia is
contemplated. In the initial assessment of a
casualty, use of the pulse oximeter whilst
assessing the airway and chest will provide a
rapid and accurate assessment of pulse rate
and saturation. Capnometery will provide
confirmation of endotracheal tube
placement and assessment of the adequacy
of ventilation. There are however significant
training and maintenance implications if
these monitoring devices are included in a
trauma bag.
Bleeding and circulatory
support
Fig 3. Contents of chest trauma pack within main trauma bag. Pre-packed emergency
pneumothorax set (containing needle, cannula, syringe, connector, extension, Heimlich flutter
valve and skin cleaning and fixing equipment), chest drain kit (containing scalpel, chest
drain, flexible introducer and drainage bag) and Asherman chest seal. Additional sutures,
forceps, gauze and tape are also packed.
Table 3. Equipment for bleeding and circulatory support (see text for details)
Equipment
Notes
First field dressings
At least three
Wide crepe roller bandage
To use as pressure dressing
Hand held suture
Scalp wounds, securing lines
Sphygmomanometer
Anaeroid
Blood pressure cuff
Arm and thigh
Venous tourniquet
Intravenous cannulae
Preferably with self retracting needles
and side ports
Adhesive tape and dressings
Gauze swabs
To clean blood and allow tape and adhesive
to stick
Cross match sample kit
Including identity bracelet, syringe and
sample bottle
Butterfly cannulae
Cut down kit
Including curved and straight forceps, scalpel,
suture material and gauze / adhesive tape
Intraosseous needle
With three way tap and syringe
Emergency infusion device
One peripheral and one central/femoral
Blood giving set (drip set)
With integral filter
Heavy duty shears
Crystalloid
Hartmann’s or Saline
Table 3 provides a list of equipment
required to control bleeding and support
the circulation. Although there continues to
be extensive debate about the pre-hospital
management of haemorrhage, some aspects
are clear (box 5). Firstly, compressible
haemorrhage must be controlled by
whatever means possible. This usually
applies to limb injuries and direct pressure,
elevation, use of arterial pressure points and
use of an arterial tourniquet may be
required. First field dressings remain ideal
for direct compression. A wide crepe roller
bandage may be used to provide additional
pressure. In bleeding scalp wounds, it is
often effective to place a large hand held
suture through the skin flap. A
sphygmomanometer with thigh and arm
cuffs can be used safely as a tourniquet.
Traction splintage of a femoral shaft
Box 5. Principles of haemorrhage control and
circulatory support
• Control compressible haemorrhage
• Identify non-compressible haemorrhage and
shock and evacuate urgently
• Do not allow cannulation attempts to prolong
scene time
• Cannulate trapped patients or while on route to
medical facility
• Titrate fluid replacement to maintenance of the
radial pulse
• Use crystalloid as fluid replacement
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R Mackenzie, I Greaves, RC Sutcliffe
fracture is possible using compact traction
splints and will reduce bleeding into the
thigh.
Secondly,
non-compressible
haemorrhage (intra-abdominal, intrathoracic or pelvic injuries) must be
identified as soon as possible and
evacuation to a surgical facility expedited.
No time should be wasted at the scene in
securing
intra-venous
access
or
administering fluids. Clearly if the patient is
Fig 4. Intravenous access equipment as packed in a trauma
bag. Two each of the five standard sizes of Safelon® are
immediately accessible along with (from left to right) a
identification wrist band, 10ml syringe, cross match sample
bottle, crepe bandage, packet of gauze, adhesive IV
dressings, venous tourniquet and adult and paediatric elbow
splints. Underneath is a pack containing specialist
intravenous access equipment (see text).
Fig 5. Intravenous access equipment for specialist or difficult access. An intra-osseous needle
is packed along with a 20 ml syringe and a 3 way tap with extension. A venous cut down set
comprises a scalpel, one pair curved forceps, two pairs of straight forceps, and a hand held
suture. Butterfly cannulae, a peripheral emergency infusion device and a long (12cm)
cannula are also included. Gauze and tape complete the kit.
238
trapped or requires intravenous analgesia
(26) then intravenous (IV) access is
required. Finally, profoundly hypotensive
casualties will require volume replacement
regardless of the injury and the current
recommendation is to allow some
hypotension
to
persist
(controlled
hypotension) and provide fluid replacement
sufficient only to maintain the radial pulse
(12,25,27). It may be very difficult to obtain
intravenous access in casualties and a range
of IV access equipment should be available.
Conventional intravenous cannulae with a
side access port for administration of drugs
are normally used. There is however some
evidence that self-retracting cannulae (e.g.
Safelons®) are safer to use in the prehospital environment because of a lower
incidence of needlestick injuries (28,29).
The Faculty of Pre-hospital Care will
shortly issue guidelines on the pre-hospital
management of shock based on a recent
expert consensus meeting.
The debate concerning whether or not to
give IV fluids does not diminish the
importance of having the relevant
equipment immediately to hand if it is
required. Figure 4 shows the IV access
equipment packed in a trauma bag. It
should be noted that there is no
requirement to open additional pouches or
packs. In some cases, innovative techniques
may be required to achieve IV access.
Placing a venous tourniquet around the
upper arm, inserting a fine cannula or
butterfly in a distal vein, and injecting a
small volume of fluid to distend the
proximal veins is often described. Thus
butterfly needles and fine gauge cannulae
are required. Intraosseous infusion may be
necessary in children and an additional
three way tap and 20 ml syringe (20 ml/kg
fluid boluses) should be packed with the
needle. Less commonly, a venous cutdown
at the brachial or long saphenous vein may
be necessary. A scalpel, forceps, suture
material and gauze will be required (figure
5). Similarly, external jugular, femoral or
central venous access may be the only
option and appropriate equipment should
be available. Emergency infusion devices
are pre-packed kits containing a needlecatheter-wire-dilator assembly that are
designed to allow a small ‘search’ needle to
be used to identify the appropriate vein and
a wire to be passed into the vein. The tract
is then dilated and a much larger cannula
(catheter) passed. These infusion devices
are available in a variety of sizes and include
a scalpel. These can also be used for
enlarging existing peripheral venous access
or creating large bore femoral or subclavian
access.
With regard to type of fluid, there is
currently no clear evidence from controlled
trials that resuscitation with colloids
reduces the risk of death compared to
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239
Pre Hospital: Equipment for Immediate Medical Care
crystalloids or that any one colloid solution
is more effective than any other (30,31).
Crystalloids are therefore considered the
most appropriate first line fluid until such
time as clear evidence of benefit from
alternatives emerges. Perhaps the most
appropriate fluid replacement for casualties
who are trapped at the scene and shocked is
blood. Blood transfusion is indicated when
the estimated blood loss is > 20% blood
volume and the expected duration of
entrapment and transfer is likely to exceed
the time required to organise blood (24). It
may take a long time to organise blood at
the scene if arrangements have not been
made in advance with receiving medical
facilities. In practice, blood is only very
rarely available in the pre-hospital
environment. If blood transfusion is an
option, an identification bracelet and the
appropriate transfusion sample bottle
should be packed (generally 10ml without
anticoagulant). Giving sets suitable for
blood transfusion must have an integral
filter. To minimize the risk of inadvertent
transfusion through a giving set without a
filter, it is recommended that all giving sets
packed in the trauma bag are blood giving
sets. Butcher’s hooks make ideal drip stands
and add little extra weight to the bag.
In practical terms, it is often difficult to
gain access to the casualty to assess a limb
injury or place the cannula. Heavy duty
shears are often required to remove clothing
and these should be packed with the IV
access equipment. Splints which hold the
elbow extended (Arm-loc®) are available in
adult and paediatric sizes and are ideal for
the casualty who is confused, agitated or is
going to be moved. They provide a fixed
platform for cannulae in the antecubital
fossae if properly applied. Other means of
protecting IV access once it has been
obtained include adhesive dressings,
adhesive tape, sutures and bandaging. All of
these options should be available.
Head and spine injuries
Primary traumatic brain and spinal cord
injury results from mechanical disruption of
neural tissues either by direct forces
(penetrating
injuries)
or
following
deformity of the skull or spinal canal. While
nothing can be done to reduce the effect of
this primary injury, secondary insults in the
minutes to hours following injury can have
a major effect on mortality and morbidity.
The common causes of this secondary
injury are hypoxia, hypoperfusion and,
particularly for spinal injuries, further
mechanical disruption (32,33). Thus the
principles of immediate care for patients
with head and spine injury, are simply to
maintain the airway, ensure adequate
ventilation and prevent hypotension. The
only additional equipment required which
can be packed into a trauma bag is a semi
rigid
cervical collar to assist with
immobilisation of the cervical spine. A
cervical collar does not adequately
immobilise the cervical spine on its own and
all patients with suspected spinal injuries
should have the entire vertebral column
immobilised. The practical implications of
this require that a deliberate assessment of
the likelihood of spinal injury is performed
and unnecessary immobilisation avoided
(34,35). If spinal injury is considered likely,
the casualty cannot be moved until
additional resources and equipment are
available. Clearly, where there is immediate
risk to life from other injuries or
environmental hazards, the casualty must
be rescued as rapidly as possible and some
risks to the vertebral column and spinal
cord must be accepted.
There are two patterns of semi-rigid
cervical collar, both of which come in a
range of sizes. The two piece collars have a
wider range of sizes if all are carried but can
take up more space. The single piece collars
come in six sizes and are only slightly less
bulky. A recent innovation is the adjustable
single piece cervical collar. This collar can
be adjusted to fit most adults. There is no
difference in the degree of cervical spine
immobilization provided by the different
types of semi-rigid cervical collar. The type
chosen should be compatible with other
emergency services and receiving medical
facilities.
One
piece
collars
are
recommended.
Environment and extremity
trauma
Hypothermia associated with trauma may
increase mortality. Where possible, the
casualty should be protected from the
environment with his or her own clothing.
Additional protection may be obtained by
covering the casualty with plastic sheeting.
Foil blankets do not provide any additional
protection over plastic sheeting. Chemical
warming packs are widely available and may
be of help when placed in the groin and
axillae. Perhaps of greater importance is
administration of warm intravenous fluids.
Warm fluids can usually only be provided if
they have been carried within the clothing
of the immediate care provider or a vehicle
warm box is available. The ambient
temperature of the area where the trauma
bag is stored may be important in this
regard. The back of a Land Rover or an
unheated room is usually inappropriate.
Once fluids have been put up, insulating
devices (some with integral chemical warm
packs) are available to cover both the blood
administration set and the fluid container.
These bulky items will be of particular value
in cold environments, winter months or
prolonged rescue.
The clinical management of limb injuries
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R Mackenzie, I Greaves, RC Sutcliffe
in the pre-hospital environment has been
recently reviewed (36). Fractures and major
soft tissue injuries should be immobilized
before movement if possible. Triangular
bandages take up little space and can be
used to splint upper limb injuries, hold
dressings in place and provide additional
support to improvised lower limb splints.
Flexible Velcro ‘Frac-straps®’ have a similar
use but are more bulky. Webbing utility
straps from the trauma bag or personal load
carrying equipment and rifle slings can all
be used to help immobilize fractures and
package the casualty. The Sam® splint is a
malleable splint which can be applied to
upper or lower limbs and, together with
crepe bandages, slings or straps, makes a
very good pre-hospital splint. One traction
splint should be carried separately. The
Sager® splint is recommended for ease of
packing, compactness, ease of use and its
facility for splinting both legs.
Drugs
In the context of trauma care, the drugs
required at the scene are predominantly
analgesic, sedative and anaesthetic agents.
Pre-hospital analgesia and sedation has
recently been reviewed (26). In essence, the
choice of agents depends entirely on the
likely circumstances (oral vs. intra-muscular
vs. intravenous) and the expertise of the
provider. A simple drug pack should
contain opiate analgesia (morphine or
diamorphine with water), anti-emetic (e.g.
cyclizine) and sedative (midazolam) agents.
Flumazenil and naloxone are mandatory
Table 4. Drugs included in the drug pack (excluding anaesthetic agents)
Adrenaline 1:1000, 1mg/ml, 1 ml prefilled disposable syringe with 25 g needle
Adrenaline 1:10000, 100 mcg/ml, 10 ml prefilled disposable syringe
Adrenaline 1:1000, 1 mg/ml, 5 ml prefilled disposable syringe
Aspirin dispersible 300 mg tablets
Atropine 600 mcg/ml, 1 ml amp
Atropine 300 mcg/ml, 10 ml prefilled disposable syringe
Chlorpheniramine 10 mg amp
Cyclizine 50 mg/ml, 1 ml amp
Diamorphine 10 mg amp
Diazemuls 5 mg/ml, 2 ml amp
Diazepam rectal tubes 2mg/ml, 2.5 ml, (5 mg) tube
Flumazenil 100 mcg/ml, 5 ml amp
Frusemide 10mg/ml, 5 ml amp
GTN aerosol spray 400 mcg / metered dose
Glucagon 1 mg vial with water
Glucose 50% solution in 50 ml prefilled disposable syringe
Hydrocortisone 100 mg vial with 2 ml water
Ketamine 10 mg/ml, 20 ml vial and 50 mg/ml, 10 ml vial
Lignocaine 20 mg/ml, 5 ml prefilled disposable syringe
Midazolam 2mg/ml, 5 ml amp
Naloxone 400 mcg/ml, 1 ml amp
Procyclidine 5 mg/ml, 2 ml amp
Salbutamol aerosol 100 mcg/metered dose (and spacer device)
Sodium bicarbonate 8.4% in 50 ml prefilled disposable syringe
Terbutaline 500 mcg/ml, 1 ml amp
Water for injections 5 ml amp
240
whenever benzodiazepines and opiates may
be used.
In the context of road traffic accidents in
civilian practice, four medical conditions
are commonly seen either as a cause or
consequence of the accident (37). The
commonest is ischaemic heart disease
which ranges from an episode of angina
(treated with glyceryl trinitrate spray) to
myocardial infarction leading to primary
cardiac arrest (treated with aspirin and
thrombolytics
or
adrenaline
and
defibrillation). The treatment of primary
cardiac arrest is very different from that of
cardiac arrest in relation to trauma. A
decision should be taken about whether or
not to provide for the management of
cardiac arrest within a trauma bag. The
authors carry a separate bag, which is
packed with the defibrillator in their civilian
pre-hospital work. Other common medical
conditions are hypoglycaemia and seizures
in the context of epilepsy, febrile
convulsions or following head injury. These
conditions are easily treated with simple
and safe drugs. The only other medical
condition commonly seen in the context of
road accident work in the authors
experience is asthma and allergy. The
motorcyclist who slides through a field of
oil-seed rape and presents with severe
anaphylaxis is perhaps the most dramatic
example. The asthmatic child whose asthma
is brought on by the shock of a minor
accident is perhaps more common. In all of
these cases, simple drugs can be carried to
effectively initiate management outside
hospital. An example of a pre-hospital drug
pack is given in table 4. There are clearly
legal and administrative difficulties
associated with the maintenance and
security of drug packs and these should be
taken into account.
When packing the drugs, the same
principles apply with regard to the
anaesthetic agents described above. All
necessary syringes, needles, syringe caps,
diluents and labels should be available in
the same pack. An aide memoire with drug
dosage and administration instructions for
each drug carried should also be available
within the pack. This is particularly
important for the care of children. A tape or
chart which relates length to body weight
and drug doses should be provided if
children are to be treated.
Additional equipment
There is clearly a broad range of additional
equipment that could be put to good use in
the pre-hospital environment. Some of this
is shown in figure 6. However, the
practicalities of maintenance, storage and
carrying this equipment should be taken
into account at the planning stage. Once
again, the need to tailor the trauma bag to
the likely circumstances in which it will be
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241
Pre Hospital: Equipment for Immediate Medical Care
Fig 6. Additional items carried by the authors. The trauma bag is in the background.
Additional items shown here are a multi-modality monitor (pulse oximetry, non-invasive
blood pressure recording, capnography and ECG), a Sager® traction splint, a Kendrick®
Extrication Device, a portable ventilator, a Samalite® emergency lighting unit and a fluid
warming bag.
used is essential. In most cases, the
equipment described above will more than
adequately cater for the needs of the
casualty and additional resources will often
be available within a relatively short time.
Less glamorous additional items of
equipment which should however be
considered are sweets or chocolate bars for
the provider, hand wipes, clinical waste bags
and a sharps container.
Training and administration
Once equipment has been selected, a cycle
of packing, experimentation and re-packing
should be commenced with simulated
casualties. The simulation need not be
sophisticated but should involve removing
the relevant equipment from the bag whilst
under pressure (rather than going through a
mental or written checklist). This
remarkably simple exercise will reveal
problems
associated
with
illogical
arrangement of equipment or over-packing
(the bag has to be emptied on to the
roadside to find one item). One of the
authors struggled with a trauma rucksack
designed by a leading teaching hospital
which failed because access to equipment
packed first was only possible by removing
everything else it contained. Simulations
should include step wise progression
through airway management options, rapid
application of oxygen and ventilatory
support, haemorrhage control and
intravenous access and management of
fractures, pain, agitation and medical
emergencies associated with trauma.
Once the packing has been completed, an
equipment checking policy and checklist
must be developed. The responsibility for
checking the equipment should lie with
those who use it. This ensures that the
immediate care practitioners remain
familiar with the equipment. Similarly, the
responsibility for cleaning and maintaining
equipment should also rest with those who
are expected to use it.
There are considerable difficulties in
maintaining sterility of equipment packed
for immediate use and, where possible,
disposable (single use) items should be
selected. There are cost implications
associated with single use items and in some
cases, it may be cheaper to consider reusable items such as laryngoscopes, pulse
oximeter probes, splints and bag-valvemask devices. A reusable bag-valve-mask
can be combined with cheap disposable
bacterial filters and a simple disinfection
routine. Before attempting any disinfection,
all equipment should be thoroughly cleaned
with warm soapy water (while wearing
household gloves). The most practical way
to rapidly disinfect equipment is to use a
fresh aqueous solution of sodium
hypochlorite (bleach) in a concentration of
1:10000 parts per million available
chlorine. This corresponds to a 1:10
dilution of household bleach but it should
be emphasised that the strengths of
individual proprietary brands of bleach may
differ. Where possible, advice should be
sought from local hospitals or other medical
facilities which disinfect and sterilise
equipment.
Summary
The equipment lists provided in this article
are not intended to be proscriptive or
definitive. They are simply an illustration of
the logical application of equipment selection
and packing principles according to the likely
needs of the casualty. Although trained
personnel with relatively little equipment can
perform simple interventions, optimal care
requires some advanced techniques and
good quality comprehensive equipment.
Such equipment is available for pre-hospital
use. Regardless of what equipment is packed,
the immediate care practitioner must
understand the circumstances in which the
equipment is likely to be used and tailor it to
the likely needs of the casualty.
Acknowledgements
The Mid Anglia General Practitioner
Accident Service (MAGPAS) provided the
equipment shown in figures 2 to 6.
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Equipment for Immediate Medical Care
R Mackenzie, I Greaves and RC Sutcliffe
J R Army Med Corps 2000 146: 232-242
doi: 10.1136/jramc-146-03-15
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