Pre-Hospital Emergency Care Course Safe patient handling Packaging and extrication Last reviewed Dec 2009

Objectives To show packaging equipment available To understand the implications of patient handling on non-compressible bleeding and spinal injuries To understand the difference between routine and rapid extrication To note the value of self-extrication

High index of suspicion! IF YOU DO NOT THINK ABOUT THE POSSIBILITY OF A SPINAL INJURY YOU WILL MISS IT!! <C>AcBCDE Refer participants to check the definitions, incidence data and who should/should not be immobilised in the spinal injury and stabilisation section of the manual.

Recognition Mechanism of injury Pain in neck/spine Pins & needles/numbness in limbs No pain response below level of injury Flaccid limbs Diaphragmatic breathing Neurogenic shock (hypotension with bradycardia) When the mechanism of injury raises the possibility of spinal damage Where there is pain/tenderness in the spine Where there are neurological signs related to spinal injury Where there is an altered level of consciousness, intoxication or distracting injury elsewhere

MILS Do not underestimate the value of manual in-line stabilisation – this can be maintained until patent needs to be packaged for transfer. Similarly, if collar is not right, or cannot be fitted safely in-situ, maintain MILS until safe to apply collar properly.

Immobilisation equipment Equipment available from ambulance – every front line ambulance in Scotland carries a scoop stretcher and vacuum mattress. Collars in Sandpiper Bag to apply IF time while waiting for crew arrival. All these will be shown in the spinal immobilisation station later plus during simulations.

Implications of patient movement Prone patient moves involved in packaging for transport Next 4 slides show impact or rotational moves associated with packaging for transport. Cautions both for non-compressible bleeds as well as spinal injuries. 150 degrees of motion

Rotational shifts using spinal board On Spinal Board 150o 90o Total = 330o At hospital On Spinal Board Using board 90o Grand Total = 510o

Net effect Tongue & secretions fall back & block airway Dislodgement of clot Loss of tamponade Movement at Sacro iliac joint Fall in blood pressure Tongue & secretions fall back & block airway

Rotational shifts using scoop stretcher Left blade in Right blade in 150o 10o On scoop Counter traction Left blade out Right blade out In hospital Scoop reduces rotational moves by 340 degrees!!! Hugely significant. 0o Total pre-hospital = 170o Total = 170o

Extrication device Long board for sliding patients out of difficult places Not for routine patient transport Scoop off long board to vaccuum mattress Long or spinal board should only be used to assist extrication from difficult location.

RCSEd guidance on extrication PLAN A = Routine extrication, patient stable and time to plan. PLAN B - Urgent extrication, concern over patient condition and need for rapid transfer to care. Snatch rescue eg: fire / immediate danger /cardiac arrest Manual mentions Plan A (ie routine) and Plan B (ie emergency) extrications. These are fire service terms – we will cover options for medical inputs.

Transportation Patient & equipment are reassessed before leaving scene Journey < 30 mins. On scoop / board Journey > 30 mins. On vacuum mattress Inform receiving unit of time the casualty was placed on scoop/board if used Specialist transport to spinal unit? Pre-alert A/E unit Important to identify if vacuum mattress is available in your area, all Scottish Ambulance Service A&E vehicles carry one. If not available do not delay transportation to wait for one to be brought to scene. Note length of time patient is on scoop and inform receiving unit. ONLY transport on scoop if total time on this (including arrival and transfer to receiving resus room) is less than 30-45 mins. Very difficult to achieve in rural Scotland!

Spinal injury & extrication Video clips 2 videos to show – one is stable patient and assessed as no significant neck or spine injury and encouraged to self extricate from car - other is unconscious patient requiring rapid side-extrication from car as circulation problems require urgent transport

Summary Assessment and management of chest injuries Packaging equipment available Implications of patient handling on non-compressible bleeding and spinal injuries Routine vs. rapid extrication Relevance of self-extrication