Week 1

Context

"ABC has become established as the ubiquitous emergency care paradigm, reflected across the spectrum of advanced life support programmes. Military practitioners have been intuitively uncomfortable with this, as experience and evidence indicate that external peripheral haemorrhage is the leading cause of combat casualty death. In the UK military, ABC has now been replaced by <C>ABC, where <C> stands for catastrophic haemorrhage" (Hodgetts et al., 2006). If 40 % or more of circulating blood volume is lost then death will occur if haemorrhage is not recognised and treated promptly. Immediate recognition of the type of bleed is essential. Stemming the bleeding in catastrophic haemorrhage is the first priority along with airway management. The PLATINUM ten minutes – ie. what you do in the first 10 minutes following catastrophic blood loss is key to survival. The ABCDE assessment is modified in this situation to be <C>ABCDE.

Content

From military to civilian practice

Your role on scene

The aim of first aid is to:

Preserve life
Prevent patient deterioration
Promote recovery (www.sja.org.uk)

Scene safety is important, look for danger to yourself and others. Exclude cardiac or respiratory arrest using Resuscitation Council guidelines (2015) or as per SJA guidance.Once danger has been excluded proceed as follows:

Airway with cervical spine (C spine) control and oxygenation . Now think - <C>= Catastrophic haemorrhage
Breathing and ventilation
Circulation and shock management
Disability due to neurological deterioration
Exposure and examination

First aid measures in haemorrhage

Your priority is to identify the source of bleeding and stem the bleeding until skilled help is available.

Assess
Elevate
Apply direct pressure and apply dressings. Apply two dressings , if seeping through, remove and reassess wound. Re apply dressing.
Tourniquet ( a skilled practitioner on scene may apply a tourniquet to stem the bleeding).

Professional First Responders

"Effective treatment of haemorrhage in the pre-hospital phase of care is dependent on rapid identification of severe bleeding, direct anatomical control of vascular injury, haemostatic resuscitation and expedient transfer to hospital. Tourniquets and topical haemostats are important adjuncts for the control of junctional or extremity injuries and augmentation of in vivo clotting processes. Prehospital thoracotomy (PHT) is a life-saving and established intervention for cardiac tamponade and pre-hospital use of resuscitative endovascular balloon occlusion of the aorta (REBOA) may provide additional treatment options to control major torso haemorrhage. Replacement of oxygen-carrying capacity with red blood cells (RBC), haemostatic resuscitation with fibrinogen supplementation and treatment of fibrinolysis with tranexamic acid (TXA) are likely to prove important therapeutic agents in the prehospital treatment of haemorrhage" Davenport, 2014).

Airway

THINK NO AIRWAY, NO PATIENT

What is your initial impression of the patient ?
Do they answers your questions ?
This can tell you a lot about a persons airway patency
Head tilt, chin lift to open airway if occluded . EXCEPT in trauma , use jaw thrust method
Use airway adjuncts if your role permits. If airway secure move on.
What does the patient look like ?
Flushed, sweating, cold, clammy – all are indications of ill health.

Breathing

If they are breathing, what does it look like ? Are they struggling to breath, are they asthmatic or have COPD ?
Apply SpO₂ probe if you role allows and give O₂ as per BTS guidelines (2017).
If breathing is ok and patient is awake – use AMPLE to ascertain :

Allergies
Medication
Previous Medical History
Last ate/ drank
Event history

Circulation

Restoring and maintaining circulation
Look for pallor
Cold, clammy skin
Changes in breathing – fast
Pulse – fast , weak
Yawning or sighing
Confusion
Loss of consciousness (in extreme cases)
Stop bleeding and await advice of further interventions

Disability assessment (ACVPU)

After establishing ABC, move to assess patient response using AVPU, Is your patient:

Alert
Vocal
C - is there new confusion present ?
Pain
Unresponsive ?
Is there neurological compromise

Look for causes of unconsciousness (FISHAPED)

Faint
Infantile convulsion
Stroke
Heart attack ( myocardial infarction)
Shock
Head injury
Asphyxia
Poison – drug OD
Epilepsy
Diabetes

Identifying the cause of unconsciousness will assist you in determining the treatment of the patient.

Exposure

Undress the patient as appropriate but do not move them to do this.
Examine for wounds and treat as appropriate
Await skilled help

References and Further Reading

British Thoracic Society guidelines 2017 Emergency oxygen use in adults available at - https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/

British Association of immediate care http://www.basics.org.uk/

DoH (2005) Building the evidence base in pre‑hospital urgent and emergency care http://www.sheffield.ac.uk/polopoly_fs/1.43655!/file/Evidence-base.pdf

(The Department of Health’s (DoH’s) 2005 review Taking Healthcare to the Patient: Transforming NHS Ambulance Services highlighted the fact that there are gaps in the evidence base in the pre-hospital urgent and emergency care sector, and that this is therefore an area where there is good potential for future research. Thus the ‘Building the evidence base in pre‑hospital urgent and emergency care ‘ report was initiated by DoH and conducted by Sheffield University. You may find it useful to explore the report findings.)

Davenport, R. (2014) Haemorrhage control of the pre-hospital trauma patient. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2014, 22(Suppl 1):A4 doi:10.1186/1757-7241-22-S1-A4

Hodgetts, T. J., Mahoney, P. F., Russell, M. Q., & Byers, M. (2006). ABC to <C>ABC: redefining the military trauma paradigm. Emergency Medicine Journal, 23(10), 745–746

Resuscitation Council Guidelines 2015 www.resus.org.uk

St John Ambulance www.sja.org.uk