Preserving the Basics of Life
Put very simply, a lack of breath and/or a lack of blood are two of the biggest contributing factors in patients not surviving road traffic collisions. With this in mind then, it is immediately obvious that in both cases, time is critical.
Over the next two blogs I am going to focus on these issues and give guidance on what operational rescuers can do to expedite their access to patients and identify injuries that affect breathing and cause bleeding. It must be remembered that any medical interventions must be performed in line with your local protocols, training and equipment. I am conscious that across the world there is a large variation in knowledge, skills and training for technical rescuers (especially when it comes to the medical aspects of rescue), but it is my belief that all persons who are expected to attend such incidents must be able to identify and manage an airway problem and have the ability to suppress bleeding.
Kinematics and Initial Assessment
Before we even get eyes on our patient we must remember kinematics. What has happened and at what speed? Has there been rapid deceleration?
The initial assessment of your patient is often carried out from outside the vehicle, through glass and as a consequence, it is often difficult to see, hear and feel your patient. It is very often not until the vehicle is stabilised that we can gain access and perform a full visual, tactile and audible assessment.
The Airway and Breathing - What to Look For
If you look at, listen to and feel your own breathing mechanism this is the baseline norm (well at least it should be if you are uninjured and healthy). Your chest rises and falls symmetrically approximately 12 times per minute. Your breathing will likely be silent (or close to) with nothing preventing flow in your airway. Your normal breathing is allowing your body to take in and absorb oxygen into the bloodstream. A failure of this mechanism will lead to hypoxia.
Your patient will likely be time critical if there is any deviation from this, i.e.:
- Any unequal rise and fall of the chest (maybe one sided)
- Any noise from the nose/throat that sounds like snoring or rattling
- Rapid breathing at >20 breaths per minute or
- Slow breathing at <8 per minute
Can you identify and deal with the above symptoms if you arrive on scene first?
Bleeding - What to Look For/Suspect
Massive external blood loss is obvious to anyone without medical training; we have all seen Hollywood movies. An external bleed, e.g. a severing of the main femoral artery in the leg, can bleed prove fatal in minutes. In the context of road traffic collisions however, whilst external bleeding may be instantly identifiable, internal bleeding is not. The body has an average of 5 litres of blood volume and any reduction in this has serious and potentially lethal consequences if not identified and dealt with.
As technical rescuers it is very difficult to identify internal bleeding but it is important to know that;
- Blunt trauma to the chest and abdomen can cause internal bleeding e.g. patient striking the steering wheel
- A broken leg (femur) can cause significant blood loss (more than 1 litre). This means that breaking both legs (not uncommon in RTC’s) can lead to the loss of nearly half the body’s blood volume
- A broken pelvis (not uncommon in RTC’s) can lead to the internal loss of the patients full blood volume
Can you identify and deal with the above symptoms if you arrive on scene first?
Conclusion
This blog asks more questions than it answers but being prescriptive about how you deal with medical aspects of extrication is not possible due to the diverse skills around the world. I do believe that technical rescuers must have the ability to immediately recognise and deal with matters affecting airway, breathing and circulation. Whilst many patients inside a vehicle may have very complicated life threatening injuries, your identification of their inability to breath or their rapidly reducing blood volume and knowing what you can do, means that you are immediately improving their chances of survival. Even if you do not have the clinical skills to intervene, you do, as technical rescuers, have the ability to extricate in a more timely manner if you better understand the patient's condition.
As ever, I welcome your comments.
Ian Dunbar