European journal of emergency medicine : official journal of the European Society for Emergency Medicine
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Management of the trapped casualty is a specialized area of prehospital care. It requires close cooperation between all the emergency services. ⋯ A variety of immobilization equipment is available, different equipment being suitable to different situations. The prehospital anaesthetist needs to understand the influence this equipment has on airway management and subsequent anaesthesia.
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Previous studies on prehospital care are mostly hampered by a large number of less-urgent missions and lack of utilization of the possibilities which blur the effect of an advanced medical service. The current analysis of the most aggressive trauma care on-scene concludes that largely all vital stabilization can be carried out prehospitally, except performing an X-ray (with its possible consequences) and an operation. ⋯ In this development, the principles in prehospital care often exceeds what is actually offered in the hospitals' emergency rooms. Since the majority of advanced prehospital methods depends on comparatively safe anaesthesia and analgesia techniques, the particular responsibility for anaesthetists in this field is stressed.
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There is substantial evidence that with better investment of human and capital resources, better evacuation procedures, and more timely delivery of trauma victims to trauma centres, that mortality and morbidity from trauma will be reduced. The integration of these advances in care, as well as the need to avoid mistakes, requires sound decisions. Thankfully, a clear consensus of the priorities in assessment and intervention is available to guide caregivers as they make these decisions. Repeated examination of the patient and concerted use of these priorities, together with data collection to monitor their use will benefit patients.
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Prehospital airway obstruction is common following traumatic injury. Airway management of these patients is difficult in the prehospital setting, particularly because those providing care are often not trained in the skills necessary for endotracheal intubation. As a result, a number of alternative devices are available for airway maintenance. ⋯ The pharyngotracheal lumen airway and Combitube are both more difficult to use than the laryngeal mask airway and risk inflating the stomach if the devices are incorrectly used. Cricothyroidotomy is associated with serious complications but is only used where there is no other option. As with other techniques, it requires regular training in its use.
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The need to consider the problem of acute toxic injury in the prehospital context emphasized by the recent use of highly toxic agents of warfare in terrorist attacks. Toxic agents differ widely in their nature but may be considered to have four distinct properties: toxicity, latency, persistency and transmissibility. Toxicity and latency determine the onset and pathophysiology of the poisoning and therefore the clinical management. ⋯ This approach, however, although essential for the safety of medical responders may not be in the best interests of the patient who may be in a life-threatening situation within a contaminated zone (CONZONE). Toxic injury may require more rapid help than traumatic injury; moreover, traumatic and toxic injury may co-exist, as in the case of explosion with toxic emission. The special skills required are defined in the TOXALS programme and must now become a standard part of the training and practice of prehospital care medical care.