Medicine In Remote Areas MIRA Manual

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COURSE MATERIAL

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CONTENTS
4
INITIAL
ASSESSMENT
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MANAGEMENT
4
CONTENTS
CHAPTER 1 INITIAL ASSESSMENT AND MANAGEMENT Page 6
CHAPTER 2 MECHANISM OF INJURY Page 10
CHAPTER 3 AIRWAY Page 15
CHAPTER 4 BREATHING AND CHEST INJURIES Page 25
CHAPTER 5 CIRCULATION AND HAEMORRHAGE CONTROL Page 36
CHAPTER 6 BURNS Page 50
CHAPTER 7 ABDOMINAL AND PELVIC TRAUMA Page 58
CHAPTER 8 HEAD INJURIES Page 65
CHAPTER 9 SPINAL INJURIES Page 73
CHAPTER 10 EXTREMITY TRAUMA Page 81
CHAPTER 11 ENVIRONMENTAL INJURIES Page 90
CHAPTER 12 CASUALTY CENTRED RESCUE Page 102
CHAPTER 13 PROLONGED FIELD CARE Page 109
CHAPTER 14 MAJOR INCIDENT MEDICAL MANAGEMENT Page 112
CHAPTER 15 DRUG CLASSIFICATION AND AND DRUG ADMINISTRATION Page 117
CHAPTER 16 ANALGESIA AND PAIN MANAGEMENT Page 120
CHAPTER 17 ANTIBIOTICS AND INFECTION Page 128
CHAPTER 18 ANATOMICAL TERMINOLOGY Page 132
SUGGESTED MEDICAL EQUIPMENT LIST Page 144

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Patient care is stressful even in a good working environment. In a remote or hostile environment, conditions are far
from ideal. It may be dark and uncomfortable, noisy, wet and cold; it will certainly be dangerous and you may be tired
and hungry.
When dealing with casualties you must consider the phases of management:
• Approach – Ensure scene safety and call for back-up
• Primary survey - Identify life-threatening problems
• Resuscitation - Deal with these problems
• Secondary survey - Top-to-toe examination
• Prolonged field care – After the casualty is stable and before evacuation
• Definitive care - Specific management
Approach
As the potential first responder on the scene, it is essential that you take a systematic approach to the incident. The
approach to the incident should always ensure the safety of the rescuer first, “dead heros can’t save lives”, “only fools
rush in”etc, etc.
6 Dimensions of safety
Up & Down, Left & Right, Front & Back, Time.
Up & Down
What is above or below the casualty? Is there any debris that could fall upon ourselves that could cause further injury.
What is below the casualty? Is the ground surface going to cause difficulty in extrication?
Left & Right
We need to be aware of what is in our surrounding area, especially pertinent if dealing with a casualty on a road.
Is the traffic still flowing?
Front & back
We are very good at looking for potential dangers in front of us but we also need to be aware of any dangers that may
be approaching from the rear which could easily be overlooked.
Time
Time is important for two main reasons, taking a note of the time at point of contact with a casualty allows the timeline
to begin and is vital information regarding ongoing care. The other reason is that it is important to ensure we do not
spend a prolonged period of time at the scene of an incident which can easily occur when treating casualties in a
stressful situation.
Communications
By supplying an ETHANE report we can ensure the vital information is relayed to the correct persons and allow the most
suitable responses to come and assist.
E – Exact location
T - Type of incident
H – Hazards
A – Access
N – Number of casualties
E – Equipment required
CHAPTER 1
INITIAL ASSESSMENT AND MANAGEMENT

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Primary Survey
a. The aim of the primary survey is to rapidly identify any life threatening conditions using a systematic approach to
patient assessment. Initially on approaching the patient a verbal response should be sought by calling out to the
patient and asking them to respond. Obtaining a verbal response at this point can be reassuring. To respond to
you the patient must have a patent airway, a reasonable tidal volume to allow phonation and adequate cerebral
perfusion to enable a coherent response.
b. On reaching the patients side the assessment process can be remembered through the acronym CABCDE.
Catastrophic haemorrhage
Airway and cervical spine control
Breathing and ventilation
Circulation and haemorrhage control
Disability or neurological status
Exposure, Environment & Evacuation
Control catastrophic bleeding
If the patient presents with a life threatening bleed then this should be controlled immediately with a tourniquet
(if the bleed is on a limb) or by direct pressure/haemostatics/packing etc (if the bleed is in a junctional area or on the torso)
Airway with cervical spine control
The mechanism of injury, if applicable, must be considered for the likelihood of causing the patient a neck injury. If the
patient is suspected to have a cervical spine injury then manual immobilisation must be initiated. The patient’s airway
must then be cleared, opened and maintained. A useful mneumonic to prompt airway management is COLMA:
a. C-spine control?
b. Open the mouth
c. Look inside the mouth and Listen for snoring/gurgling
d. Manually open the airway using head tilt or jaw thrust as necessary
e. Adjunct – use an NPA, OPA, iGel to maintain an open airway
After clearing, opening and maintaining the airway the patient may require oxygen. Trauma patients may require
oxygen. Begin at 15L/min through a reservoir mask but this rate may be decreased to prolong the cylinders life so long
as the oxygen reservoir on the face mask remains fully inflated. Medical patients require additional oxygen to maintain
their oxygen saturations at 94% or higher. A pulse oximeter can be used to guide the oxygen flow rate.
Breathing and ventilation
A thorough examination of the patient’s respiratory system is essential.This should begin with a check of the respiratory
rate, effort and depth.
R- Is the respiratory rate within the goal posts of life: 10-30 breaths per minute?
E - Is the patient breathing easily or is their effort of breathing increased.
D - Is the patient breathing at a normal depth, too shallow or too deep?
Feel the chest wall
Look at the chest wall
Auscultate the chest. Check the Armpits
Percuss the chest
Search the back
Tracheal deviation
Wounds to neck
Emphysema to face/neck
Laryngeal crepitus
Veins in the neck
Evaluate your findings

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Circulation and haemorrhage control
A pulse rate should be obtained at the radius if possible, otherwise at the carotid artery. A central capillary refill time
should also be sought either on the forehead or over the sternum.
If life threatening haemorrhage was controlled at the beginning of the primary survey this should be reassessed now.
Any areas of haemorrhage should now be search for and controlled as quickly and efficiently as possible.
Blood may be lost externally and internally: Blood on the floor and four more. External, chest, abdomen, pelvis, long
bones (2x femur, 2x humerus).
External haemorrhage should be controlled using the most appropriate method ie. Pressure dressings, haemostatic
agents, tourniquets. Pelvic fractures should have a pelvic splint applied. Long bone fractures should be splinted in
position or have a traction splint applied.
Intravenous or intraosseous access should be obtained as necessary and intravenous fluid therapy started if the patient
has an absent radial pulse.
If external haemorrhage continues or if there is internal bleeding suspected then Tranexamic Acid should be
administered. (see medications section).
Disability
A brief evaluation of the patients level of consciousness should take place using the AVPU scale.
Alert (patient will call out to you without prompting)
Voice (patient will only respond when you call out to them)
Pain (patient will only respond when you provide a painful stimulus)
Unresponsive (patient will not respond at all)
The pupils then need to be assessed for their equality and response to light.
A blood glucose level should then be obtained to rule out hypoglycaemia (low blood sugar) as the cause of the patients
decreased level of consciousness.
A final check should be done for wounds and deformities around the head/scalp and a check carried out for battle sign,
racoon eyes or blood/csf from the ears or nose.
Environment/Evacuation
Considerationmustbegiventoprotectingthepatientfromthesurroundingenvironment.Whetherthatisearprotection,
eye protection or protection from the environmental conditions. In particular, the patient MUST be protected from
developing hypothermia. Hypothermia will significantly affect the patient’s ability to survive their injuries.
The patient must now be packaged in preparation for evacuation. Ideally, as part of your pre-expedition or deployment
planning a casualty evacuation plan will have been developed which can now be initiated.
Secondary Survey
The secondary survey is designed to identify non-life threatening injuries and is carried out when the casualty is stable.
Casualties have backs, sides, fronts, bottoms, tops and lots of holes, both natural and as a result of injury. You must be
systematic, going through a top-to-toe process as follows:
• Scalp and vault of skull
• Face and base of skull
• Neck and cervical spine
• Neurological examination
• Remainder of spine and limbs
• Chest
• Abdomen
• Pelvis
• Limbs

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Obtaining a relevant history from the patient can also be carried out during this phase of the assessment.
The acronym AMPLE can be used to guide this process:
Allergies
Medications
Past medical history
Last meal (time of)
Events leading up to the patient presenting to the medic
Prolonged Field Care
In the remote environment, casualty evacuation times can vary dramatically. If we can’t remove the casualty to definitive
care, we must take over that care until we have the means or resources to move the casualty to an appropriate facility.
This can often be one of the most challenging aspects of remote medicine, as we then have to care for a sick or injured
person with very few or no resources.This phase of care requires the use of antibiotics and long term pain relief, we must
now feed the casualty, replace lost fluids, change dressings and ensure that correct body temperature is maintained, as
well as taking care of ourselves. A system that we can use to enable us to ensure that we are completing the process is
‘FIELD CARE’(See Chapter 13).
Definitive Care
Deliver the doctor a live patient. If we can do this, the casualty has a very good chance of not only surviving, but also full
recuperation. Definitive care has the resources and facilities to look after the sick or injured person. As a remote medic
you may have the skills to maintain someone for a few hours or even days, but definitive care is an essential part of our
evacuation plan and must be considered before venturing out into a remote environment. A through handover to the
receiving clinician is vital to ensure good patient care and accurate patient records. An acronym to assist us with this
process is MIST.
Mechanism of injury
Injuries/illness
Signs and symptoms
Treatment
A consistent, systematic approach to the primary survey is vital to the casualty’s survival.

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‘The difference between a good clinician and an indifferent one is
the time spent on history taking’
Sir Faraqar Buzzard - 1933
Assessment of a patient can begin even before reaching the patients side. Understanding and interrogating the
mechanism of injury is a vital step in this process. If the medic can interpret the incident and develop an appreciation
of the forces that were exerted on the patient during the insult then it is possible to predict the injuries that the patient
may have suffered.
Laws of Motion
To understand the MOI, it is necessary to have a basic understanding of some of the laws of motion. The first is that a
body in motion remains in motion, at the same velocity, until acted upon by an outside force.This is known as Newton’s
first law of motion. A person in a vehicle travelling forward at 60mph, for example, will continue to travel at this velocity
when the vehicle stops suddenly until he strikes an object, such as the steering wheel or seat belt,that stops his forward
momentum.
The speed (velocity) of the vehicle or projectile is a major contributing factor to the forces involved in the impact.
A pedestrian struck by a vehicle travelling at 20mph has a 5 per cent chance of sustaining fatal injuries. In comparison,
someone struck by a vehicle travelling at 50mph has an 85 per cent chance of being killed.
Consider the driver of the vehicle travelling at 50mph that hits a wall or other stationary object. He will be subjected to
four separate impacts or transfers of forces:
• The vehicle collides with an object, possibly another vehicle. It decelerates, and the air bags or crumple zone are
activated to dissipate the energy of the driver’s velocity.
•The driver hits the internal structures of the vehicle, decelerates further, and is subject to compression forces, or will
• The driver’s internal organs continue moving forward despite his body stopping, and they may undergo shearing
forces.
• The driver recoils, with a velocity that is possibly enhanced by the position of the seatbelt, and experiences rebound
injuries.
The above example shows that the energy of movement – kinetic energy – is subsequently transferred into other forms
of energy such as compression, cavitation or shearing forces.
Acceleration and Deceleration (A/D) Forces
The injuries that occur due to A/D forces fall into one of two groups: shearing injuries and compression injuries. Shearing
injuries, such as damage to the arch of the aorta, occur almost exclusively as a result of the A/D forces themselves. By
contrast, compression injuries, such as those to the head from hitting the dashboard or windscreen, occur due to the
impact causing deceleration forces.
Shearing forces can cause the liver, heart and other heavy organs to pull away or fold round the ligaments or muscles
securing them, and so result in dramatic internal haemorrhage.
Compression injuries that occur due to an impact secondary to the A/D forces can include knee or femur injures,
including dislocations in an RTA, or Pneumothorax if the chest walls or lungs are forcibly compressed at impact.
Rebound injuries, which occur due to recoil following deceleration, include spinal fractures and contra-coup injuries to
the brain.
CHAPTER 2
MECHANISM OF INJURY

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Cavitation & Blunt Trauma
Permanent cavitation occurs when a tract or hole is made through tissue and it remains even after the energy has
been removed or dissipated. Temporary cavitation is not so easily recognised because the structures involved may
have returned to their original location once the energy has been dissipated. Cavitation in blunt trauma is often only
temporary because elastic body tissues return to their original position.
Cavitation can be obvious, but is not always so. For example, if a bat strikes the skull, it is fairly likely that there will
be a depressed fracture that is easily detectable. But if the abdomen is struck, cavitation is less obvious because of
the underlying structure’s ability to recoil. The results however, which may include organ damage or life threatening
haemorrhage, can be just as serious. Remote medics must therefore be aware of the degree of cavitation that is likely to
occur following blunt injury and the consequent damage to related organs and other structures.
When considering penetrating trauma the medic needs to identify whether the damaging object was travelling at
either a low or high velocity (speed).
a. A stab wound is a good example of a low velocity penetrating
injury. In these injuries the energy transfer from the object
to the tissues is much less than in high velocity injuries
and therefore the degree of cavitation and tissue damage
is reduced. However, in both low and high velocity injuries
there will be a degree of both permanent and temporary
cavitation.
b. In low velocity penetrating injuries damage to the tissues
is limited to the wound track and therefore damage to
tissues and organs can be predicted by tracing the path of
the object. In general male attackers tend to thrust in an
upward motion and female attackers strike in a downwards
fashion. However, predicting internal injury may be quite
complicated. For example, a small external wound may mask
significant internal injury if the knife was moved around
inside the victim. Additionally, unless the object is able to be
inspected it may be very difficult to determine how far the
object has penetrated and in what direction. This means that
a stab wound to the upper abdomen may also injure organs
in the lower chest cavity or a stab wound to the lower chest
may damage upper abdominal organs.
c. High velocity penetrating injuries, such as those from a
bullet or bomb shrapnel have additional complications.
In particular, due to the high energy transfer involved, the
degree of cavitation caused by a high velocity penetrating
injury can be devastating. The yaw and tumble of projectiles,
particularly bullets, also increases the degree of cavitation to
the point that a high velocity bullet can cause a temporary
cavity twenty five times larger than the calibre of the bullet.
Due to this cavitation, high velocity projectiles damage not
only the tissue directly in the path of the missile but also the
tissue involved in the temporary cavity on each side of the
missile’s path. In general, high velocity objects cause more
damage to solid organs, such as the liver and kidneys, than
if they pass through air filled organs such as the intestines or
stomach.
Blast
An explosive is a substance that can be made to undergo a rapid chemical reaction that will transform a liquid or a solid
into a gas, liberating a large amount of energy. The products of detonation (or explosion) of a conventional explosive
are:
A region of highly compressed gas (the blast), that rapidly expands to occupy a volume at least 10 times greater than
that of the original explosive. Various solid residues from the explosive or casing

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Beyond the fireball, the blast wave appears as a sharp line, which is caused by refraction of light by the higher
density gas at the shock front
Classification of Blast Injuries
PrimaryBlastInjuries:Therapidexpansionofgasafteranexplosiontakesplacealmostinstantaneouslyandcompresses
the surrounding air into a shock or blast wave that moves supersonically in all directions from the explosion.
Secondary Blast Injuries: Secondary blast injury occurs when flying debris, buildings and other material energised by
the explosion and picked up be the blast winds strike the body. A high incidence of casualties with secondary injuries
from broken glass can be expected when a blast occurs in urban areas.
Tertiary Blast Injuries: Tertiary blast injury occurs when a casualty’s body is thrown against the ground, equipment,
structures, trees or other stationary objects by the pressure differentials or blast winds. Mutilating blast injuries
(traumatic amputations) occur as a combination of secondary and tertiary blast effects.
Quaternary blast injuries: Quaternary blast injuries may be seen after the initial blast has passed. Injuries may include
burns from subsequent fires, trauma from collapsing buildings, infection from open wounds or possibly contamination
from radiation or chemicals
Primary Blast Injuries
This is caused by the direct effects of the shock wave/pressure front on the body with the greatest effect on gas
containing organs, and may occur with out any external signs of injury. Organs Affected in Primary Blast Injuries include
the middle ear, the lungs, intestines, the heart and the central nervous system as these are all gas containing organs
whether as a gas or as a solute.

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Effects of Pressure Wave on Air Containing Organs
Air spaces within the body are under the influence of atmospheric pressure (A) under normal conditions. When a
pressure wave such as a high-pressure blast wave passes through these spaces (B) the increase of pressure results in a
reduction in volume (Boyle’s Law), this can result in damage occurring such as implosion of the tympanic membrane.
Immediately behind the pressure wave is a negative pressure vacuum that results in an increase in volume of air
spaces (C), thus resulting in damage (D), whether temporary or permanent.
Injuries resulting from the blast wave include:
Blast Ear: Common with other forms of injury, small over pressures can injure the ear with tympanic memebrane
rupture being very common. Ossicle dislocation and cochlear injury can also occur. Symptoms include tinnitus or
hearing loss
Blast Lung: blast lung can take time to manifest clinically and can include
Disruption of alveolar capillary interface
Disruption of bronchi and attachments
Disruption of pulmonary vessels
Accumulation of blood and fluid
Blood flow Shunting
ARDS – Acute Respiratory Distress Syndrome
Blast Gut: Air spaces within the gut being affected by the blast wave can result in damage to both the small and large
intestines. There are several types of injuries related to blasts, it is important to remember primary blast injuries may
go unrecognised for some time and communication with the casualty/casualties may be difficult. Most immediate
deaths as a result of pure primary blast injury are related to air embolism to the heart or brain.

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Secondary Blast Injuries
The blast winds cause the secondary classification of injuries, due the winds picking up debris or material from the
explosive device (i.e. – grenades, claymore mines, vehicle bourne IED) causing both blunt and penetrating injuries from
shrapnel/missile injuries and objects striking the body. In large explosions blast winds can cause traumatic amputations
to limbs at joints, this is usually associated with pressure injuries and multiple traumatic injuries due to the proximity
to the blast.
Displaced structures that become displaced causing falling masonry and structural collapse can result in crush/bury
injuries and account for greatest number of victims statistically.
Tertiary Blast Injuries
This is a secondary result of the blast winds where the victim may become a thrown against objects primarily resulting
in blunt, deceleration injuries.
Quarternary Blast Injuries
Miscellaneous injuries as a result of exposure to blast mechanism include burns and fractures which in themselves can
be life threatening.
Conclusion
Understanding the direction and extent of the forces that patients have been subjected to, and a working knowledge
of the structures that might have been injured as a result, allows remote area medics to make targeted assessments to
identify any life or limb threatening injuries. Alternatively, the information can be used to initiate appropriate diagnostic
or treatment interventions to ease patient suffering and minimise the time required for recuperation.

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15
AIRWAY
Introduction
Once life threatening haemorrhage has been controlled it is necessary to gain airway control at the earliest available
opportunity. Without a patent airway, any casualty will die in a very short space of time. Methods of gaining a patent
airway vary from the positioning of the casualty and simple manoeuvres to the insertion of specialist devices.
The ability to provide an artificial airway or to assume control of respirations may be quite limited within the remote
environment; optimally the victim can be an active participant in the remote-site rescue effort. The drive to breathe is
one of the most powerful brainstem reflexes. Although they may be depressed, the autonomic reflexes to cough, gag,
swallow, gasp, flare nostrils, open the vocal cords during inspiration, hyperventilate in response to hypoxia or head
injury, and recruit accessory muscles of respiration are generally preserved until the victim is near death. The remote
area medic should avoid any medications or interventions that might impair these reflexes.
Only a small minority of airway emergencies occur instantaneously, such as sudden complete airway obstruction by
an aspirated foreign body or a crushed larynx from impact with a steering wheel. Certain other rapidly evolving life-
threatening emergency situations have major immediate airway considerations, but if the underlying condition can be
stabilized or relieved, the need to manage the airway becomes less pressing. Examples in this second category include
suffocation, near drowning, intoxication, or any circumstance in which absence of breathing (apnoea) can be converted
to spontaneous respiratory effort or an obstructed airway can be converted to a patent one.
Airway compromises that are anticipated to worsen with time fall into a third important category.Without intervention,
an otherwise viable victim might die from a potentially preventable airway death. Examples in this third category
include inhalation burns, soft tissue trauma, infections involving the pharyngeal or hypopharyngeal soft tissues and
allergic reactions.
CHAPTER 3
AIRWAY
Causes of Airway Obstruction
INTERVENTION
Aspiration of foreign body 5 x back blows
5 x abdominal thrusts
Unconsciousness/Tongue Manual manoever. Airway adjunct
Facial or neck trauma Remove debris in mouth/Account for teeth
Assess potential for swelling
Positioning
Secretion assistance - Suction
Anaphylactic reactions Adrenaline if available
Consider inhaled b-agonists - Salbutamol
Consider airway adjuncts / Surgical Cricothyroidotomy
Seizures If possible, turn on side to facilitate gravity drainage of saliva or vomit.
Insert NPA if possible, do not place anything into the mouth

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Assessment and management of the airway
As with all aspects of patient assessment, the airway should be assessed and managed in a stepwise and logical fashion.
The acronym COLMA can be used to guide the medic through this process:
a. C – is a c-spine injury suspected due to the patient’s mechanism of injury? If so then the head should be moved
into an in-line position and manually stabilised from here onwards.
b. O – open the mouth
c. L – look in the oral cavity. Are there any foreign bodies or vomit apparent? If so then this material will need
removing immediately. Listen for abnormal airway sounds which may also indicate airway obstruction.
d. M – manually open the airway using either the head/tilt chin lift or jaw thrust manoeuvre as determined by
their mechanism of injury
e. A – an airway adjunct should then be inserted appropriate to the patients condition
Recognition of Airway Obstruction
Cyanosis can be present as a result of hypothermia, hypovolaemia, insufficient cardiac output or inadequate tissue
perfusion so is not always indicative of airway compromise. Also airway compromise can be present without cyanosis;
an allergic reaction with airway oedema and vasodilatation is one example of an airway emergency in the absence of
cyanosis; unconsciousness (with associated upper airway obstruction) resulting from carbon monoxide poisoning is
another.
Laboured respirations are typified by a rate that is forcefully rapid, irregular, or gasping. Unusual sounds or noisy
respirations could be present and accessory muscles of the chest wall, shoulders, neck, and abdomen strain with the
effort.
Retractions result from mismatch between chest wall effort (when the rib cage expands) and ease of pulmonary air
inflow.Pulmonaryairinflowcanbeimpededbyupperairwayobstructionorbystifflungsthatdonotreadilyexpand.The
“restrictive”respiratory pattern for stiff lungs typically involves intercostal retractions, tachypnoea, and the respiratory
noises of rales (alveolar fine crackles) and“grunting”(the brief holding of breath at the end of inspiration then letting it
go with an expulsive and audible quick exhalation).
In contrast, the “obstructive” respiratory pattern for upper airway obstruction exhibits greater use of neck and
abdominal accessory muscles; greater supraclavicular, subcostal and sternal retractions, stridor, snoring, gurgles, or
other abnormal respiratory noises.
Description of Airway Sounds
SOUND DESCRIPTION
Stridor A sharp, high-pitched squeaky sound with vocal quality that emanates
from the larynx (upper airway) and is usually more prominent on
inspiration than expiration
Wheezing A sustained whistling sound made by air passing through narrowed
airways usually distal to the larynx (lower airway), and generally more
prominent on expiration than inspiration.
Rhonchi Gurgling, congested, low-pitched rattling sounds in the chest caused by
secretions in the large and medium-sized airways
Grunting A staccato noise heard at the end of expiration only, with a lower
pitch than that of stridor; can be found in tension pneumothorax or in
association with restrictive lung disease or with thoracic or abdominal
pain
Snoring A characteristic low-pitched, very low-frequency inspiratory noise caused
by periodically interrupted airflow through the soft tissues of the pharynx.
Caused by tongue obstructing
Gurgling Due to a fluid in the upper airway eg. vomit, saliva or blood

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Head Positioning
The most common causes of upper airway obstruction are a floppy tongue and lax pharyngeal muscles, or soft tissue
enlargement from infection or oedema. Because teeth play such an important role in preserving the size and patency of
the mouth, lack of teeth (the young, elderly, poorly dentition, and recently traumatised) increases vulnerability to upper
airway obstruction. Upper airway obstruction is almost always improved by optimal head positioning, mouth opening,
clearing of nasal passages, and/or tongue manipulation.
Keeping the mouth of an unconscious person open is very important. With the interior of the mouth in view, it is
possible to gauge the position of the tongue and the presence of vomit, foreign debris or pooling of secretions and can
hear the quality and regularity of respiratory noises, even at a distance.
No matter what the person’s age, the most desirable posture is maintaining “neutral” head position with the chin
“proudly” jutted forward, nose in the “sniffing” position, mouth open, tongue resting on the floor of the mouth. The
least desirable head position in any age group is with the neck flexed and chin pointed towards the chest. Flexion also
increases unfavourable stresses on a potentially unstable cervical spine. Extreme hyperextension of the head in any age
group angulates the airway, and should be avoided.
If there is a suggestion of a possible cervical spine injury, efforts to stabilise the neck and head should be undertaken.
Neck flexion, hyperextension, or lateral rotation must be minimised as much as possible. Fortunately, the best head
position for the airway is also good for the cervical spine.
Non-Invasive Airway Manoeuvres
If the upper airway is obstructed, there are three basic non invasive airway-opening manoeuvres. The most simple is
the head tilt, chin lift. The intended result is the sniffing position. Problems arise if the mouth is closed or soft tissues
are infolded because of the chin lift. One hand should be placed on the patients forehead and the fingertips of the
other hand placed underneath the patients chin. The head should now be tilted backwards and the patients chin lifted
upwards.
A second manoeuvre is the jaw thrust. Pressure is applied to the angle of the mandible to dislocate it upwards while
forcefully opening the mouth. This is painful, and the conscious or semi conscious victim may object by clamping.
The tips of the index and middle fingers of each hand should be placed onto the angles of the jaw, just below the ear
lobes. Upwards pressure should then be applied and if necessary, additional pressure can be achieved by applying
downwards pressure with the thumbs over the cheekbones.
A third manoeuvre is the internal jaw lift. The rescuer’s thumb is inserted into the victim’s mouth under the tongue,
and the chin is lifted, thus stretching out the soft tissues and opening the airway. This is the best manoeuvre for the
unconscious victim with a shattered mandible. The internal jaw lift is dangerous to the rescuer if the victim is semi
conscious and can bite.
All non-invasive airway manoeuvres except the internal jaw lift can be used in conjunction with rescue breathing or
bag-valve-mask assisted ventilation.
Tongue position in the unconscious adult.
Note airway obstruction by the base of the
tongue against the posterior pharyngeal wall
with closure of the epiglottis over the trachea
Jaw thrust

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Dedicated suction devices such as
this Suction Easy©
can be inexpensive
and compact, and can provide good
portable suction.
Suctioning
In the remote area, secretions must be removed without the benefit
of electrically powered suction devices. A number of products are
on the market that the remote area medic might want to consider
for the medical kit.
The patient can also be positioned so that gravity facilitates
drainage of blood, vomit, saliva, and mucous; something absorbent
or basin like can be placed at the side of the mouth to catch drained
secretions. Several positions are suitable for providing postural
drainage depending on the severity of the fluid accumulation and
the patients injuries.The recovery position is suitable for patients in
whom a c-spine injury is not suspected. If the patient is suspected
to have a spinal injury then the log roll should be utilised. Finally,
if the bleeding is severe or the vomiting persistent then, if the
patients injuries allow, they should be placed in the prone position.
This is achieved by lying the patient face down to allow maximum
drainage from the oral cavity. A rolled up blanket or pillow may be
placed under the hips and shoulders to allow improved respiratory
effort.
Suction devices can be included in an expedition first aid kit not
just for secretion management purposes but also for gentle wound
irrigation and burn dressing or wet compress moisturising. The
rubber self-inflating bulbs marketed for infant nasal suctioning can
also be used to suction out debris from the mouths and noses of
adults. Large syringes with a piece of oxygen tubing attached can
also be used for suction and wound irrigation.
Secretion removal by gravity or suctioning is key to the
management of epistaxis and for maintaining the airway of a victim
with mandibular fractures.
Airway Equipment
Masks and One-Way Valves
The purpose of the one-way non-re-breathing flap-valve is to
permit air to be pushed into the victim through one aperture while
exhaled air (and secretions) are exhausted through a separate
route, thus helping minimise exposure to infectious substances.
These one-way valves are small, lightweight, and inexpensive and
would be easy to tuck into a small container along with gloves and
a face barrier.
Facemasks differ in shape, type of seal, transparency, and materials
used for construction. The universal connector at the peak of the
mask dome provides a 22-mm female adaptor that connects the
mask to a one-way valve to go to the rescuer’s mouth, the elbow
of a Bag- Valve-mask system or the breathing circuit of a ventilator.
Non-cushioned masks are more difficult to use and demand a
greater array of sizes. The cushioned masks are a far better choice
for responding to out-of-hospital emergencies.

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This picture shows the British NPA, the
American version is similar, however
it has a larger flange and the sizes are
described differently
Nasopharyngeal Airway
Compared with the OPA, the nasopharyngeal airway (NPA) is
better tolerated in the semi conscious person. Since it does not
have to withstand the forces of biting teeth, the NPA can be more
flexible and compliant. A flange outside the nostril prevents the
NPA from slipping or being swallowed or aspirated. The flange can
be improvised with a safety pin through the tube itself. The gentle
curvature of the NPA follows the superior surface of the hard palate,
descends through the hidden nasopharynx and down the visible
posterior oropharynx, and ends up behind the base of the tongue.
The key to successful and atraumatic insertion involves lubrication
(saliva works well); an understanding of nasal anatomy; and steady,
gentle pressure. If the NPA has a bevel, the flat edge of the bevel
is oriented toward the nasal septum. The direction of insertion is
straight back. As the NPA passes through the turbinates, there will
be mild resistance, but once the tip has entered the nasopharynx,
there will be sensation of a “give.” The tube should be visible in
the oropharynx as it passes behind the tonsils, and the tip should
come to rest behind the base of the tongue.
The NPA is an ideal airway for the semi-conscious patient who is responding to pain and also a person with trismus. This
is a condition where the jaw clamps shut meaning access to the oral cavity is impossible. This may occur in a patient
suffering from a seizure or who is semi-conscious due to hypoxia.
Complications of NPAs include failure to pass through the nose (usually resulting from a deviated septum), epistaxis,
mucosal tears and creation of pressure sores. If the NPA or any nasal tube is left in place for more than several days,
impedance to normal drainage may predispose the victim to sinusitis or otitis media. NPAs are permitted for use in
patients with a base of skull fracture so long as the correct insertion technique is used and excessive force is not used.
Sizing and Insertion
Sizing – As with the OPA, the NPA comes in a variety of sizes. Sizing is very easily accomplished with the NPA, average
females – size 6.0 and average males – size 7.0. The larger the casualty is, the larger the tube will have to be and vice-
versa with a small casualty.
Insertion – Lubricate the tube (either saliva or KY jelly work well). Carefully insert the tube into the right nostril, parallel
to the palate. Push the tube straight down towards the floor and NOT up the nose. If resistance is felt, withdraw the tube
and try the left nostril.
After insertion, the patency of the airway must be checked.

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Oropharyngeal Airway
An Oropharyngeal airway (OPA) holds the base of
the tongue away from the posterior pharyngeal wall
and keeps the mouth open and the lips apart. It may
stimulate gagging or induce vomiting and is not
well tolerated in the responsive or semiconscious
victim. Improper or forceful insertion can cause soft
tissue, palatal, or dental injury, as can subjecting the
structures of the mouth to prolonged or intense
pressures from biting down or holding the OPA in
place with tethers.
An overly large oral airway can occlude the upper
airwayorwillpressdownonandcausetheepiglottis
to fold over and occlude the glottis. Additionally,
glottic stimulation can result in laryngospasm and
a complete loss of airway. Too small an oral airway
will miss the curvature of the tongue and will press
down in the middle of it, worsening occlusion at the
base of the tongue or causing the epiglottis to close
over the glottis.
Sizing and Insertion
Sizing - The OPA comes in a variety of sizes; from 00 for babies to 4 for large adults. As already discussed the correct size
is vital if the airway is going to work correctly. The OP airway is sized from the centre of the teeth to the angle of the jaw.
Typical adult sizes are size 2 for females and size 3 for average males. This does of course vary from casualty to casualty.
Insertion – The airway is inserted ‘upside’ down at first and then twisted through 180 as the end passes under the
palate and into the oropharynx.
After insertion, the patency of the airway must be checked.
The OPA comes in a variety of sizes that must be measured
correctly to prevent further airway blockage

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i-gelTM
Supraglottic Airway
The i-gel airway is a novel and innovative supraglottic airway management device, made of a medical grade
thermoplastic elastomer, which is soft, gel-like and transparent. The i-gel is designed to create a non-inflatable
anatomical seal of the pharyngeal, laryngeal and perilaryngeal structures whilst avoiding the compression trauma
that can occur with inflatable supraglottic airway devices.
The i-gel is a truly anatomical device, achieving a mirrored impression of the pharyngeal, laryngeal and perilaryngeal
structures, without causing compression or displacement trauma to the tissues and structures in the vicinity.
The i-gel has evolved as a device that accurately positions itself over the laryngeal framework providing a reliable
perilaryngeal seal and therefore no cuff inflation is necessary.
The i-gel is used to secure and maintain the airway of an unconscious patient. It has the advantage of allowing
delivery of high concentrations of oxygen, enabling effective ventilations via a bag/mask device, reducing gastric
inflation and therefore the risk of vomiting, being easy to insert in awkward positions and during CPR it allows for
continuous chest compressions to take place.
Sizing
i-gel size Patient size Patient weight guidance (kgs)
1 Neonate 2 – 5
1.5 Infant 5 - 12
2 Small paediatric 10 - 25
2.5 Large paediatric 25 - 35
3 Small adult 30 - 60
4 Medium adult 50 - 90
5 Large adult + 90 +

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Pre-insertion preparation - Adult i-gel. Sizes 3, 4 and 5.
1. Always wear gloves
2. Open the i-gel package, and on a flat surface take out the protective cradle containing the device.
3. In the final minute of pre-oxygenation, remove the i-gel and transfer it to the palm of the same hand that is
holding the protective cradle, supporting the device between the thumb and index finger. Place a small bolus of
a water-based lubricant, such as K-Y Jelly, onto the middle of the smooth surface of the cradle in preparation for
lubrication. Do not use silicone based lubricants.
4. Grasp the i-gel with the opposite (free) hand along the integral bite block and lubricate the back, sides and front
of the cuff with a thin layer of lubricant. This process may be repeated if lubrication is not adequate, but after
lubrication has been completed, check that no BOLUS of lubricant remains in the bowl of the cuff or elsewhere
on the device. Avoid touching the cuff of the device with your hands.
5. Place the i-gel back into the cradle in preparation for insertion.
NB.The i-gel must always be separated from the cradle prior to insertion.The cradle is not an introducer and
must never be inserted into the patient’s mouth.
Insertion
A proficient user can achieve insertion of the i-gel in less than 5 seconds.
1. Grasp the lubricated i-gel firmly along the integral bite block. Position the device so that the i-gel cuff outlet is
facing towards the chin of the patient.
2. The patient should be in the ‘sniffing the morning air’ position with head extended and neck flexed. The chin
should be gently pressed down before proceeding to insert the i-gel.
3. Introduce the leading soft tip into the mouth of the patient in a direction towards the hard palate.
4. Glide the device downwards and backwards along the hard palate with a continuous but gentle push until a
definitive resistance is felt.
WARNING: Do not apply excessive force on the device during insertion. It is not necessary to insert fingers or
thumbs into the patient’s mouth during the process of inserting the device. If there is early resistance during
insertion a‘jaw thrust’,‘Insertion with deep rotation’or triple manoeuvre is recommended.
5. At this point the tip of the airway should be located into the upper oesophageal opening and the cuff should be
located against the laryngeal framework. The incisors should be resting on the integral bite-block.
WARNING: In order to avoid the possibility of the device moving up out of position prior to being secured in
place, it is essential that as soon as insertion has been successfully completed, the i-gel is held in the correct
position until and whilst the device is secured in place.
Tip of cuff at oesophageal opening
Opening of cuff at laryngeal opening
Black line on bite block
level with teeth

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Cricothyrotomy
If the upper airway is completely obstructed and obstruction cannot be relieved or bypassed, the only way to avoid
death is to create an air passage directly into the trachea. The most accessible and least complicated access site is
through the cricothyroid membrane.
The essential indication for a surgical airway is the need for an airway where all else has failed.
A Surgical Airway should be performed if all other methods have failed and there is no other way to secure the airway.
There are some exceptions to this rule. Situations in which a Surgical Airway should be considered as the primary
method include Major Maxillo-Facial Injury (eg compound mandibular fractures, Le Forte III Midface Fracture),
Oral Burns, Fractured Larynx and anaphylaxis.
Complications include bleeding, puncture of the posterior trachea and oesophagus, creation of a false passage, inability
to ventilate, aspiration, subcutaneous and mediastinal emphysema, vocal cord injury, and subsequent tracheal stenosis.
Identifying the cricothyroid
membrane
The thyroid cartilage in the neck should initially be found.
One finger should then be slide downwards from the thyroid
notch (Adams Apple) until a hollow area is palpated. This is
the cricothyroid membrane. Just below this notch is the cricoid
cartilage which is felt as a thin band. Confirmation of the correct
location may be approximated at one fingers width below the
thyroid notch, or alternatively, place the little finger of one hand
in the sternal notch and the index finger of that hand should land
in the cricothyroid membrane.
Surgical airway technique
a. The immediate area over and around the cricothyroid
membrane should be cleaned thoroughly
b. The thyroid cartilage should be stabilised using the thumb
and middle finger of the non-dominant hand, leaving the
index finger free to relocate the cricothyroid membrane as
necessary.
c. Carefully make a 2cm long vertical incision down the midline
above the cricothyroid membrane with a scalpel held in the
dominant hand
d. Re-identify the cricothyroid membrane
e. Incise the membrane horizontally using a stab technique
f. Place the forceps through the incision and into the trachea,
using them to enlarge the incision particularly in the
superior/inferior direction
g. Now introduce the tracheostomy tube and insert it into the
trachea until the wings sit flush with the neck
h. Now inflate the cuff of the tube and remove the stylet from
within the tracheostomy tube
i. Confirmtubepositionandpatencybyfeelingairfloworeasily
administering ventilations through a resuscitation bag with
no resistance or appearance of subcutaneous emphysema
j. Secure the tube around the patients neck
If a specialist tracheostomy tube is not available then a size 6
endotracheal tube may be utilised as an alternative.
The equipment required – Tube,
syringe, forceps, scalpel, sutures,
ribbon gauze
Thyroid cartilage
Incision
Cricoid cartilage

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When an evacuation by air or over radically different altitudes, is anticipated, the cuff should be filled with water. Why?
Different altitudes cause air to expand or contract. This could then mean that the cuff may deflate or expand. As water
does not expand or contract with differing air pressure, it will ensure that the cuff is kept a constant size and therefore
reduce the risk of the tube from becoming dislodged.
Other Airway Adjuncts
Other commercial airway adjuncts used in pre-hospital circumstances include the endotracheal tube and the
esophageal-tracheal Combitube. Successful insertion of these devices requires formal instruction and practice. Their
use in the wilderness setting is limited to appropriately trained and experienced providers.
Summary
The conscious or semi conscious person with an airway emergency instinctively seeks an optimal posture for air
exchange. The unconscious person, unless deeply anesthetized, paralyzed, or profoundly hypoxic, continues effort to
breathe until death is very near. If a victim shouts or cries out, the airway is intact and the lungs are filling. If a victim is
breathing but obstructed, determination should be made as to why. If a victim is making no respiratory effort at all, a
choice must be made about whether or not to initiate CPR.
The fundamental goals of airway management in the field are to promote conditions supporting airway patency with:
• Optimal positioning
• Facilitated removal of secretions or debris
• Close observation for emesis, bleeding, seizures, or other events leading to obstruction or aspiration
• Avoid doing or administering anything that could further depress respirations, obstruct airway, or depress
respiratory reflexes
• Assess the potential for worsening
• Plan the evacuation accordingly
• Communicate the situation and concerns to others
• Prepare for escalated intervention

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Introduction
Thoracic injuries account for 20-25% of deaths due to trauma and contribute to 25-50% of the remaining deaths.
Approximately 16,000 deaths per year in the United States alone are attributable to chest trauma. The increased
prevalence of penetrating chest injury and improved pre-hospital and peri-operative care has resulted in an increasing
number of critically injured but potentially salvageable patients presenting to trauma centres.
Blunt injury to the chest can affect any one or all components of the chest wall and thoracic cavity. These include the
ribs, clavicles, scapulae, sternum, lungs and pleurae, tracheobronchial tree, oesophagus, heart, and great vessels of
the chest. In the subsequent sections, each particular injury and injury pattern resulting from blunt mechanisms is
discussed. The patho-physiology of these injuries is explained and diagnostic and treatment measures are outlined.
Penetrating trauma to the thoracic vessels was not extensively reported until the 20th century because of the absence
of survivors. In 1934, Alfred Blalock was the first American surgeon to successfully repair an aortic injury. Guidelines for
treating thoracic trauma were not established until World War II.
Additional experience in the treatment of penetrating trauma to the thorax was gained in later military experiences,
including the conflicts in Korea and Vietnam, and to a lesser degree, in US actions in Grenada, Panama, the Balkans,
Somalia and the Persian Gulf. Other large international experiences have derived from the Falkland Island conflict,
various Middle Eastern engagements, and multiple conflicts in the African states.
The thoracic cavity, or chest
The thoracic cavity, or chest, consists of 12 pairs of ribs which are connected in the posterior aspect to the spinal
vertebrae.The first seven pairs of ribs are attached anteriorly to the sternum and the next three pairs of ribs are attached
to cartilage. The final two pairs of ribs are termed“floating ribs”and are not attached to the sternum or cartilage.
The trachea
The trachea extends from the larynx in the neck, down to the lungs and is about 11cm long. It is surrounded by several
rings of cartilage which support the trachea and prevent it from collapsing. At the level of the fifth thoracic vertebrae
the trachea branches into the left and right main bronchi which enter the lungs.
The Alveoli
Each lung has about 300 million alveoli. They are very small
and cannot be seen easily with the naked eye. Each alveolus is
surrounded by a capillary blood vessel. Gases, e.g. oxygen and
carbon dioxide, move across the alveolar membrane into the
blood vessels and vice versa. A continuous exchange of gases
takes place between the alveoli and the capillary blood vessels
that surround them.
The Covering of the Lungs -
The Pleura
There is a double-layered covering of the lungs called the pleura.
The visceral pleura adheres to the surface of the lungs whilst the
parietal pleura adheres to the inside of the chest wall. There is a
small amount of lubricating fluid in between the two layers of the
pleura.
CHAPTER 4
BREATHING & CHEST INJURIES

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Divisions of the lungs
The lungs are divided into lobes. The right lung has three lobes (upper, middle, lower) and the left lung has two lobes
(upper and lower).
Anatomy & Physiology
The Mechanism of Breathing
To inhale, the intercostal muscles contract causing the chest wall to rise and expand, whilst the diaphragm flattens.
This then produces a negative pressure inside the chest, which draws air in through the upper airway and then down
into the lower respiratory tract. Breathing out is a reversal of the process, the diaphragm relaxes, the chest wall falls
and air is forced out.

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The Function of the Lungs - Exchange of Oxygen and
Carbon Dioxide
The main function of the lungs is to keep the correct amount of oxygen and carbon dioxide in the blood. In order to
do this we breathe air into the airways which then moves all the way down to the sac-like endings of the airways called
the alveoli. In the alveoli, the oxygen from the air moves into the blood stream that surrounds each tiny alveolus. The
blood then carries the oxygen around the body to the tissues where it is required. Carbon dioxide is carried from the
cells of the body to the lungs, where the carbon dioxide moves across the alveoli into the airways and is then exhaled.
The exchange of gases can be increased or decreased by breathing at a faster or slower rate, or by breathing more
deeply consequently, the body can increase the amount of oxygen and decrease the amount of carbon dioxide in the
blood stream by breathing at a faster rate or more deeply.
The body needs more oxygen e.g. during exercise, running or straining. There may be some obstruction to the flow of
air in the airways or there may be an obstruction to the flow of gases across the alveoli into the blood stream. This may
be due to diseases like asthma, bronchitis or pneumonia. Whatever the cause, the body will try to increase the amount
of oxygen in the blood stream by breathing at a faster rate or more deeply. Most of the time the lungs are able to
provide enough oxygen for the body’s needs. If there is a severe shortage of oxygen in the blood, this is termed hypoxia
and may result in a blueish tinge around the lips or face called cyanosis.
Carbon dioxide is an acidic waste product of body metabolism, levels of carbon dioxide in the blood may rise because
there may be an over production of carbon dioxide, e.g. from running or exercising. In some medical conditions, e.g.
diabetes, there may be an over production of acid (ketones) which will also result in deeper breathing. By breathing
faster or deeper the body will usually be able to correct the level of carbon dioxide. The faster we breathe, the more
carbon dioxide is moved from the blood into the airways and then exhaled.
The normal respiratory rate is 12 - 20 breaths per minute in adults. The goalposts of life are described as being between
10 and 30. If we are breathing at rate lower than 10 breaths per minute, then we are simply not moving enough oxygen
into the body or removing enough carbon dioxide away from the body. If the respiratory rate is above 30 per minute,
the air is moving into and out of the body at such a rapid pace that respiration cannot take place sufficiently. A faster
breathing rate is called tachypnoea (tachy = fast, pnoea = breathing). A fast breathing rate (tachypnoea) is an important
sign of respiratory dysfunction. A slow breathing rate is called bradypnoea.
A fast breathing rate can cause dehydration. There is always some moisture (water) in the air that is breathed out.
Therefore a fast breathing rate will result in water being lost from the body. If the breathing rate is increased for long
periods of time it can result in dehydration.
The heart rate increases when the breathing rate increases. A faster breathing rate increases the amount of gases
exchanged. The heart rate will increase the flow of blood through the lungs. When there is a normal breathing rate
(12 - 20 breaths per minute), the amount of oxygen and carbon dioxide in the blood stream is at the correct level for the
body’s needs. Most respiratory conditions cause the breathing rate to increase.
Chest & Neck Examination
A thorough assessment of the patients respiratory status is vital, not only allow us to identify life threatening breathing
problems but also to give us a baseline to judge our interventions against to determine whether they have been
beneficial. The respiratory status is assessed using the acronym RED FLAPS TWELVE. Initially we need to assess the
adequacy of the patients breathing using the format RED:
a. R – Rate
b. E – Effort
c. D – Depth
Rate - Look, listen and feel for breathing over 15 seconds then multiply the number of breaths by four to determine the
rate in one minute.
Effort - Is the patient struggling to breathe?
Depth – How deeply is the patient breathing? Look at the height of their chest rise

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The chest is examined using the acronym – FLAPS.
• F – Feel
• L – Look
• A – Auscultate & Armpits
• P – Percussion
• S – Search the back
Feel
When we feel the chest, we are initially feeling for the rigidity of
the chest and the symmetrical rise and fall of the chest.The hands
must then feel every inch of the chest including the armpits
and breasts. Some deformities may be felt but not seen easily,
especially at night, so a thorough feel of the chest is essential.
Look
What can we see? Can we see any holes or deformities? Is the
chest moving a normal amount? Can we see a section of the chest
that is not moving in the same direction as the rest of the chest?
Auscultate & Armpits
What can we hear? Using a stethoscope, we must check for breath
sounds over both lungs. Air entry must be equal on both sides. Air
entry is assessed at the top and sides of the lungs. Comparison is
the easiest method of ascertaining normality. Armpits are often
overlooked and can hide injuries that can easily be missed.
Percussion
This process is used in conjunction with auscultation to determine
if there is blood or air inside the chest. A finger is placed along
a rib and then tapped. Comparison is used again as the best
method to clarify if there actually is an abnormality.The noise that
is produced may be hyper-resonant or snare drum like, indicating
air in the chest, hypo-resonant or a dull thud, indicates blood in
the chest.
Search the Back
The back is just as important as the front and can be easily
disregarded, especially if there is a large (or distraction) injury on
the front of the chest. If possible (injuries allowing), the casualty
should be turned, so that a full examination can be carried out.
When this is not possible or if you happen to be on your own,
hands must be used to feel for any abnormalities. The hands are
placed underneath the casualty until the fingertips touch and
are then removed. We then look at our (gloved) hands to see if
there is any blood present. This process is then repeated until the
entire back has been felt and any wounds have been located and
dressed appropriately. The neck is examined using the TWELVE
acronym. This is a vital step as findings here can indicate the type
and severity of injury.
• T – Tracheal deviation
• W - Wounds
• E – Emphysema
• L – Laryngeal crepitus
• V – Veins, distended or flat
• E - Evaluate
Percussion of the chest
A small wound in the centre of the back
could be easily missed

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Tracheal deviation
The trachea is examined to establish if it is sitting in the correct position. If the trachea is deviated to one side, this could
be an indicator of increased pressure inside the chest, usually due to tensioned air.Tracheal deviation is usually a late or
pre-terminal sign of tension pneumothorax.
The method for ascertaining the correct position is best examined as low down the trachea as possible. Find the sternal
notch (where the two clavicles meet the sternum) and then placing two fingers into the notch, feel the trachea. If the
trachea is deviated, it will have moved away from the injured side.
Tracheal tugging may also be seen or felt. This can be a sign that there is a blockage in the airway.
Wounds
Any wound on the neck could have penetrated
the chest cavity. Evaluation of the mechanism
of injury will help to confirm or deny any chest
injury. Wounds that have transected the trachea
become an airway problem, which may need an
intervention such as a surgical Cricothyroidotomy.
Any wound that has affected the great vessels in the
neck becomes a circulation problem that must be
managed aggressively.
Emphysema
Surgical emphysema is a result of air escaping into
the tissues. Emphysema is indicative of some sort of
pneumothorax. It can usually be felt at the base of
the neck. The feeling has been described as being
similar to Rice Crispies or bubble wrap.
Laryngeal Crepitus
When the larynx becomes disrupted due to a direct insult, it is possible for the fractured parts of the larynx to collapse in
onthemselves.Swellingwillalsooccur.Thisisessentiallyanairwayproblemthatcanbesolvedwithsurgicalintervention
in the field. We can feel for crepitus by placing three fingers onto the larynx and slowly moving the structure, feeling
for any grating sensation.
Veins, Distended or Flat
The large veins that run along the sides of the neck can be examined to see how full or empty they are. When the veins
on the neck are distended, this means that they are not able to empty into the heart as they normally do. This is due to
an increase in pressure inside the chest as found in a tension pneumothorax.
Flat neck veins can indicate that significant blood loss has occurred, possibly due to some sort of haemothorax. This is
not always the case and cannot be used as a definite indicator of a chest problem alone. A casualty with blood loss in
another part of the body could also present with flat neck veins.
Evaluate
Evaluate your findings during the breathing assessment. How is the patients respiratory status? Do they have a life
threatening injury? Have they responded to any treatment?
Life Threatening Chest Injury
There are several life threatening chest injuries that need to be identified and treated quickly.
These are:
• Tension Pneumothorax
• Open Pneumothorax
• Massive Haemothorax
• Cardiac Tamponade
• Flail Chest
These conditions are described on the next page. The specific treatments are listed at the end of the section.
What direction did the wound track take?

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Tension Pneumothorax
This is an increasing accumulation of air in one, or both, pleural spaces. The increasing intrathoracic pressure causes
lung collapse, mediastinal distortion and compression of the lung on the opposite side.
Signs and symptoms of a tension pneumothorax may include:
a. R – Tachypnoea
b. E – Significant difficulty breathing. Patient may be grunting
c. D – Variable
d. F – Variable
e. L – Unequal chest rise
f. A – Absent or decreased breath sounds on the injured side
g. P – Hyper-resonance on the injured side
h. S – Variable
i. T – Deviated towards the uninjured side
j. W – Variable
k. E – Variable
l. L – Variable
m. V – Distended
n. E – Patient requires urgent intervention of tension is suspected
Air is sucked in through the penetrating wound in the chest. Eventually the
lung will collapse due to the excess amount of pressure

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Signs such as distended neck veins or cyanosis depend on a normal circulating blood volume; these signs are likely
to be absent in a hypovolaemic casualty. The main signs - respiratory distress and shock - demand immediate action.
Immediate treatment for a tension pneumothorax is to perform a needle thoracocentesis (needle chest decompression)
using a large bore cannula such as a 12 or 14 gauge medicut/cannula, with a syringe, inserted into the pleural space via
the second intercostal space in the mid-clavicular line on the affected side.
At some stage the move towards a definitive chest drain must be considered, dependant on whether someone skilled
in the technique is available of if there is:
• Delayed evacuation to definitive care due to terrain, assets, geography
• High altitude evacuation route to definitive care in non-pressurised airframe
• Failure of the needle thoracocentesis after prolonged management
• Lack of further medical support/definitive care referral
Open Pneumothorax (Sucking Chest Wound)
The critical size of a defect in the chest wall allowing air to flow in and out of the chest cavity (as opposed to the normal
route through the trachea) is two-thirds the diameter of the trachea. Smaller defects in the chest wall are not usually
associated with sucking; they are more likely to result in a tension or simple pneumothorax.
The adult trachea is approximately 2.5cm wide and therefore any open wound on the chest which is less than 2cm wide
has the potential to create a“sucking chest wound”and therefore an open pneumothorax.
However, any open wounds found on the chest wall should have a commercial chest seal applied over them.
When more than one open chest wound is present on a hemithorax, then the uppermost hole is sealed using a
commercially available chest seal and the others are sealed with an occlusive dressing. The chest seal aim to produce a
one-way valve that will allow air out of the chest, but no air in.
If respiratory distress follows the application of an occlusive chest seal, first burp the dressing to allow any trapped air
to escape. If this fails then, assume the development of a tension pneumothorax and perform needle thoracocentesis
as described above.
Massive Haemothorax
The chest cavity is one of the four classical sites of hidden blood loss. Each hemithorax can hold up to 2·5 litres of blood.
The most common cause is a penetrating wound disrupting the systemic or pulmonary vessels. A massive haemothorax
is defined as 1500 ml or more of blood in the chest cavity.
Signs and symptoms may include:
a. R – Tachypnoea
b. E – May be some difficulty breathing
c. D – Variable
d. F – Variable
e. L – Variable
f. A – Decreased or absent breath sounds on injured side
g. P – Dull or hyporesonant
h. S – Variable
i. T – unaffected
j. W – Variable
k. E – unaffected
l. L – Variable
m. V – Flat
n. E – Evaluate

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Treatment of a massive haemothorax will require management of both the breathing and circulatory issues that the
patient is facing. Additional oxygen will be required to compensate for the poorly functioning lung on the injured side
and if no radial pulse is present then IV fluids will be required. A needle thoracocentesis is not used in this case as the
lost blood may actually be slowing the bleeding. If we release the lost blood through a needle then we make the blood
loss more severe.
Cardiac Tamponade
Cardiac tamponade occurs when blood becomes trapped
between the heart and the non-elastic pericardial sac. This will
resultinpressurebeingappliedtotheheartcausingreducedfilling
of the heart chambers and therefore reduced cardiac output. It
is most commonly caused by penetrating injury but can be as a
result of blunt trauma to the chest. It is immediately fatal except
when the leak from the heart or great vessels into the pericardial
sac is small. You should consider the possibility of this condition
in any casualty with a chest injury who does not respond quickly
to management of airway and breathing problems coupled with
adequate fluid resuscitation. Signs such as distended neck veins
can be absent in hypovolaemia; muffled heart sounds can be
very difficult to detect in a noisy environment. If you suspect this
condition, little can be done in the remote setting and evacuation
to definitive care is paramount.
Flail Chest
When two or more consecutive ribs are fractured in two or more
places, a freefloating, unstable segment of chest wall is produced,
this is called flail chest. Separation of the bony ribs from their
cartilaginous attachments can also cause flail chest. Patients
report pain and tenderness at the fracture sites and pain upon
inspiration.
Physical examination can reveal paradoxical motion of the flail
segment, however this is not always immediately apparent as
muscular splinting of the flail segment can hide this until the
casualty tires. The chest wall moves inward with inspiration and
outward with expiration. In large flail segments with developed
paradoxical movement the casualty can demonstrate“air hunger”
where little or no movement of air is present at the mouth/nose.
Dyspnoea, tachypnoea, and tachycardia may be present.
A significant amount of force is required to produce a flail segment. Therefore, associated injuries are common and
should be aggressively sought. The medic should specifically be aware of the high incidence of associated thoracic
injuries such as pulmonary contusions and closed head injuries.
Pain relief and the establishment of adequate ventilation are the therapeutic goals for this injury. Flail segments should
not be immobilised due to the risk of restricting chest wall movements. Rarely, a fractured rib lacerates an inter-costal
artery or other vessel, which requires surgical control to achieve haemostasis.
Sternal Fractures
The majority of sternal fractures are caused by road traffic accidents. The upper and middle thirds of the bone are
most commonly affected. Patients report pain around the injured area. Inspiratory pain or a sense of dyspnoea may be
present. Physical examination reveals local tenderness and swelling. A palpable defect or fracture-related crepitus may
be present.
Associated injuries occur in 55-70% of patients with sternal fractures. The most common associated injuries are rib
fractures, long bone fractures, and closed head injuries. The association of blunt cardiac injuries with sternal fractures
has been a source of great debate. Blunt cardiac injuries are diagnosed in fewer than 20% of patients with sternal
fractures. Caution should be used before completely excluding myocardial injury.

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Treatments
Needle Thoracocentesis
This procedure is for the rapidly deteriorating
casualty who has a life-threatening tension
pneumothorax. If this technique is used
with a casualty who does not have a tension
pneumothorax, there is a small risk of producing
a pneumothorax or causing damage to the lung,
or both.
A large bore (12 or 14 gauge) cannula is inserted
into the 2nd intercostal space, in larger or muscular
patients a degree of failure has been reported,
therefore consideration of the alternative lateral site
should be considered.
Identify landmarks:
Find the angle of Louis on the sternum. Attached
to the sternum at this point is the second rib. Run
a finger along the second rib until the mid-line of
the clavicle. Underneath this rib is the intercostal
space where the needle will be inserted. The
needle should be inserted over the top of the 3rd
rib and not below the 2nd. This is because there is a
neurovascular bundle that sits below the rib.
An alternative lateral site for needle chest decompression is in the “triangle of safety”, in the fourth or fifth intercostal
space on the patients’side.
a. An imaginary line is drawn from the nipple to the floor in a supine patient (one lying down)
b. A second line is drawn following the lateral edge of the pectoralis muscle
c. A further line is drawn anterior to the mid-axillary line
The cannula is then inserted at a 90° angle to the skin with a syringe containing 5ml of water attached to the end of the
cannula. The cannula should be advanced up until the hub of the cannula is adjacent to the skin. Bubbles of air may be
seen rising through the water. Then the needle is fully removed. A hiss of air may be heard at this point. The breathing
rate will decrease. The cannula must then be protected so that it cannot become kinked or blocked.
This procedure is not definitive. It will buy time whilst a chest drain is setup before insertion. If no formal chest drain
is available, the process can be repeated and multiple needles put in place until the casualty can be evacuated to a
facility that is equipped to deal with the problem. If additional needles are to be placed they should proceed in a lateral
direction, towards the armpits.
After the needle has been inserted, a reassessment of the casualty must take place in order to see if the intervention
has worked.
Potentially Life-threatening Injuries
There are also six potentially life-threatening injuries, which may not have been obvious during the primary survey.
These are grouped into two contusions and four disruptions as follows:
• Pulmonary contusion
• Myocardial contusion
• Diaphragmatic disruption
• Tracheobronchial disruption
• Oesophageal disruption
• Aortic disruption
The landmarks for needle thoracocentesis

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Pulmonary Contusion
This can result from penetrating injury or, more likely, from blunt
injury either by direct compression of the chest wall or from
the effects of blast. The most obvious feature is the resulting
respiratory compromise that increases as time elapses. The
earlier this respiratory compromise appears, the more likely it is
to be lethal. This is especially true in blast injury, producing blast
lung, in these cases severe respiratory distress associated with
haemoptysis can present very quickly.
Casualties with blast lung may initially appear to have minimal
injury. They then sit up to breathe and try to use their accessory
muscles of respiration; they are literally drowning in their own
fluid.Thissevereblastlungwillusuallydevelopwithintwotothree
hours following injury. In such cases, the mortality approaches
100%. Delayed onset may mean the casualty can be saved, but he
will certainly require the high levels of oxygenation only achieved
by intubation and ventilation and not necessarily possible in a
field setting.
Myocardial Contusion
Where there is a history of a crush injury to the central chest, myocardial contusion should be suspected. Irregular
heart rhythms may be present; these casualties run the risk of developing sudden ventricular fibrillation. Proof of
myocardial contusion depends on finding ECG abnormalities and abnormal serum cardiac enzymes; therefore remote
area treatment should be rest, administration of oxygen and early transfer to a unit with monitoring facilities.
Diaphragmatic Disruption
This occurs most commonly to the left hemi-diaphragm and is associated with severe blunt compressive abdominal
injury. It produces tears in the diaphragm allowing the abdominal contents to herniate into the chest. Clinically, there
may be pain in the area of the left chest with an absence of breath sounds.
Tracheobronchial Disruption
The site of disruption may be the larynx, the trachea or a bronchus. Laryngeal fractures are rare; they can present
early with airway obstruction. Initial management requires a tracheostomy, not surgical cricothyroidotomy. Suspect
this condition when there is hoarseness with localized subcutaneous emphysema in the absence of airway obstruction.
Casualties with injuries to the bronchus have a high mortality rate and many die quickly. Those with lesser injuries
may present with haemoptysis or a tension pneumothorax. A classical sign is a pneumothorax that continues to leak
significant amounts of air after a chest tube has been inserted. A second tube may be required in order to prevent air
accumulating in the chest cavity and producing a tension pneumothorax.
Oesophageal Disruption
This is an uncommon injury, caused not only by direct penetration but also by blunt injury to the abdomen producing
increased pressure at the oesophagogastric junction. Forceful retching can also cause it. The most common symptom
is severe pain, usually out of proportion to the apparent injury. Early surgical intervention is required.
Aortic Disruption
Of all casualties with this injury, 80% will die immediately. Of those who do not die immediately, only a third will survive
more than five days. Survivors from traumatic aortic disruption have usually received blunt injuries. In the initial phase
there are usually very few symptoms and signs because, in survivors, the haematoma is contained. Early diagnosis is
made from X-ray findings as fractures of the first and second ribs or a widened mediastinum. Accurate diagnosis in a
field setting is impossible.
Lung contusion

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Non-Lethal Injuries
These should be sought in the secondary survey. They are:
• Simple pneumothorax
• Simple haemothorax
• Rib fractures
Simple Pneumothorax
In the context of trauma, a simple pneumothorax is best treated with needle thoracocentesis and/or chest drainage.
In the field, this is the case even with a small spontaneous pneumothorax since the casualty must be evacuated and
cannot be monitored continually. Furthermore, evacuation by air – with a fall in atmospheric pressure – will allow the
pneumothorax to expand.
Simple Haemothorax
There must be at least 500 ml of blood in the chest cavity for it to show on chest X-ray. A haemothorax of this magnitude
requires chest drainage even if there is no gross upset to the circulation. Most cases will settle spontaneously.
Rib Fractures
Rib fractures are the most common blunt thoracic injuries. Ribs 4-10 are most frequently involved. Patients usually
report inspiratory chest pain and discomfort over the fractured rib or ribs. Physical findings include local tenderness
and crepitus over the site of the fracture. Fractures of ribs 8-12 could include associated abdominal injuries.
Summary
Casualties presenting with immediate life-threatening injuries can be dealt with by simple measures if diagnosed at an
early stage. It is vital that these crisis injuries are detected and managed during the primary survey and resuscitation
phases. Potentially lethal injuries come to light during the secondary survey. These in particular can deteriorate with
time, and proper management requires repeated assessment both in the field and throughout the evacuation process.

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Introduction
The circulatory system is responsible for the
delivery of oxygen and nutrients to the body cells
and the removal of waste products from the tissues.
Any breakdown in the system can lead to serious
tissue damage or death within a short space of
time. Therefore remote medics need to be able to
identify and treat any circulatory problem as it is
found. This chapter will describe the basic anatomy
and physiology of the system, the most common
and life threatening conditions and what methods
are needed to deal with them most effectively.
Anatomy & Physiology
During our lifetime, the heart will beat more than
3 billion times and move 300 million litres of blood
around the body. The usual pulse rate is between
60 and 100bpm. There are several factors that can
influence the rate of the heart. A high level of fitness
can lower the resting heart rate, whereas smoking
can raise the normal heart rate of an individual.
Blood loss through injury will raise the heart rate.
An injury to the brain may actually lower the rate.
These factors will be discussed in more detail later
in this and in other chapters.
The Heart
The heart is a muscular organ, roughly the size of
a clenched fist, located in the centre of the chest
with two thirds of the myocardium on the left side
of the midline of the sternum. The heart is covered
by the pericardial sac, which is a tough, non-elastic,
protective bag.
Blood flows through the superior and inferior vena
cava into the right atrium, the heart contracts and
then pumps the blood through the tricuspid valve
into the right ventricle. The heart contracts again
and the blood is pumped through the pulmonary
artery to the lungs, where diffusion and gaseous
exchange takes place. The blood then returns to
the heart through the pulmonary vein into the
left atrium. The heart contracts and blood is then
pumped into the left ventricle through the bicuspid
(mitral) valve. The heart contracts again and the
blood is pumped out of the heart into the aorta and
around the body.
There is an intrinsic electrical system inside the
heart that emits an electrical pulse that stimulates
different parts of the heart to contract at different
times. Several chemicals can affect the heart, some
of which will block or hamper the electrical system
from working and others will stimulate the heart to
work faster or with more contractile strength.
CHAPTER 5
CIRCULATION AND HAEMORRHAGE CONTROL
The flow of blood through the heart

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Radial Pulse
These chemicals are released in the body naturally or can be introduced to have the appropriate desired effect.
The Pulse
The usual pulse sites that are used are the radial and the carotid. The pulse can also be taken at several sites around the
body. A healthy adult at rest will have a heart rate of approximately 60-100bpm. The goal posts of life for an adult are
40-120bpm.
The presence of a pulse at different locations can give an approximate measurement of the systolic blood pressure.
• Carotid Pulse = BP > 60mmHg
• Femoral Pulse = BP > 70mmHg
• Radial Pulse = BP > 80mmHg
Blood Pressure
This is the measurement of pressure of blood against the inner walls of the arteries. The top number or systolic blood
pressure (SBP) reflects the pressure in the arteries when the heart is pumping. The bottom number or the diastolic
blood pressure (DBP) represents the arterial pressure when the heart is resting (e.g. 120/80 mmHg).
The Blood
Blood is the only fluid that can carry oxygen around the body. Blood is able to do this because erythrocytes (red blood
cells) contain haemoglobin (Hb). Oxygen binds to Hb so that it can be carried around the body.The blood also contains
leukocytes (white blood cells) for fighting infection.
Blood Vessels
Therearethreetypesofbloodvessels,arteries,veinsandcapillaries.
The arteries are thick, muscular tubes that carry oxygenated
blood away from the heart. The veins are relatively thin walled in
comparison to the arteries and contain non-return valves because
the blood that is contained within is at a lower pressure. Veins
return deoxygenated blood to the heart. Capillaries are very small
vessels that enable the exchange of oxygen and nutrients into the
tissues and the removal of carbon dioxide and waste products.
The Arteries and Veins
Carotid Pulse
Pulse locations

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Capillary Refill Time (CRT)
CRT can give a quick evaluation of the circulatory status. Blood is squeezed out of the capillary’s and the time it takes to
refill will show how well the skin is perfused, giving a good indication as to the general circulatory state. In a shocked
casualty, this time will be prolonged.The disadvantage of using this technique is that if the casualty is cold, the capillary’s
that are close to the surface of the skin will have a long refill time regardless of the casualty’s haemodynamic state.
The method involves pressing on either the forehead or the sternum for 5 seconds and then releasing. The skin will
become white and then‘pink’back up again and this gives the result. Normal time is less than 2 seconds.
Types of Bleeding
Bleeding can be described as being arterial, venous
or capillary.
Arterial
This particular type of bleeding is the most life
threatening. The blood is being pumped out of
the vascular system under a great deal of pressure
and therefore quicker than with other types of
bleed. Arterial bleeding occurs when an artery has
been disrupted, either laterally or longitudinally. A
complete transection of the artery will detract back
inside the body because the muscular wall of the
artery will contract in order to protect itself. This
muscular contractility is not available in a wound
that disrupts the artery longitudinally because of
the anatomy and physiology of the vessels.
Venous
Large venous bleeds can also be life threatening. Varicose veins that become disrupted will bleed profusely until the
correct management has been carried out. This dark red blood that flows from a wound can usually be controlled with
simple measures that will be described below. There is no muscular wall to aid with the stopping of the bleed, however
this bleed is under a much less pressure, making it easier to control.
Capillary
The least serious type of bleed is the capillary bleed. Again the wall of the vessel becomes disrupted and blood oozes
from the wound. There is very little pressure behind this bleed and due to the size of the vessels involved; stopping this
type of bleed is very simple.
Haemorrhage Control
As blood is the only oxygen carrying fluid in the body, the blood needs to remain inside the body! There are several
techniques that the remote area medic can use to control compressible external haemorrhage. These methods
include, direct pressure, elevation, compression dressings, wound packing, indirect pressure, splinting, haemostatic
agents, pressure enhancement and tourniquet’s. Each of these methods can be effective, but when used in combination
they produce the most desirable results.
Internal haemorrhage can be controlled by applying traction splints to fractured femurs, applying pelvic splints to
fractured pelvis’ and administering Tranexamic Acid to suitable patients. These interventions will be discussed in later
chapters.
Direct Pressure
Direct pressure is probably the most simple and effective method of haemorrhage control. Press on the wound with
a pad, preferably a sterile wound dressing, but even a tea towel or a scarf will achieve a similar effect. By applying
pressure directly over the top of the wound, this will compress the bleeding edges of the wound.
Elevation
We can use gravity to our advantage. Whilst applying direct pressure, elevate the limb above the level of the heart to
slow down the blood flow into limb.
Types of bleeding

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Compression Dressing
In order to provide both direct pressure and a sterile compression field a good quality trauma dressing should be
used that will apply pressure directly over the wound. A dedicated dressing i.e. First Care Bandage or with a pad from
a field dressing and a crepe bandage will provide this. Whilst using either dressing, the pad should completely cover
the wound and then the crepe bandage is wrapped around the limb. After application the peripheral pulse should be
checked to ensure that the bandage hasn’t been applied too tightly.
Wound Packing
A large bleeding wound does not just bleed at the surface. A good compression dressing will deal with surface bleeding,
however any large wound will need to be packed to ensure that the entire wound has been dressed, using either sterile
gauze or material such as curlex.The gauze is pushed into the wound until they are standing proud of the surface of the
skin. A compression dressing is then applied over the top. This then has the effect of dressing the inside and outside of
the wound, providing better haemorrhage control.
Indirect Pressure
Using a pressure point will stop the entire flow of blood into a limb or area of the body. A pressure point is a point
where an artery crosses over a bone close to the surface of the skin. We can apply pressure to these points to occlude
the blood flow through the artery. Several pressure points are easy to find and occlude.
• Superficial Temporal Artery – Slightly anterior to the tragus of the ear and can be compressed against the
temporal bone to occlude the blood flow to scalp lacerations on that side of the head.
• Axillary Artery – This artery lies along the lateral line of the armpit. With the arm raised, a thumb can be used to
compress the artery. •
• Brachial Artery – This artery lies between the bicep and tricep muscles. We press in and up in between these two
muscles.
• Radial and Ulna Arteries –The radial pulse site can be used to occlude the artery that supplies part of the palmer
arch. Because of the anatomy, this will not stop an arterial bleed on the hand alone. The Ulna artery must also be
compressed at the same time. This can be found by placing two fingers on the little finger side of the wrist. The
artery can then be palpated in a similar manner to the radial artery. Brachial Artery – This artery lies between the
bicep and tricep muscles. We press in and up in between these two muscles.
The First Care Bandage is an excellent compression dressing

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• Femoral Artery – This is the compressible artery that is at the greatest pressure. Even though there is a great deal of
pressure involved, it does not require a great deal of pressure to occlude the artery. Some of the older first aid manuals
described having to use a great deal of force to achieve the desired effect. Methods included using the heel or knee
to press over the general area. This amount of force is inappropriate and can be damaging to the underlying tissues.
Practical methods of locating and compressing the Femoral artery using two thumbs are very effective.
• Popliteal Artery – The Popliteal artery supplies the lower leg and can be located in the centre of the posterior aspect
of the knee. Pressure is then applied with the fingers until the bleed stops.
• Dorsalis Pedis – The main artery that supplies the foot. The pulse may be felt in the centre of the anterior aspect of
the ankle, level with the malleolus. As with the others pressure is applied until the bleed stops.
Splinting
The full immobilisation of bleeding limbs in the pre-hospital environment will aid in the stopping of large bleeds.
And will also avoid further soft tissue damage, has an analgesic effect and therefore reduce the heart rate. Methods of
applying splintage will be discussed in the chapter on extremity trauma.
Pressure Enhancement
The use of an improvised windlass tourniquet directly over the site of a wound will apply not only direct pressure
over the top of the wound, but also circumferential pressure around the limb. Both of which will reduce bleeding. The
method of application is very simple. A broad fold triangular bandage (the width should be approximately 7-10cm’s) is
wrapped around the limb and a knot is tied over the top of the wound. Then place a pen, a small stick, an unused OP
airway, a pair of scissors or something similar on top of the knot.Tie another knot on top of the pen.Then twist the pen,
so that a large knot starts to form directly over the top of the wound. This presses down on top of the wound and gives
good circumferential pressure around the limb.
Tourniquet
These are the primary method of arresting haemorrhage from a life threatening bleed on an extremity eg. Arm or leg.
They should be applied as soon as a life threatening bleed has been identified and prior to assessing the airway.The site
of application of the tourniquet depends on where the life threatening bleed is located.There are two discreet methods
according to the Faculty of Prehospital Care who state:
a. Wound above knee/elbow: The first tourniquet should be place mid-point over the single bone and if bleeding is
not controlled then a second tourniquet is placed just below the first.
b. Wound below knee/elbow: The first tourniquet should be placed on the single bone above the wound and as
close to the joint as possible. If bleeding is not controlled then a second tourniquet should be applied about two
inches above the edge of the wound.
Tie the ends away
securely
Place a solid object on
top of the knot and
then tie another
Start to twist the
object until the knot
starts to form over the
top of the wound
Tie a knot over the top
of the wound

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Some things to note:
a. If the initial bleeding has been controlled by a single tourniquet then as the muscles relax or blood pressure
increases due to fluid resuscitation, bleed from the wound may restart. Tightening the initial tourniquet or
application of a second tourniquet may be necessary to regain control of bleeding.
b. When applying a tourniquet above the knee joint it is important not to be too close to the knee as the femoral
condyles can prevent adequate compression of the artery here.
c. In blast injury to lower limbs, application of a second tourniquet within two inches of the wound edge may be
impossible due to the associated tissue damage. In these cases, the second tourniquet should be applied as
close to the wound as is possible.
The CAT
The CAT uses a windlass type mechanism to apply the relevant amount of pressure in order to stop the bleed.
The method of application is below.
There are other types of tourniquet available but, as with all medical equipment, familiarity is essential.
Before using any piece of equipment, the full functions of it must be examined and tested.
Haemostatic agents
There are an increasing number of products available in the
commercial setting that are aimed at providing increased
ability for the blood to form into a clot around large, potentially
uncontrollable haemorrhage. Examples of these include
QuikClot, Hemcon and Celox.
Most of these products are inert and have no chemical action
and work due to their ability to absorb water molecules (plasma)
from the blood enabling rapid localised coagulation and the
formation of a stable blood clot in a variety of wounds. Celox has
the additional benefit of additionally containing clotting agents.
These agents do not absorb into the body and are safe to leave
in wound as long as necessary.
Most haemostatic agents are now produced bound to gauze
and are relatively simple to use. The wound is packed with the
gauze so that the wound space is filled with the gauze. Pressure
is then applied over the gauze for three minutes (depending
on the product) and finally a pressure dressing is applied above
the wound prior to evacuation. It is important to note that these
products alone will not arrest haemorrhage, they must be used
in conjunction with direct pressure.
Wrap the CAT around the
affected limb, feeding the tail
through the belt buckle
The bar is then twisted.
This tightens the CAT. Once the
bleed has stopped, enough
pressure has been applied
The bar is then locked off
and another piece of Velcro is
used to ensure the bar does
not come loose. The time of
application MUST be noted

MIRA
MEDICINE IN
RE M O T E A R EAS
TM
www.exmed.co.uk
42
CIRCULATION
AND
HAEMORRHAGE
CONTROL
Hypovolaemic Shock
Shock is defined as an inadequate supply of oxygen or nutrients to tissues because of inadequate tissue perfusion,
misdistribution of cardiac output or abnormal microcirculation. Prolonged shock states can lead to multiple organ
failure. Prompt recognition and treatment of shock can avoid costly, prolonged intensive care unit (ICU) stays and more
importantly unnecessary deaths.
Hypovolaemic shock is the most common form of shock after trauma and potentially one of the easiest to treat. There
are many causes of hypovolaemic shock, including internal or external bleeding, losses from the gastrointestinal
tract, such as diarrhoea or vomiting and “third space” losses after major surgery or trauma. The loss of intravascular
volume causes decreased cardiac filling with decreases in intraventricular pressure and volume. The sympathetic
nervous system allows some compensation by increasing peripheral impedance (resistance) to flow and by increasing
myocardial contractility. This causes blood flow to be diverted from organs that can withstand temporary decreases
in oxygen and nutrient supply, such as the intestines and kidney, while preserving blood flow to the brain and heart.
Physiology
Oxygen is carried in the blood in two forms. Most is carried combined with haemoglobin but a small amount is also
dissolved in the plasma. Each gram of haemoglobin can carry 1.31ml of oxygen when it is fully saturated. Every litre
of blood, therefore, (which has a haemoglobin concentration of 150g/l) can carry about 200ml of oxygen when
fully saturated (occupied) with oxygen (partial pressure 100mmHg). At this partial pressure, only 3ml of oxygen will
dissolve in every litre of plasma. When considering the adequacy of oxygen delivery to the tissues, the haemoglobin
concentration, cardiac output, and oxygenation need to be taken into account.
Severalfactorscontributetodecreasedoxygensupplytothetissuesfollowinghaemorrhage.Whensubstantialamounts
of blood loss occur, the fall in the oxygen carrying capacity of the blood and the reduction in blood volume cause a fall
in oxygen delivery.
Hypovolaemic shock is divided into four categories depending on its severity as described below.
Class I haemorrhage corresponds to a less than 15% blood volume loss and generally is well tolerated (blood donors
fall into this category). Treatment is oral rehydration or judicious use of IV fluids. These patients do have a diminished
intravascular volume, but generally compensate well enough to have no classic physical signs of shock.
Classification of
Shock
Class I
Up to 750ml
<15% Lost
II
Up to 750-1500ml
15-30% Lost
III
1500-2000ml
30-40% lost
IV
>2000ml
>40% Lost
Heart Rate <100/min >100-120/min 120-140/min >140/min
Systolic Blood
Pressure
Normal Normal Decreased Decreased,
unrecordable
Pulse Pressure Normal Weak Weak Very Weak, absent
Capillary Refill Time <2 Seconds 2-3 Seconds >3 seconds >4 Seconds, absent
Respiratory Rate 14-20/min 20-30/min >30/min >35/min
Urine Output >30ml/hr 20-30 ml/hr 5-20ml/hr Negligible
Cerebral Function Normal, slightly
anxious
Anxious, frightened,
hostile
Anxious, confused Confused,
unresponsive

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