Chapter 17: Emergency Procedures

Two standard tables are shown for comparison.

The pulse oximeter measures oxygen saturation of arterial blood (SpO₂).

Facts and figures

In a healthy young person the O₂ saturation should be 95–99%. It varies with age, the degree of fitness, current altitude and oxygen therapy. Studies show that white race, obesity and male sex but not smoking are associated with lower SpO₂ readings.¹

The ideal value is 97–100%.

The median value in neonates is 97%, in young children 98% and adults 98%.

Target oxygen saturation

• Asthma—the aim is to maintain it > 94%

• Acute coronary syndromes ≥ 94%

• Opioid effect ≥ 94%

• Type 1 (hypoxemic) respiratory failure (e.g. interstitial lung disease, pneumonia, pulmonary oedema) ≥ 94%

• Severe COPD with hypercapnoeic respiratory failure 88–92%

• Critical illness (e.g. major trauma, shock) 94–98%

• Children > 94% (< 94% is a concern)

Indications for oxygen therapy to be beneficial

• Australian guideline to improve quality of life > 88%

• UK: adults < 50 years 90%, asthma 92.3%

Availability and cost

Pulse oximeters are readily available from medical and surgical suppliers with a range in cost from about $40 to $3000. A good-quality unit is available for about $400.

In the author’s rural practice, over a period of 10 years, the most common cause of sudden death was myocardial infarction, which was responsible for 67% of deaths in the emergency situation. The importance of confirming early diagnosis with the use of the electrocardiogram and serum markers, especially troponin, is obvious. A summary of acute coronary syndromes is presented in Table 17.2.

Recording a 12 lead ECG

Interesting tips

• The 12 lead ECG uses 10 wires (also known as leads) attached to electrodes.

• There are four limb leads and a chest lead.

• It is important that the leads are placed in correct positions since incorrect positions will change the proper signal and may lead to an incorrect diagnosis.

• The limb leads are attached to both arms and legs.

• The right and left arms are active recording leads.

• The ‘standard leads’ (I, II, III, aVR, aVL and aVF) are recorded from the limb electrodes.

• The electrodes can be placed far down the limb or close to the hips and shoulders (e.g. in case of an amputee or heavily clothed patient) but they must be evenly placed on corresponding sides.

• The right leg lead is used as an electrical ground or reference lead and not used for measurement.

• The leads work effectively through stockings, including pantyhose.

The label of each of the 10 electrodes and their placement is as follows (Fig. 17.1):

• RA: on right arm (avoid thick muscles)

• LA: same location to RA but on left arm

• RL: on right leg, lateral calf muscle

• LL: same location as RL but on left leg

• V1: in 4th intercostal space—between ribs 4 and 5, just to right of sternum

• V2: as above but just to left of the sternum

• V3: between leads V2 and V4

• V4: in 5th intercostal space in mid-clavicular line

• V5: at the same level with V4 and V5 in anterior-axillary line

• V6: at the same level with V4 and V5 in mid-axillary line.

Areas ‘looked at’ by the standard leads are shown in Figure 17.2.

Interpreting rate and rhythm

Rate

• R to R interval (i.e. from the pointy tip of one QRS to the next): 300 ÷ number of big squares between the QRS complexes.

• For an irregular rhythm use the 6 second method: 5 big squares = 1 second; 30 big squares = 6 seconds.

• Count QRS complexes in 6 seconds and multiply by 10.

Rhythm

Based on QRS complexes, use a piece of paper to mark the spaces between the QRS complexes and assess their regularity (e.g. Fig. 17.3). Is it regular or irregular? If it is irregular, is there a regular pattern or are they irregularly irregular?

The ECG and myocardial infarction

From Figure 17.4 it is apparent that:

• the leads overlying the anterior surface of the left ventricle will be V2–5 and these will be the leads giving evidence of anterior infarction

• the leads overlying the lateral surface will be the lateral chest leads V5–6

• no leads directly overlie the inferior or diaphragmatic surface. However, the left leg leads, although distant, are in line with this surface and will show evidence of infarction in this area

• there are no leads directly over the posterior surface.

Typical acute inferior infarction

The typical ECG changes of acute myocardial infarction (AMI) with pathological Q waves, S-T segment elevation and T wave inversion are highlighted in leads III and aVL of acute inferior infarction (Fig. 17.5). Lead aVL facing the opposite side of the heart shows reciprocal S-T depression.

Atypical acute anterior infarction pattern is demonstrated in Figure 17.6. This ECG strip shows sinus rhythm with a rate of 75 (300 ÷ 4).

In emergencies, especially those due to acute blood loss, intravenous cannulation for the infusion of fluids or transfusion of blood can be difficult. For the short-term situation, a surgical cutdown into the long saphenous vein at the ankle or the cephalic vein at the wrist is life-saving. Ideally, the long saphenous vein should be used in children.

Surface anatomy

Long saphenous vein: The vein lies at the anterior tip of the medial malleolus. The best site for incision is centred about 2 cm above and 2 cm anterior to the most prominent medial bony eminence (Fig. 17.7a).

Cephalic vein: The cephalic vein ‘bisects’ the bony eminences of the distal end of the radius as it winds around the radius from the dorsum of the hand to the anterior surface of the forearm. The incision site is about 2–3 cm above the tip of the radial styloid (Fig. 17.7b).

Equipment

You will need:

• scalpel and blade (disposable)

• small curved artery forceps

• aneurysm needle (optional)

• vein scissors

• absorbable suture material

• vein elevator

• intravenous catheter.

Method of cutdown

After fitting gloves and using a skin preparation:

1. Make a 1.5–2 cm transverse skin incision over the vein.

2. Locate the vein by blunt dissection. (Do not confuse the vein with the pearly white tendons.)

3. Loop an aneurysm needle or fine curved artery forceps under and around the vein.

4. Place a ligature around the distal vein and use this to steady the vein.

5. Place a loose-knotted ligature over the proximal end of the vein.

6. Incise the vein transversely with a small lancet or scissors or by a carefully controlled stab with a scalpel.

7. Use a vein elevator (if available) for the best possible access to the vein.

8. Insert the catheter (Fig. 17.7c).

9. Gently tie the proximal vein to the catheter.

10. After connecting to the intravenous set and checking the flow of fluid, close the wound with a suitable suture material.

In an emergency situation where intravenous access in a collapsed person (especially children) is difficult, parenteral fluid can be infused into the bone marrow (an intravascular space). Intraosseous infusion is preferred to a cutdown in children under 5 years. It is useful to practise the technique on a chicken bone.

Site of infusion:

• adults and children over 5: distal end of tibia (2–3 cm above medial malleolus)

• infants and children under 5: proximal end of tibia

• the distal femur: 2–3 cm above condyles in midline is an alternative (angle needle upwards).

Avoid growth plates, midshafts (which can fracture) and the sternum. Complications include tibial fracture and compartment syndrome.

Note: Any fluid or drug that can be given by IV can be given by intraosseous infusion.

Method for proximal tibia (Fig. 17.8)

Note: Strict asepsis is essential (skin preparation and sterile gloves).

1. Inject local anaesthetic (if necessary).

2. Choose a 16-gauge intraosseous needle (Dieckmann modification) or a 16- to 18-gauge lumbar puncture needle (less expensive).

3. Hold it at right angles to the anteromedial surface of the proximal tibia about 2 cm below the tibial tuberosity (Fig. 17.8). Point the needle slightly downwards, away from the joint space.

4. Carefully twist the needle to penetrate the bone cortex; it enters bone marrow (medulla) with a sensation of giving way (considerable pressure usually required).

5. Remove the trocar, aspirate a small amount of marrow (blood and fat) or test with an ‘easy’ injection of 5 mL saline to ensure its position.

6. Hold the needle in place with a small POP splint.

7. Fluid can be infused with a normal IV infusion—rapidly or slowly. If the initial flow rate is slow, flush out with 5–10 mL of saline.

8. The infusion rate can be markedly increased by using a pressure bag at 300 mmHg pressure (up to 1000 mL in 5 minutes).

In paraphimosis the penile foreskin is retracted, swollen and painful. Manual reduction should be attempted first. This can be done without anaesthesia, but a penile block with local anaesthetic (never use adrenaline in LA) can easily be injected in a ring around the base of the penis.

Method 1

Manual reduction can be performed by trying to advance the prepuce over the engorged glans with the index fingers while compressing the glans with the thumb (Fig. 17.9a).

Method 2

1. Take hold of the oedematous part of the glans in the fist of one hand and squeeze firmly. A gauze swab or warm towelette will help to achieve a firm grip (Fig. 17.9b).

2. Exert continuous pressure until the oedema passes under the constricting collar to the shaft of the penis.

3. The foreskin can then usually be pulled over the glans.

Method 3

If manual reduction methods fail, a dorsal slit incision should be made in the constricting collar of skin proximal to the glans under local or light general anaesthesia (Fig. 17.9c). The incision allows the foreskin to be advanced and reduces the swelling. Follow-up circumcision should be performed.

Method 4

Cover the swollen oedematous prepuce with fine crystalline sugar and wrap a cut rubber glove over it to exert continuous pressure. Leave for 1 to 2 hours. The foreskin can then be readily retracted.

One of the most puzzling problems in emergency medicine is how to diagnose the unconscious patient caused by a conversion reaction. These patients really experience their symptoms (as opposed to the pretending patient) and resist most normal stimuli, including painful stimuli.

Method

1. Hold the patient’s eye or eyes open with your fingers and note the reaction to light.

2. Now hold a mirror over the eye and watch closely for pupillary reaction (Fig. 17.10). The pupil should constrict with accommodation from the patient looking at his or her own image.

Household shocks tend to cause cardiac arrest due to ventricular fibrillation (Fig. 17.11).

Principles of management

• Make the site safe: switch off the electricity. Use dry wool to insulate the rescuers.

• ‘Treat the clinically dead.’

• Attend to the ABC of resuscitation.

• Give a praecordial thump in a witnessed arrest.

• Consider a cervical collar (? cervical fracture).

• Provide basic cardiopulmonary resuscitation, including defibrillation (as required).

• Give a lidocaine infusion (100 mg IV) after cardiac

• Investigate and consider:

  • careful examination of all limbs

  • X-ray of limbs or spine as appropriate

  • check for myoglobinuria and renal failure

  • give tetanus and clostridial prophylaxis.

• Get expert help—intensive care unit, burns unit.

Head injury is the main cause of death in major trauma. The Glasgow coma scale (below) can be used to assess a patient’s cerebral status. A useful simplified method of recording the conscious state is the following five-level system rating:

1. awake

2. confused

3. responds to shake and shout

4. responds to pain

5. unresponsive coma.

Glasgow coma scale (Table 17.5)

The Glasgow coma scale (GCS) is frequently used as an objective guide to the conscious state.

If the GCS score is:

• 8 or less: severe head injury

• 9 to 10: serious

• 11 to 12: moderate

• 13 to 15: minor.

Arrange urgent referral if the score is less than 12. If the score is 12 to 15, keep under observation for at least 6 hours.

Emergency exploratory burr hole

After a head injury, a rapidly developing mass lesion (classically extradural) is heralded by a deteriorating conscious level (e.g. Glasgow coma scale 15 to 3); a rising blood pressure (e.g. 140/70 to 160/100 mmHg); slowing respirations (16 to 10); a slowing pulse (70 to 55) and a dilating pupil. In such conditions an urgent burr hole is indicated, even in the absence of a plain X-ray and a CT scan of the head. Even elevating a depressed fracture may be sufficient to alleviate the pressure. The relative sites of extradural and subdural haematomas are shown in Figure 17.12 and the classic development of the extradural haematoma in Figure 17.13. This procedure may be life-saving in a rural or remote location.

Method (in absence of neurosurgical facilities)

• This is ideally performed in an operating theatre.³

• The patient is induced, paralysed, intubated and ventilated (100% oxygen). Dehydrating dose of 20% mannitol (1 g/kg IV in 1 hour) administered.

• After shaving the scalp, a mark is made over the site of external bruising, especially if a clinical fracture is obvious. A 5 cm long incision is made over the site of external bruising or swelling. Otherwise the burr hole is made in the low temporal area. A vertical incision is made above the zygoma 2.5 cm in front of the external auditory meatus and extending down to the zygoma, and the skull is trephined 2–3 cm above it (Fig. 17.14). This is the site of the classic middle meningeal haemorrhage.

• The clot is gently aspirated and the skin is loosely sutured around the drain.

• If there are difficulties controlling the bleeding, the intracranial area is packed with wet balls of Gelfoam^® or similar material.

• Other areas that can be explored in the presence of subdural haematoma include:

  • frontal region: a suspicion of an anterior fossa haematoma (e.g. a black eye)

  • parietal region: haematoma from the posterior branch of the middle meningeal artery (Fig. 17.14).

What you should do for the patient is to first offer and provide privacy, confidentiality and emotional support.

Four important things to say initially to any victim

• ‘You are safe now.’

• ‘I am sorry this happened to you.’

• ‘It was not your fault.’

• ‘It’s good that you are seeing me.’

Initial advice to the victim

• If victim reporting to police

  1. Notify the police at once.

  2. Take along a witness to the alleged assault (if there was a witness).

  3. Do not wash or tidy yourself or change your clothing.

  4. Do not take any alcohol or drugs.

  5. Don’t drink or wash out your mouth if there was oral assault.

  6. Take a change of warm clothing.

• If not reporting to police or unsure

  Contact any of the following:

  1. a friend or other responsible person

  2. ‘Lifeline’ or ‘Lifelink’ or similar service

  3. a doctor

  4. a counselling service.

Obtaining information

1. Obtain consent to record and release information.

2. Take a careful history and copious relevant notes.

3. Keep a record, have a protocol.

4. Obtain a kit for examination.

5. Have someone present during the examination (especially in the case of male doctors examining women).

6. Air-dry swabs (media destroy spermatozoa).

7. Hand specimens to the police immediately.

8. Work with (not for) the police.

Examination

If possible the victim should be dressed when seen. When the victim is undressing for examination, get them to stand on a white sheet. This helps to identify small foreign objects that fall to the floor.

Note any injuries as each item of clothing is removed. Each part of the body should be examined under good illumination, and all injuries measured and recorded carefully on a diagram.

Injuries should be photographed professionally. Examine the body and genital area with a Wood’s light to identify semen, which fluoresces. Perform a careful speculum examination. Palpate the scalp for hidden trauma. Collect appropriate swabs.

Making reports

Remember that as a doctor you are impartial. Never make inappropriate judgments to authorities (e.g. ‘This patient was raped’ or ‘Incest was committed’).

Rather, say: ‘There is evidence (or no evidence) to support penetration of the vagina/anus’ or ‘There is evidence of trauma to ____________’.

Handy tips

• Remember that some experienced perpetrators carry lubricants or amylnitrate to dilate the anal sphincter.

• Urine examination in female children may show sperm. (If the child is uncharacteristically passing urine at night, get the mother to collect a specimen.)

• Vaginal and rectal swabs should be air-dried.

• For suspected abuse of children, you cannot work in isolation: refer to a sexual assault centre or share the complex problem.

Post-examination

After the medical examination a discussion of medical problems should take place with the patient. This should be done in private and kept totally confidential. A management plan for physical injuries and emotional problems is discussed.

Consider the possibility of STI and possible referral. Consider also the possibility of pregnancy and the need for postcoital hormone tablets. Organise follow-up counselling and STI screening.

Management issues

• Take swabs and/or first-void specimen for testing gonococcus and chlamydia (PCR).

• Take blood for HIV, syphilis.

• Collect specimens—swab aspirate of any fluid and keep for DNA analysis.

• Give prophylactic antibiotics—depends on type of assault and assailant.

• Emergency contraception.

• Review in 3 weeks—check tests.

• Screen for syphilis and HIV in about 3 months.

• Refer to rape crisis centre.

Drug-assisted sexual assault

Consider this when patient has no memory of events and time or other suspicious circumstances. Urine or blood testing may be appropriate.

At first symptoms:

• start drinking 1 litre of water over 20 minutes

• aspirin or paracetamol + anti-emetic, e.g.

  • soluble aspirin 600–900 mg (o) and

  • metoclopramide 10 mg (o)

  • if vomiting: metoclopramide 10 mg dissolved sublingually.

  For established migraine:

• IV metoclopramide 10 mg, then 10 to 15 minutes later give 2 to 3 soluble aspirin and/or codeine tablets

  or

• IM metoclopramide 10 mg, then 20 minutes later IM dihydroergotamine 0.5–1 mg

  or

• lidocaine 4% topical solution—as spray 2.5 mL per nares

  or

• serotonin receptor agonist:

  • sumatriptan (o), SC injection or nasal spray

    or

  • zolmitriptan (o), repeat in 2 hours if necessary

    or

  • naratriptan (o), repeat in 4 hours if necessary. If very severe (and other preparations are unsuccessful):

    or

  • haloperidol 5 mg IM or IV.

    Note: Avoid pethidine.

The IV fluid load method

Many practitioners claim to obtain rapid relief of migraine by giving 1 litre of intravenous fluid over 20 to 30 minutes, supplemented by oral paracetamol.

Intravenous lidocaine

Lidocaine (1% solution intravenously) can give rapid relief to many people with classic or common migraine.

The dose is 1 mg lidocaine per kg (maximum) (a 70 kg adult would have a maximum dose of 7 mL of 1% solution). The IV injection is given slowly over about 90 seconds with monitoring of pulse and blood pressure.

Improvised methods to help alleviate the distress of anxiety-provoked hyperventilation include:

• Breathe in and out of a paper bag.

• Breathe in and out slowly and deeply into cupped hands.

• Suck ice blocks slowly (a good distractor).

Pneumothoraces can be graded according to the degree of collapse:

• small: up to 15% (of pleural cavity)

• moderate: 15–60%

• large: > 60%.

A small pneumothorax is usually treated conservatively and undergoes spontaneous resolution.

Simple aspiration can be used for a small to moderate pneumothorax—usually 15–20%.

Traumatic and tension pneumothoraces represent potential life-threatening disorders.

Tension pneumothorax requires immediate management.

Intercostal catheter

A life-saving procedure for a tension pneumothorax is the insertion of an intercostal catheter (a 14-gauge intravenous cannula is ideal) or even a needle as small as 19-gauge (if necessary) into the second intercostal space in the midclavicular line along the upper edge of the third rib. The site should be at least two finger-breadths from the edge of the sternum, so that damage to the internal mammary artery is avoided. The catheter is connected to an underwater seal.

An alternative site, which is preferable in females for cosmetic reasons, is in the mid-axillary line of the fourth or fifth intercostal space (Fig. 17.15).

Simple aspiration for pneumothorax

For patients presenting with pneumothorax, the traditional method of insertion of an intercostal catheter connected to underwater seal drainage may be avoided with simpler measures. Patients with a small pneumothorax (less than 15% lung collapse) can be managed conservatively.⁴ Larger uncomplicated cases can be managed by simple aspiration using a 16-gauge polyethylene intravenous catheter.

Method

1. The patient lies propped up to 30–40°.

2. Infiltrate LA in the skin over the second intercostal space in the midclavicular line on the affected site.

3. Insert a 16-gauge polyethylene intravenous catheter into the pleural space under strict asepsis.

4. Aspirate air into a 20 mL syringe to confirm entry into this space, and then remove the stilette.

5. Connect a flexible extension tube to this catheter, and then connect this tube to a three-way tap and a 50 mL syringe.

6. Aspirate and expel air via the three-way tap until resistance indicates lung re-expansion.

Obtain a follow-up X-ray. Repeat aspiration may be necessary, but most patients do not require inpatient admission.

This procedure may be life-saving when endotracheal intubation is either contraindicated or impossible. It may have to be improvised or performed with commercially available kits such as the Surgitech rapitrac kit or the Portex^® Minitrach^® II kit. Cricothyroidostomy can be performed using a standard endotracheal tube, from which the excess portion may be excised after insertion.

Method for adults

1. The patient should be supine, with the head, neck and chin fully extended (Fig. 17.16a).

2. Operate from behind the patient’s head.

3. Palpate the groove between the cricoid and thyroid cartilage.

4. Make a short (2 cm) transverse incision (or longitudinal) through the skin and a smaller incision through the cricothyroid membrane (Fig. 17.16b).

   • Ensure the incision is not made above the thyroid cartilage.

   • Local anaesthesia (1–2 mL of 1% lidocaine) will be necessary in some patients.

     An artery clip or tracheal spreader may be inserted into the opening to enlarge it sufficiently to admit a cuffed endotracheal or tracheostomy tube.

5. Use an introducer to guide the cannula into the trachea.

6. Insert an endotracheal or tracheostomy tube if available.

Since damage to the cricoid cartilage is a concern in children, surgical cricothyroidostomy is not recommended for children under 12 years of age.

Method for children

1. Do not perform a stab wound in children because of poor healing.

2. Use a 14- to 15-gauge intravenous cannula.

3. Pierce the cricothyroid membrane at an angle of 45°. Free aspiration of air confirms correct placement.

4. Fit a 3 mm endotracheal tube connector into the end of the cannula or a 7 mm connector into a 2 mL or 5 mL syringe barrel connected to the cannula.

5. Attach the connector to the oxygen circuit; this system will allow oxygenation for about 30 minutes but carbon dioxide retention will occur. The oxygen enriched air needs to be properly humidified.

Improvisation tips

1. Any piece of plastic tubing, or even the ‘shell’ of a ballpoint pen, will suffice as a makeshift airway.

2. A 2 mL or 5 mL syringe barrel will suffice as a connector between the cannula and the oxygen source.

Children: Encourage coughing. If unsuccessful, place the child over your knees with head down and give hard blows with the heel of the hand to the upper back (5 to 10 blows). Also chest compression to depress the chest by one-third of its diameter can be used. In older children, get them to lean over you as you deliver blows to the back.

Adults: Encourage coughing. If unsuccessful give 5 firm blows to the upper back followed by chest thrusts if neccessary. This is first-line treatment.

The Heimlich manoeuvre

This procedure is most useful for an adult with an impacted foreign body in the pharynx.

Method

1. Remove any dentures and try hooking out the bolus with a finger. Ask them to cough.

2. The rescuer stands behind the patient and grasps the arms firmly to make a fist over the epigastrium 2 finger breaths below the xiphisternum (keep the elbows out).

3. Following a ‘gasp’, a firm squeeze is given to the upper abdomen. If necessary, this is repeated every 10 seconds for half a minute.

Problems with procedure

• Wrong position

• Damage to underlying organs and structures

• May precipitate regurgitation of stomach contents

The older, simple methods used to treat SVT, including carotid sinus massage, are now regarded as unsafe, especially in the elderly. A method that is now used routinely in emergency departments is to ask the patient to blow into a plastic syringe.

Method

Slightly loosen the plunger of a 20 mL syringe and ask the patient to blow into the tip of the syringe, attempting to move the plunger. This type of Valsalva manoeuvre may abort the tachycardia. Another method is to briefly immerse the patient’s face in cold water.

For failed procedure

Give IV adenosine or verapamil.

Snake bites

Most bites do not result in envenomation, which tends to occur in snake handlers or in circumstances where the snake has a clear bite of the skin.

First aid

1. Keep the patient as still as possible.

2. Do not wash, cut or manipulate the wound, or apply ice or use a tourniquet.

3. Immediately bandage the bite site firmly (not too tight). A crepe bandage is ideal: it should extend above the bite site for 15 cm, e.g. if bitten around the ankle, the bandage should cover the leg to the knee.

4. Splint the limb to immobilise it: a firm stick or slab of wood would be ideal.

5. Transport to a medical facility for definite treatment. Do not give alcoholic beverages or stimulants.

6. If possible, the dead snake should be brought along.

Note: A venom detection kit can be used to examine a swab of the bitten area or a fresh urine specimen (the best) or blood.

The bandage can be removed when the patient is safely under medical observation. Observe for symptoms such as vomiting, abdominal pain, excessive perspiration, severe headache and blurred vision.

Treatment of envenomation

1. Set up a slow IV infusion of N saline.

2. Give IV antihistamine cover (15 minutes beforehand) and 0.3 mL of adrenaline 1:1000 SC (0.1 mL for a child).

3. Dilute the specific antivenom (1:10 in N saline) and infuse slowly over 30 minutes via the tubing of the saline solution.

4. Have adrenaline on standby.

5. Monitor vital signs.

Spider bites

First aid

Sydney funnel-web: as for snake bites.

Other spiders: apply ice pack, do not bandage.

Treatment of envenomation

• Sydney funnel-web:

  • specific antivenom

  • resuscitation and other supportive measures.

• Red-back spider:

  • give antihistamines

  • antivenom IM (IV if severe) 15 minutes later.

Human bites and clenched fist injuries

Human bites, including clenched fist injuries, often become infected by organisms such as Staphylococcus aureus, streptococcus species and beta-lactamase producing anaerobic bacteria.

Principles of treatment

• Clean and debride the wound carefully, e.g. aqueous antiseptic solution or hydrogen peroxide.

• Give prophylactic penicillin if a severe or deep bite.

• Avoid suturing if possible.

• Tetanus toxoid.

• Consider rare possibility of HIV, hepatitis B or C, or infections.

For wound infection

• Take swab.

• Procaine penicillin 1 g IM, plus Augmentin^® 500 mg, 8 hourly for 5 days.

For severe penetrating injuries, e.g. joints, tendons

• IV antibiotics for 7 days.

Dog bites (non-rabid)

Animal bites are also prone to infection by the same organisms as for humans, plus Pasteurella multocida.

Principles of treatment

• Clean and debride the wound with aqueous antiseptic, allowing it to soak for 10 to 20 minutes.

• Aim for open healing—avoid suturing if possible (except in ‘privileged’ sites with an excellent blood supply, such as the face and scalp).

• Apply non-adherent, absorbent dressings (paraffin gauze and Melolin™) to absorb the discharge from the wound.

• Tetanus prophylaxis: immunoglobulin or tetanus toxoid.

• Give prophylactic penicillin for a severe or deep bite: 1.5 million units of procaine penicillin IM statim, then orally for 5 days. Tetracycline or flucloxacillin are alternatives.

• Inform the patient that slow healing and scarring are possible.

Cat bites

Cat bites have the most potential for suppurative infection. The same principles apply as for management of human or dog bites, but use flucloxacillin. It is important to clean a deep and penetrating wound. Another problem is cat-scratch disease, presumably caused by a Gram-negative bacterium.

Sandfly (biting midges) bites

For some reason, possibly the nature of body odour, the use of oral thiamine may prevent sandfly bites.

Dose: Thiamine 100 mg orally, daily.

For relief of itching apply an anti-itch cream and consider oral anti-histamines if severe.

Bed bug bites

The common bed bug (Cimex lectularis, Fig. 17.17) is now a major problem related to international travel. It travels in baggage and is widely distributed in hotels, motels and backpacker accommodation. Clinically bites are usually seen in children and teenagers. The presentation is a linear group of three or more bites (along the line of superficial blood vessels), which are extremely itchy. They appear as maculopapular red lesions with possible wheals. The lesions are commonly found on the neck, shoulders, arms, torso and legs. A bed bug infestation can be diagnosed by identification of specimens collected from the infested residence. Look for red- or rust-coloured specks about 5 mm long on mattresses.

Management

• Clean the lesions.

• Apply a corticosteroid ointment.

• A simple anti-pruritic agent may suffice.

• Call in a licensed pest controller.

Control treatment is basically directed towards applying insecticides to the crevices in walls and furniture.

Tip: If a backpack is thought to harbour the bugs, put it in the freezer overnight.

Bee stings

First aid

1. Scrape the sting off sideways with a fingernail or knife blade. Do not squeeze it with the fingertips.

2. Apply 20% aluminium sulfate solution (Stingose^®).

3. Apply ice to the site.

4. Rest and elevate the limb that has been stung.

If anaphylaxis occurs, treat as appropriate.

Centipede and scorpion bites

The main symptom is pain, which can be very severe and prolonged.

First aid

1. Apply local heat, e.g. hot water with ammonia (household bleach).

2. Clean site.

3. Local anaesthetic, e.g. 1–2 mL of 1% lidocaine infiltrated around the site.

4. Check tetanus immunisation status.

Other bites and stings

This includes bites from ants, wasps and jellyfish.

First aid

1. Wash the site with large quantities of cool water. Consider soapy water for mosquito bites.

2. Apply vinegar (liberal amount) or 20% aluminium sulfate solution (Stingose^®) to the wound for about 30 seconds.

3. Apply ice for several minutes.

4. Use soothing anti-itch cream e.g. hydrocortisone 0.5 or 1% cream or 5% lidocaine cream or ointment if very painful.

Medication is not usually necessary, although for a jellyfish sting the direct application of Antistine-Privine drops onto the sting (after washing the site) is effective.

Special tip: A cost-effective and antipruritic agent for insect stings is Mylanta^® or similar antacid, containing aluminium sulfate or hydroxide.

Box jellyfish or sea wasp (Chironex fleckeri)

Treatment

1. The victim should be removed from the water to prevent drowning.

2. Inactivate the tentacles by pouring vinegar over them for 30 seconds (do not use alcohol)—use up to 2 L of vinegar at a time. Gently remove the tentacles.

3. Check respiration and the pulse.

4. Start immediate cardiopulmonary resuscitation (if necessary).

5. Give box jellyfish antivenom by IV injection.

6. Provide pain relief if required (ice, lidocaine and analgesics).

Stinging fish and stingrays

The sharp spines of stinging fish and stingrays have venom glands that can produce severe pain if they spike or even graze the skin. The best known of these is the stonefish. The toxin is usually heat sensitive.

Treatment

1. Bathe or immerse the affected part in very warm to hot (not scalding; aim at 45°C⁵ (measured with a thermometer) for 20 minutes) water—this may give instant relief. If immersion or hot water is not available, heat packs are suitable.

2. If pain persists, give a local injection/infiltration of lidocaine 1% or even a regional block. If still persisting, try pyroxidine 50 mg intralesional injection.

3. A specific antivenom is available for the sting of the stonefish.

Note: Heat immersion is worth trying for other marine ‘stingers’ such as the bluebottle jellyfish.

Treatment

1. Carefully debride the wound.

2. If infected, phenoxymethyl penicillin 500 mg (o), 6-hourly.

Dose

• Adult and child > 30 kg: 300 mcg

• Child 15–30 kg (usually 1–5 years): 125 mcg

Types

• EpiPen^® or Anapen^®

Method

• Hold the pen tightly in the palm of the hand with the needle tip down.

• Place the needle tip gently against the mid-outer thigh in the ‘fleshiest’ part of the muscle (with or without clothing). It should be perpendicular to the thigh.

• Push down hard against the thigh until you hear or feel a ‘CLICK’ (in case of the EpiPen^®) or for the Anapen^® press the red button until it clicks (Fig. 17.18).

• Hold in place for 10 seconds.

• Remove and massage the injection site for 10–20 seconds.

• Call 000 for an ambulance.

Note: Do not inject into the buttock.

A rapid assessment is made of the circulation and possible blood loss. Haemostasis should be achieved with direct pressure rather than the use of tourniquets. Multiple packs into wounds should be avoided. Two important monitors are a cardiac monitor and a central venous line.

To replace blood loss two peripheral lines should be inserted into the cubital fossa, if possible. The larger the needle gauge the better; for example, the rate of flow for a 14-gauge cannula is 175–220 mL/min and for a 16-gauge cannula is 100–150 mL/min. Flow rates are improved by using pressure bags to 300 mmHg.

Cutdown can be used and if problems occur an interosseous infusion is a suitable alternative or addition. A colloid solution (e.g. Gelofusine^® or Haemaccel^®) can be used initially with 1 L infused rapidly. If there are two lines, a crystalloid solution such as normal saline or Hartman’s solution can be used on one side and the plasma volume expander on the other line.

Blood is required after a major injury or where there has been a limited response to 2 L of colloid. Blood should be warmed before use. Beware of those suspected of having fractures of the pelvis and legs. Massive amounts of blood loss can be associated with these fractures (Table 17.6).

It must be remembered that young patients can compensate well for surprising degrees of blood loss and maintain normal vital signs simply by increasing the cardiac stroke volume. Such patients can collapse dramatically.

When certain injuries, especially bony fractures, are found it is important to consider associated soft-tissue injuries. Table 17.7 presents possible associated injuries with various fractures, while Table 17.8 outlines possible associated injuries with various physical signs or symptoms.

The first two hours after injury can be vital: proper care can be life-saving, inappropriate care can be damaging. The first step is for someone to notify the police and ambulance or appropriate emergency service. The site of an accident should be rendered safe by eliminating as many hazards as possible, e.g. turning off the ignition of a vehicle, warning people not to smoke, moving victims and workers out of danger of other traffic.

Attention should be given to:

• the airway and breathing

• the cervical spine: protect the spine

• circulation: arrest bleeding

• fractured limbs (gentle manipulation and splintage)

• open wounds, especially open chest wounds, should be covered by a firm dressing.

Major haemorrhage is a common cause of death in the first few hours. Lacerated organs and multiple fractures can lose 250 mL of blood a minute; pressure should be applied to control haemorrhage where possible. Colloids that can be administered intravenously for blood loss include Haemaccel^® and Gelofusine^®.

Intramuscular narcotic injections (morphine, pethidine) and alcohol ‘to settle the victim’s nerves’ must be avoided. Consider inhalational analgesia with the Penthrox^® Inhaler. It can be used with oxygen or air. It provides pain relief after 8 to 10 breaths and it continues for several minutes. When the patient is under control, he or she should be shifted into the coma position (Fig. 17.19).

Administration of first aid to the injured at the roadside

A simple guide is as follows:

1. Check airway and breathing (being mindful of cervical spine)

   1. Check oral cavity

      • tongue fallen back

      • dentures or other foreign matter in mouth

      Clear with finger and place in oral airway if available, or hold chin forward.

   2. Check breathing

      If absent, commence artificial respiration if feasible.

2. Check circulation

   If pulse absent, commence external cardiac massage if possible.

3. Check for haemorrhage, especially bleeding from superficial wounds. Apply a pressure bandage directly to the site.

4. Check for fractures, especially those of the cervical spine.

   Rules to remember

   • Immobilise all serious fractures and large wounds before shifting.

   • Always apply traction to the suspected fracture site.

   • Splint any fractured limbs with an air splint, wooden splint or to body, e.g. arm to chest, leg to leg.

   • For a suspected or actual fractured neck, apply a cervical collar, even if made out of newspaper; or keep the head held firmly in a neutral position with gentle traction (avoid flexion and torsion).

   • Lay the patient on his or her back with head supported on either side.

5. Shifting the patient

   • Immobilise all fractures.

   • Lift the casualty without any movement taking place at the fracture site, using as much help as possible.

   • Always support the natural curves of the spine.

   • Protect all numb areas of skin (e.g. remove objects such as keys from the pockets).

6. The unconscious patient

   • Transport the casualty lying on the back if a clear airway can be maintained.

   • If not, gently move into the coma position.

7. Reassure the patient (if possible)

   • Reassurance of the casualty is most important.

   • Conduct yourself with calmness and efficiency.

8. Help the medical team

   Take notes of your observations at the accident, e.g. record times, colour of casualty, conscious level, respiration, pulse, blood pressure.

Roadside emergency ‘tricks of the trade’

• Emergency split towel: The inner sterile paper envelope of sterile surgical gloves can be used as a split towel to cover the wound and the inner sterile side of the outer paper envelope as a sterile sheet for instruments.

• Emergency sterilisation: The tip of forceps, knives, needles and other instruments can be sterilised by passing through the flame of a gas lighter.

• Emergency flushing fluid: One can use the water jet stream from the hole punctuated at the neck of the purified water bottle.