Chapter 2.

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PRE-HOSPITAL EMERGENCY CARE

Note:
Procedure standards for pre-hospital emergency care provided by Emergency Medical Services (EMS) are described. The emergency personnel in Czech Republic consists of a physician, a nurse, and a driver. Only one victim is supposed to be dealt with. Procedures for simultaneous management and triage of more victims are not included.

Contents:
2.1.: Assessment of vital functions
2.2.: Breathing
2.3.: Blood circulation
2.4.: Neurological assessment
2.5.: Traumatological diagnosis
2.6.: Glucocorticoids
2.7.: Nursing care
2.8.: Transport
2.9.: Admission to hospital
2.10: Documentation

STANDARD 2.1: ASSESSMENT OF VITAL FUNCTIONS Hvezdicka.GIF (147 bytes)

The aim of critical care at the site of accident is to resuscitate and stabilize adequate ventilation and circulation in accordance with the recommendations of the European Council for Resuscitation.

If the person with head injury is unconscious, not breathing and/or without a pulse, start advanced life support. Follow the advanced life support procedures as recommended by the Czech Association for Anesthesiology, Resuscitation, and Intensive Medicine.

STANDARD 2.2.: BREATHING Hvezdicka.GIF (147 bytes)

If the TBI casualty has an altered level of consciousness but is breathing and has a pulse, secure the airway. Administering 100% oxygen by mask is recommended to prevent secondary hypoxic episodes. Unconscious casualties (GCS 8 or less) are intubated and artificially ventilated already before transport at the site of accident .

Recommended central nervous system depressants are benzodiazepines, propofol, and thiopental. All available skeletal muscle relaxants can be used depending on circulatory parameters.

Artificial pulmonary ventilation should be maintained at:
- PaCO2 35 mmHg (4.5 kPa),
- PaO2 >75 mmHg (10 kPa) or SaO2 >95%.
There are no convincing data that hyperventilation is of value for treatment of ICP in pre-hospital care.

STANDARD 2.3.: BLOOD CIRCULATION Hvezdicka.GIF (147 bytes)

After assisted ventilation has been ensured in the TBI casualty, concentrate on stabilizing blood pressure.

 STANDARD 2.4.: NEUROLOGICAL ASSESSMENT Hvezdicka.GIF (147 bytes)

As soon as the vital functions of the TBI casualty are under control, perform a brief neurological examination. We assess level of consciousness according to Glasgow Coma Scale (GCS) - eye opening, best motor and verbal response, - size and reactivity of the pupils, and neurological deficit at the extremities. It is extremely important that the scalp of the victim should be carefully examined. This is crucial for determining the mechanism of injury.

STANDARD 2.5.: TRAUMATOLOGICAL DIAGNOSIS Hvezdicka.GIF (147 bytes)

After securing the vital functions (level of consciousness, breathing, and circulation), proceed with a brief traumatological examination of other parts of the body, i.e. the thorax, abdomen, spine, and extremities. The Champion Trauma Scale is recommended.

STANDARD 2.6.: GLUCOCORTICOIDS Hvezdicka.GIF (147 bytes)

Glucocorticoids are not indicated in isolated head trauma. If spinal trauma is diagnosed with head trauma, administer methylprednisolon (in accordance with the results of NASCIS-II and NASCIS-III). Glucocorticoids are not also indicated if head trauma is part of multiple trauma.

STANDARD 2.7.: NURSING CARE Hvezdicka.GIF (147 bytes)

The head of the TBI casualty should be elevated (10 degrees is optimal) and kept in a neutral position all the time. The position of the head and body should only be changed if necessary, and with great care. If the person is unconscious and if an injury to the cervical region of the spine is suspected, apply a cervical collar as soon as possible, even before establishing an airway.

STANDARD 2.8.: TRANSPORT Hvezdicka.GIF (147 bytes)

A casualty with isolated TBI should be taken to the nearest trauma centre by ambulance or helicopter (see also Standard 8.2.).

A person with traumatic brain injury as part of multiple trauma should be transported to the nearest hospital capable of providing adequate treatment. If the vital functions have been stabilized during pre-hospital care, transport to the nearest trauma centre is more appropriate.

STANDARD 2.9.: ADMISSION TO HOSPITAL Hvezdicka.GIF (147 bytes)

The victim with brain injury is handed over to the Emergency Department staff by Emergency Service personnel. It is necessary to maintain the level of monitoring and nursing care which have been ensured during pre-hospital care. All necessary information concerning the circumstances of the injury from the police, fire brigade, and eye witnesses should be given to the treating physician.

STANDARD 2.10: DOCUMENTATION Hvezdicka.GIF (147 bytes)

Note down any information necessary for further diagnostic and therapeutic procedures in the accident and emergency department. First, describe your examination and management of the person at the site of accident. Then state when and where it happened; the delay between the accident and effective therapeutic measures; cause and mechanism of the accident; signs of ebriety or strangulation, etc.

Coordinated by Jiri POKORNY Jr., M.D.

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Last updated: 1999-09-06