FPHC consensus statements

Question 1

How does the FPHC consensus statement divide airways burns? (2)

Answer 1

1. Supraglottic (nose/oropharynx and larynx) - most common
2. Infraglottic

Question 2

How can infraglottic burns be caused?

Answer 2

Steam inhalation
Aspiration of scalding liquid
Blast injury
Flammable gas under pressure
Aerosolised chemicals

Question 3

What are the features of infraglottic burns? (5)

Answer 3

1. Impaired ciliary activity
2. Hypersecretion
3. Oedema
4. Mucosal ulceration
5. Bronchial spasm

Question 4

What 3 considerations should be made with intubation in patients with airway burns?

Answer 4

1. Largest size tube that will be placed (bronchoscopy on ITU)
2. Uncut (airway will swell)
3. Careful with tube tie

Question 5

What features have been shown to correlate with need for RSI (FPHC)? (6)

Answer 5

1. Full thickness facial burns
2. Stridor
3. Resp distress
4. Swelling on larygnoscopy
5. Smoke inhalation
6. Singed nasal hairs

Question 6

When does FPHC recommend using cyanide antidote?

Answer 6

Suspected smoke inhalation AND:
- altered mental status
- CV instability

Question 7

What 3 categories of burns severity does FPHC recommend using pre-hospital?

Answer 7

< 20%
20-50%
> 50 %

Question 8

What does FPHC say about water cooling of thermal burns? (3)

Answer 8

1. Water < 20 degrees (12 ideal)
2. 20 mins
3. Not ice water secondary to risk of tissue necrosis

Question 9

What does FPHC recommend with regards to first aid for chemical burns? (3)

Answer 9

1.Treat any chemical burn ASAP regardless of delay to presentation

2. Use amphoteric solution as first line
3. Irrigate for as long as possible

Question 10

When does FPHC state fluid resus should be commenced pre-hospital in:-
- adults
- paeds

Answer 10

> 20%

Question 11

What analgesia should be avoided in burns?

Answer 11

NSAIDs if requiring fluid resus

Question 12

When does FPHC recommend chest escharatotomy?

Answer 12

Circumferential or near circumferential eschar with imprending or established respiratory compromise to to thoraco-abdominal burns

Question 13

Describe the 3 parts to the FPHC extrication decision tool for non-medical personel

Answer 13

1. Can the casualty self extricate
2. Is a snatch rescue indicated?
3. Deliver quickest appropriate extrication

Question 14

What is the FPHC recommended first line extrication method?

Answer 14

Self/minimally assisted

Question 15

What is the acronym USTEP, what is it used for and who recommends it?

Answer 15

FPHC

Non-clinicians for helping self extricate

Understanding (get patient understand)
Support (emotionall)
Try moving (if unable then can’t self extricate)
Egress (clear route out)
Plan - where will they go next (chair/trolley)

Question 16

Under what circumstances does FPHC state MILS is not needed inside the vehicle?

Answer 16

Fully conscious and no neurology

Question 17

If patients have neurology what extrication measure does FPHC recommend

Answer 17

Rapid extrication with gentle handling

Question 18

When does the FPHC recommend using a hard collar in extrication? (2)

Answer 18

1. Suspected serious neck injury

or

2. GCS <15 + evidence of significant injury to any body compartment

Question 19

When should a binder be placed during extrication according to FPHC?

Answer 19

After extrication

Question 20

What does the FPHC consensus statement recommend with respects to airway in pregnancy? (4)

Answer 20

1. NP relatively c/i due to increased friability of mucosa in pregnancy
2. Use smaller ETT due to swelling
3. Use second generation SGA
4. Use vertical incision for front of neck as increased tissue oedema seen in pregnancy makes landmarking more challenging

Question 21

What does FPHC recommend for pregnancy trauma patients with respects to breathing? (2)

Answer 21

1. High flow oxygen in all trauma patients
2. Thoracostomies/chest drains should be 3rd or 4th IC space

Question 22

What does FPHC recommend with respects to circulation in pregnant trauma patients? (7)

Answer 22

1. Limited reliance on BP as marker of hypovolaemia
2. Examination of uterus and external genitalia mandatory in evaluation of haemorrhage
3. Tilt/manual displacement recommended at all times for pregnant trauma patients
4. IV access above diaphragm
5. Early blood products as fluid will exacerbate pre-existing haemodilution that occurs in pregnancy
6. TXA
7. Pelvic binders

Question 23

What does FPHC recommend in pregnant patients being resusitated? (2)

Answer 23

1. Supine with manual displacement of uterus
2. RH within 15mins of witnessed arrest with ongoing CPR

Question 24

What does FPHC recommend for all pregnant trauma patients in terms of conveyance/destination? (3)

Answer 24

1. All trauma patients should be seen in the ED not maternity
2. If >20/40 should go to nearest TU with maternitry (if trauma negative) or MTC with maternity (if positive). If <20/40 can go to hospital without maternity
3. All MTCs should have co-located obstetrics

Question 25

In a self ventilating patient with suspected PTX/tension PTX what does FPHC recommend as: 1. First line 2. Second line 3. Third line

Answer 25

1. Needle decompressoin 2nd IC space mid clavicular 2. 5th IC space mid-axillary line 3. Thoracostomy followed up by CD if level 6 practitioner

Question 26

What does the FPHC say about chest drains pre-hospital in their consensus statement

Answer 26

Should be avoided where possible due to: - prolongation of on-scene time - risks of kinking - blocking or falling out during transfers - long-term infection risks with non-sterile insertion techniques. It is accepted that chest drain insertion will be necessary in some circumstances eg high-altitude aero-medical retrieval.

Question 27

What is the complication rate of pre-hospital thorocostomy?

Answer 27

10-15%

Question 28

What does FPHC recommend with respects to abx and thoracostomy?

Answer 28

Should be considered for pre-hospital thoracostomy, especially in cases of penetrating chest trauma, or with transport times >3 hours

Question 29

What does FPHC recommend for treatment open PTX? (2)

Answer 29

1. Commercial chest seal, vented preferably (3 sided dressing no longer recommended) 2. IV abx prophx

Question 30

What is the FPHC consensus statement on massive HTX? (3)

Answer 30

1. If no respiratory compromise then drainage should be delayed until ED 2. Where thoracostomy has shown significant haemorrage then a chest drain maybe beneficial to monitor blood loss, however should not significantly impact of scene time. 3. Clamping chest drain for exsanguinating chest trauma, however caution needed as high chance of co-existing PTX which could tension with PPV etc.

Question 31

What is the FPHC consensus statement recommendations on flail chest? (4)

Answer 31

1. Where possible, sit up 2. Patient may find holding their ribs helps with pain 3. Pain score and suitable analgesia 4. No entonox a 1/3 patients with >3 rib #s have PTX as well

Question 32

What factors associated with ribs #s have been shown to lead to worse outcomes and trigger clinicians to convey to centre with CTS? (8)

Answer 32

1. age 65 years or more 2. three or more rib fractures 3. bilateral flail chest 4. chronic lung disease 5. co-existent underlying lung injury 6. anticoagulant use 7. BMI >25 8. oxygen saturation <90% in the Emergency Department.

Question 33

What does FPHC consensus statement say about pre-hospital pericardiocentesis?

Answer 33

1. No evidence for its use 2. Can cause damage 3. Unlikely to be able to aspirate clotted blood from needle

Question 34

What are the 4 things needed for to indicate pre-hospital thoracotomy according to FPHC?

Answer 34

1. Stab wounds to the chest or upper abdomen 2. Cardiac arrest with loss of vital signs ≤ 15 minutes 3. The suspected injury is suitable for temporary repair and control 4. A chain of survival exists for definitive management following Resuscitative Thoracotomy

Question 35

What does the FPHC define exertional heat illness as?

Answer 35

A syndrome associated with a raised core temperature and disordered thermoregulation which occurs on a spectrum of severity, during or immediately after physical activity

Question 36

What does FPHC require alongside a raised temperature during or immediately after exercise to diagnose EHI?

Answer 36

Symptoms

Question 37

What does FPHC define as mild EHI?

Answer 37

core body temperature from 38.5°C to 40°C associated with signs or symptoms of heat illness other than CNS during or immediately after exercise

Question 38

What does FPHC define as severe EHI?

Answer 38

A life-threatening condition of disordered thermoregulation with central nervous system dysfunction, associated with a core body temperature above 40°C during or immediately after physical activity

Question 39

What are the signs/symptoms of severe EHI? (12)

Answer 39

Temp > 40 degrees + CNS dysfunction (less than A on AVPU) +/- 1. Confusion 2. Agitation or agression 3. Behavioural changes 4. Stumbling gait/ataxia 5. Seizures 6. LOC + coma 7. Vomiting 8. Urinary/faecal incontinence 9. Flushed/pale skin 10. Collapse 11. Hypotension 12. Arrhythmias

Question 40

What does FPHC recommend with regards to temperature measurement in EHI?

Answer 40

1. Core temperature should be measured with flexible rectal probe (rigid can cause injury) 2. Oesophageal temp probe acceptable if I+V 3. Core body temperature measurement should not be delayed, priority 4. Peripheral temprature measurement is unreliable and may lead to false reassurance, not recommended 5. Cooling recommended if not able to measure core body temp if EHI suspected until core temp can be measured

Question 41

What does FPHC state about transfer before cooling in EHI?

Answer 41

Shown increase mortality, transfer should be delayed until cooling

Question 42

How quickly should we aim to cool patients with EHI?

Answer 42

0.15 degrees C / min

Question 43

What does FPHC recommend for cooling in EHI?

Answer 43

Cold Water Immersion (CWI) up to neck with continous core temp monitoring

Question 44

What are the main relative contraindications to cold water immersion in EHI? (2)

Answer 44

1. Hypotension 2. Arrhythmia

Question 45

If cold water immersion is c/i or not available in severe EHI what does FPHC recommend?

Answer 45

Shade, strip and spray

Question 46

What temperature should we aim for in cold water immersion post EHI and why?

Answer 46

38.5 to 39 degrees to prevent hypothermia

Question 47

How long should patients core temp be measured following cold water immersion ?

Answer 47

30 mins

Question 48

What should be done if patients become hypothermic post cold water immersion?

Answer 48

Gentle rewarming with coretemp measurement

Question 49

What patients with EHI should be 1. conveyed and 2. who can be discharged?

Answer 49

1. Anyone with severe EHI (will need bloods) 2. Mild EHI with resolution of symptoms post cooling wth robust safety netting

Question 50

How and to what temp should patients with mild EHI be cooled?

Answer 50

1. Shade, strip and spray 2. 37.5 degrees as low risk of hypothermia post cooling

Question 51

What does FPHC not recommend in management of EHI in pre-hospital setting? (6)

Answer 51

1. Anti-pyretics 2. Dantrolene 3. Steroids 4. Depolarising neuromuscular blockers 5. Abx 6. IV fluids unless clinically indicated (caution with ? hyponatreamia)