TARGET DECK: MED::I::BLS

Some Issues About Medical Emergency Situations

Croce Rossa Italiana — Comitato di Bologna Dr. Luciano Trentin MD — Dr. Stefano Badiali MD

Course Topics

Part One

Forewords: Technical and Non-technical Skills

Part Two

Some medical emergency situations
Anaphylaxis
Hypothermia and Hyperthermia
Physical Trauma and Immobilization

Forewords

Approach to This Course The goal is not a boring lecture focused only on notions, references and so on, but rather some inputs aiming to trigger a method to deal with some medical emergency situations.

On Technical vs Non-Technical Skills During your professional education you will be given notions, data, protocols and so on. Those are «technical skills» that you have to learn by lectures, books, journals, etc.

Unfortunately, medical profession is not only made by technical skills; you will have to think about «non-technical skills» as well!

Frequently, «non-technical skills» have to be learnt by yourself.

Part One: Technical and Non-Technical Skills

Medicine and Aviation: Key Similarities

Why Start with Aviation? Medicine has a lot of similarities with the aeronautical world.

Like a pilot, you will be asked to make decisions that, if the wrong ones, unfortunately could be catastrophic, either for the patient either for you.

During the profession, you will perform both technical skills (ability to perform manoeuvres) and non-technical skills (communication, cross-checking assessment, decision making).

It is important that, especially in emergencies, you learn to understand well what you are about to do and to know how to choose.

Burke CS - Team task analysis in: Handbook of human factors and ergonomics methods - London, Taylor & Francis, 2004

You Will Always Have to Decide

What Contributes to Effective Decision-Making?

A good situational awareness
High levels of thought organization:
- Definitions of the problem
- Drawing up a plan
- Determining the decisions to be taken
- Determination of the necessary information and resources
- Determination of available info/resources
Shared mental models
Effective resource management

How to Face Emergency Problems?

Priority Assessment
Monitoring/Cross Checking
Communication is Important
Continual Reassessment is Required
Use all Available Resources and Information
Avoid Fixation of Goals and Ideas
Problem Assessment

Technical Skills

Theoretical knowledge
- Anatomy
- Pathology
- Pharmacology
Ability to perform technical manoeuvres
- Surgical procedures
- Fracture splinting

Non-Technical Skills

Communication
Resources management
- Time
- Available equipment
- Personnel
Methods
- Cross-checking
- Reassessment
Situational awareness

Perception

Perception Is Filtered What we know influences what we perceive. "Man believes more easily true what he prefers to be true." — Francis Bacon

Perception filters include:

Prior knowledge and expectations
Distraction and high workload
Task saturation (taskload)
Use of the “wrong” mental model

Case Study: Eastern Airlines Flight 401

Eastern Flight 401 — December 29, 1972

Departed JFK at 21:20 with 163 + 13 on board; cleared to Miami under IFR.

During approach, the nose landing gear handle was placed in the “down” position; the green indicator light (nose gear locked) failed to illuminate.

Captain recycled the gear — green light still failed.

Local weather: clear, unrestricted visibility; accident occurred in darkness with no Moon.

At 23:36:04, captain instructed first officer to engage autopilot.

At 23:36:27, first officer removed nose gear light lens assembly — it jammed when he attempted to replace it.

At 23:37:08, second officer sent to forward electronics bay to visually check nose gear indices.

From 23:38:56 to 23:41:05, captain and first officer discussed the faulty nose gear position light lens assembly.

At 23:40:38, a half-second C-chord (indicating deviation >250 feet from selected altitude) sounded in cockpit. No crewmember commented. No altitude correction was made.

At 23:41:40, Miami controller noted altitude reading of 900 feet on radar — momentary deviations were not uncommon; no action taken.

At 23:42:07, first officer asked: “We’re still at two thousand, right?” — captain exclaimed: “Hey, what’s happening here?”

At 23:42:10, the first of six radio altimeter warning “beep” sounds began.

At 23:42:12, the aircraft crashed into the Everglades.

Cause of Eastern 401 Crash The cause of this accident was the failure of the flightcrew to monitor the flight instruments during the final 4 minutes of flight, and to detect an unexpected descent soon enough to prevent impact with the ground.

Preoccupation with a malfunction of the nose landing gear position indicating system distracted the crew’s attention from the instruments and allowed the descent to go unnoticed.

Situational Awareness Model

Endsley MR. Toward a theory of situation awareness in dynamic systems. Hum Factors 1995;37:32-64

The three levels of situational awareness:

Level	Process	Description
1	Perception	Acquire the data — inputs, information, stimuli
2	Understanding	What happened?
3	Anticipation	What may happen?

Case Study: The Rudine Derailment (Croatia, July 24, 2009)

Rudine Train Derailment

In order to prevent bush fires, some servicing trains regularly discharge an oily fire retardant along the railways.

After a while, a passenger train derails in a stretch of railways in strong descent in the middle of a rocky gorge.

The derailment occurred on 24 July 2009 at 10:08 GMT near the village of Rudine in southern Croatia, on the Zagreb-Split railway line, on the slopes of Kozjak. 6 people died, 55 were injured.

Helicopters are unable to land because of the lay of the terrain.

Ambulances can only drop down the crews at a railroad crossing about 470 meters upstream from the accident where the descent begins.

The same train which few minutes before discharged the fire retardant liquid is dispatched as a rescue train; it stops at the same railroad crossing where the ambulances are parked.

Situational Awareness Failure Key question: was situational awareness adequate when the rescue train — the same one that had just deposited a slippery, oily retardant on the tracks — was sent back down the same descent?

You Will Always Have to D.E.C.I.D.E.

Letter	Meaning
D — Detect	Realize that the operating framework has changed. What has changed? Why?
E — Estimate	Assess the impact of the change on the operating scenario
C — Choose	Make a choice for the safety of operations
I — Identify	Identify the appropriate action and monitor the implementation of the change
D — Do	Put in place the chosen procedure
E — Evaluate	Assess the effects and consequences of the intervention

Mnemonic — D.E.C.I.D.E.

Detect → Estimate → Choose → Identify → Do → Evaluate

Problems in Maintaining Good Situational Awareness

SA Level	Error Type	Causes
Perception	Errors in correct perception of what happened	Data not available; data difficult to detect or perceive; data scanning/observation error (omission, distraction, high workload, taskload)
Understanding	Errors in correctly understanding what’s going on	Data seen but not acquired; lack of mental models; using the wrong mental model; overevaluation of the “standard” mental model
Anticipation	Errors in anticipating or forecasting what could happen in the near future	Poor correlation of perceived data; lack of models; use of the “standard” mental model

Crew Resource Management (CRM)

Definition

Crew resource management (CRM) is a set of training procedures for use in environments where human error can have devastating effects. Used primarily for improving aviation safety, given the many similarities with aeronautical world, CRM (now renamed «Crisis Resource Management») has been applied to the medical environment, with the same purposes: to reduce human errors that can have devastating effects.

CRM is mainly focused on «non-technical» skills!

CRM Topics

Situational awareness:

Receiving, sending, confirming information about team members
Maintaining a correct perception of one’s role in rapport to the external environment
Identifying the problem / problems
Early recognizing possible situations requiring reactions

Decision making:

Identifying possible solutions to the problem
Assessing the consequences for each alternative
Choosing the best alternative
Collecting the necessary information before deciding
Avoiding crystallisation of ideas and objectives

Mission analysis:

Monitoring, deploying and coordinating staff and resources — team materials
Prioritising the tasks
Setting objectives
Developing plans to achieve them

Leadership:

Directing the activities of the team members
Monitoring and evaluating team members’ performance
Motivating the team
Communicating mission requirements

Burke CS - Team task analysis in: Handbook of human factors and ergonomics methods - London, Taylor & Francis, 2004

Part Two: Some Medical Emergency Situations

Looking at the Patient — Vital Functions

First Assessment Step Is there any vital function impairment?

YES → Use the A-B-C-D method immediately

NO → Proceed to further assessment

The A-B-C-D Method

A = Airway

Anatomy of the airway:

Nasal cavity
Oral cavity
Tongue
Pharynx
Larynx
Trachea, bronchi, lungs

B = Breathing

What Is Breathing? Breathing allows the body either to introduce and use oxygen and dispose carbon dioxide.

How to evaluate breathing:

Look at the patient: look at the chest expansion; chest movements — are they normal or rapid, difficult?
Which position did the patient take on?
Is the patient cyanotic?

Respiration (Gas Exchange at Alveolar Level)

Mechanism of CO₂ Release in Alveoli Red blood cells give up carbon dioxide ( $CO_{2}$ ) in the pulmonary alveoli mainly due to a passive diffusion mechanism, driven by the partial pressure difference of the gases and facilitated by the arrival of oxygen ( $O_{2}$ ) in the lungs (Haldane effect).

Pressure gradient (Difference of $p CO_{2}$ ): The partial pressure of $CO_{2}$ is higher in venous blood reaching the alveolar capillaries than in air in the alveoli. $CO_{2}$ then naturally diffuses from blood (high pressure) to the socket (low pressure) to be exhaled.

Haldane Effect (Oxygen Binding): When blood rich in $O_{2}$ reaches the lungs, hemoglobin binds to the newly inspired oxygen. Oxygenated hemoglobin (oxyhemoglobin) has a lower affinity for $CO_{2}$ and tends to release it. Furthermore, binding to oxygen promotes the release of hydrogen ions ( $H^{+}$ ), which help convert bicarbonates into $CO_{2}$ .

Carbonic Anhydrase Conversion: Most of the $CO_{2}$ travels in the blood in the form of bicarbonate ions ( $HCO_{3}^{-}$ ). In the alveoli, bicarbonates re-enter red blood cells, bind to ions $H^{+}$ freed from hemoglobin and, thanks to the enzyme carbonic anhydrase, are converted back into $CO_{2}$ and $H_{2} O$ . This free $CO_{2}$ then spreads into the alveolus.

In short, blood “discharges” the $CO_{2}$ because in the alveoli its pressure is lower and because the inhaled oxygen “hunts” away the $CO_{2}$ from hemoglobin.

Key reaction:

$HCO_{3}^{-} + H^{+} carbonic anhydrase CO_{2} + H_{2} O$

Ventilation (Mechanical)

Inhalation: Chest cavity enlarges as it fills with air; diaphragm falls and flattens.
Exhalation: Chest cavity decreases; diaphragm relaxes and moves upward.

Signs of Dyspnea (Laboured Breathing)

Restlessness, anxiety
Agitation, mental impairment
Changes in skin colour (pallor, cyanosis, marbling)
Trouble talking
Heart rate increased
Shallow breathing
Abnormalities of breathing rhythm and mode
Noisy breathing
Patient uses the “Tripod” position
Use of accessory respiratory muscles in the effort to breathe

Mnemonic — Signs of Dyspnea: "RACE-THAN" Restlessness/anxiety · Agitation/mental impairment · Colour change (pallor, cyanosis) · Effort breathing (tripod, accessory muscles) · Trouble talking · Heart rate increased · Abnormal rhythm/mode · Noisy breathing

C = Circulation

Circulatory System Analogy Think of the heart-vessels-blood system as a heating/cooling plant made by:

A pump → the HEART

A pipeline (ARTERIES/VEINS) connected to radiators (CAPILLARY BED)

A liquid carrier → the BLOOD

How to check circulation:

Patient State	Pulse to Check	Significance
Conscious	Radial pulse (2nd, 3rd, 4th fingertips)	If present → $SBP > 80 mmHg$
Unconscious	Carotid pulse	If present → $SBP > 50 mmHg$

SBP = Systolic Blood Pressure

Age Group	Heart Rate (bpm)	Systolic BP (mmHg)	Respiratory Rate (bpm)
Newborn/Baby	160	70–80	40
Child until 6 years	120	80–90	30
Teenager	100	100	20
Adult	60–100	100–150	12–20

Shock (Bare Bones)

Definition

A sudden, unbalanced failure of one of the parts of the heart-vessels-blood system leads to a SHOCK.

Types of Shock

Type	Mechanism	Causes
Hypovolemic	Loss of liquids (not only blood!)	Massive haemorrhage, wide burns, persistent vomiting, profuse diarrhoea, heavy sweating, diuretic drug abuse
Vasoplegic	Rise of blood vessels diameter	Spinal cord injuries, poisoning, allergic reactions, serious infections
Cardiogenic	Decrease of the heart’s contractile energy	Myocardial infarction, acute vessel obstruction (embolism), severe arrhythmias, poisoning

Signs of Shock

Blood pressure fall
Rapid and shallow breathing
Pallor, sweating
Radial pulse rapid and shallow
Agitation first, then drowsiness
Chill
Severe, persistent thirst

Mnemonic — Signs of Shock:

“BP-PRACS-T” Blood pressure fall · Pallor/sweating · Pulse rapid and shallow · Respiration rapid and shallow · Agitation → drowsiness · Chill · Severe persistent thirst

Dealing with Shock (All Kinds) — Without Equipment or Drugs

TO DO:

Continuously check the vital functions
Lay down the patient in supine position
Protect from heat loss
Stop/reduce the bleeding
Get ready to start C.P.R.

NOT TO DO:

Stand the patient
Give drinks

Priority Rule

The management of airway patency, breathing and bleeding control problems MUST be done as soon as the problem arises!!!

Find the killer in A–B–C

D = Disability

Why Is D Fourth?

The brain regulates all body activities, including metabolism. Deep in the brain there is the brainstem, regulating the automatic activity of breathing and circulation.

Unfortunately, the brain is enclosed within a rigid skull that serves to protect it but can turn into a fatal prison if:

Inside it a bleeding happens

The brain tissue “swells” because blood arrives with little pressure and/or poor in oxygen

In order to protect the brain, you MUST first warrant a good oxygenation (steps «A+B») AND a good blood pressure (step «C»)!!

A-V-P-U Consciousness Scale (Simplified)

Level	Meaning	Description
A	Alert	Awake, answers your questions and speaks normally
V	Verbal	Drowsy, but able to react if called
P	Pain	Drowsy, reacts ONLY if given a standard painful stimulus
U	Unresponsive	Does not react to any kind of stimulus

Note

This is a simplified scale, mainly used by rescuers. Professionals use the Glasgow Coma Scale (GCS).

Key Pain Stimulus Methods

Sternal Rub: Rubbing knuckles firmly on the patient’s sternum (centre chest)
Trapezius Squeeze: Gripping and squeezing the trapezius muscle at the shoulder
Supraorbital Pressure: Applying pressure with a thumb to the ridge below the eyebrow
Nail Bed Pressure: Applying pressure to the fingernail bed with a pen or similar object

Emergency Problem Assessment — Framework for Clinical Cases

For each emergency situation, apply:

What happened? (according to A-B-C-D checklist)
What’s going on? (again, according to A-B-C-D checklist)
What may happen? (even according to A-B-C-D checklist)

Anaphylaxis

Definition and Mechanism

Definition

Anaphylaxis is an acute, potentially fatal, multiorgan system reaction caused by the release of chemical mediators from mast cells and basophils. The classic form involves prior sensitization to an allergen with later re-exposure, producing symptoms via an immunologic mechanism.

Pathophysiology

The physiologic responses to the release of anaphylaxis mediators include:

Smooth muscle spasm in the respiratory and gastrointestinal (GI) tracts

Vasodilation

Increased vascular permeability

Stimulation of sensory nerve endings

Cardiovascular effects result from decreased vascular tone and capillary leakage. Hypotension, cardiac arrhythmias, syncope, and shock can result from intravascular volume loss, vasodilation, and myocardial dysfunction.

Increased vascular permeability can produce a shift of 35% of vascular volume to the extravascular space within 10 minutes.

$Intravascular volume + 10 min 35% shifts to extravascular space$

Symptoms and Findings

Anaphylaxis — Symptoms by System

System	Symptoms/Findings
General	Patients commonly restless, anxious, agitated and/or combative (due to hypoxia/hypotension)
Dermatologic/Ocular	Flushing, urticaria (hives), angioedema, cutaneous and/or conjunctival injection or pruritus, warmth, swelling
Respiratory	Nasal congestion, rhinorrhea, sneezing, throat tightness, wheezing, shortness of breath, cough, hoarseness, dyspnea, severe angioedema of tongue and lips, tachypnea, stridor, severe air hunger, loss of voice, hoarseness, and/or dysphonia
Cardiovascular	Dizziness, weakness, chest pain, palpitations, tachycardia, hypotension; cardiovascular collapse and shock can occur immediately, without any other findings
Gastrointestinal	Dysphagia, nausea, vomiting, diarrhoea, bloating, cramps
Neurologic	Headache, dizziness, blurred vision, and seizure; altered mentation
Other	Metallic taste, feeling of impending doom

Mnemonic — Anaphylaxis Systems:

“Dr. CONGA” Dermatologic · Respiratory · Cardiovascular · Other (metallic taste, doom) · Neurologic · Gastrointestinal · Agitation/general

Management

Anaphylaxis is a Medical Emergency

Anaphylaxis is a medical emergency that requires immediate recognition and intervention.

Prehospital Supportive Care

Airway management (bag/valve/mask, endotracheal intubation, Supraglottic Airway Devices such as I-Gel or Laryngeal Mask; in extreme circumstances, cricothyrotomy or catheter jet ventilation may be lifesaving when orotracheal intubation or bag/valve/mask ventilation is not effective) — per A-B-C-D!!
High-flow oxygen
Cardiac monitoring and/or pulse oximetry
Intravenous access (large bore)
Fluid resuscitation with isotonic crystalloid solution
Supine position (or position of comfort if dyspneic or vomiting) with legs elevated

Posture Warning

In a retrospective review of prehospital anaphylactic fatalities in the United Kingdom, the postural history was known for 10 individuals. Four of the 10 fatalities were associated with the assumption of an upright or sitting posture during anaphylaxis.

Postmortem findings were consistent with an “empty heart” attributed to reduced venous return from vasodilation and redistribution of intravascular volume from the central to the peripheral compartment.

Drug Treatment

Drug	Role	Notes
Epinephrine	Drug of choice for treating anaphylaxis	—
H1 Antihistamines	Adjunct only	Much slower onset of action than epinephrine; exert minimal effect on blood pressure; should not be administered alone
Corticosteroids	No immediate effect	Delayed onset of action; do not reverse the cardiovascular effects of anaphylaxis

Key Principle

Because hypotension in anaphylaxis is due to a dramatic shift of intravascular volume, the fundamental treatment intervention after epinephrine is aggressive IV fluid administration.

Case Study: John — Anaphylactic Shock

John, 25 years old, farmer

Has been stung by several bees some 10 minutes ago. He complains of pruritus, swollen lips and mild dyspnea. He has troubles in speaking. Radial pulse is very weak and rapid. He is pale.

What happened? Young farmer stung by several bees few minutes ago.

Current A-B-C-D:

Step	Finding
A — Airways	Partially obstructed
B — Breathing	Mild (for the moment!) dyspnea
C — Circulation	Radial pulse weak, rapid
D — Disability	Alert (until now!)

What may happen? — Projected A-B-C-D:

Step	Projected Finding
A — Airways	Complete obstruction
B — Breathing	Respiratory arrest
C — Circulation	SHOCK, cardiac arrest
D — Disability	Deep coma

What to do? (without equipment or drugs):

Supine position
DON’T give drinks
Continuously check the vital functions
If he gets unconscious, IMMEDIATELY start C.P.R.

Thermal Injuries — Burns

Burns as a Systemic Injury

Pathophysiology

Tissue burn involves direct coagulation and microvascular reactions that may result in extension of the injury.

Large injuries are associated with a systemic response caused by:

A loss of the skin barrier

The release of vasoactive mediators from the wound

Subsequent infection

Loss of fluids

This results clinically in an initial decrease in cardiac output.

A hypermetabolic response occurs, with near doubling of cardiac output and resting energy expenditure.

Key Vasoactive Mediators Released

Mediator	Source/Mechanism	Effect
Histamine & Serotonin	From mast cells	Rapid oedema formation and increased capillary permeability
Prostaglandins & Leukotrienes	Arachidonic acid metabolism	Severe oedema and local tissue ischaemia
Cytokines (TNF-α, IL-1, IL-6, IL-8)	Immune activation	Widespread inflammation, systemic capillary leak, myocardial depression
Bradykinin & Kinins	Kallikrein–bradykinin system	Further vasodilation and increased permeability
Reactive Oxygen Species (ROS)	By neutrophils	Damage to vascular endothelium, exacerbating oedema
Thromboxanes	Platelet activation	—
Catecholamines	Epinephrine/norepinephrine	—
Complement (C3a, C5a)	Complement system	—

Pathophysiological Impact

Burn Shock: Combined effect of mediators creates a “distributive shock” — systemic vasodilation, significant intravascular fluid loss, and reduced cardiac output (often requiring aggressive fluid resuscitation).

Wound Progression: Mediators in the “zone of stasis” (area surrounding the maximum damage) can lead to ischaemia and progression to deeper necrosis.

Systemic Capillary Leak: Mediators break down the endothelial barrier, causing plasma to leak into the interstitial tissue.

Immediate vs. Delayed Effects: Early responses (0–24h) are dominated by profound fluid shifts and shock; the later phase (24–72h) involves a shift to a hyperdynamic and hypermetabolic state.

Depth of Burns

Degree	Layer Affected	Appearance	Pain?
1st degree	Epidermis (stratum corneum/granulosum)	Reddened, like a sunburn	Yes
2nd degree — Superficial partial-thickness	Epidermis + superficial dermis	Blisters	Yes
2nd degree — Deep partial-thickness	Epidermis + deep dermis	Blisters + deeper damage	Yes
3rd degree — Full-thickness	Through epidermis, dermis, into hypodermis	Dry, stiff, leathery; white, brown, or black	NO

Why Don't 3rd Degree Burns Hurt?

Because 3rd degree burns destroy the nerve endings in the dermis that would normally transmit pain signals.

Ointments — NEVER Apply to Burns!

Ointments prevent excess heat from being dispersed; it will be reflected to deeper skin layers instead and will worsen the burn.

Burns Evaluation

Burn Depth Classification (Summary)

Superficial (1st degree burns): reddened appearance of the skin
Partial thickness (2nd degree burns): will also have blisters
Full thickness (3rd degree burns): may appear dry, stiff, and leathery, and/or can also be white, brown, or black

Estimating Burn Size — Rule of Nines

Extension is expressed as % of TBSA (Total Body Surface Area) using the Rule of 9s.

Severity Factors

Extent: Rule of 9s
Depth: 2nd–3rd degree
Location of burn injury: face, crotch, hands, feet, etc.
Age of patient: children <10 yrs, or adults >50 yrs
Etiologic agents involved: caustic, electrical
Presence of inhalation injury
Coexisting injuries or preexisting illnesses

Major Burns — Definition

Criteria for Major Burns

2nd degree burns >25% of TBSA in adults, or 20% of TBSA in children <10 years, or adults >50 years

3rd degree burns >10% of TBSA

2nd and 3rd degree burns of face, crotch, hands, feet and main joints

Burns caused by caustic chemical agents, high-voltage electrical injury

Burns complicated by inhalation injury

Burns sustained by high-risk patients (those with underlying debilitating diseases)

Circumferential full-thickness burns

Prehospital Burns Management

First Step

Cool down the burned area of body with running water for at least 10 minutes
Extinguish flames on clothing
Remove outer layers of clothing (in case of boiling liquid)

Second Step

Protect the body from heat loss
Cover with wet gauze or damp blanket
Over this, wrap a thermal blanket (Metalline or Domopack-like)

Additional Care

Don’t give drinks
Supine position
Continuously check the vital functions

Airway Priority in Burns

Assess the respiratory tract and prepare for early intubation if patients have respiratory symptoms, carbonaceous sputum, perioral burns, bruised nasal hair, or have been confined in a fire.

Assessment of the posterior pharynx is useful for assessing airway injury. If there is no evidence of oedema or posterior pharyngeal erythema, airway involvement is unlikely.

Fluid Resuscitation in Burns

Parkland Formula

The Parkland formula for fluid resuscitation of burn patients:

$V = 4 mL \times kg \times % TBSA burned$

Administered as Lactated Ringer solution intravenously in the first 24 hours:

$\frac{1}{2}$ given in the first 8 hours

$\frac{1}{2}$ given over the next 16 hours

Calculate fluid loss from the time of injury.

Adequate resuscitation is evidenced by:

Normal urinary output ( $1.5 mL/kg/h$ in children <2 years, $1 mL/kg/h$ in older children, at least $30 - 40 mL/h$ in adults)

Normal sensorium

Stable vital signs

Fluid Resuscitation Formulae

Formula	Calculation
Parkland (Baxter)	$4 mL/kg/%TBSA$ ; 50% in first 8h, 50% in next 16h
Modified Parkland	$2 mL/kg/%TBSA$
Brooke	$1.5 mL/kg/%TBSA$ crystalloid and $0.5 mL/kg/%TBSA burn + 2 L free water$
Cincinnati	$4 mL/kg/%TBSA + 1500 mL/m^{2} BSA$
Galveston	$5000 mL/m^{2} TBSA + 2000 mL/m^{2} BSA$
Evans	$1 mL/kg/%burn$ crystalloid + $1 mL/kg/%burn$ colloid + $2000 mL$ glucose in water (first 24h); half of crystalloid and colloid + same glucose in water (next 24h)
USA ISR Burn Centre	Estimate burn size to nearest 10; $% TBSA \times 10$ = initial rate (mL/h); +100 mL/h per 10 kg over 80 kg

Case Study: Sam — Electrical Burns

Sam, 47 years old, electrician

Electrocuted at 380 Volts. There are severe burns on both hands. His mouth is locked. Heart rate and respiratory rate are rapid. He is unconscious even though he reacts to the standard pain stimulus by waving the arms.

What happened? Electrocuted electrician showing electrical burns to the hands.

Current A-B-C-D:

Step	Finding
A — Airways	Partially obstructed (the mouth is locked)
B — Breathing	Rapid
C — Circulation	Radial pulse rapid
D — Disability	Unconscious (level P as «Pain» on the A-V-P-U scale)

What may happen? — Projected A-B-C-D:

Step	Projected Finding
A — Airways	Complete obstruction
B — Breathing	Respiratory arrest
C — Circulation	Severe arrhythmia, cardiac arrest
D — Disability	Deeper coma

Key Point — Electrical Injuries Are the burns the main problem? NO!

First support the vital functions

THEN care for the burns

In Case of Electrical Injury

Secure the power, if possible.
Otherwise, remove the casualty from the electrical source using a nonconductive object such as a wooden stick. Move the casualty to a safe place.

Heat Stroke

Definition

Definition

Heat stroke is defined as a body temperature $> 40° C$ ( $104° F$ ) associated with neurologic dysfunction.

With the influence of global warming, incidence of heat stroke cases and fatalities will become more prevalent.

When heat gain exceeds heat loss, the body temperature rises.

Thermoregulation

Thermoregulation Mechanism

Thermosensors in the skin, muscles, and spinal cord send information regarding the core body temperature to the anterior hypothalamus.

Heat Production	Heat Loss
Basal metabolic processes produce $1 kcal/kg/h$ ; can raise body temperature by $1.1° C / h$ if heat-dissipating mechanisms are nonfunctional	Increased cardiac output and blood flow to the skin (as much as $8 L/min$ ), which is the major heat-dissipating organ
Strenuous physical activity can increase heat production to $> 1000 kcal/h$	Dilatation of the peripheral venous system
Fever, shivering, tremors, convulsions, thyrotoxicosis, sepsis, sympathomimetic drugs	Stimulation of the eccrine sweat glands to produce more sweat

Aetiology of Heat Stroke

Increased Heat Production	Decreased Heat Loss
Infections, sepsis, encephalitis	Reduced sweating
Stimulant drugs	Dermatologic diseases
Thyroid storm	Drugs
Drug withdrawal	Burns
Increased muscular activity (exercise, convulsions, tetanus, strychnine poisoning)	Reduced CNS responses
Sympathomimetics	Advanced age, young age (toddlers and infants)
—	Alcohol
—	Barbiturates and other sedatives
—	Reduced cardiovascular reserve (advanced age, diuretics, cardiovascular drugs)
—	Reduced behavioural responsiveness (infants, bedridden/chronically ill patients unable to control their environment and water intake)

Heat Loss Mechanisms

The skin transfers heat to the environment through:

Mechanism	Description	Notes
Convection	Transfer of heat between the body’s surface and a gas or fluid with a differing temperature	Most important mechanism at rest in temperate climates
Conduction	Transfer of heat between 2 surfaces with differing temperatures in direct contact	—
Radiation	Transfer of heat in the form of electromagnetic waves between the body and its surroundings	—
Evaporation	Conversion of a liquid to a gaseous phase	Most effective mechanism at high ambient temperatures

Evaporation Limits

Evaporation does not occur when the ambient humidity >75%

Non-acclimated individuals can only produce $1 L/h$ of sweat, which only disperses $580 kcal/h$ of heat

Acclimated individuals can produce $2 - 3 L/h$ of sweat and can dissipate as much as $1740 kcal/h$ of heat

Heat Stroke — Assessment

Critical Threshold Temperatures $> 106° F$ ( $41.1° C$ ) require immediate aggressive therapy.

Excessive heat denatures proteins, leading to cardiovascular collapse, multiorgan failure, and death.

The redistribution of blood flow to the periphery, coupled with the loss of fluids and electrolytes in sweat, place a tremendous burden on the heart, which ultimately may fail to maintain an adequate cardiac output.

Indicators of Poor Prognosis

Initial temperature $> 41° C$ ( $106° F$ ) or a temperature $> 42° C$ ( $108° F$ ) or a temperature persisting $> 39° C$ ( $102° F$ ) despite aggressive cooling measures
Coma duration longer than 2 hours
Severe pulmonary oedema
Delayed or prolonged hypotension
Lactic acidosis in patients with classic heat stroke
Acute kidney injury and hyperkalemia
Aminotransferase levels greater than $1000 IU/L$ during the first 24 hours

Case Study: Jack — Heat Stroke

Jack, 50 years old, farmer

For 8 hours he has been working in the fields under the scorching sun. He feels more and more tired, headache, dizziness, is red and warm in the face. Pulse and breath are accelerated. He speaks in a somewhat confused way. Body temperature is $40.5° C$ .

What happened? Mild-severe heat stroke.

Current A-B-C-D:

Step	Finding
A — Airways	Patent
B — Breathing	Rapid
C — Circulation	Radial pulse rapid
D — Disability	Conscious but confused (level A as «Alert» on the A-V-P-U scale)

What may happen? — Projected A-B-C-D:

Step	Projected Finding	Explanation
A — Airways	Patent, until alert	—
B — Breathing	Pulmonary oedema	Excessive heat denatures proteins, leading to multiorgan failure
C — Circulation	Shock/collapse	All kinds of shock
D — Disability	Worsening of consciousness	Brain oedema (see B and C steps)

Hypothermia

Definition

Definition

A systemic cold injury in which the core body temperature has decreased to $35° C$ ( $95° F$ ) or less.

Pathophysiology

Progression of Hypothermia

Hypothermia affects multiple organs.

Initially, the metabolic rate increases, with tachycardia, tachypnea, increased muscle tone, and peripheral vascular resistance to generate maximal shivering.

Once hypothermia sets in, the body loses the ability to cope.

With continued hypothermia, the metabolism progressively declines, with bradycardia and hypoventilation and subsequent carbon dioxide retention.

Cerebral metabolism is decreased 6–7% per every 1°C drop in temperature, resulting in worsening of consciousness.

Autoregulation of cerebral blood flow is impaired at temperatures below $25° C$ ( $77° F$ ).

Thermoregulation in Cold

Sympathetic Response to Cold When the hypothalamus is stimulated, various heat conservation and production mechanisms become activated.

When the sympathetic nerves are excited, they cause the blood vessels in the skin to markedly constrict. This reduction of blood flow in the skin is the prime physiologic regulator of heat loss from the body.

This is protective in terms of safeguarding the more vital organs of the body from hypothermia, but it places the extremities at particular risk for peripheral cold injury.

Stimulation of the sympathetic nerves also causes secretion of epinephrine and norepinephrine, which increase the metabolic rate of all cells, thereby enhancing heat production.

Stages of Hypothermia

Stage	Temperature	Features
Mild hypothermia	$35° C$ ( $95° F$ )	Shivering
Moderate hypothermia	$\leq 33° C$ ( $91° F$ )	Shivering mechanism of thermoregulation stops
Severe hypothermia	$< 28° C$ ( $82.4° F$ )	Heart rate drops to half its normal rate; ventricular contractility decreases; risk of ventricular fibrillation; coma
Cardiac standstill	$\approx 20° C$ ( $68° F$ )	Usually occurs at this temperature

Heat Loss Mechanisms (Relevant in Hypothermia)

Mechanism	Notes Relevant to Cold
Convection	Becomes more significant in a windy environment
Conduction	The thermal conductivity of water (or wet clothing) is approximately 30 times that of air
Radiation	Transfer of heat as electromagnetic waves
Evaporation	Conversion of liquid to gas phase

Clinical Presentation of Severe Hypothermia

Severe Hypothermia May Mimic Death

In severe hypothermia the patient may appear clinically dead, with:

Nonpalpable peripheral pulses

Fixed and dilated pupils

Loss of ocular reflexes

Stiff extensor posturing

Priority in Frostbite + Hypothermia

If a patient presents with severe frostbite, the obvious damage to the involved areas, especially the extremities, can be quite distracting. Although it is important for these injuries to be addressed in a timely manner, never forget that the most imminent threat to life and limb is systemic hypothermia.

This must be treated and corrected prior to focusing on peripheral cold injury.

Prehospital Management of Hypothermia

General Principles

Prevent further heat loss

Rewarm the body core temperature in advance of the shell

Avoid precipitating ventricular fibrillation

The patient should:

Be moved out of the cold environment and out of the wind
Be provided with warm shelter
Be given warmed fluids
Be kept off the ground (contact with ground increases loss of body heat)

Do NOT Rub

Rubbing affected parts of the body is not recommended because this potentially can worsen tissue injury.

Active Rewarming Risk

Rapid changes in temperature can affect the cardiovascular status, and these rapid changes are often the cause of complications associated with active rewarming methods.

Hypothermia could be worsened by a massive blood loss.

Rewarming Methods

Method	Rate	Notes
Passive rewarming	$0.5 - 2° C / h$ ; up to 24 hours may be required	Safe; may be slow
Active external rewarming	Much faster	May precipitate hypovolemic rewarming shock by decreasing the circulating blood volume secondary to peripheral vasodilation in an already hypovolemic patient
Active internal (core) rewarming	Fastest; safest for severe hypothermia	Methods: heated humidified inhalation; peritoneal dialysis with warmed fluids; mediastinal irrigation (through chest tubes); gastrointestinal tract irrigation; arterial venous shunting including hemodialysis; extracorporeal bypass; warm irrigation through a Foley catheter inserted into the bladder

Localized Cold Injuries

Stage	Analogous To
Frostnip	1st degree burn
Superficial frostbite	2nd degree burn (superficial)
Deep frostbite	2nd degree burn (deep) / 3rd degree

Principles of Frostbite Treatment

The patient must be removed from the cold environment.

Treatment should not be attempted in the field if a hospital is available within a short distance.

Once the rewarming process has begun, weight bearing on the affected limb will result in additional injury.

Rubbing the frostbitten part with snow or exercising it is absolutely contraindicated.

Contrary to popular belief, walking some distance on frostbitten feet can result in tissue fracture.

Case Study: Bill — Hypothermia

Bill, 27 years old, homeless

Found drunk in a street, early in a rainy and windy winter morning. Slow respiratory rate, radial pulse weak and rapid. He responds only by moaning to pain stimuli. Body temperature is $28° C$ ( $82.4° F$ ). Extensive bruising to the pelvis.

What happened?

Person unable to protect himself from cold
Prolonged exposure to wind and rain
Vasodilation due to alcohol consumption
High suspicion of pelvic fracture (bruising)

Current A-B-C-D:

Step	Finding
A — Airways	(not specified — must assess)
B — Breathing	Slow respiratory rate
C — Circulation	Radial pulse weak and rapid
D — Disability	Impaired consciousness (level P as «Pain» on the A-V-P-U scale)

What may happen? — Projected A-B-C-D:

Step	Projected Finding	Explanation
A — Airways	Patent, until now	—
B — Breathing	Respiratory arrest	—
C — Circulation	Ventricular fibrillation	—
D — Disability	Worsening of consciousness	Brain oedema (see B and C steps)

Trauma — The Very Essentials

Myth: Don’t Move a Trauma Patient

Exception — Impending Danger

IN CASE OF IMPENDING DANGER (fire, wall collapse, etc.): MOVE THE PATIENT.

Keep the main axis of the body aligned!

This is only to go away from an impending danger — obviously you can’t transport the patient this way to the hospital.

High Suspicion Criteria for a MAJOR Trauma

Trapped patient
Ejection from a vehicle
Fall from more than 3 metres
Penetrating wounds
Pedestrian or biker projected
Cockpit intrusion $\geq 30 cm$
Other patients killed in the same vehicle

Mnemonic — Major Trauma Criteria:

“TEFF-PCI” Trapped · Ejection from vehicle · Fall >3 m · Fatal incident (others killed in same vehicle) · Penetrating wounds · Cockpit intrusion ≥30 cm · Impact (pedestrian/biker projected)

Spine Injuries

Anatomy

Nerves come out of the spinal cord through emerging nerve roots. Like the brain, the spinal cord is protected by bones but has a very narrow space around itself.

Features and Symptoms of Spinal Cord Injury

Possible pain in the spine area where trauma occurred
Possible tingling, numbness of limbs
Possible loss of limb sensitivity
Possible functional impotence
Possible loss of urine and faeces
None of the foregoing

Cross Check!

Any of the above symptoms — or even none — can be present with a serious spinal cord injury.

Early Management of Spine Injuries

Assess the mechanism of injury
Check the vital functions (A-B-C-D)
Avoid unnecessary movements
Keep the patient’s head still, in NEUTRAL POSITION (HEAD-NECK AXIS)
Immobilize with rolled-up blankets if available

Chest Trauma

Types of Chest Injury

Penetrating wounds
Blast injury

IMPORTANT — Chest Wounds

DO NOT pack chest wounds with a haemostatic (or other) dressing.

REPORT a severe CHEST INJURY to medical personnel immediately.

Pneumothorax and Flail Chest

Signs of pneumothorax:

Respiratory difficulty
Cough with possible foamy blood emission
Abnormal movements of the rib cage
Swelling of the neck and/or face
Cyanosis

Early Management of Chest Trauma (Without Equipment)

If «Blowing» wound: «valve» dressing (three-sided unsealed dressing)
If penetrating object: DO NOT remove it; try to make it fixed
Loosen what holds
Semi-sitting or semi-reclining position on the injured side
Continuously check the vital functions («A-B-C-D»)

NEVER Remove a Penetrating Object!

Bleedings

How to Recognize Massive Life-Threatening Bleeding

Signs of Massive Bleeding

Bright red blood is pulsing, spurting or steady bleeding from the wound

Overlying clothing or ineffective bandaging is becoming soaked with blood

Bright red blood is pooling on the ground

Amputation of the arm or leg

Severe injuries can bleed to death in as little as 3 minutes.

Simple External Bleedings — Early Management (Without Equipment)

PROTECT YOURSELF!

Sit or lie the wounded
Lift the injured limb
Wash the wound under cold running water
DIRECT compression on the wound
Compressive bandage

NO cotton wool! NO alcohol!

Severe External Bleedings — Early Management (Without Equipment)

Lie on the ground with raised lower limbs (antishock position)
COMPRESSION AT DISTANCE (remote compression)
Thermal protection
Exceptionally, tourniquet (only in case of obvious, massive bleedings!)
DO NOT give alcohol to drink!
Keep vital functions under control

Why Lay the Patient Down?

Lying down the patient ensures the brain receives adequately oxygenated blood even with reduced perfusion pressure.

Arterial Tourniquet

ONLY IN CASE OF EXTREME NEED

What should be used:

Strip or belt of cloth
Tie
Scarf
NO twine, NO cord, NO iron wire, NO nylon stockings

Where it has to be placed:

Upstream of the wound, between the wound and the heart
Always ABOVE the elbow and ABOVE the knee

Risks of Improvised Tourniquets

DAMAGE may occur to skin if the band is too narrow

Bleeding may WORSEN

Bleeding MAY NOT BE COMPLETELY CONTROLLED

An improvised tourniquet may likely LOOSEN over time from not being properly secured

Head Trauma

Mechanism of Brain Trauma

Type	Mechanism
Primary damage	Due to the direct impact of the trauma
Secondary damage	Due to poor oxygenation of the blood; due to poor blood pressure; due to both

Signs of secondary damage:

Brain oedema (due to poor ventilation and/or hypotension)
Extradural haematoma compressing and displacing the brain

Clinical signs:

Raccoon eyes
Battle sign

Warning Signs in Head Trauma

Warning Signs — Seek Immediate Help

Worsening level of consciousness

Onset of drowsiness, disorientation, amnesia

Onset of headache, nausea, sudden vomiting

Onset of seizures

Functional impairment

Always True in Head Trauma

IT IS NOT ALWAYS TRUE THAT: no external injury = no internal injury

IT IS NOT ALWAYS TRUE THAT: conscious at once = conscious always

IT IS ALWAYS TRUE THAT: head trauma = suspected cervical trauma

Early Management — Head Trauma (Without Equipment)

Assess the state of consciousness and its variations over time
If conscious: semi-sitting position
If unconscious:
- Keep vital functions under control
- Lateral position if he vomits
- Where necessary, C.P.R. (obviously supine)
Ensure the immobility of the axis head-neck-trunk!!
NO antishock position (the head should always be a little more elevated above the heart)
DO NOT obstruct leakage of fluids from ear/nose
DO NOT give beverages

Bones Trauma

Dislocations

Signs and symptoms:

Acute pain
Swelling
Absolute and immediate functional impotence
Possible tingling
Joint deformity

Early management (without equipment):

DO NOT attempt to “fix” the joint
Immobilize it in its position
Apply ice
Rapid hospitalization, especially if it involves shoulder, elbow, knee, or if tingling is present

Fractures

Type	Description
Complete	Full break through the bone
Incomplete	Partial break
Closed	Skin intact
Open	Bone penetrates or exits through skin

Signs and symptoms:

Spontaneous pain, accentuated by movement
Swelling
Functional impotence
Crackling/rustling (crepitus)
Possible deformation of the limb (shortening, angles, abnormal rotations)

Warning Signs of a Fracture

Significant pain and swelling

An audible or perceived “snap”

Different length or shape of limb

Loss of pulse or sensation in the injured arm or leg

Crepitus (crackling or popping sound under the skin)

Fractures With High Blood Loss — Not Always Visible!

The following fractures can cause huge blood loss even if you do not see it:

Pelvic fractures

Long bone fractures (femur, humerus, tibia)

Early Management of Fractures (Without Equipment)

Evaluate the vital functions — danger of major bleeding NOT VISIBLE in pelvic and long bone fractures
Open fractures:
- Do not touch the injury site
- DO NOT bring back the bone that comes out
- Control the bleeding by remote compression
- If contamination (soil, grass, etc.) wash with a jet of water
- DO NOT DISINFECT!!
Splinting: immobilize both the joint above AND the joint below the area where a fracture is suspected
Arm fractures can easily be secured to the shirt using the sleeve as a sling

Case Study: Car/Motorbike Accident

Biker — Road Traffic Accident

You are driving along a two-lanes roadway with a kerb in between and in front of you a car/motorbike accident just happened.

Scene overview:

Motorcyclist on the ground, 3–4 meters away from the bike

Helmet flew away (was not fastened)

He lies on his back, across the kerb

Rapid respiratory rate

Rapid and weak radial pulse

Bleeding from his left knee completely shattered, but he only complains of severe back pain

A bone stump comes from the knee wound

He does not remember what happened, but he remembers his name and knows what day of the week is

What happened?

Biker projected far away after the impact; lying down in between of a roadway; poor head protection; important bleeding from an open knee fracture
High suspicion of pelvic fracture as well (fall on the kerb)

Current A-B-C-D:

Step	Finding	Notes
A — Airways	Patent (until now!)	—
B — Breathing	Rapid respiratory rate	—
C — Circulation	Radial pulse weak and rapid	—
D — Disability	Impaired consciousness (even level A as «Alert» on A-V-P-U scale)	Does not remember what happened; complains of back pain BUT NOT limb pain

What may happen? — Projected A-B-C-D:

Step	Projected Finding	Explanation
A — Airways	Likely to remain patent	—
B — Breathing	Respiratory labour	—
C — Circulation	Hypotension/shock	Direct bleeding from open knee fracture; possible pelvic fracture; likely spinal cord injury → vasoplegic shock
D — Disability	Worsening of consciousness	Poor oxygen delivery to the brain (see B and C steps)

Summary

Summary — Decision-Making in Medical Emergencies

You will always have to D.E.C.I.D.E.

Step Meaning
D Define the problem
E Establish the criteria
C Consider all the alternatives
I Identify the best alternative
D Develop and implement a plan of action
E Evaluate and monitor the solution

Key pillars:

High levels of thought organization

A good situational awareness

Shared mental models (i.e. A-B-C-D)

Decision-making process leads to more effective decisions

Step	Meaning
D	Define the problem
E	Establish the criteria
C	Consider all the alternatives
I	Identify the best alternative
D	Develop and implement a plan of action
E	Evaluate and monitor the solution

TLDR

Complete Summary — Medical Emergency Situations (CRI Bologna)

Non-Technical Skills & Decision-Making

Medicine resembles aviation: both require technical skills (procedures, knowledge) and non-technical skills(communication, resource management, cross-checking, reassessment, situational awareness)
Situational awareness has three levels: (1) Perception, (2) Understanding, (3) Anticipation
D.E.C.I.D.E. framework: Detect → Estimate → Choose → Identify → Do → Evaluate
CRM (Crisis Resource Management): now applied in medicine; focuses on non-technical skills to reduce human error
Common SA errors: fixation on one problem (like Eastern 401), tunnel vision, distraction, high workload
How to face emergencies: Priority Assessment, Monitoring/Cross-Checking, Communication, Continual Reassessment, Use All Resources, Avoid Fixation, Problem Assessment

A-B-C-D Assessment Method

Step	Content
A — Airway	Patent? Obstructed?
B — Breathing	Rate, effort, dyspnea signs, cyanosis
C — Circulation	Pulse (radial if conscious, carotid if not); SBP >80 mmHg if radial present
D — Disability	A-V-P-U scale; address only after A and B secured

A-V-P-U: Alert / Verbal / Pain / Unresponsive
D comes last because brain needs oxygenation (A+B) and perfusion (C) first

Shock

3 types: Hypovolemic (fluid loss), Vasoplegic (vessel dilation — spinal, allergic, sepsis, poisoning), Cardiogenic (pump failure)
Signs: BP fall, pallor, sweating, rapid shallow pulse and breathing, agitation → drowsiness, chill, thirst
Management: supine, thermal protection, stop bleeding, check vitals, prepare CPR; DO NOT stand patient or give drinks

Anaphylaxis

Acute multiorgan reaction: mast cell/basophil mediator release; prior sensitization + re-exposure
Mediators cause: smooth muscle spasm, vasodilation, increased vascular permeability (35% of volume can shift extravascularly in 10 min)
Symptoms: urticaria, angioedema, stridor/wheezing, hypotension, cardiovascular collapse, GI symptoms, neurologic changes, “feeling of doom”
Management: epinephrine (drug of choice), high-flow O₂, IV access (large bore), isotonic crystalloid, supine + legs elevated (sitting = risk of “empty heart” and death), cardiac monitoring
Antihistamines: slow onset, don’t use alone; corticosteroids: no immediate effect

Burns

Systemic mediators: histamine, serotonin, prostaglandins, leukotrienes, cytokines (TNF-α, IL-1, IL-6), bradykinin, ROS, complement → distributive shock
Depth: 1st (epidermis, red) → 2nd superficial (blisters, pain) → 2nd deep (blisters, pain) → 3rd full-thickness (painless, leathery, white/brown/black)
Rule of 9s for TBSA estimation
Major burns criteria: 2nd° >25% TBSA adult / >20% child <10 or adult >50; 3rd° >10% TBSA; face/crotch/hands/feet; electrical; inhalation; circumferential
Prehospital: cool with running water ≥10 min; remove outer clothing; prevent heat loss with wet gauze + thermal blanket; no drinks; supine; check vitals; NO ointments
Parkland formula: $4 mL \times kg \times % TBSA$ Lactated Ringer; ½ in first 8h, ½ in next 16h
Electrical burns: secure power first; do NOT remove from source without nonconductive object; support vitals before treating burns
Airway: intubate early if carbonaceous sputum, perioral burns, singed nasal hair, confined in fire

Heat Stroke

Core temp $> 40° C$ + neurologic dysfunction
Causes: increased heat production (fever, exertion, drugs) OR decreased heat loss (poor sweating, advanced age, alcohol, sedatives)
Evaporation most effective at high ambient temperatures; ineffective when humidity >75%
Temp $> 41.1° C$ requires immediate aggressive therapy; proteins denature → multiorgan failure
Poor prognosis indicators: temp >42°C, coma >2h, pulmonary oedema, persistent hypotension, lactic acidosis, AKI, aminotransferases >1000 IU/L in first 24h
ABCD trajectory: airways patent → pulmonary oedema → shock → worsening consciousness

Hypothermia

Core temp $\leq 35° C$ ; cerebral metabolism $↓$ 6–7% per 1°C drop
Stages: 35°C = shivering; ≤33°C = shivering stops; <28°C = VF risk, coma; ~20°C = cardiac standstill
Water/wet clothing conducts heat 30× better than air; wind increases convective loss
Severe hypothermia may appear clinically dead (fixed dilated pupils, no pulses)
Management: remove from cold, warm shelter, warmed fluids, keep off ground, NO rubbing
Active external rewarming → risk of rewarming shock (vasodilation in hypovolemic patient)
Safest for severe hypothermia: active internal rewarming (heated humidified inhalation, peritoneal dialysis, extracorporeal bypass, etc.)
Always treat systemic hypothermia before peripheral frostbite
No walking on frostbitten feet; no rubbing with snow

Trauma

Move patient ONLY in impending danger — keep body axis aligned
Major trauma criteria: trapped, ejection, fall >3m, penetrating wound, pedestrian/biker projected, cockpit intrusion ≥30 cm, fatalities in same vehicle
Spinal injury: maintain HEAD-NECK neutral position; symptoms variable or absent; always suspect with mechanism
Head trauma: head trauma = suspect cervical trauma; NO antishock position; DO NOT obstruct ear/nose leakage; DO NOT give drinks; monitor consciousness changes — secondary damage (oedema, extradural haematoma) from hypoxia/hypotension
Chest trauma: DO NOT pack chest wounds; DO NOT remove penetrating objects; valve dressing for blowing wounds; semi-sitting on injured side
Bleedings: direct compression; remote compression for severe; tourniquet only as last resort ABOVE elbow/knee; NEVER use thin cord/wire; NO cotton wool, NO alcohol on wound
Fractures: splint above + below; DO NOT reduce open fractures; wash contamination (do NOT disinfect); pelvic + long bone fractures = large hidden blood loss
Dislocations: DO NOT reduce in field; immobilize as found; ice; rapid hospitalization

Quartz 5

Explorer

Some Issues about Medical Emergency Situations

Some Issues About Medical Emergency Situations

Course Topics

Part One

Part Two

Forewords

Part One: Technical and Non-Technical Skills

Medicine and Aviation: Key Similarities

You Will Always Have to Decide

What Contributes to Effective Decision-Making?

How to Face Emergency Problems?

Technical Skills

Non-Technical Skills

Perception

Case Study: Eastern Airlines Flight 401

Situational Awareness Model

Case Study: The Rudine Derailment (Croatia, July 24, 2009)

You Will Always Have to D.E.C.I.D.E.

Problems in Maintaining Good Situational Awareness

Crew Resource Management (CRM)

CRM Topics

Part Two: Some Medical Emergency Situations

Looking at the Patient — Vital Functions

The A-B-C-D Method

A = Airway

B = Breathing

Respiration (Gas Exchange at Alveolar Level)

Ventilation (Mechanical)

Signs of Dyspnea (Laboured Breathing)

C = Circulation

Age-Related Normal Vital Parameters

Shock (Bare Bones)

Types of Shock

Signs of Shock

Dealing with Shock (All Kinds) — Without Equipment or Drugs

D = Disability

A-V-P-U Consciousness Scale (Simplified)

Key Pain Stimulus Methods

Emergency Problem Assessment — Framework for Clinical Cases

Anaphylaxis

Definition and Mechanism

Symptoms and Findings

Management

Prehospital Supportive Care

Drug Treatment

Case Study: John — Anaphylactic Shock

Thermal Injuries — Burns

Burns as a Systemic Injury

Key Vasoactive Mediators Released

Depth of Burns

Burns Evaluation

Burn Depth Classification (Summary)

Estimating Burn Size — Rule of Nines

Severity Factors

Major Burns — Definition

Prehospital Burns Management

First Step

Second Step

Additional Care

Fluid Resuscitation in Burns

Fluid Resuscitation Formulae

Case Study: Sam — Electrical Burns

Heat Stroke

Definition

Thermoregulation

Aetiology of Heat Stroke

Heat Loss Mechanisms

Heat Stroke — Assessment

Indicators of Poor Prognosis

Case Study: Jack — Heat Stroke

Hypothermia

Definition

Pathophysiology

Thermoregulation in Cold

Stages of Hypothermia

Heat Loss Mechanisms (Relevant in Hypothermia)

Clinical Presentation of Severe Hypothermia

Prehospital Management of Hypothermia