Pre-hospital Care at Road Accidents

The number of deaths and injuries on British roads is falling. The UK has the lowest rate of road accident fatalities in the EEC. It is lower than Japan or Australia and just over a third of the rate in the USA. The aim of pre-hospital care is to reduce the morbidity and mortality of those who are injured before they reach hospital. Inappropriate pre-hospital care is potentially dangerous and may seriously aggravate the injuries sustained.

Accident prevention is discussed elsewhere. See separate article Accidents and their Prevention.

Assessment

See separate article on Trauma Assessment.

• If there has been an accident with many people injured and possible fatalities, the principles outlined in major disaster plans are appropriate. See separate article Major Incident Plans.
• When attending an accident, check that the scene of the accident is safe. Your personal safety is paramount or you may add to the problem rather than contributing to the solution. If you have access to high visibility clothing, wear it.

Hazards

There are a number of hazards that may need to be considered for personal safety and that of others.

Passing traffic

• One risk is that oncoming traffic may plough into those there. Leave on hazard lights and a green beacon if you have one.
• Park safely so that your car doesn't cause an obstruction, especially for the emergency services.
• The problem is discussed further in Road Accidents - Attending as a Passing Doctor.

Fire

• Fewer than 5% of road traffic accidents result in fire, and less than 1 in 500 results in significant burns.
• Switch off the ignition of your and any other vehicle.
• Ensure nobody at the scene of the accident is smoking or produces a naked flame.

Electricity

• If electricity cables are brought down, the power may be restored after 20 minutes without investigation.
• It is therefore necessary to telephone the power company to ensure that the source is turned off.
• High tension cables can be lethal, even when standing several metres away.

Rail

• Accidents on level crossings can kill or injure occupants of cars and even derail trains.
• An electrified rail may be short-circuited by a bar carried in the guard's van.
• Cutting power does not stop diesel locomotives that may also operate on the same line.
• Trains may be stopped by signal lights, red flags, or a series of charges placed on the rail. The noise warns the driver.

Chemical

• Lorries carrying hazardous loads are required to display an orange HAZCHEM board. This contains:
  • Information on how to fight a fire, what protective equipment to wear, if the chemical can be safely washed down the storm drains, and whether to evacuate the area (TOP LEFT).
  • A United Nations (UN) product identification number of 4 digits (MIDDLE LEFT), eg 1270 = petrol; a pictorial hazard diamond warning (TOP RIGHT).
  • An emergency contact number (BOTTOM).
• A white plate means the load is non-toxic.
• The European 'Kemler' plate contains only the UN product number (BOTTOM) and a numerical hazard code (TOP - note repeated number means intensified hazard).
• As a concession to freight carriers, mixed loads of < 500kg need only be identified by a plain orange square at the front and rear.
• To obtain information about the chemical at the scene of an accident look at the transport emergency card (TREM card) carried in the driver's cab.
• The fire tender may be equipped with CHEMDATA - a fax service with the national chemical information centre at Harwell.
• Alternatively phone a Poison's Information Centre (eg 0131 229 2477 or 01132 430715), or the company.

Assess the situation

• If there are many people injured, triage will be necessary to order priority; see separate article on Trauma Triage and Scoring (ATLS).
• Read the wreckage and relate the damage of the vehicle to potential injuries:^[1]
  • Steering wheel deformed = chest injury
  • Dashboard intrusion = patella/femur fracture ± posterior dislocation of the hip
  • Bodies are softer than metal, so major bodywork distortion = major injury
• Talk to the patient or patients if conscious. Come over as competent and reassuring as they will be very anxious.
• Ask where it hurts to get an idea of injuries.
• They may well be in severe pain. Parenteral opiates are often appropriate. Give IV if possible as peripheral circulation is probably shut down.
• Fractures and abdominal trauma may produce considerable concealed haemorrhage. Check for signs of hypovolaemic shock. Unless injuries are minor get venous access sooner rather than later, before peripheral circulation collapses. If you are unsuccessful at cannulation do not persevere.^[2] Two attempts is regarded as reasonable.
• Identify the time-critical patient. Some will die unless rapidly removed from the vehicle, at whatever cost. Entrapped patients should be removed in less than half an hour.^[3]
• Resuscitation:
  • When the patient is unconscious remember the ABC of airways, breathing, circulation. If there is sudden deterioration check ABC again for a possible cause.
• Whether the person is conscious or not, beware of neck injuries and spinal cord compression. Many head restraints are unsatisfactory. If there is any doubt at all apply a collar if you have one but still there is need to support the neck, as even a well-fitted and applied collar allows some movement.
• If a car has rolled over on to a person, there may be crush injuries. See separate article Crush Syndrome for further detail.

Principles of extrication

• Stabilise the vehicle where it lies as movement may exacerbate injury.
• Make the vehicle safe. Switch off the ignition, disconnect the battery, swill away any petrol.
• The easiest way to enter a car is through the door, so try this before removing the windscreen or the roof.
• Remove the wreckage from the casualty, not the casualty from the wreckage. Do not try to manoeuvre the casualty through too small a hole.
• Do not move from one entrapment situation straight into another. If necessary spend a short time stabilising the patient before moving into the back of the ambulance.

Stabilisation or evacuation?

The question is whether it is better to arrange immediate transfer to hospital, wasting no time, or if resuscitation first would improve the patient's chance of surviving the journey and prognosis once there. In deciding which is better, take the following into account:

• There is no single answer for all circumstances. Local geography, such as the distance to the hospital, plays a part, as does the fitness of the casualty.
• Often a minimal amount of resuscitation can be done without causing too much delay. A consensus paper from Birmingham in 2002 highlighted a number of issues.^[2] One is that there should not be undue delay in getting the patient to hospital.
• Penetrating chest injuries have been studied in a pseudo-randomised trial of 289 patients. This study showed that the balance of benefit probably lies in immediate transfer to hospital for this type of injury.^[4]
• Fluid resuscitation aiming for normotension without an operating theatre to hand may be dangerous, as clot may be displaced by the rising BP. There may be consequent fatal haemorrhage, which could only have been prevented by major surgery.
• In another study, 70% in the delayed-resuscitation group survived, compared with 62% who received immediate fluid resuscitation. Duration of hospital stay was shorter for survivors in the delayed-resuscitation group. A computer model showed that, if the rate of bleeding is slow, there is not much difference in giving fluid or not but if bleeding is profuse it is beneficial.^[5]
• The consensus statement advice was that fluid should not be administered to trauma victims before haemorrhage control if a radial pulse can be felt. Judicious aliquots of 250 ml should be titrated for other patients. If the radial pulse returns, fluid resuscitation can be suspended for the present and the situation monitored. In penetrating torso trauma the presence of a central pulse should be considered adequate. In children less than 1 year old, the use of a brachial pulse is more practical as it is easier to feel.^[2]

Vicarious liability

• In the United Kingdom there is no legal obligation for anyone to stop and help at a road accident.
• The GMC states, "In an emergency, wherever it arises, you must offer assistance, taking account of your own safety, your competence, and the availability of other options for care."^[6]
• If you stop you are legally responsible for your actions and omissions.
• The "Good Samaritan" is not covered by NHS trust indemnity but both the Medical Protection Society^[7] and the Medical Defence Union include medico-legal cover for accidents in their basic policies.
• It is recognised by most authorities that a doctor willing to stop is acting out of beneficence for the casualties and in this country legal repercussions are fortunately rare.