Pre-Hospital Care at Road Accidents

The number of deaths and injuries on British roads is falling. In 2005 there were 3,201 deaths on the roads in Great Britain. Just over half (52%) of people killed in road accidents in 2005 were in cars. Pedal cyclists and motor cyclists represented 5 and 18% of those killed respectively. Pedestrian deaths are at a 40 years low of 671 or 21%. Occupants of buses, coaches, goods and other vehicles accounted for the remaining 4% of road deaths.¹

Total casualties of all severities fell by 3% between 2004 and 2005 to approximately 271,000 in Great Britain. The decline in the casualty rate, which takes into account the volume of traffic on the roads, has been much steeper. In 1964 there were 240 casualties per 100 million vehicle kilometres. By 2005 this had declined to 55 per 100 million vehicle kilometres.

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.

These figures are falling and are a great achievement but they still represent an enormous burden. The aim here is to reduce the morbidity and mortality of those who are injured before they reach hospital.

Accident prevention is discussed elsewhere.

If there has been an enormous accident with many people injured and perhaps fatalities too, the principles outlined in major disaster plans are appropriate.

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.

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. It may be best to park obliquely behind the incident to fend off oncoming traffic. Leave on hazard lights and if you have one, a green beacon. The problem is discussed further in Road traffic accidents - attending as a passing doctor.

Fire

Fewer than 5% of RTAs result in fire, and less than 1 in 500 results in significant burns. The world's worst ever road traffic accident was in the Salang tunnel, Afghanistan, in November 1982 and involved a petrol tanker explosion with an estimated 1,100 to 2,700 killed. Unleaded petrol is far more inflammable than 4-star. Diesel is difficult to burn without a wick. LPG (liquid petroleum gas) in dual fuel cars is potentially explosive. If the engine is still running, turn it off.

Electricity

If electricity cables are brought down, the power may be restored after 20 minutes without investigation. It is 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); and 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. Do not approach a chemical incident until declared safe by the fire service.

• If there are many people injured, triage will be necessary to order priority.
• Read the wreckage and relate the damage of the vehicle to potential injuries:²
  • 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.³ 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.⁴
• 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 onto a person, there may be crush injuries. Crush syndrome is discussed elsewhere.

• Stabilize 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.

Some texts refer to this as scoop and run or stay and play. Scoop and run refers to rapid evacuation of casualties to hospital. Stay and play entails detailed resuscitation at the scene of trauma. 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.
• Scoop and run and stay and play are two ends of a spectrum of activity. 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.³ One is that there should not be undue delay in getting the patient to hospital.
• Penetrating chest injuries have been studied in a pseudo-randomized trial of 289 patients. Full randomization was impossible but scoop and run operated for one day, and stay and play for the next.⁵ This showed that the balance of benefit probably lies in scoop and run for this type of injury.
• 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.⁶
• 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.³

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."⁷

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 Society⁸ 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.