Professionals prepare properly

Cite this article as:
Shane Broderick. Professionals prepare properly, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29456

Throughout my career, I’ve always had a keen interest in trauma. As I prepare to depart to take up a trauma fellowship at the Alfred hospital in Melbourne, I was interviewed for the case report podcast and asked for some of my ‘tips and tricks’ of the trauma care trade. When I started to prepare for that talk and now this blog post, I thought, what would I like to have known when I started off receiving major trauma patients? What advice would I give to my more junior self?

Professionals prepare properly”. That phrase that I first heard from friend/colleague/mentor Dr Cian McDermott (@cianmcdermott) is still ringing in my ears. We need to prepare now for that patient that we might meet on shift later on today, perhaps tomorrow or maybe even years into the future. If preparation is key, then I feel that the ‘zero-point survey’ from Cliff Reid et al. is a great place to start. It represents somewhat of a change to the traditional teaching that we are all familiar with such as ATLS (Advanced Trauma Life Support) in that it asks you to prepare to receive the patient before the point of first patient contact. It asks you to ready yourself, your team, your environment, and your system. So here are some of my hopefully helpful hints, framed around the survey.

Me, myself and I

Is it just me or does a major trauma pre-alert bring about the flight before the fight response? How often does a team member come to you and their first contribution is… do I have time to run quickly to the toilet? They do. You do. Always. Manage your own stress.

Tip 1: Take 30 seconds for yourself

When I am the Trauma Team Lead (TTL) preparing to receive a patient, I often walk the long way around to the resus room. This may seem strange when time is of the essence, but it affords me that thirty seconds of headspace for a quick personal pep/prep-talk. It allows me to clear my mind, focus on the task at hand, formulate a plan, rationalise my ‘fight-flight’ response that will allow me to optimise my ability and to meet the patient on the correct side of the Yerkes-Dobson curve. When a patient is at their worst, they demand your best!

The Yerkes-Dobson curve of how stress affects performance

Tip 2: Acknowledge your weakness and then address it

As trainees, at the end of each year, we are asked to fill out an end of year assessment for ourselves and our training sites. The questions are straightforward until, question four. List your weaknesses.

This can sometimes be hard, not because we are perfect (far from it), but because we often either do not acknowledge our weaknesses or indeed somewhat suppress them. We need to look critically at ourselves, to find our weaknesses and then, to address them. For me, as a junior trainee, I felt that I needed to improve my airway skills, so I attended the TEAM course. I wanted to enhance my critical care management, so I attended the ED-Critical care course in Ede, Netherlands with Cliff Reid. Are you confident with the advanced resuscitation skills that are required in trauma?  Could you perform a lateral canthotomy, pericardiocentesis or thoracotomy? If not, find a course (shameless plug www.resuscitate.ie)!

Trauma is a team sport

Emergency Medicine is far better than General Surgery (cue onslaught)! To qualify this, I started life as a basic surgical trainee before transitioning to Emergency Medicine and for me, my work-life balance instantly became better! There were many reasons for this.

  • I no longer had a bleep
  • I only had to be in one place at one time (albeit often that means being thinly spread over a large department). And most importantly…
  • My team were always with me (onsite).

I am passionate about Trauma Teams (TTs) as they have been shown to optimise patient care by reducing time to diagnostics and interventions. In Ireland, there are currently no accepted TT configuration or activation criteria for such a team. This presents a massive challenge in terms of data capture with only 8% of major trauma patients documented as being met by a trauma team on arrival. I have recently written a position paper for IAEM (Irish Association for Emergency Medicine) and the Emergency Medicine Programme (EMP) on TTs that can be used for collaborative engagement with the National Trauma Office as well as to engage with the key stakeholders including Surgery, Critical Care, Trauma & Orthopaedic Surgery and nursing amongst others to aid the development and roll-out of TTs for Ireland so, watch this space!

Back to the survey. Prepare the team. As the TTL; assess the pre-alert (remembering Mansoor Khan’s wise words that in major trauma, “the word stable only refers to the place where a horse lives”), activate the appropriate team, allocate appropriate roles, and anticipate what this resus may entail.

Tip 3. In expecting the unexpected, set out a shared plan.

What is the best-case scenario? What is the worst-case scenario? Create a shared mental model with the team. If a thoracotomy is required then having anticipated this prior to the patient’s arrival might alleviate some of the fear factor. If a team member is not comfortable witnessing such a resuscitation, then it allows them to excuse themselves at an earlier stage.

Tip 4. Insist on a silent resuscitation

Noise suggests chaos. It may indeed be the pen perfect resuscitation, but if people have to raise their voice and even shout to be heard, this can often be disruptive.

Centre stage

Is the environment ready? Is there sufficient space to receive the trauma? If anticipating a Code Red (massive transfusion), could two resus bays be made available? Is there a dedicated trauma bay? If not, can one be established?

Tip 5. Better to be looking at it than looking for it

Check and re-check equipment. Are there blood products in the fridge? Have the rapid infusers been primed and readied? Is there any additional equipment that is likely to be required such as good trauma shears (preferably ones with no plaster of Paris on it!), pelvic binder, good haemostats (not Kaltostat), bite blocks etc. If the equipment that you require is not available, where can you get it from? Can you improvise?  Two quick tips; CAT (Combat Application Tourniquet) MIA? Use a manual blood pressure cuff. No McKesson bite blocks for your Le fort II/III? No problem! Use a few tongue depressors taped together (Thanks to Jason van der Velde).

If the equipment is there, then use it. When it comes to POCUS, you may not be using E-FAST, but, in a major trauma patient with complex facial fractures, marking the CTM (cricothyroid membrane) ultrasonographically informs the team that surgical cricothyroidotomy is a potential. Pre-empting the requirement for life, limb and sight-saving procedures and discussing them out loud, as a group in advance will go a long way to help avoid decision paralysis.

A Trauma System for Ireland? Hopefully.

We can start today by ensuring that our own house is in order. How do we do this? Teach. Train. Simulate. MDT simulation in your resus room allows new processes to be vetted and existing systems tested. Logistics are far more difficult to test in simulation labs. Practice where we preach. Can processes be streamlined? Can default trauma identifications be used? Does the trauma call generate the same response as your STEMI or FAST call? Out-of-hours are trauma calls consultant-led? If not, can telemedicine be used for offsite support? 

Tip 6. TRAUMA CALL = STEMI CALL = FAST CALL

Are there checklists out there that will allow trauma care delivery in a safer manner? Trauma proformas allow accurate and efficient documentation and also serve to prompt the delivery of time-critical actions.

Multidisciplinary teaching is key. Having a regular trauma forum to discuss the major trauma cases that have attended is crucial.  Too often the only forum that these cases are openly discussed is in some Morbidity and Mortality meeting when there has been a bad, or at least unexpected outcome? Do we discuss the ‘good’ cases? Do we hot and cold debrief? Have we Schwartz rounds in our institution?

Nobody will forget 2020 in a hurry. COVID-19 has had a profound impact on each of us. Has it all been bad? I suggest not. Staff numbers have increased (perhaps not as good as they were in May, but certainly an improvement). Emergency Departments have increased in size. Equipment that was on an exceptionally long wish list has suddenly appeared. With this newfound political resource and energy, healthcare has by-in-large, improved (or maybe it is just less bad). With this in mind, trauma care in Ireland is set to undergo reconfiguration with the development of an inclusive System and based on similar international systems, destined to save lives. The political standstill that marred healthcare might be changing. Trauma Care delivery is changing. The Southern and Central trauma leads for Ireland have recently been appointed.  With very tightly crossed fingers and a few more grey hairs for the Clinical Lead for Trauma Mr Keith Synnott, a trauma system for Ireland seems to be on the horizon.

Lastly, the handover from your pre-hospital colleagues.

Final tip. Before taking handover, ask three important questions

  1. Does the patient have any exsanguinating haemorrhage?
  2. Do they have a central pulse?
  3. Are they protecting their airway? If so, carry on with the patient transfer.

Sometimes in my career, I have felt like the proverbial rabbit in headlights, nodding in seeming agreement with my paramedic colleague but occasionally with little information being retained. Nowadays, I try to summarise the handover in a one-sentence synopsis. This helps me to focus and hopefully the team to do likewise. Always ask for silence and sterility for handover. It only takes 30 seconds and may save much more than this if there is a missed communication piece.

References

1. Reid C, Peter Brindley P, Hicks C, Carley S, Richmond C, Lauria M, and Weingart S. Zero pointsurvey: a multidisciplinary idea to STEP UP resuscitation effectiveness. Clin Exp Emerg Med;Sept (5(3)):

Concussion: Neha Raukar at DFTB19

Cite this article as:
Team DFTB. Concussion: Neha Raukar at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22181

After spending 12 years as the Director of the Division of Sports Medicine in the Department of Emergency Medicine at the Warren Alpert Medical School at Brown University, Dr. Raukar joined the Department of Emergency Medicine at the Mayo Clinic in 2018 as full-time faculty.

In this fascinating talk she explores what happens to those children we see every weekend in the emergency department. Whether it is a clash of elbow versus head on the footy oval or a punch to the face at karate practice or something as innocuous as a simple fall from the monkey bars we don’t give these head injuries the attention they deserve.

 

 

©Ian Summers

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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Maturing your approach to trauma: Anne Weaver at DFTB19

Cite this article as:
Team DFTB. Maturing your approach to trauma: Anne Weaver at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22196

Anne Weaver is a consultant in Emergency Medicine & Prehospital Care at The Royal London Hospital and Lead Clinician for London’s Air Ambulance. In this talk she shares her experience of caring for the ever-increasing number of stabbing victims in the United Kingdom. 


There is a disconnect between what adult trauma surgeons and paediatric trauma surgeons are exposed to and are expected to manage. Just one year shy of 16 and the paediatric surgeon, who may never have performed a paediatric thoracotomy, is looking after you, one year over and it’s the adult trauma surgeon with many a notch on their Finochietto.

©Ian Summers

 

DoodleMedicine sketch by @char_durand 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. 

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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Blast Injuries: Paul Reavley at DFTB19

Cite this article as:
Team DFTB. Blast Injuries: Paul Reavley at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21941

Paul Reavley works as a consultant at the Bristol Royal Infirmary.  In this talk he uses his experience in the armed forces to talk about blast injuries. According to Save the Children, one in five children worldwide is living in a conflict zone.  We heard from Nat Thurtle about the crisis in Syria and the bombing of those places which should be safe havens for all. It is a public health problem. And unfortunately, as we have seen recently in Manchester, no one is immune.

 

 

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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Taking your trauma team to the next level: Anna Dobbie at DFTB19

Cite this article as:
Team DFTB. Taking your trauma team to the next level: Anna Dobbie at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22066

Anna Dobbie works in HEMS, PEM, and Adult ED and is a badass at all of them. She is the person you’d want leading your trauma team. Want to be just a little more like Anna? Then watch her talk and find out how to step up.

As we are so fond of saying, “You set the tone.” That first two minutes of any resus is critical – and not just because of the decisions you make. If you can appear calm and in control, your teams’ actions will reflect that. Running every trauma call the same allows for cognitive off-loading as some behaviours become automatic. Whether they are ‘real’ calls or not so serious ones the team is expected to act the same either way.

 

 
 
DoodleMedicine sketch by @char_durand 
 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

iTunes Button
 

 

Orbital fractures

Cite this article as:
Orla Kelly. Orbital fractures, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21843

Epidemiology

Facial fractures in children accounted for just 4.6% of paediatric trauma admissions on review of the American National Trauma Databank. However, even though they are less prevalent than in an adult population, they are associated with other severe injuries and higher mortality compared with adults. The pattern of injury descends the face as the patient ages – the under 5s are more likely to sustain frontal bone and orbital roof fractures, while the 6-16-year-olds are more likely to have midface and mandibular fractures. Orbital fractures as a subset comprise between 5 to 25% of facial fractures.

 

Anatomy

  • The orbit is comprised of 7 bones – maxilla, zygomatic, frontal, ethmoid, lacrimal, sphenoid and palatine.
  • The rim is formed by the frontal bone, maxilla, and zygoma.
  • The orbits are pyramidal structures, with a wide base opening on the face, with its apex extending posteromedially.
  • They lie anterior to the middle cranial fossa and inferior to the anterior cranial fossa.
  • Their close proximity to the sinuses coupled with the ophthalmic veins communicating with the cavernous sinus creates a possible introduction of infection into the intracranial cavity.

 

  • The infra-orbital nerve exits through the inferior orbital foramen inferior to the orbital rim and innervates lateral aspect of the external nose, inferior eyelid and cheek and upper lip and related oral mucosa.
  • Paediatric anatomy and development confer different injuries depending on age, with orbital floor fractures becoming more common than roof fractures at approximately age 7 due to the development of the maxillary sinus.

 

History and Examination

Mechanism of injury is always important to elicit in trauma as well as careful and thorough (and documented) examination. Initial assessment as always in trauma is by the ATLS ABC approach followed by a careful secondary survey.

Children are prone to a pronounced oculocardiac reflex which may become apparent in the initial ABC assessment; this is caused by compression of the globe or traction on the extra-ocular muscles. Connections between the sensory afferent fibres of the ophthalmic division of the trigeminal nerve and visceral motor nucleus of the vagus nerve cause bradycardia and hypotension often with headache, nausea, and vomiting.

Have a systematic approach to examination so as to ensure all important aspects are covered. Always examine and document:

  • General inspection – oedema, laceration, and bruising
  • Enophthalmos/proptosis
  • Subconjunctival haemorrhage
  • Periorbital emphysema
  • Pupillary response including RAPD
  • Eye movements in all directions
  • Visual acuity
  • Diplopia
  • Palpation of the orbital rim for tenderness or step
  • Abnormalities of the nasal bridge (saddle nose deformity) and widening of the midface (telecanthus)
  • Disruption to the infraorbital nerve: numbness of the ipsilateral cheek, lip, and upper gum

Sensory distribution of infra-orbital nerve

 

Investigation and Management

Investigation of orbital fractures is by x-ray and CT, with CT being the modality of choice, though it can be unreliable in children with blowout fractures. A CT may already be appropriate due to a mechanism of injury or red flags for a head injury.

The aim of initial management in the ED is to prevent further damage to the globe.

Patients should be advised to not blow their nose and to sneeze with their mouths open. A cold compress and raising the head of the bed can help alleviate periorbital oedema. Ensure the eyelids can close fully and lubricate the cornea. Provide a protective patch if necessary.

Types of Injuries

 Orbital Floor and Medial Orbital Wall Fractures

The term ‘blow out fracture’ has historically meant a fracture of the orbital floor secondary to a direct blow to the globe, causing an increase in pressure that results in the thin orbital floor fracturing. Children presenting with floor or medial wall fractures are at high risk of entrapment, as paediatric bones are more prone to greenstick fracture, which then creates a ‘trapdoor’ effect ensnaring the inferior oblique and inferior rectus muscles or other orbital contents. Clinically, the child will be unable to complete upwards gaze. Entrapment is a surgical emergency, as ischaemia of the involved musculature can cause permanent damage. The infraorbital nerve is commonly damaged in these injuries.

Orbital blow out fracture: the orbital floor has fractured, the inferior rectus muscle has herniated through, and then become trapped in a bony trapdoor. Reproduced with permission from AO Surgery Reference, www.aosurgery.org. Copyright by AO Foundation, Switzerland.

 

Children with orbital floor fractures may not have any facial bruising, classically presenting with a ‘white-eyed’ fracture with the only sign being limitation of eye movement secondary to entrapment.

(A) Restriction of upgaze in the right eye with no evidence of periocular trauma. (B) CT scan of the orbits demonstrating inferior rectus muscle entrapped within inferior orbital wall fracture (arrow). Reproduced with permission from www.emj.bmj.com

 

Orbital Roof Fractures

Orbital roof fractures are more common in childhood as the frontal sinus has not yet pneumatised, therefore all posterior force to the superior orbital rim is transferred to the anterior cranial base. Another mechanism of injury is a ‘blow-in’ fracture, where there is an inferiorly directed supraorbital force.

 

NOE (nasal-orbital-ethmoidal) Fractures

Nasal bone injuries are common in older children and adults and must always be assessed for an underlying NOE fracture. When direct force is applied to the nasal bone, it can cause a collapse of the paired nasal, lacrimal, and ethmoidal bones. If this fracture is missed in a child, significant midface deformities can result.

 

Midfacial fractures

Although children are more likely than adults to suffer isolated orbital rim fractures, orbital fractures are often involved in midfacial fractures of the maxilla and zygoma: the orbit is involved in Le Fort II and III; zygoma fractures are often accompanied by orbital floor or medial wall fractures.

 

Globe Injuries

Orbital fractures can often result in globe injuries ranging from corneal abrasion to rupture. If there are any signs of globe rupture (360 degrees conjunctival haemorrhage, misshapen pupil or a flat anterior chamber) a gross visual examination should be completed, vaulted eye protection applied, and immediate ophthalmology consult sought. Do not apply pressure to a possibly ruptured globe.

 

Retrobulbar haemorrhage

A rare but sight-threatening complication is a retrobulbar haemorrhage which causes increased pressure, stretching of the optic nerve and can result in permanent blindness. If optic pressure is low, medical management with mannitol, steroids, and acetazolamide can be used after expert involvement. However, if there is an indication that the pressure is high, a lateral canthotomy should be performed as a matter of urgency. The procedure should ideally be performed by an ophthalmologist, but when ophthalmology are delayed or unavailable, the procedure must be performed by an emergency clinician in the ED. Do not delay a lateral canthotomy for imaging if sight is threatened.

 

Indications for lateral canthotomy include:

  • Retrobulbar haematoma
  • Decreased visual acuity
  • Afferent pupillary defect
  • Proptosis

 

Pearls

  • Repeat a child’s eye examination while they are in the emergency – repeated examination can drastically change disposition from maxillofacial non-urgent transfer to a blue light ophthalmological review
  • Oculo-cardiac reflex can cause bradycardia and hypotension
  • Children are more likely to have other and significant injuries: the secondary and tertiary survey is imperative.
  • Children are more likely to suffer ‘trapdoor’ floor fractures causing entrapment that can present as a ‘white eye’ fracture– this is a surgical emergency, act fast.
  • Patients should avoid nose blowing and should sneeze with their mouth open following injury.
  • Ophthalmological assessment should be sought in all patients with orbital trauma.

 

Selected references

Imahara SD, Hopper RA, Wang J, Rivara FP, Klein MB. Patterns and outcomes of pediatric facial fractures in the United States: a survey of the National Trauma Data Bank. J Am Coll Surg. 2008;207:710–716

Oppenheimer AJ, Monson LA, Buchman SR. Pediatric orbital fractures. Craniomaxillofac Trauma Reconstr. 2013;6(1):9–20.

Koltai PJ, Amjad I, Meyer D, Feustel PJ. Orbital fractures in children. Arch Otolaryngol Head Neck Surg. 1995;121:1375–1379

Cohen SM, Garrett CG. Pediatric orbital floor fractures: nausea/ vomiting as signs of entrapment. Otolaryngol Head Neck Surg. 2003;129:43–47

Grant JH III, Patrinely JR, Weiss AH, Kierney PC, Gruss JS. Trapdoor fracture of the orbit in a pediatric population. Plast Reconstr Surg. 2002;109:482–489; discussion 490–495

Boyette, J. R., Pemberton, J. D., & Bonilla-Velez, J. (2015). Management of orbital fractures: challenges and solutions. Clinical ophthalmology. 2015;9:2127–2137.

Cobb ARM, Jeelani NO, Ayliffe PR. Orbital fractures in children. British Journal of Oral and Maxillofacial Surgery. 2013;41–46

Kassam K, Rahim I, Mills C. Paediatric orbital fractures: the importance of regular thorough eye assessment and appropriate referral. Case Rep Emerg Med. 2013:376564. doi:10.1155/2013/376564

Paediatric ophthalmology: Siobhan Wren at DFTB19

Cite this article as:
Team DFTB. Paediatric ophthalmology: Siobhan Wren at DFTB19, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.21733

Siobhan Wren is an ophthalmologist based at Imperial College in London. It’s a rotation that most of us skipped out on in medical school but with paediatric ocular trauma accounting for a third of all ocular trauma it is something that needs to be on our radar.

In this talk she focuses on the first sixty minutes after the injury – keeping the patient comfortable and safe, not making things worse and a stepwise approach to the basic examination.

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

iTunes Button
 

Selected References

Sii F, Barry RJ, Abbott J, Blanch RJ, MacEwen CJ, Shah P. The UK Paediatric Ocular Trauma Study 2 (POTS2): demographics and mechanisms of injuries. Clinical ophthalmology (Auckland, NZ). 2018;12:105.

Seat Belt Injuries

Cite this article as:
Keith Amarakone. Seat Belt Injuries, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20575

A 10 year old boy presents to your emergency department following a high speed MVA – car vs tree. He was seated in the rear middle seat.  On arrival he is noted to have significant bruising across his lower abdomen from the seat belt but otherwise appears well.

Trauma, Teams and Tribes: Vic Brazil at DFTB18

Cite this article as:
Team DFTB. Trauma, Teams and Tribes: Vic Brazil at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20194

Victoria Brazil is a senior staff specialist at the Gold Coast University Hospital. She is a world renowned expert in the role of simulation in medical education.

Catch 22

Cite this article as:
Ana Waddington. Catch 22, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19122

James was 13 the first time I treated him in A&E. He was rushed in after being hit on the head with a metal bar, but he wouldn’t tell us what had happened. Some others had seen him, rushed him, started beating him with bats and bars – that was all he said he remembered. It was clear that James was already deeply involved in the world of gang violence, and it was equally clear that if he wasn’t saved from it soon this world would destroy him. We tried to get James to stay in A&E long enough to hear the results of his scan, but as soon as he got a chance he slipped out and back onto the streets. My fear was that before long the streets would deliver him back to us, only this time he wouldn’t be able to walk out again.

pHirst Aid – Management of Chemical Attacks in Children

Cite this article as:
Anna Dobbie. pHirst Aid – Management of Chemical Attacks in Children, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18552

Chemical attacks (or acid attacks as they are colloquially known) are increasing. The latest numbers show the UK has one of the highest rates of violent acid attacks per capita in the world. The latest figures released report 601 attacks in the UK in 2016 but 400 in first 6 months of 2017. London has emerged as a hot-spot for acid attacks in recent years and it is thought that many attacks still go unreported.