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When a patient is physically trapped by a limb with imminent threat to life from cardiac arrest due to hypovolaemia, or a scene emergency such as fire or flooding, and there is no other method of rapid extrication then life-saving limb amputation may be necessary. Advanced prehospital practitioners should have the equipment, training and organisational governance to be able to undertake these rare time-critical procedures in the field. Whilst the actual surgical procedure of a guillotine amputation is very simple, the decision-making to undertake the procedure is more stressful and a successful outcome requires adequate preparation and briefing of the team. This chapter covers the key indications and considerations for field amputation including helpful advice to support the decision, as well as considerations before starting the procedure, after the patient has been extricated and after handover at hospital. This chapter describes the use of procedural sedation for amputation as well as other painful procedures which may be undertaken in the prehospital environment. Practitioners should have a comprehensive understanding of the pharmacology, dosing and potential side effects of the sedative drugs available in their formulary, as well as having experience and training to optimally provide sedation in the field.

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This article is concerned with the in situ negotiation of epistemic authority through the mobilisation of summaries in the context of medical emergencies. It focuses on the use of the discourse marker so in prefacing summaries as a strategy for claiming epistemic primacy, with particular attention being paid to so's multimodal accomplishment. Taking an interactional sociolinguistic approach, we bring together simulated and real-life trauma emergencies and zoom in on the role of the institutionally defined team leader.

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Fatigue is a common presenting complaint in patients seen in clinics and same-day emergency care. Although it has a simple presentation, it can be challenging to diagnose and manage, particularly when an underlying medical condition presents atypically as fatigue. Here we present an interesting case of giant cell arteritis (GCA) with only fatigue as the presenting complaint. GCA is the inflammation of medium and large vessels in the body, including the aortic arch and its branches. It typically manifests above the age of 50 with headaches, jaw claudication, temporal tenderness, arthralgia, night sweats, and unintentional weight loss. Early diagnosis and treatment are of paramount importance to prevent complications, particularly permanent blindness.

Most hypobaric hypoxia studies have focused on oxygen delivery and therefore cerebral blood inflow. Few have studied venous outflow. However, the volume of blood entering and leaving the skull (∼700 ml/min) is considerably greater than cerebrospinal fluid production (0.35 ml/min) or edema formation rates and slight imbalances of in- and outflow have considerable effects on intracranial pressure. This dynamic phenomenon is not necessarily appreciated in the currently taught static "Monro-Kellie" doctrine, which forms the basis of the "Tight-Fit" hypothesis thought to underlie high altitude headache, acute mountain sickness, and high altitude cerebral edema. Investigating both sides of the cerebral circulation was an integral part of the 2007 Xtreme Everest Expedition. The results of the relevant studies performed as part of and subsequent to this expedition are reviewed here. The evidence from recent studies suggests a relative venous outflow insufficiency is an early step in the pathogenesis of high altitude headache. Translation of knowledge gained from high altitude studies is important. Many patients in a critical care environment develop hypoxemia akin to that of high altitude exposure. An inability to drain the hypoxemic induced increase in cerebral blood flow could be an underappreciated regulatory mechanism of intracranial pressure

Pre-hospital care is emergency medical care given to patients before arrival in hospital after activation of emergency medical services. It traditionally incorporated a breadth of care from bystander resuscitation to statutory emergency medical services treatment and transfer. New concepts of care including community paramedicine, novel roles such as emergency care practitioners, and physician delivered pre-hospital emergency medicine are re-defining the scope of pre-hospital care. For severely ill or injured patients, acting quickly in the pre-hospital period is crucial with decisions and interventions greatly affecting outcomes. The transfer of skills and procedures from hospital care to pre-hospital medicine enables early advanced care across a range of disciplines. The variety of possible pathologies, challenges of environmental factors, and hazardous situations requires management that is tailored to the patient's clinical need and setting. Pre-hospital clinicians should be generalists with a broad understanding of medical, surgical, and trauma pathologies, who will often work from locally developed standard operating procedures, but who are able to revert to core principles. Pre-hospital emergency medicine consists of not only clinical care, but also logistics, rescue competencies, and scene management skills (especially in major incidents, which have their own set of management principles). Traditionally, research into the hyper-acute phase (the first hour) of disease has been difficult, largely because physicians are rarely present and issues of consent, transport expediency, and resourcing of research. However, the pre-hospital phase is acknowledged as a crucial period, when irreversible pathology and secondary injury to neuronal and cardiac tissue can be prevented. The development of pre-hospital emergency medicine into a sub-specialty in its own right should bring focus to this period of care.