Introduction The Midland Trauma Guidelines have provided a useful source of information and guidance since they were launched, and have improved the journeys of thousands of patients and their whānau by allowing us to apply a common language of best practice to our crafts. They have been updated to the current state of the art and we have included several new sections on request of our clinicians. Prior to endorsement they went through extensive regional consultation to ensure agreement between the large number of groups that deliver care to trauma patients and whānau. There is scope for flexibility dependent on the variation in size and resources of individual hospitals however the principles underlying best practice in trauma are not related to volume, but to knowledge, fine decision-making and excellent communication. We encourage everyone that provides care to trauma patients to be familiar with the content and layout of the guidelines so that you get the information you need, when you need it for the benefit of our patients and whānau.
Acknowledgement s MTS Hub Team, MTS clinical teams in Lakes, Tairāwhiti, Taranaki, Bay of Plenty and Waikato DHBs Midland Trauma Research Centre Midland DHB Trauma Committees, Regional Nursing and Allied Health services, Regional subspecialty clinicians, St John Ambulance, Design and Print Services, Midland DHB Chief Executives, Midland trauma patients and whānau
© Waikato District Health Board 2021 This work is copyright. Apart from any use as permitted under the New Zealand copyright act 1994. No part maybe reproduced without the prior written permission of the Midland Trauma System (MTS).
ISSN 2744-5038 (Print) ISSN 2744-5046 (Online) Title: Midland Trauma Guidelines 2022
Doc ID: Version: 02 Issue Date: MAR 2021 Review Date: Editors: G R Christey Facilitator Title: Clinical Director Department: MTS Publication date: June 2022 IF THIS DOCUMENT IS PRINTED, IT IS VALID ONLY FOR THE DAY OF PRINTING
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Responsibilities and Authorisation Department Responsible for Protocol
Midland Trauma System
Document Facilitator Name
Grant Christey
Document Facilitator Title
Clinical Director
Document Owner Name
Rosemary Clements
Document Owner Title
Chief Executive Officer
Target Audience
All staff
Authorised By
Rosemary Clements
Date Authorised
01 June 2022
Disclaimer: This document has been developed by TMT/Midland District Health Boards specifically for their own use. Use of this document and any reliance on the information contained therein by any third party is at their own risk and TMT/Midland District Health Boards assume no responsibility whatsoever.
Guideline Review History Date Updated Aug 2020
Version
Updated by
2
Grant Christey
2
MTS Operational Group
Sept 2020
Completed reviews of draft guidelines. Responses from local trauma committees
2
Grant Christey
Dec 2020
Final version compiled and submitted
2
Rosemary Clements
Dec 2020
Final version endorsed on behalf of DHB CEs
3
Grant Christey
June 2022
Section additions: Trauma in Pregnancy; Code Red and T30; Severe Traumatic Brain Injury; Paediatrics; Abdominal Trauma; Clinical Frailty Score.
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Summary of Changes Upgrades to all sections; addition of several new sections. Appendices removed and linked to eBook.
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Contents 1
Overview .............................................................................................................................................. 7 Introduction .................................................................................................................................. 7 Guiding Principles of Quality Trauma Care ................................................................................. 8 Scope and Limitations.................................................................................................................. 8 Patient Group ............................................................................................................................... 8
2
Guidelines ............................................................................................................................................ 9 Single Point of Entry..................................................................................................................... 9 The Trauma Team Activation....................................................................................................... 9 Adult Trauma Call Criteria.......................................................................................................... 10 Paediatric Trauma Call Criteria .................................................................................................. 11
3
Code Red ........................................................................................................................................... 13 Major Trauma Response............................................................................................................ 13 Code Red Response.................................................................................................................. 15 Trauma Call ’T30’ .................................................................................................................................. 19
4
Surgical Cascade for Trauma Calls ................................................................................................... 22
5
Structure of Trauma Call .................................................................................................................... 23 Prior to Patient Arrival ................................................................................................................ 23 Ambulance Handover ................................................................................................................ 23 Primary Survey .......................................................................................................................... 23 Haemostasis and Resuscitation................................................................................................. 24 Secondary Survey and Adjuncts................................................................................................ 24 Definitive Care............................................................................................................................ 24 Tertiary Survey........................................................................................................................... 25 Hot Tips ...................................................................................................................................... 25 “5 Sites” Algorithm for Rapid Evaluation and Treatment of Bleeding ........................................ 26 Immediate Care Algorithms ....................................................................................................... 27
6
Guidelines for Staff Protection in the Resuscitation Room ................................................................ 28 Rationale .................................................................................................................................... 28 Body Fluid Protection ................................................................................................................. 28 Radiation Protection................................................................................................................... 28
7
Trauma Patient Transfer and Admission Criteria............................................................................... 29 Criteria for Transfer of Trauma Patients to Waikato Hospital .................................................... 29
Single Surgical Call with Consultant-to-Consultant Referral Process for Severely Injured Patients to Waikato Hospital .............................................................................................................. 29 Doc ID: Version: 02 Issue Date: MAR 2021 Review Date: MAR 2024 Facilitator Title: Clinical Director Department: MTS IF THIS DOCUMENT IS PRINTED, IT IS VALID ONLY FOR THE DAY OF PRINTING
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General Criteria for Admission to TMT DHBs of Trauma Patients with Minor Injuries .............. 30 Traumatic Brain Injury (TBI)....................................................................................................... 32 TMT/Midland Patient Repatriation Program ............................................................................... 34 8
Trauma Radiology.............................................................................................................................. 35 Plain Radiology .......................................................................................................................... 35 Computed Tomography (CT) Scanning ..................................................................................... 36 Interventional Radiology ............................................................................................................ 39
9
Paediatric Trauma.............................................................................................................................. 41 Primary Survey (focus on the differences compared with adults) ............................................. 41
10
Special Situations .............................................................................................................................. 45 Trauma in the Elderly ................................................................................................................. 45 Trauma in Pregnancy................................................................................................................. 47 Burns.......................................................................................................................................... 52
11
MTS Trauma Quality Improvement Program ..................................................................................... 55
12
Evidence base ................................................................................................................................... 57 Summary of Evidence, Review and Recommendations ............................................................ 57 References................................................................................................................................. 57
13
Inter-Hospital Referral and Acceptance Matrices for Regional Facilities........................................... 58
14
Appendices ........................................................................................................................................ 84 Appendix A – TMT / Midland Trauma System (MTS) ........................................................................ 84 84 Appendix B – Waikato Hospital Trauma Service ............................................................................... 85 Appendix C. Roles of Trauma Call Team Members .......................................................................... 86 Appendix D - Primary Survey ............................................................................................................. 92 Adult Glasgow Coma Scale................................................................................................................ 94 Paediatric Glasgow Coma Scale........................................................................................................ 94 Appendix E - Secondary Survey ........................................................................................................ 96 Appendix F - Tertiary Survey ........................................................................................................... 104 Appendix G - Emergency Procedures.............................................................................................. 108 Appendix H - Guidelines for Referral of Adult Patients with Head Injury from South Waikato Rural Hospitals to Waikato Hospital for CT Brain ...................................................................................... 117 Appendix Ia – Adult Massive Transfusion Protocol (MTP) ............................................................... 119 Appendix Ib – Paediatric Massive Transfusion Protocol (MTP)....................................................... 119 Appendix J - Management of the haemodynamically unstable patient with a pelvic fracture with Angiography available ..................................................................................................................... 121 Appendix K - Management of the haemodynamically unstable patient with a pelvic fracture without Angiography available ..................................................................................................................... 121
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Appendix L - Extremity Penetrating Algorithm ................................................................................. 123 Appendix M - Moribund penetrating chest trauma ........................................................................... 123 Appendix N - Penetrating abdominal wound .................................................................................... 125 Appendix O - Suspected thoracic injury ........................................................................................... 128 Appendix P - Suspected spinal cord injury ...................................................................................... 128 Appendix Q - Cervical spine evaluation ........................................................................................... 130 Appendix S - Chest Wall Injury Guideline ........................................................................................ 132 Appendix T - Pregnant trauma patient ............................................................................................. 135
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Overview Introduction Comprehensive, specialised care is the international standard for trauma patients, particularly those with severe or multiple injuries who are time critical and highly vulnerable to deviations from best practice. Optimal outcomes depend on how well their complex needs can be addressed and this is best delivered by dedicated, skilled personnel using a patient-focussed, multidisciplinary approach. This protocol and algorithms have been developed to assist all trauma care providers in providing best practice in trauma care to patients and their families. They are a distillation of evidence-based best practice in trauma systems similar to our own and have been adapted for use within the New Zealand healthcare system. They utilise the standardised language of major trauma care EMST™ (Early Management of Severe Trauma) and DSTC™ (Definitive Surgical Trauma Care) / DATC™ Definitive Anaesthetic Trauma Care. This has updated version been endorsed by the (TMT)/Midland CEs after an extensive, regional consultative process involving the clinical leads, clinical nurse specialists and trauma committee members in each of the TMT district trauma services on behalf of their clinicians, staff and organisations. We acknowledge the contribution of knowledge and advice from the following sources across TMT/Midland Region:
•
MTS Trauma Committees
•
DHB Executives
•
Emergency Departments
•
District Trauma Services
•
Radiology
•
Specialty Surgical Services
•
Nursing Services
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Anaesthesia
•
Intensive Care
•
Physiotherapy
•
Allied Health Professionals
•
Women’s Health
•
Quality and Risk
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Disclaimer: Trauma patients are variable in their injury patterns and clinical requirements and different organisations and services have variable capabilities and capacities, therefore Te Manawa Taki/Midland Trauma System can accept no responsibility for suboptimal outcomes as a result of these guidelines.
Guiding Principles of Quality Trauma Care •
The needs of the patient come first
•
Patients with severe or multiple injuries are time critical and all unnecessary delays that add no clinical benefit will be eliminated
•
Adherence to consistent application of best practice leads to favourable clinical and financial outcomes
•
Patients and whānau do best when the clinical teams work together to provide equitable and efficient care of the highest quality
Te Manawa Taki / Midland Trauma System Equity Statement ‘The TMT/Midland Trauma System and its staff view variation in trauma incidence and access to care as inequities in healthcare. Our clinical and prevention programmes are focused on identifying and defining these inequities so they can be addressed and resolved by MTS and our partners that are responsible for healthcare delivery and injury.’
Scope and Limitations The TMT/Midland DHBs have endorsed these guidelines to be used by all health professionals to guide management of all trauma patients in the TMT/Midland region. These guidelines are founded on common principles that should apply to the care of all trauma patients and whānau. There may be situations where local resource limitations make rigid adherence to these guidelines impossible so it is expected that best local efforts are made to comply on the understanding that performance and outcomes are measurable and that all reasonable efforts should be made to meet common standards of care. Patient Group Patients admitted to the TMT/Midland regional hospitals as a result of their injuries.
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Guidelines Single Point of Entry All trauma patients must be assessed in the Emergency Department (ED) prior to admission to any in-hospital service. This includes all major trauma patients transferred from other hospitals within 48 hours from the time of injury and all trauma ICU transfers. The only exception is patients who are expected to go directly to the operating theatre. This step ensures that clinical status is reviewed, clinical information is present, immediate resuscitation requirements are met and appropriate registration is completed prior to entering the DHB system. The Trauma Team Activation Rationale for Trauma Call •
Trauma calls are essential to standardise the in-hospital response to severely injured patients whether the injuries are obvious or not. Clinical examination alone is inadequate to diagnose all serious injuries, and a multidisciplinary approach to severely injured patients is proven to significantly improve outcomes.
•
The trauma call has the equally important functions of immediate intervention and notification to a wide range of hospital personnel that a major trauma patient may require urgent intervention.
•
A Code Red response is required for severely injured patients that need immediate lifesaving interventions (Refer Code Red).
Trauma Call Criteria •
Mandatory criteria are the most predictive of severe injury and represent situations where a trauma team response is always required. The rules of discretionary criteria rely on judgement of consultants. If there is any doubt about the implications of discretionary criteria or if the consultant is not immediately available, a trauma call must be made.
•
Slight overcall of trauma patients is an acceptable safety feature of a trauma response. Most major errors in trauma care are due to under-recognition and under-treatment of significant injuries. Always err on the side of caution.
•
Trauma calls are an all-or-nothing phenomenon. All trauma calls must go out to the same personnel as on the current list, every time. There is no role for “partial” trauma calls.
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Adult Trauma Call Criteria Physiologic Criteria •
Glasgow Coma Scale (GCS) < 13 sustained for > 5 minutes
•
Respiratory Rate <10 or >29 at any stage (from point-of-injury)
•
Systolic Blood Pressure (SBP) < 90mmHg at any stage
•
Heart Rate (HR) > 120bpm at any stage
Anatomic Criteria •
Non-trivial penetrating injury to head, neck, torso or limbs adjacent to major nerves or vessels.
•
Known or suspected spinal cord injury
•
Airway obstruction
•
Burns >25% (or >15% paediatrics) or involving airway
Special Criteria •
Age > 70 years with chest injury
•
Pregnancy > 24 weeks with torso injury
•
Major trauma from any other hospital within 48 hours of injury
•
Major crush injury
Discretionary Criteria Two or more criteria mandate a trauma call. One criterion alone mandates a trauma call unless cancelled at the discretion of the on-call ED consultant. The following patients are at very high risk of occult injury or trauma-related complications: •
Major co-morbidities and evidence of significant impact or injury
•
Significant injury to two or more body regions
•
Two or more long bone fractures
•
Fall greater than three metres
•
Cyclist, motorcyclist or pedestrian hit by vehicle >30kph
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Paediatric Trauma Call Criteria Criteria Physiological Abnormalities Abnormal vital signs as below GCS < 13 for > 5 minutes Specific Injuries Known or suspected spinal cord injury Flail chest Major vascular injury Burns > 15% BSA or inhalation injury Limb amputation Severe blunt head, chest, abdominal injury Penetrating injury to the head, chest or abdomen Crush injury to head, chest or abdomen ED trauma team leader request (if no other criteria apply)
Age-based Physiologic Criteria < 3 months RR outside of 25-60 HR outside of 110-170 Systolic < 60 Sats < 90% 1-4 years RR outside of 20-40 HR outside of 85-150 Systolic < 70 Sats < 90%
3-12 months RR outside of 25-55 HR outside of 105-165 Systolic < 65 Sats < 90%
5-11 years RR outside of 16-34 HR outside of 70-135 Systolic < 80 Sats < 90% >11 years RR outside of 14-26 HR outside of 60-120 Systolic < 95 Sats < 90% References Doc ID: Facilitator Title:
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• •
Royal Children’s Hospital Melbourne Starship Hospital
Requesting a Trauma Call If the patient meets the trauma criteria, a trauma call should be made by calling the operator and requesting a trauma call. Different DHBs vary in how this is done however the system that is used must be accessible, reliable and immediate.
The Role of ICU in Trauma Calls and Code Red Where resourcing is available it is recommended that ICU assists the treating teams (ED, general surgery and anaesthesia) as part of the effort to gain control of the unstable patient with haemorrhage or undifferentiated intracranial injury or to prepare a patient for immediate, safe transfer to another hospital. Formal handover of care to the ICU will occur through an appropriate specialist to specialist conversation following operating theatre / interventional radiology (OT/IR) intervention if indicated, or after appropriate investigations and robust open decision-making.
General Criteria for ICU to attend Trauma Calls: •
Code Red activation
•
Intubated major trauma patient
•
Patient for urgent OT or IR with likelihood of ongoing organ support
•
Major chest trauma at risk of respiratory deterioration
•
Paediatric major trauma
•
Burn >20% Total Body Surface Area (TBSA)
•
Traumatic cardiac arrest/imminent arrest and/or resuscitative thoracotomy
•
At the discretion of the Trauma Team Leader (TTL)
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Code Red Major Trauma Response Background Code Red is activated for trauma patients at risk of death from exsanguination or brain injury that require time critical interventions including: activation of the Massive Transfusion Protocol (MTP), Interventional Radiology (IR), or surgery. It is expected that all patients will go directly, and without any delay to a definitive therapeutic environment to save life and limb, however in some circumstances it may be necessary to gain specific information from an emergent CT scan. The common language of trauma care is Early Management of Severe Trauma (EMST™) and Definitive Surgical Trauma Care (DSTC™), Definitive Anaesthetic Trauma Care (DATC™). The goal is to eliminate deficiencies that can compromise the process of one way flow through ED such as: •
Delays in surgical decision-making
•
Delays due to lack of available operating theatre / IR venue and/or anaesthetic team
•
Delays from unnecessary imaging or lack of immediate availability of Computed Tomography (CT) scan, especially after hours.
•
Non-critical procedures that slow progress to haemostasis Trigger Trauma Team Leader (TTL) or ED lead nurse will activate ‘Code Red’ for trauma patients that meet activation criteria. Code Red can be activated at any time, including on the basis of pre-hospital information, if the attending consultants agree that immediate transfer directly to the operating theatre or IR, if available, is necessary to save a life.
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Activation criteria All trauma patients with remedial, immediately life-threatening injuries or evidence of exsanguination (obvious clinical signs and/or haemodynamic instability) requiring immediate life-saving haemostasis or other interventions. The two common indications are exsanguination and/or expanding intracranial haematoma. Performance will assessed and is likely to involve the following parameters: Audit Parameters •
Target for total time for Code Red patient in ED is 20 minutes.
•
Target time for completion of trauma CXR and Pelvic XR is 7 minutes from arrival in resus.
•
A patient is deemed unstable if unable to maintain systolic BP >90mmHg after two litres of fluid administration, or 4 units of RBCs or whole blood including pre-hospital, or remains clinically shocked.
•
A child (<15 years old) is deemed unstable if the heart rate is persistently above normal range for age despite fluid resuscitation of >20mL/kg blood at 10mg/kg, or remains clinically shocked.
•
All members of the Code Red Team will attend all Code Red activations. It is expected that all staff treating major trauma patients are thoroughly familiar and compliant with the Midland Trauma Guidelines.
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Code Red Response Emergency Department It is acknowledged that Midland DHBs have variability in staff volumes and resourcing, particularly after hours. The following recommendations imply that best efforts are employed to respond adequately when staff and resource limitations exist. • Activate Trauma Call and Designate it a Code Red. ‘Code Red’ is an addition to the trauma call. A ‘Code Red’ call generates a message to surgical registrar or RMO, duty anaesthetist, theatre coordinator, radiology RMO or consultant, ICU coordinator, ICU RMO or consultant on call. NOTE: a Code Red call will not automatically activate the Massive Transfusion Protocol. This must be activated separately, based on immediate clinical assessment. • Brief the team and identify roles (see T30 below). • Prepare resus to receive patient including: rapid infuser, ultrasound, check O-Neg blood available in fridge. Order these early if held outside ED. • Assign NHIs and print stickers. • Execute the response. The ED physician or designated TTL is responsible for and should remain with the patient until a plan has been made as to the patients’ definitive therapeutic destination (OT/ IR / ICU) and a formal handover to the appropriate team (ICU / anaesthesia) by the TTL has occurred. The ED nurse stays with the patient if going to IR. • If patient is transferred to IR, if available, out of hours extra nursing support will be required during the procedure. ED nurse to liaise with duty nurse manager and staff members at the likely end destination to ensure nursing support. (This role may require adjustment to fit local resources) • Follow organisational Massive Transfusion Protocol requirements. • Please note that most patients with exsanguinating single organ injuries require immediate surgical treatment and aggressive resuscitation en-route to, and into the OT. Notification must be made to theatre and surgical groups as soon as the likely need for OT is determined, preferably commencing with an alert from ambulance staff of the potential need for immediate intervention on arrival. • In Mass Casualty Incidents (MCI), follow the organisational MCI Plan. Surgery •
The appropriate surgical specialist(s), as determined by the pattern of injury are to attend ED immediately on notification by the TTL. If there is any dispute over who should be there the attending general surgeon on call and the attending ED physician will determine which other specialists are required.
•
Define the consultant that the patient is admitted under as soon as possible and prior to leaving ED.
•
Coordinate collaborative decision-making between relevant surgical specialties, ED and anaesthesia regarding priorities of investigation and management (CT / IR / OT).
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•
If CT scan is appropriate and safe to perform, move with patient to CT to enable in situ discussion with radiologist and other surgical teams regarding CT scan results and the clinical plan. Intensive Care
•
ICU to attend ED and assist with patient management as indicated (resuscitation / lines / transfer to OT / IR).
•
Plan for admission to ICU bed as appropriate. Anaesthesia / Theatres
•
Identify appropriate theatre or IR location, if available.
•
On activation, the duty anaesthetist (or ICU consultant depending on local processes), or both, will attend resus as soon as available in order to:
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Familiarise themselves with patient and anticipate any additional resources required in OT/ IR, and
o
Assist with patient management as indicated (airway at ED request, resuscitation / lines, transport to CT / OT / IR).
o
Assume responsibility for patient transfer after the pathway involving OT and/or interventional radiology is decided and handed over by the TTL. Decisions are made in collaboration with the surgical team.
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Radiology •
The TTL or delegate will contact Radiology staff.
•
If urgent CT is safe and appropriate, contact radiologist or radiology RMO immediately. For IR, if available, discuss immediately with the interventional radiologist on call.
•
Deliver provisional report to surgical team immediately in the CT room. This should occur in the CT or reporting room with surgical representatives present and includes an immediate after-hours response from all members. The time from patient arrival in ED to CT should generally be of enough duration to have surgical RMO and/or SMO presence in the CT room.
• ‘T30’ for Code Red Patients The journeys of critically injured patients are improved by the routine use of timed process guides to facilitate rapid and thorough processing through the resuscitation bays and on to definitive intervention. It implies that all team members are well organised and that allocated tasks for most trauma call patients are completed within 30 minutes and the patient is then transported out of the resuscitation area. The process for patients with exsanguinating single organ injuries should be shortened to T15 or less. The time endpoint is not intended as an absolute requirement, rather a schema to focus the team leader and team members on waypoints it is reasonable to achieve. T30 will apply to all Code Red patients however senior team leaders can apply T30 to any severely injured patient in need of immediate intervention. Adequate prior warning of patient arrival (T-15) will give staff time to present in the ED resus, particularly after hours in hospitals that need to call in staff that may be off.
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CODE RED MAJOR TRAUMA RESPONSE
2
=
F
1.0B ac kgr ou nd
3.0 Response
Code Red is activated for trauma patients at risk of exsanguination or other conditions that require time critical interventions including: surgery or interventional radiology (IR). It is expected that all patients will go directly, and without any delay to a definitive therapeutic environment, however in rare circumstances it may be necessary to gain specific information from an emergent CT scan en route. The common language of trauma care is EMST and DSTC/DATC, and processes will be consistent with the Waikato Trauma Protocol. The goal is to eliminate deficiencies that can compromise the 'One way flow' paradigm, such as:
Emergency Department • Activate Trauma Call. 'Code Red' is an addition to the trauma call. A 99777 'Code Red' call - generates a message to surgical registrar/ duty anaesthetist / theatre coordinator/ radiology registrar/ ICU coordinator/ ICU reg. N.B. A Code Red call will not automatically activate the Massive Transfusion Protocol. This must be activated separately, based on immediate clinical assessment
• Delays in surgical decision-making • Delays due to lack of available operating theatre/IA venue and/or anaesthetic team • Delays from unnecessary imaging • Non-critical procedures that slow progress to life-saving interventions.
2.0 Trigger Trauma team leader or ED charge nurse will activate 'Code Red' for trauma patients that meet activation criteria. Code Red can be activated in any situation, including on the basis of pre-hospital information if the attending consultants agree that immediate transfer directly to the operating theatre or IR is necessary. Activation criteria: Trauma patient with remedial life-threatening injuries or evidence of exsanguination (obvious clinical signs and/or haemodynamic instability) requiring immediate haemostasis or other interventions.
Audit
• • • •
Brief team and identify roles Prepare resus to receive patient including: Rapid infuser, Ultrasound, Check 0-Neg blood available in fridge Assign NHls and print stickers The ED Physician or designated Trauma Team Leader (TTL) is responsible for and should remain with the patient until a plan has been made as to the patients' definitive therapeutic destination (OT/ IR/ ICU) and a formal handover to the appropriate team (ICU/ anaesthesia) by the TTL has occurred. The ED nurse stays with patient during transfer to OT/ IR and until appropriate handover to the nursing team responsible for the next phase of patient care has occurred • Follow MTP management protocol requirements Surgery The general surgeon on call should present for any Code Red patient that has multiple injuries and undifferentiated bleeding. The Team Leader must determine this on best evidence and inform the on call general surgeon. • For patients that have obvious, severe, single organ injuries and identified bleeding sources, the TTL is responsible for calling in the appropriate consultant(s) • Engage in collaborative decision-making between relevant surgical specialties / ED / Anaesthesia regarding priorities of investigation and management (CT I IR / 01) • If CT scan is appropriate and safe to perform, move with patient to CT to enable in situ discussion with radiologist and other surgical teams regarding CT scan results and the clinical plan Intensive Care • ICU registrar to attend ED and assist with patient management as indicated (resuscitation/ lines/ transfer to OT/ IR) • Plan for admission to ICU bed as appropriate Anaesthesia / Theatres • Identify appropriate theatre (Default is OT2) or IR location and prepare according to 'Emergency Response Trauma Card' • On activation, the duty anaesthetist (or delegate) will attend resus as soon as available in order to: - Familiarise themselves with patient and anticipate any additional resources required in OT/ IR, and; - Assist with patient management as indicated. • Assume responsibility for patient after the pathway involving OT and/or interventional radiology is decided and handed over by the TTL Radiology • Radiology Reg will contact CT and IR staff on request of TTL (1. Stand by 2. Activate). If Reg is busy contact the radiologist on call • If urgent CT is safe and appropriate, contact Radiology Reg to attend scanner immediately • Deliver provisional report to surgical team immediately in the CT room, (This should occur in the CT or reporting room with surgical representatives present)
Endorsed by the Waikato Hospital Trauma Committee: 27 August 2019
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Trauma Call ’T30’
T-15 15 minutes before arrival of patient
T=0 Patient arrives
Declare code red if:
Team brief
Make ready
Team leader briefs the team with information from the pre-hospital alert. Team discusses what they expect to happen
Equipment
Allocation of roles
Inform transfusion laboratory if a ‘shock pack’ is required
Initial assessment
Patient handover
Team assembles Ensure all team members present Introductions
Prior to receiving a clear handover confirm: Patient airway Central pulse
Drugs PPE / lead aprons Name/ Specialty label
Prehospital handover is received with trauma team silence using ‘AT-MIST’. Nurse 2 to apply monitoring during handover A
T
M
I
S
T
Age
Time of injury
Mechanism of injury
Injuries sustained
Signs and symptoms
Treatment givens so far
No visible active haemorrhage Horizontal assessment Components of the <C> ABCD paradigm and initial investigations (such as chest and pelvic X-ray, and blood tests) are carried out by several people at the same time, coordinated by the trauma team leader. This allows the team to have the required clinical information quickly <C>
A
B
C
D
Control of catastrophic haemorrhage / activation of Code Red
Airway
Breathing
Circulation
Disability
T+5 Immediate actions
Declare Code Red patient’s condition meets Activation criteria Initial treatment Oxygen – 15L via non re-breather mask Secure large bore venous, intraosseous access or place MAC lines to allow rapid administration of blood and blood products.
Example of <C> ABCD systematic Approach
<C>
Amputated limb: Apply tourniquet and compression bandage with or without topical haemostatic agents Actual or impending airway compromise: RSI* with Cervical Spine control. Utilise RSI checklist.
A Consider need for C-spine collar/ immobilisation
Activate MTP if ongoing blood product requirement anticipated
Ventilatory failure: RSI* and consider need for chest decompression: needle (? Are we still advocating needle decompression) versus thoracostomy versus chest drain insertion
B
Blood tests Full blood count Venous blood gas Blood group and save Urea & Electrolytes Coag Testing – if patient is on anticoagulants
Pelvic fracture suspected: apply pelvic binder Long bone fractures: Splint and assess peripheral pulses (FAST)
C
Unconsciousness (GCS8 or less), unmanageable, combative or severely agitated patient with a head injury: RSI*
D
Review <C> ABCD Assess whether essential bodily systems are under control
T+10 5 minutes after arrival
<C>
A
B
C
Catastrophic haemorrhage controlled? 3u given and MTP activated?
Reassess airway and indications for RSI* if nor yet performed
Assess ventilation status and effectiveness of chest decompression
Consider whether a massive transfusion is required
Consider Brain Injury Management
D Reassess Glasgow Coma Scale
Analgesia
Consider next destination and inform Imaging: CXR/ PXR/ eFAST as indicated Ensure active warming of patient instituted
Consider risks and benefits of RSI*. It may be needed for humane reasons; if patient is in very severe pain an operation is planned very soon
Ensure trauma drugs given; TXA: antibiotics: ADT
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→ Transfer Situational update
T+15 15 minutes after arrival
Secondary survey
Immediate CT scan versus transfer to operating theatre Set goals on physiology and blood products
Prepare for transfer
May be performed if patient does not require time critical interventions
Reassess splinting and all dressings Secure patient and all IV access lines
Ongoing transfusion requirements?
Command huddle
T+20-30 20-30 minutes after arrival
Once the initial examination of the patient is complete, a decision on the next steps of treatment is made by senior members of the team. This is then communicated to the whole trauma team.
Utilise pre-departure checklists
Confirm drugs given so far
Analgesia
Tranexamic acid (15mg/kg)
Inform family
Transfer
The trauma team leader and a senior nurse (usually the scribe) will talk with the patient’s family to explain the situation
If a CT scan has been performed elsewhere, consider priority transfer to: Operation theatre
Antibiotics
Critical care
Tetanus prophylaxis
Interventional radiology
Calcium chloride
Trauma ward Other facility
* RSI = Rapid sequence induction of anaesthesia # Non-crucial investigations and treatment should not be done if they will delay the above timeframes. This includes: • Arterial line • CV line
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Surgical Cascade for Trauma Calls •
It is acknowledged that DHBs have variation in staff resourcing, particularly after hours. The following recommendations imply that best efforts are employed to cover required tasks when resource limitations exist.
•
It is mandatory for the on-call adult general surgical RMO to attend all trauma calls, 24/7. If this registrar cannot get to the resuscitation room immediately, it is the responsibility of that RMO to notify the switchboard immediately and activate the cascade to ensure immediate attendance at the trauma call.
•
Once available, the on-call adult general surgical RMO must immediately follow up the patient. Patients may only be admitted under a team after they have formally accepted by a member of that team. The general surgeon on call must be contacted if there is any confusion about disposition.
•
The call cascade will be activated if designated registrars cannot attend immediately: 1. General Surgical RMO 2. General Surgeon On-Call
•
If the general surgical RMO on call is unable to activate the cascade for any reason or does not respond within 5 minutes, the ED SMO on call may call the general surgeon on call. In hospitals with 24/7 onsite registrar cover, it may be appropriate to insert orthopaedic registrar into the second position in the cascade.
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Structure of Trauma Call Prior to Patient Arrival •
Team leader designated and wearing coloured team leader jacket
•
Team assembled, gowns donned and identification stickers applied (Refer Appendix C Trauma Team Roles and Responsibilities)
•
Equipment checked and activated
•
Intervention kits and ultrasound machine ready (Refer Appendix G Emergency Procedures)
•
Mechanism of Injury, Injuries, Signs & Treatment (MIST) information written on a resus white board in plain sight of the resus team
•
Standard Precautions and identification stickers for all clinical team members
•
Chest X-ray (CXR) plate in place
•
Pelvic binder available and positioned as appropriate
•
Check O-neg available in ED blood fridge (if present) and activate MTP if appropriate (Refer Appendix I Massive Transfusion Algorithm)
Ambulance Handover 45 seconds One person talking to team leader, everyone listening A.T.M.I.S.T Format Age Time of Injury Mechanism of injury Injuries noted Signs at the scene Treatment applied Then move the patient. Airway doctor to instruct Primary Survey (Refer Appendix D Primary Survey) •
<C>ABCDE as per EMST TM (includes CXR + PXR, and FAST for unstable patients, and inline neck stabilisation (Refer Appendix G Emergency procedures). <C> means immediate local haemostatic procedures such as tourniquet or local pressure.
•
Monitoring
•
Secure IV access: peripheral or intra-osseous
•
NB: Major decision node occurs at this point: Imaging or intervention? This decision is made with input from ED, surgeons and anaesthetics/ICU
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Haemostasis and Resuscitation •
Immediate therapy for the life-threatening injuries and physiologic abnormalities is detected in the Primary Survey. This may require immediate transfer to the operating theatre within minutes for: o
Control of external haemorrhage
o
Traction splinting for femoral fractures
o
Pelvic sling or bed sheet if suspected pelvic fracture and haemodynamically unstable.
o
Targeted fluid resuscitation (Refer Appendix I Massive transfusion algorithm).
o
Keep the patient warm whenever possible
Secondary Survey and Adjuncts (Refer Appendix E Secondary Survey)
•
Thorough “top to toe, front to back” examination of the patient (Refer Appendix E Clinical Examination Tip)
•
Review trauma views
•
Clinical staff are to record findings and interventions: gastric tube, catheters, etc.
•
Stabilise limb fractures and dress wounds
•
Prophylactic antibiotics and tetanus toxoid if indicated
•
Imaging as required (e.g. additional plain films, CT, etc
•
Consider tranexamic acid
Consultation with additional specialist teams as required. Definitive Care •
A clear, unequivocal, multidisciplinary plan is documented and activated by the team leader.
•
All speciality service registrars who are likely to be required for the patients care should be notified early so they can attend if able and participate in decisions about further investigations and interventions.
•
The patient must have a defined primary care team for every second of admission. This will require direct communication between the ED SMO and admitting specialty SMO.
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Tertiary Survey (Refer Appendix F Tertiary Survey) •
Thorough head to toe physical examination of patient within 24 hrs of admission
•
Review of all documentation, imaging and investigations ensuring all requests have been completed
•
Initiate any further requests required
•
Complete tertiary survey form
Hot Tips
•
Resuscitation is eventually futile in the absence of haemostasis.
•
Airway control is usually straightforward but can be challenging due to facial injuries and anatomic variation. In these situations early consideration should be given to getting the most experienced airway practitioner available.
•
Finding and stopping occult bleeding is the commonest cause of preventable death and is our biggest challenge.
•
If the patient is exsanguinating at any stage, activate Code Red.
•
If you can’t determine the source and approximate volume of all blood loss, keep evaluating the five sites of bleeding thoroughly until you do.
•
In exsanguinating, multi trauma patients the general hierarchy for immediate intervention is: External > Abdomen or Chest > Pelvis > Head > Long Bones
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“5 Sites” Algorithm for Rapid Evaluation and Treatment of Bleeding Haemodynamically Unstable or High Risk of Deterioration Possible Source
Test
Immediate Treatment if +
Chest
CXR/EFAST
Chest Drain
Abdomen
FAST
Laparotomy
Pelvis / Retroperitoneum
PXR
Binder, then angioembolisation or pelvic packing.
Long Bones
Look
Splint
External
Look
Control the bleeding point
Haemodynamically Stable and Low Risk of Deterioration Possible Source
Test
Treatment if +
Chest
CXR +- CT
Chest Drain
Abdomen
CT
Various
Pelvis / Retroperitoneum
CT
Various
Long Bones
Look/X-ray
Splint then fix later
External
Look
Control the bleeding point
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Immediate Care Algorithms Best practice algorithms have been developed to ensure safe and efficient early treatment of severely injured patients. They include the following: •
Appendix I Management of adult massive blood transfusion
•
Appendix J Management of haemodynamically unstable patient with a pelvic fracture with Angiography available
•
Appendix K Management of haemodynamically unstable patient with a pelvic fracture without Angiography available
•
Appendix L Penetrating extremity
•
Appendix M Moribund penetrating chest
•
Appendix N Penetrating abdominal
•
Appendix O Suspected thoracic injury
•
Appendix P Suspected Spinal cord injury
•
Appendix Q Cervical Spine evaluation
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Guidelines for Staff Protection in the Resuscitation Room Rationale •
Patient behaviour and spillage from interventions are frequently unpredictable in the resuscitation room usually involving patients whose infection status is unknown.
•
It is essential that all team members practice Standard Precautions for body fluid protection in the trauma room as per infection control protocols and ionising radiation protection. These may vary between DHBs but will have commonalities. Emergency imaging and interventions must not be delayed by unprepared and unprotected personnel.
Body Fluid Protection •
All members of the trauma team put on protective gowns, gloves and eye protection for all trauma calls, prior to arrival of the patient and during treatment. It is the responsibility of individuals to put on this protective equipment, and the team leader’s responsibility to ensure compliance for the safety of the team ( Refer Appendix C Team Roles).
Radiation Protection •
Exposure to repetitive medical radiation has well known risks and should be routinely avoided by wearing lead gowns or staying at least three metres from the radiation source during exposures.
•
Trauma views must be taken within 5 minutes of the patient’s arrival: any hindrance to this may delay the time to execution of emergent major decisionmaking. All personnel in the resus room during the taking of trauma views must wear lead gowns and allow trauma radiographers to proceed as a high priority.
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Trauma Patient Transfer and Admission Criteria Criteria for Transfer of Trauma Patients to Waikato Hospital •
Massive multi-system injuries requiring, or likely to require ICU, Trauma Service intervention and/or multiple specialities that cannot be provided in the referring facility.
•
Emergent trauma cases with complex injury syndromes requiring tertiary subspecialty input such as: major brain injury, complex maxillo-facial injuries, complex spine injuries, burns (see national burns plan http://www.nationalburnservice.co.nz/policies-and-guidelines/), complex pelvic fractures, and complex cardio-thoracic and vascular injuries.
•
Adult Neurotrauma-Isolated Brain Injury: sustained GCS < or = 8, unconscious patients or with intracranial haematoma on CT ( Refer Appendix H Adult neurotrauma transfer management)
•
Paediatric Neurotrauma: Waikato neurosurgeons will operate on any child aged 2 and over. The on call Neurosurgeon should be alerted prior to transfer. Initial calls may go to the neurosurgical registrar on call for acceptance however if the referring clinician has further concerns the neurosurgeons invite the referring SMO to call them directly.
•
Acute cases requiring specific tertiary subspecialty input.
•
Non-acute cases for repatriation or rehabilitation.
•
Patients meeting transfer criteria in the TMT/Midland Pre-hospital Matrix.
Single Surgical Call with Consultant-to-Consultant Referral Process for Severely Injured Patients to Waikato Hospital For severe single organ system injuries requiring specialist treatment: •
The referrer calls the on call specialist of the service required.
•
The referrer provides a name and contact phone number that is accessible for at least an hour after the first call.
•
The referring facility arranges transport through the usual process.
•
The patient receives a trauma call on arrival and is reassessed for clinical status and requirements.
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Admission process to Waikato Hospital for severe multisystem injury patients requiring multiple service involvement: •
The referrer calls the on call general surgeon. If the on call surgeon is unable to answer the call, and the patient requires ICU admission, the intensivist on call can accept a patient on behalf of that surgeon. If the general surgeon on call cannot respond and the patient does not require ICU, the ED physician on duty can accept the patient on behalf of the Waikato general surgeon on call.
•
The referrer provides a name and contact phone number that is accessible for at least an hour, and should have a written clinical summary ready for reference.
•
The on call general surgeon will alert other relevant services that may wish to contact the referrer directly for more information.
•
The referrer must highlight any time-critical issues to the accepting surgeon, or any accepting subspecialists if that is likely to improve the exchange of detailed injury information for the benefit of the patient (e.g. discussing CT head results with the neurosurgeon on call).
•
The referring facilty arranges transport through the usual process and ensures that the accepting ED is aware of the pending arrival.
•
The patient receives a trauma call on arrival and is reassessed for clinical status and requirements. General Criteria for Admission to TMT DHBs of Trauma Patients with Minor Injuries Background Patients with more than one minor injury are at risk of delays to admission, or may be admitted by default under services that may not be the most appropriate to deal with those injuries. This can occur when specialty services have an expectation that a patient only needs their care if they will undergo a procedure. Our DHBs have variability in on-call resources however, to help resolve this issue the following guidelines for admission are recommended. Please note that individual DHBs may develop processes specific to their structure and function that define clear pathways for admission.
Criteria for Admission Concussion: All patients with concussion require expert assessment and treatment • A patient with a sustained GCS of 14 or 15 on admission and no evidence of acute brain injury on CT brain may be admitted to the general surgical service on the understanding that four hourly neurological observations are provided and urgent surgical consultation is available. In Waikato Hospital these patients will be admitted directly under the neurosurgical service.
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Minor Chest Injury: Patients should be expertly assessed and treated •
Patients with chest injuries and no other significant injuries requiring intervention should be admitted to the general surgical service. In Waikato Hospital these patients are admitted to the cardiothoracic surgical service.
•
Patients with minor chest injuries and other injuries requiring intervention, close monitoring or specialised nursing care can be admitted to general wards if they have the following features.
•
o
No respiratory compromise
o
Estimated <10% pneumothorax or haemothorax
o
No chest intervention in place or required (i.e. intercostal drains)
Patients with intercostal drains or those at high risk of deterioration should be managed on specific wards and by surgical teams that routinely care for patients with these drains.
Possible intra-abdominal injury for observation: Patients with minor injuries and seat belt bruising or other significant signs of abdominal wall injuries from high energy transfer mechanisms, with or without abnormalities on CT abdo / pelvis should be observed by the general surgical service for at least 12 hours before transfer to the specialty appropriate to their other injuries. Conflict resolution: Each DHB will designate a specialty lead who is authorised to determine the optimal destination of trauma patients if there is uncertainty regarding these criteria. In ED it is likely to be the ED physician in charge; for inpatients it will be the trauma medical director or designate if not available.
Multi-System Trauma The optimal destination of multi-trauma patients is outlined in the pre-hospital and interhospital matrices. The majority of issues in the first phases of care are caused by undercall and/or delays to definitive care facility e.g. unnecessary interventions in the wrong environment can harm patients by delaying their progress to definitive care. The goal is to eliminate all the unnecessary delays that add no clinical benefit from point of injury through to definitive care e.g. Do not stop en-route unless absolutely necessary. •
Aim for 10% overcall of severity and 0% under-call. This is a reasonable safety buffer for complex patients with unclear diagnoses.
•
Complex or potentially unstable patients require immediate consultant-level conversations. Multiple calls between referring staff and receiving registrars regarding these patients are not acceptable.
•
No patient should ever be stranded between services.
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Traumatic Brain Injury (TBI) Adult TBI Direct transfer to Waikato Hospital if isolated brain injury sustained with 1. GCS < or = 8, 2. unconscious patients or 3. intracranial haematoma on CT Transfer management •
Transfer to neurosurgery direct with CT results, if available at the referring facility, without unnecessary delay.
•
Transfer with a health care worker with adequate airway management skills that must be able to intubate and ventilate the patient and provide brain-oriented intensive care in transit.
•
Treat with mannitol / hypertonic saline where required and maintain physiological BP.
•
All potential patients for transfer must be discussed with the neurosurgical service prior to transfer. Multi trauma patients with TBI These patients should be admitted under the general surgeon on call with immediate coconsultation with neurosurgeon on call. Prior warning must be given prior to transfer of any patient who may require immediate surgical intervention on arrival. Paediatric Neurotrauma Waikato Hospital neurosurgeons will provide emergency decompressive neurosurgery on injured children over 2 years of age, however do not have the facility to offer routine paediatric services for under 2s as there is no paediatric ICU. Potential transfers should be discussed as soon as possible with the neurosurgeon on call. These patients are likely to be transferred to Starship Hospital at the earliest safe opportunity. Guideline Refer to the Midland interhospital and prehospital trauma matrices for agreed destination policy and advice. “Single Surgical Call” Emergency Extradural Haematoma (EDH) Referral Protocol to Waikato Hospital Neurosurgeons. Background Trauma patients with acute expanding extradural haematomas are likely to require emergency craniotomy to release intracranial pressure. The following protocol has been developed to ensure immediate and efficient communications and transport to the
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neurosurgical services at Waikato Hospital. In the event that the patient cannot be transported from the referring hospital and an immediate craniotomy is required, the local operating surgeon will be supported by phone by the on call neurosurgeon. As noted above, Waikato Hospital neurosurgeons can operate on any patient over 2 years of age. Selection Criteria for Direct Emergency Neurosurgical Transfer to Waikato Hospital 1.
EDH >15mm on CT, or any size if age <13, or
2.
No CT but rapid deterioration related to brain injury (falling GCS with localising signs or pupillary dilation) or
3.
Open brain injury
Process 1. The patient meets selection criteria. 2. The referring clinician (consultant or senior RMO) calls the neurosurgeon on call at Waikato Hospital. 3. The airway is secured and exsanguination is treated (Refer Appendix D). If intervention occurs, the decision to transfer is re-confirmed. 4. Once the decision to transfer is confirmed, the neurosurgeon alerts the operating theatre and informs ICU of the pending arrival of the patient. 5. Referring clinician organises immediate and safe transport by the most rapid means available. This may include sending a doctor from the referring hospital to manage the airway and give medications en route. Warning of a patient transfer must be made to the accepting ED at the earliest opportunity. 6. Trauma call is made in Waikato Hospital ED to alert all staff, including on call general surgical team, of the arrival of a critical patient. 7. On arrival at Waikato Hospital ED the patient goes directly through to the operating theatre. (A rapid ID check and registration will be done on transit through the ED).
Admission Protocol for Hangings and Near Drownings 1. Attempted hangings without significant physical injury should be managed by medical services. 2. Attempted hangings with physical injury requiring surgical input (e.g. surgery or specialised care and monitoring) should be managed by the appropriate surgical service with support from medical services. 3. Patients with undifferentiated and multiple severe injuries should generally be managed by general surgery and referred to other teams on the basis of their injuries and clinical status. This is agnostic to whether they are attempted hanging or not. Consider early referral of all patients to local psychiatric liaison services.
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TMT/Midland Patient Repatriation Program Approximately 20% of major trauma patients in TMT / Midland region will be transferred from their DHB of domicile to another DHB for definitive treatment. Once initial treatment is completed, these patients may go to a brain rehabilitation facility or return to their own DHBs for ongoing treatment or assessment and planning of ongoing care and rehabilitation. This will generally involve the support of their family/whānau and local rehabilitation service providers. A negative consequence of transition between DHBs is potential loss of important information that is vital to addressing the needs of individual patients and their whānau. Transfer can be delayed or difficult to organise if on call teams without a trauma focus are asked to take patients they are not confident in treating comprehensively. Deficiencies in the handover and interpretation of this information can lead to delays to discharge, inadequate rehabilitation and potentially preventable complications. Trauma service personnel that are already present in each of the DHBs have the clinical abilities, relationships and established networks that allow them to understand the requirements of these complex patients and maintain specialised oversight of ongoing care and rehabilitation. To provide consistency in the transfer process each DHB will have a designated surgical consultant under whom patients can be admitted. The trauma CNS can then provide clinical oversight to nursing and early rehab processes as part of a clinical team. To access this service please contact your local trauma CNS and/or trauma medical director. They will advise on how to facilitate smooth and safe transfer between clinical teams across the region. Please note that repatriation of multi-trauma patients to Tauranga Hospital will require admission under the general surgical team on call.
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Trauma Radiology Overview Trauma radiology is a critical component of high-quality trauma care and has both diagnostic and therapeutic benefits. There are risks associated with the use of ionising radiation however these risks must always be considered in context with the risks of not gaining crucial information that is required to diagnoses and treat a severely injured patient. The mortality risk of having undiagnosed and uncontrolled intra-cavity bleeding is approximately 1% per three minutes. Recurrent and unnecessary trips to Radiology Department must be avoided by good planning. In general, it is better to gain all required images on the first visit to the CT room than having to go back later to complete an incomplete series. Communication with radiology staff is vital to ensure seamless and timely movement of the patient through a busy department. For efficiency, one-way flow of patients from ED through radiology to the final ward or location should be standard. Unstable patients should not be taken to the radiology department. The exception is the exsanguinating patient requiring emergency angio-embolisation or immediate surgery.
Plain Radiology Chest X-ray This image is critical to determine respiratory compromise requiring intervention and to exclude sites of life-threatening haemorrhage. Plates should be on the trauma bed before the patient arrives. The image should be on the viewing screen within seven minutes of the patient’s arrival. Any symptomatic tension pneumothorax may be treated prior to CXR if the diagnosis is clear and the patient is compromised. Pelvic X-ray This is also mandatory in major blunt trauma patients. A pelvic fracture that is not clinically obvious can be the site of unexplained blood loss. A dislocated hip is an orthopaedic emergency can be missed in a patient with multiple injuries, especially if unconscious. Call the orthopaedic RMO immediately. Lateral Cervical Spine X-ray (Refer Appendix Q Cervical Spine Management Algorithm) •
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The C-spine cannot be radiologically cleared with a lateral X-ray alone. This rarely alters treatment and may slow the trauma call process, so is generally not recommended. As a general rule, if there is enough force to cause a brain injury, there is enough to cause cervical spine injury. Brain and neck CTs should therefore be done together and early. Recurrent trips to CT are expensive and unnecessary. Version: 02 Clinical Director
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•
Lateral views may be useful if the hypotensive patient has a suspected cervical cord injury or if a patient has severe multiple injuries including to the head and neck and requires immediate anaesthesia for damage control surgery.
•
Do not delay urgent surgical interventions to get C-spine X-rays- just consider the spine as being fractured and manage in a hard collar. Change to a well fitted Philadelphia or Aspen collar within an hour of arrival. Shocked and unstable patients are put at increased risk if interventions are delayed by inappropriate imaging.
•
Cervical spine clearance should be done as soon as possible prevent problems with airway control, avoidable pain and soft tissue injury.
Computed Tomography (CT) Scanning Whole Body CT (WBCT) WBCT has been shown to reduce time in the ED and time to diagnosis, but not overall mortality. Almost 50% of patients scanned selectively go on to have WBCT. WBCT protocol Brain, c-spine, dual bolus (combined arterial and portal venous) single pass chest, abdomen and pelvis with review for any delayed phase. Additional CTA carotid/vertebral if skull base/C-spine fracture. Relative Indications for WBCT:
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•
High speed vehicle crash (>50km/hr)
•
Pedestrian/cyclist hit by car >30kph)
•
Vehicle roll over/ejection from vehicle
•
Fall from height>3m
•
Torso crush injury
•
Open/flail chest
•
Unstable pelvic fracture
•
Proximal amputation
•
Multiple long bone fractures
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Abdominal/Pelvic CT •
Abdominal/Pelvic CT for trauma is highly sensitive and specific for significant injury and is the definitive test of choice in stable blunt trauma patients.
•
Clinical assessment of the abdomen is unable to exclude many occult, life-threatening injuries within the abdominal cavity therefore CT should be used to exclude these with knowledge of the risks of ionising radiation.
•
CT abdo/pelvis accurately diagnoses pelvic fractures, retroperitoneal injuries, solid organ injuries, lumbar spine fractures, sacral fractures and most hollow viscus injuries. Contrast blush in a solid organ may indicate the need for angio-embolisation in stable patients.
•
Hollow viscus injury can have devastating effects if it is missed and CT has a false negative rate (missed injury rate) of 25%. The CT signs consistent with hollow viscus injury are: free air or oral contrast extravasation (hard signs); or free fluid, bowel thickening, mesenteric stranding and haematoma (soft signs). Hard signs warrant laparotomy; soft signs warrant either laparotomy or careful serial examinations. Diagnostic Peritoneal Lavage (DPL) is sensitive for hollow viscus injury.
•
Moderate to large volume of free fluid in the abdomen in the absence of obvious solid organ or bowel injury on CT is strongly associated with bowel or mesenteric injury and should prompt consideration of immediate laparotomy.
•
The risk of bowel injury and requiring a therapeutic laparotomy is increased with volume (moderate to large), associated features such as bowel wall thickening / mesenteric injury.
•
If the patient is not assessable because of medications or head/spinal injury – then this should lower the threshold for a laparotomy.
•
The negative predictive value of contrast-enhanced abdominal CT is 99.5%.That means if the scan is negative, there is almost no chance of significant injury. Certainty in diagnosis allows other interventions to occur and enables confident decision-making in patients with multiple injuries and multiple competing priorities.
•
Incidentalomas found on CT must have appropriate treatment and follow-up arranged by the primary care team. Chest CT
•
CT of the chest gives detailed information on the chest and its contents and can reveal injuries that are not well defined by plain radiology. Most thoracic injuries do not require chest CT, with some notable exceptions.
•
Chest CT will reveal occult pneumothoraces, haemothoraces, pulmonary contusions, thoracic spinal injuries and mediastinal injuries, all of which should be excluded or accurately diagnosed prior to prolonged anaesthesia, transport or positive pressure ventilation. The presence of an occult pneumothorax or basal pulmonary contusion may often be seen in the uppermost cuts of an abdominal CT.
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Indications for Chest CT include: • Abnormal CXR • High risk mechanism o
Severe crush to chest
o
High speed RTC (>60km/hr)
o
High fall (>3metres)
Note: CXR alone has 41% sensitivity for blunt aortic injury. For this reason, CXR is not a good screening test for aortic injury. Brain CT Scanning for Neurotrauma Patients CT scanning is the diagnostic test of choice for blunt traumatic brain injury. All patients with moderate to severe TBI (sustained GCS<14 at any stage) require CT brain. Patients meeting transfer criteria to Waikato Hospital should be referred without delay. The indications for brain CT scan in patients with mild TBI (GCS = 13 or 14) are:
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Sustained loss of consciousness > 5 minutes (estimated)
•
Persistent neurological signs
•
Persistent decrease in level of consciousness
•
Unable to clinically assess (anaesthesia, drugs, young children, etc.)
•
Elderly patient taking anticoagulants
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Indications for repeat CT scanning of TBI patients are: CONDITIONS
ADMISSION STATUS
TIME OF SCAN
REASONS
Brain injury
No surgery required
As per head injury guideline
Haematoma Contusion Skull fracture Hydrocephalus
Follow up
In 24 hrs
Evolution of injury
Slow recovery
CT scan- day 2 & 5
Check progression
Clinical deterioration
Urgent scan
Oedema Hydrocephalus
(operated or not operated on)
Chronic haematoma Infarction Head injury-operated
CT scan day 1 &3
Check progression
CT of the Cervical Spine In general CT scanning of the cervical spine gives information that is accurate enough to describe all significant injuries and therefore allow definitive clinical decision-making. Scanning of the brain and cervical spine at the same time is rapid and efficient. Returns to the CT scanner for cervical imaging are wasteful of resources and put patients at risk (Refer Appendix Q Algorithm Cervical Spine evaluation).
Interventional Radiology Although not readily available in some TMT / Midland hospitals, this modality has an important role in trauma management, particularly in early diagnosis and treatment of exsanguination in organ systems where surgical access and haemostasis is challenging and less effective. Angioembolisation can also be used in conjunction with stenting procedures in proximal vascular injuries.
Angioembolisation •
Catheter angiography is both diagnostic and therapeutic, and gives excellent results when applied judiciously. Angioembolisation can be done with coils (permanent) or gel foam (absorbed in three weeks). It can be proximal (non-selective) or distal (selective).
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•
The main indications in current practice include; control of pelvic bleeding in the haemodynamically unstable patient with a pelvic fracture, prophylactic angioembolisation of actively bleeding solid organs in patients that are haemodynamically stable.
•
In splenic injury, indications for angioembolisation include grade ≥ 4, active extravasation, pseudoaneurysm. Angioembolisation significantly reduces the failure rate of non-operative management in these high risk injuries from about 75% to 5%.
•
In hepatic injury, the higher the grade of injury the higher risk of bleeding. Indications for angioembolisation include active contrast blush especially in high grade injuries (grade ≥ 4). Another use of angioembolisation is in hepatic injury in the unstable patient where active bleeding seems to continue despite packing and responds to the Pringle manoeuvre suggesting an arterial origin. The procedure can be done as an adjunct to damage control surgery in the hybrid theatre. Reported success of angioembolisation in hepatic injuries is up to 90%.
•
High grade renal injuries (grade ≥ 3) may require intervention if there is active bleeding. Failure rates of non-operative management (NOM) are as high as 27% probably relating to the inability to perform proximal embolization as there is no rich collateral blood supply as in the spleen. Therefore, a high index of suspicion for ongoing bleeding or re-bleed should remain after angioembolisation.
•
Other endovascular therapies (including stenting) for:
•
o
Thoracic or abdominal aortic injuries
o
Visceral arterial injuries
o
Carotid arterial injuries
Interventional radiological therapies are usually applied in the context of multiple conflicting priorities and therefore require expert judgement and careful risk profiling of individual patients around sound clinical principles. The decision-making processes are incorporated into the exsanguinating patient algorithms (Refer Appendix J Pelvic Algorithm). Magnetic Resonance Imaging MRI) MRI has a limited role in trauma imaging owing to the inherent dangers of undiagnosed metallic foreign bodies, cost and availability. Its use is mainly restricted to non-emergent spinal cord, brain and joint injuries on request of appropriate specialists.
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Paediatric Trauma Overview The same algorithms as adults apply in children but there is more scope for non-operative management. Children differ from adults psychologically, cognitively and physiologically. The mechanism of injury also differs and even more so depending on the age of the child: •
Infants tend to be injured at home
•
1-4 year olds tend to fall, ingest objects or sustain burns
•
5-9 (school age) tend to get injured in the playgrounds
•
Older children and teenagers tend to get injured from risk taking behaviours e.g. motor vehicle crashes, assault, etc
•
Be aware also of non-accidental injuries: Suspect if: o
Mechanism does not fit with developmental age
o
Inconsistent history
o
Suspicious injury patterns e.g. bruises in < 9 month old, bruises resembling objects, posterior rib fractures, bruises on face/ears/buttocks or back
Understand the risks of ionising radiation but do not withhold critical imaging: •
Mortality from uncontrolled bleeding =1% per 3 minutes
•
The lifetime risk of any neoplasia from 2 abdominal CT scans goes from 25% to 25.5%
•
Choice of diagnostic modality must be based on careful risk assessment not guesswork Primary Survey (focus on the differences compared with adults) Tips
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Children do best when close to parents, caregivers and whānau.
•
Emergency Departments are noisy, cold and frightening places – speak quietly and explain what is happening finding and stopping occult bleeding is the commonest cause of preventable death and is our biggest challenge.
•
Use toys or songs for distraction.
•
Estimate weight of child and prepare drugs early: Up to 10 yrs.: Wt in kilos = (2 x age) + 10: 10 years and over: Wt in kilos = Age x 3.
•
Give analgesia early and titrate.
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Airway •
Apply manual inline immobilisation of the cervical spine.
•
Suction and clear the airway if there are signs of obstruction. Paediatric airways are smaller and are at greater risk of obstruction with small foreign bodies or minor swelling.
•
Perform a chin lift or place a pad on the torso to neutralise the position of the head. Infants have a relatively larger tongue and smaller oral cavity. They also have a larger occiput which can flex the head on a flat surface obstructing the airway.
•
Ensure the nares are patent in infants as they nose breathe.
•
If intubation is necessary, an experienced clinician should perform this as it can be difficult. Larynx is higher and more anterior which can make visualisation of the airway more difficult. An un-cuffed endotracheal tube is used as the cricoid is the narrowest point of the upper airway: uncuffed ETT size = age/4 + 4A paediatric anaesthetist should be called if a difficult airway is anticipated.
•
If intubation has failed a surgical cricothyroidotomy is necessary. This should be performed by an experienced clinician. Consider the use of front-of-neck kits if available. Breathing
•
Infants have a limited respiratory reserve. Their ribs are positioned more horizontally limiting the capacity to increase tidal volume.
•
Be suspicious of intrathoracic injury if there is respiratory distress even in the absence of external trauma due to the great compliance of the chest wall in infants and young children.
•
Respiratory rate varies with age.
•
Heart rate is also influenced by respiratory insufficiency. Infants become bradycardic when hypoxic.
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Circulation •
Blood volume is relatively larger, but absolute volume is smaller so be aware e.g. a one year old has 800 mls of blood – losing a 100 mls is 12.5% of their volume.
•
Hypotension is a late sign as children have very efficient compensatory mechanisms, and will remain normotensive until they have lost large intravascular volumes (25%).
•
Infants are limited to increasing their heart rate as they are unable to increase stroke volume.
•
Obtain IV access – cubital fossae. If difficult consider CVL or IO access.
•
If hypovolaemic, give 20 ml/kg crystalloid and reassess. Repeat if still under filled. If still hypovolaemic, use packed red cells next within a plan of balanced fluid and blood product administration.
•
Adjuncts for the assessment of cavity/pelvic bleeding or obstructive / neurogenic causes of shock is the same as adults. Disability
•
The anterior fontanelle can be palpated in most children up to the age of 12 - 18 months. A bulging fontanelle suggests a high intracranial pressure and therefore intracranial bleeding.
•
Thinner cranial bones means less protection of brain tissue.
•
The head is relatively larger than the body therefore produce a higher centre of gravity. This in turn contributes to a higher incidence of head trauma in children.
•
Infants have a small glycogen reserve so are prone to hypoglycaemia.
•
Assess GCS as per the paediatric scale and assess for spinal cord injury (moving all limbs). Exposure
•
Infants are prone to hypothermia because of a larger surface area to body mass ratio therefore keep them warm as much as possible.
•
Adjuncts to the primary survey are the same as adults (CXR/PXR and FAST).
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Paediatric Glasgow Coma Scale Score
Eye Opening
Verbal Response
Motor Response to Pain
1
nil
nil
nil
2
To pain
Inconsolable, Agitated
Extends limbs
3
To voice
Moaning
Flexes limbs
4
Spontaneous
Cries, Consolable
Withdraws from pain
Interacts
Withdraws from touch
5 6
Purposeful Movements
TOTAL /15
Paediatric Assessment Tips •
Non-operative management of abdominal solid organ injury has 90% success. Safety demands close serial observations and a low threshold to re-image or operate.
•
Consider SCIWORA (Spinal Cord Injury Without Radiological Signs).
•
C2-C3 subluxation is normal in 40%.
•
Growth plate injuries can cause disability. Gain orthopaedic input early. Criteria for Ending Resuscitation
•
CPR >20 minutes and asystole
•
Pulseless and HR<40
•
ED thoracotomy: Blunt trauma = No, Penetrating = Consider
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Special Situations • • •
Elderly patients Pregnancy Burns Trauma in the Elderly Overview
•
Although no changes in protocols and algorithms are required, elderly patients present special challenges and are highly vulnerable to deviation from best practice.
•
The elderly typically have reduced physiologic reserve, medications that affect their physiology and coagulation profile. They will also more likely have co-morbidities which affect treatment options and outcomes.
•
In addition, serious injury can result from seemingly minor impact as a result of age-related tissue and skeletal insufficiency.
•
The overall aim is return to independent living whenever possible.
Helpful Tips in Acute Phase
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•
Consider involvement of the geriatric team early for those aged 70 and over or with multiple co-morbidities.
•
Generally, given that these patients are vulnerable because of their reduced physiological reserve they require a more aggressive approach in terms of management.
•
Intubate early if major chest wall injury and consider transfer to Cardiothoracic Service for early rib plating.
•
Pulmonary complications are common – consider thoracic epidurals or ventilation early.
•
Multiple rib fractures are associated with high mortality: use the chest injury pathway and treat aggressively
•
Excessive saline can push an elderly patient into cardiac failure.
•
Treat new limb weakness as trauma until proven otherwise, not stroke.
•
Elderly patients are vulnerable to hypothermia – cover them up early.
•
It is important to ascertain any advanced directives or wishes of the patient as the optimal outcome would be driven by a balance of not just quantity but as well as quality of life.
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Investigations •
Osteoporosis can make fractures difficult to spot: plain radiology may be difficult to interpret.
•
Have a low threshold for CT imaging these patients but exercise caution as IV contrast can affect their renal function.
•
Arterial blood gas gives an indication of hypo-perfusion and the physiologic impact of comorbidities. Co-morbidities
•
β-blockers prevent tachycardia and may cause hypo-perfusion.
•
Warfarin / Pradaxa can cause irretrievable bleeding from seemingly minor injuries. Beware slow bleeding in soft tissue de-gloving injuries.
•
Presence of warfarin or other modern anticoagulant therapies mandates brain CT following head injury resulting in loss of consciousness. Consider reversal of anti-coagulation early if possible.
•
Co-morbidities tend to be multiplicative rather than additive.
•
Apply the Clinical Frailty Score to all patients >65 years and record in the notes.
•
Patients at advanced age of exhibiting frailty are also at risk of complications and poor outcomes after trauma. The Clinical Frailty Score (CFS) should be calculated on patients with evidence of frailty or poor function, then recorded in the patient notes.
* It has been recommended by TMT geriatrics services that the following criteria should prompt immediate referral for consultation whenever those resources are available. * Age 75 and over, * Age 65 and over, and Māori * or CFS>5.
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Return to Optimal Function •
Early input from the multidisciplinary team is vital for optimisation of recovery: o
This includes subspecialty surgical or geriatric medical services
o
Allied Health Services
•
Psychological support: this is an often neglected area of care for the elderly – screen for psychiatric illness or PTSD (post-traumatic stress disorder) and involved the psychiatric liaison team or a psychologist
•
Effects of immobility are early and more severe.
•
Spine boards can cause pressure ischaemia and skin necrosis within 30 minutes. Patients should be transferred off them immediately on arrival.
•
Pneumonia is likely without early physio and adequate analgesia especially in those with chest injury.
•
Mobilise early and get rehab services involved early.
•
Attention to nutrition is critical because deconditioning occurs rapidly and can produce severe consequences.
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Trauma in Pregnancy Trauma is the commonest cause of non-obstetric maternal mortality. The priority of care is to rapidly restore physiologic stability to the mother. The key concept is to treat the mother and manage the pregnancy. Inform the obstetrician on call as soon as pregnancy is known. Anatomical and physiological changes occur during pregnancy that can mask or mimic injury and physical signs can be misinterpreted. It is important that there is no delay in the correct diagnosis and prompt initiation of treatment as you would for any major trauma patient. Inexperience can lead to a less aggressive approach for fear of damaging the fetus, when the opposite approach is required. More harm is likely to result from undiagnosed significant injuries than from the risks of radiation exposure, or from simply withholding critical interventions from indecision or unsubstantiated fears. The key statistic to remember is that the mortality in major trauma patients rises by 1% every three minutes of uncontrolled body cavity bleeding. This is strongly associated with failure of diagnosis. The risks of irradiation must be understood and acted on in the context of the patient’s condition. The indication for radiological imaging in the setting of trauma is exactly the same as a non-pregnant patient. Treat the mother first. The effect of radiation on the foetus is related to the effective fetal dose of radiation and the organogenesis stage of the pregnancy. Very few abnormalities are observed after seven weeks gestation in a foetus who receives < 500 millisieverts/mGy of radiation.
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Foetal Radiation Doses The following table demonstrates foetal radiation dose ranges based on UK studies (this table is adapted from the Royal Melbourne Hospital Trauma Guidelines):
Physiologic Changes Associated with Pregnancy •
Increased blood volume, stroke volume and reduced Hb
•
Delayed gastric emptying
•
Increased gastroesophageal reflux
•
Upward displacement of the peritoneal contents
•
Displacement of the urinary bladder, and
•
Widening of the symphysis pubis
Maternal Assessment •
Primary Survey (highlighting key differences compared to a non-pregnant patient)
Airway •
Maintain cervical spine in-line immobilisation
•
Pregnant patients have an 8 times risk of failed intubation. Have the difficult airway trolley available. Intubation should be carried out by an experienced clinician
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Breathing •
If intubated, place a nasogastric tube to reduce the risk of aspiration.
•
Intercostal catheters should be placed 1-2 intercostal spaces higher than usual in the 3rd trimester Circulation
•
Left lateral tilt with a wedge (30-45 deg) to reduce pressure on the IVC and optimise venous return
•
Maintenance of circulating volume or aggressive volume resuscitation in hypovolaemia is essential to maintain uteroplacental perfusion
•
Up to 2 litres can accumulate in the uterus which can contribute to maternal shock
•
Look for causes of hypovolaemic and obstructive shock with the use of the usual adjuncts e.g. FAST, CXR and PXR
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Obstetric assessment •
Assess gestation based on last USS or LMP. If not available then assess by fundal height (viable foetus is >23 weeks: at least 2-4 cms above the umbilicus).
•
Placental abruption is the primary cause of foetal death. Clinical findings of placental abruption may include vaginal bleeding, abdominal cramps, uterine tenderness, amniotic fluid leakage and maternal hypovolaemia out of proportion to visible bleeding.
•
If a vaginal exam needs to be performed, it should be done by an obstetrician (looking for ruptured membranes / cervical dilatation).
•
Abdominal examination is generally inadequate to rule out significant injury in either pregnant or non-pregnant patients. CT scanning gives the best injury information but must be used judiciously and in the context of the patient’s risk profile.
•
FAST ultrasound of the abdomen is useful to detect free fluid in unstable patients, but cannot rule out significant injuries to the retroperitoneum or solid and hollow viscera.
Foetal Assessment Apply Cardiotocography (CTG) as soon as pregnancy is known. A minimum of 4 hours of CTG is recommended for viable pregnancies >23 weeks. This includes patients with no signs of abdominal injury. Normal foetal HR is 110-160 – deceleration and loss of variability may indicate foetal distress. Change in foetal heart rate may also indicate placental injury. Ultrasound can detect significant foetal injuries; however it has an accuracy of only 50% in detecting abruption. It can also be used to detect the presence of a foetal heart rate. In the presence of placental abruption, when the foetus is alive on presentation, foetal distress is present in over 60% of these cases and an immediate caesarean section (CS) is required. •
Resuscitation of the mother is the priority and if maternal shock occurs foetal mortality approaches 80%. Resuscitation of the mother may be more successful once the CS has been done.
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Risks of Trauma in Pregnancy In minor trauma: •
pre-term labour = 8%
•
abruption = 1%
•
foetal mortality = 1%
In major trauma qualifying for trauma call: •
Maternal mortality approx. 8%
•
foetal injuries occur in isolation in 5%
•
foetal mortality = 20%
Foetal maternal haemorrhage Foetal Maternal Haemorrhage (FMH) is the transplacental haemorrhage of foetal cells and is a unique complication of pregnancy. The reported instance of FMH in major trauma is 8-30%. Anterior placental location and uterine tenderness are associated with an increased risk of foetal maternal haemorrhage. Complications of FMH include rhesus sensitisation in the mother, foetal anaemia, foetal paroxysmal tachycardia and foetal death. As little as 1ml of rhesus positive blood can sensitise 70% of rhesus negative women. Therefore, all mothers who present with a history of abdominal trauma should receive a prophylactic dose of Rh immune globulin. The Kleihauer-Betke test has been utilised to determine the presence of foetal maternal haemorrhage.
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Summary •
Treat the mother; manage the pregnancy
•
Consider the need for anti-D therapy
•
Detect foetal heart sounds by auscultation or USS.
•
An obstetrician should be consulted early. CTG monitoring should be applied as soon as pregnancy is known
•
Steroids may be considered
•
All patients with minor trauma should be admitted to an acute surgical ward for at least 24 hours after consultation between obstetric and general surgical consultants
•
Patients with major trauma always require a multidisciplinary approach
•
Careful foetal monitoring is essential once foetal viability has been established (Refer Appendix T Pregnant trauma patient).
Burns Waikato Hospital is designated as one of the four Regional Burns Units in New Zealand by the Australian and New Zealand Burns Association (ANZBA). Waikato Hospital manages the majority of burn injuries from the region although small number of patients with severe burns can be referred to the National Burns Unit at Middlemore Hospital by the burns / plastic consultants at Waikato Hospital using a defined referral process. Some burns patients sustain other serious injuries as well as burns. All patients with multiple injuries including burns must go through the routine trauma call process and be admitted under the general surgeon on call with immediate consultation by the burns / plastics team on call at Waikato Hospital (see below). The patient may be transferred at the earliest opportunity once the full extent of the patient’s injuries has been diagnosed and an appropriate treatment plan has been defined. If a plastics registrar accepts a regional burns patient with other serious injuries it is appropriate to notify the ED and admit the patient through the routine trauma call process.
For referrals to Waikato Regional Burns Unit please contact the following: •
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Phone 07 839 8899 and ask for the plastics registrar on call
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ANZBA Criteria for Referral to Waikato Regional Burns Service at Waikato Hospital are: •
Burns greater than 10% total body surface area (TBSA)
•
Burns of special areas, e.g. face, hands, feet, genitalia, perineum, and major joints
•
Full thickness burns greater than 5% TBSA
•
Electrical burns (including lightning injury)
•
Chemical burns
•
Burn injury with inhalation injury
•
Circumferential burns of the limbs or chest
•
Burns at the extremes of age e.g. young children and the elderly
•
Burn injury in patients with pre-existing medical disorders that could complicate management, prolongs recovery, or affects mortality
•
Any patient with burns and concomitant trauma (e.g. fractures) in which the burn injury poses the greater immediate risk of morbidity or mortality For further information refer to the National Burns Service.
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National Burns Service Referral Flowchart
Referring Doctor assesses & stabilises burn patient & completes Burn Referral Form http://www.nationalburncentre .co.nz/pdf/referralform.pdf
National Burn Service Referral Form (for use for both NBC & RBU)
Referral Criteria for National Burn Centre
http://www.nationalburncentre.co.nz/pdf/referralfor m.pdf
• Burns >30% total body surface area • Full thickness burns to – face, hands, feet, genitalia, perineum
– fax to NBC 09 276-0114 – include with notes to RBU
• Burn injury with significant inhalation injury • High voltage electrical burns • Significant chemical burns
Suitable for NBC referral?
No
On-Call Burn Coordinator NBC
Refer to RBU
Phone: 09 250-3800 Fax: 09 276-0114 Email: oncallburnsnurse@middlemore.co.nz
Yes
Referral Criteria for Regional Burn Unit
Referring Doctor rings On-Call Burn Coordinator 09 250-3800 & FAXES REFERRAL 09 276-0114
• Burns >10% total body surface area (TBSA) or 5% in a child • Burns to special areas – face, hands, feet, perineum, over major joints • Full thickness burns >5% TBSA
On-Call Burn Coordinator liases with On-Call Burn Consultant ± ICU Consultant re referral
• Circumferential burns of the limbs or chest • Burn injury with inhalation injury • Electrical burns • Chemical burns
Decline Referral Accepted for NBC transfer?
No
On-Call Burn Coordinator informs Referring Doctor and contacts On-Call Plastic Registrar and forwards original Faxed Referral to RBU
On-Call Burn Coordinator coordinates Transfer to NBC AND informs RBU next working day
• Burn injury in patients at the ex tremes of age – children and elderly • Burn injury in patients with pre- existing medical disorders which could complicate management, prolong recover or affect mortality • Any burn patient with associated trauma in which the burn injury poses the greater immediate risk of morbidity or mortality • Any burn suspected with abuse
Regional Burn Centre Contacts call the on-call plastic surgery reg istrar Middlemore Hospital 09 276 0000 / 021 784 057 Waikato Hospital 07 839 8899 Hutt Hospital 04 570 9999 Christchurch Hospital 03 364-0640
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MTS Trauma Quality Improvement Program Trauma Quality Assurance Injury is widely reported as the leading cause of death and morbidity for persons below the age of 45 in NZ¹ with falls and vehicle related incidents the major contributors to injury within Te Manawa Taki². Quality assurance is essential to the achievement of high standards of care in trauma systems and should focus on optimising care for all trauma patients. This focus avoids variance that is costly both to the patient and the facility³. Targeted evaluation of care relies on information from the Midland trauma registry and clinical staff that manage injured patients.
Goals By engaging in QA, trauma staff will be able to directly influence and enhance the trauma system. The net result of the process should be a system that enables all team members to provide equitable care in an effective and efficient manner, improving patient outcomes. The principles include: • • • •
Patient and whānau focus Objective investigation, monitoring and reporting Use of registry data to drive evidence based change Timely and effective loop closure (issue resolution)
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• •
Setting and achieving targets Supportive corrective actions
Patient population Within the Te Manawa Taki region, detailed information is collected on trauma patients of all age groups and severity (see Appendix B) that are hospitalised following trauma. This amounts to approximately 6,800 admissions per year within the region, 500 of whom sustain major trauma. This criteria is consistent with international trauma registries. For a full list of inclusions, exclusions, please refer to Appendix A.
Information Sources Data collection is a daily activity associated with clinical care and where patient information and subsequent processes of care are documented. Trauma data is reliant on multiple sources to provide essential information: • • • • •
Pre hospital and hospital provider records Daily clinical rounds and verbal reports Diagnostic interpretations (lab, x-ray, etc.) Clinical network discussions Current academic literature
Outputs These include: • Regular quality reports to clinical teams, operational and strategic groups • Ad—hoc reports and warnings as required • Identification and action on equity issues • Case reviews and educational forums • Clinical case reporting and loop closure system • Process indicator reporting • Trend analyses and notifications • Presentations at local and region forums • QA Innovation and peer-reviewed QA research • Collaborations with national and international QA groups
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Evidence base Summary of Evidence, Review and Recommendations •
All recommendations made in this document reflect evidence-based practice
References •
Manual of Definitive Surgical Trauma Care 3rd Edition, Boffard (Including DATC)
•
Advanced Trauma Life Support 9th Edition, American College of Surgeons Committee on Trauma
•
Royal Melbourne Trauma Guidelines o
Trauma in pregnancy
o
Trauma in the elderly
• https://www.rch.org.au/trauma-service/manual/ • Role of angioembolisation in solid organ injury • Peitzman et al, Trauma and Critical Care 2000 • Haan et al, Trauma and Critical Care 2004 • Aiofi et al, J Trauma Cute Care Surgery 2017 • Bhullar et al, J Trauma Acute Care Surgery 2017
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Inter-Hospital Referral and Acceptance Matrices for Regional Facilities Patients come first TMT/Midland Pre-hospital Major Trauma Destination Matrix This has been developed through multiple consultation loops with regional clinicians, trauma services and St John Ambulance. It is compatible with the National Major Trauma Pre-hospital Triage Criteria and will be supplied as part of that document.
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Inter-Hospital Matrices Overview This matrix is designed to clarify expectations and simplify the referral process in conjunction with regular inter-hospital transfer process. The greatest proportion of referrals for tertiary level care with the region are to Waikato HospitaI however it is acknowledged that IHTs occur for specific patients transferring between other hospitals. To cover the great bulk of IHTs in TMT/Midland the acceptance matrix at Waikato Hospital has been designed to be compatible with the referral matrices of Regional DHBs and the TMT/Midland Pre-hospital Destination Matrix. The list is not exclusive; referring clinicians are free to call Waikato services if, in their view, transfer would be beneficial to the patient. Sound clinical judgement from the referring clinician has priority if clear clinical benefit can be demonstrated. The following conditions apply to ensure patients are delivered efficiently to facilities providing early definitive care. Multi-trauma patients with combinations of lesser injuries may also require transfer to Waikato Hospital for definitive care. General conditions 1. Life-saving, time-critical interventions should be performed in the nearest hospital environment where definitive skills are available. 2. Stopping en-route from the scene injury to Waikato Hospital must be justifiable by clear clinical benefit to the patient. 3. Waikato Hospital will accept patients who meet these criteria when there is no local or district capability to provide timely definitive care. 4. The ED is the single point of entry to Waikato Hospital for all trauma patients. 5. All major trauma patients who arrive at Waikato Hospital within 48 hours of injury will receive a trauma call on arrival. 6. Inter-hospital transfers from Waikato rural hospitals should be preceded by a discussion with the Waikato ED physician on call. 7. Inter-hospital transfers from District Base Hospitals must be preceded by specialty consultant notification. 8. Consistent with inter-facility ICU transfers processes, severely injured patients at referring hospitals must be notified to Waikato ICU before inter-hospital transfer. 9. General surgery is the admitting service at Waikato Hospital for patients with severe, multi-system injuries. 10. If a specialty registrar accepts a patient with severe or multi-system injuries they must refer the patient through ED for a trauma call. 11. If a trauma call made, the ED team leader is responsible for ensuring that all appropriate contacts are made with other specialities. 12. If no trauma call is made, the accepting team is responsible for ensuring that all appropriate contacts are made with other specialities. 13. Communications and logistics for transfer are defined by the inter-hospital transfer guidelines. Doc ID: Facilitator Title:
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Waikato Trauma Acceptance Matrix (Defines criteria for inter-hospital transport to Waikato Hospital from Pre-hospital, Rural hospital or District Base Hospital)
Origin: Pre-Hospital
Waikato District Brain
GCS < 9
Origin: District Base Hospital
Origin: Rural
TMT/Midland Open brain injury and awake
Localising signs
Waikato District GCS < 13 and CT unavailable
TMT/Midland Open brain injury and awake
Requires CT Brain SDH/EDH or contusion on CT* Paeds for immediate craniectomy Localising signs Open brain injury
Open brain injury
TBI and unstable
Intubated
TMT/Midland Needs craniectomy Likely to need craniectomy Severe TBI + multi-trauma
Localising signs are: Unilateral weakness
* Thames only: Call N-surgeon
Pupillary asymmetry Spine
Possible spinal injury (as per Matrix)
Paraplegia
Possible spinal injury
Tetraplegia
Pelvis
Maxfacial
Open pelvic #
Facial fractures (compound or closed) Exsanguinating face
Spinal cord injury Spinal injury + multi-trauma
Pelvic # on PXR
Exsanguinating face Supraglottic airway threat
Supraglottic airway threat Doc ID: Version: 02 Facilitator Title: Clinical Director
(Excl = elderly insuffic #s) Facial fractures
Spinal cord injury Complex spinal injury Spinal injury and multi-trauma Fits spinal unit criteria Complex cases by consultation Pelvic/acetabulum # (by consultation)
Exsanguinating face Supraglottic airway threat
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Major facial fractures for ORIF Exsanguinating face Supraglottic airway threat
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Plastics
Viable amputation
Viable amputation
Facial dog bite
Burns
Chest
Any non-trivial burn
Viable amputation
Viable amputation
Facial dog bite
Refer as per NZ Burns Plan
Complex hand injuries Soft tissue loss Refer as per NZ Burns Plan >10% TBSA all burns Face, hands, genitalia, feet Perineum, major joints >5% TBSA full thickness Electrical, Chemical Inhalation
Multiple rib #s
Significant comorbidity risks Any burns + other trauma Circumferential Limb/Chest Extremes of age Open chest wound Multiple rib #s
Flail chest
Flail chest
Open chest wound
Refer as per NZ Burns Plan
Requiring complex reconstructions Requiring free flap Re-implants Massive soft tissue loss Refer as per NZ Burns Plan >10% TBSA all burns Face, hands, genitalia, feet Perineum, major joints >5% TBSA full thickness Electrical, Chemical Inhalation Significant comorbidity risks Any burns + other trauma Circumferential Limb/Chest Extremes of age Thoracic injury requiring CTS Requiring VATS
Pulmonary contusions Air leak Vascular
Threatened limb
Penetrating globe injury
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Threatened limb Potential or known aortic injury Penetrating globe injury
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Thames Trauma Referral Matrix 1. These criteria should prompt bypass or immediate transfer to definitive care facilities. 2. Activate transfer process as soon as the decision to transfer is made. 3. All transfers must be safe and confer clinical benefit to the patient. 4. Notification between senior transferring and accepting medical staff precedes all transfers. KEY W
Waikato Hospital
S
Starship
T/F
Transfer
D/W
Discuss with
Condition
Go To:
Consider these actions before transfer
Traumatic Brain Injury GCS >= 13, KO > 5mins
CT observe for a clinically appropriate amount of time
GCS >= 13 not resolving
W
GCS < 13
W
GCS < 9
W
Intubate, mannitol, transfer to W ASAP
Open brain injury
W
T/F ASAP
Possible skull base #
W
CT D/W neurosurgery
<2 yrs old and GCS <9
S
D/W S (can go to W if in extremis and closer)
Spine Spinal fracture suspected
CT then D/W ortho. Direct to W if no CT
Spinal fracture diagnosed
W
Cervical spine injury
W
Spinal cord injury (SCI)
W
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Direct to SCI Centre if isolated SCI (as per definition in SCI Plan), otherwise direct to Waikato
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Ortho Pelvic # except minor/insufficiency #s in the elderly
W
Pelvic sling if open-book and/or bleeding. T/F ASAP
Open pelvic #
W
T/F ASAP
Bleeding pelvis
W
Pelvic sling, T/F ASAP
Acetabulum #
W
Compound limb #
W
IV a/b, splint, T/F ASAP
W
Displaced jaw fracture direct to W if isolated injury discuss 1st re timing of T/F
Maxillofacial Jaw fracture displaced
Jaw fracture un-displaced
CT D/W Waikato max-facial
Facial fractures( minor)
CT D/W Waikato max-facial
Facial fracture (major)
W
Consider intubation if airway threatened
Exsanguinating face
W
Pack, D/W W and T/F ASAP if safe
Supra glottic airway threat
W
Consider intubation prior to T/F
Facial dog bite
W
D/W W prior to transport
Viable digit amputation
W
D/W W prior to transport
Partial limb amputation
W
D/W plastics/ortho/vascular
Burns
W
Refer National Burns Plan
Major soft tissue loss
W
D/W W
Open chest wound
W
CXR +- ICD
Multiple rib #s
W
CXR
Flail chest
W
CXR +- ICD (D/W cardiothoracic)
Pulmonary contusions
W
CXR
Plastics
Thoracic
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Pneumothorax
W
CXR +- ICD
Haemothorax
W
CXR + ICD
Chest stab
W
CXR +- ICD t/f ASAP (D/W cardiothoracic)
Vascular Avascular limb
W
Threatened limb
W
Thoracic aortic injury
W
Abdominal Expansile abdomen
W
Seat belt bruising
For laparotomy CT
Open abdomen
W
For laparotomy
Abdo penetrating
W
For laparotomy
Solid organ injury
W
CT T/F direct if high probability
Peritonism
W
Unstable, FAST +
W
For laparotomy
Stable, but high risk
W
CT
Perineal injury
W
Urologic Injury Frank haematuria
W
Penile injury
W
Severe Multisystem Injury
W
Direct to W if: 1) High risk of deterioration or occult injury 2) Potentially requiring angioembolisation 3) Need neurosurg, plastics, max-facial, CTS, Trauma Service, Spine Service, Other tertiary service
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4) Multiple casualties (>4) Paediatric Known or Suspected NAI
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W
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Tauranga Trauma Referral Matrix 1. These criteria should prompt bypass or immediate transfer to definitive care facilities. 2. Activate transfer process as soon as the decision to transfer is made. 3. All transfers must be safe and confer clinical benefit to the patient. 4. Notification between senior transferring and accepting medical staff precedes all transfers. NB: For clinical information please refer to regional trauma guidelines. KEY W
direct transfer to Waikato Hospital
(W)
consider direct transfer to Waikato Hospital if high risk or requires tertiary service
S
Starship
D/W
Discuss with
T/F
transfer
Condition
Transfer to
Action
Traumatic Brain Injury
GCS >= 13, KO>5mins
CT D/W W if deteriorating or mass lesion
GCS 9- 13
(W)
CT D/W W if deteriorating or mass lesion
GCS < 9
(W)
Intubate, T/F W
Open brain injury
W
Immediate T/F, notify Waikato of T/F
Skull base # + CSF Leak
(W)
CT D/W W
Paediatric TBI
S
D/W S and T/F as indicated
Spine Spinal fracture
Admit Tauranga
Spinal cord injury
Ortho to D/W SCI Centre: direct T/F if isolated SCI and safe for transport.
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If multi-trauma, treat in TGA or T/F to WKO. For T/F to SCI Centre when safe to do so. Ortho Open or complex pelvic #
Admit TGA ortho
Bleeding pelvis
Admit TGA ortho, D/W W if no angio
Maxillofacial Facial fracture (major)
D/W TGA max-facial
Exsanguinating face
D/W TGA max-facial
Supra-glottic airway threat
D/W ENT or max-facial TGA
Plastics Facial dog bite
(W)
D/W W
Viable digit amputation
W
Initial assessment by TGA ortho team, D/W WKO if plastics required
Partial limb amputation
D/W TGA vascular/ortho
Burns
(W)
As per National Burns Plan
Soft tissue loss
(W)
D/W W prn
Major chest wall injury
(W)
D/W CTS
Persistent air leak
(W)
D/W CTS
Chest stab
(W)
D/W CTS, T/F W if thoracotomy likely, and stable. If unstable operate on site.
W
D/W vascular surgeons W
Cardiothoracic
Vascular Thoracic aortic injury
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Whakatane Trauma Referral Matrix 1. These criteria should prompt bypass or immediate transfer to definitive care facilities. 2. Activate transfer process as soon as the decision to transfer is made. 3. All transfers must be safe and confer clinical benefit to the patient. 4. Notification between senior transferring and accepting medical staff precedes all transfers. Condition
Action (examples only)
Traumatic Brain Injury Any abnormality on CT or clinical deterioration
Discuss with WKO neurosurgery, manage and transfer as arranged
Open brain injury
Immediately initiate transfer to and discussion with WKO neurosurgery
Paediatric TBI
Discuss with Starship neurosurgery, manage and transfer as arranged
Spine Spinal fracture
Consult ortho. Discuss with TGA, T/F if indicated Consult ortho to D/W SCI Centre: direct T/F to SCI Centre if isolated SCI and safe for transport.
Spinal cord injury If multi-trauma, T/F to TGA or Waikato depending on other injuries. T/F to SCI Centre when safe to do so. Ortho Pelvic fractures Bleeding pelvis
Consult ortho. T/F to TGA if indicated
Acetabulum fractures Compound limb fracture
Consult ortho. T/F to TGA if indicated
Maxillofacial Jaw and facial fractures
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Discuss with TGA max-facial. If not available and needs are urgent, discuss with WKO max-facial. Manage/ T/F as arranged. Patients discussed with WKO but not transferred should still be sent to TGA max-facial for follow up.
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Exsanguinating face T/F TGA ENT Supra-glottic airway threat Plastics Facial dog bite
D/W Plastics WKO
Viable digit amputation
T/F Plastics WKO
Partial limb amputation
T/F ortho TGA (with vascular input)
Burns
As per National Burns Plan (usually plastics WKO)
Soft tissue loss
D/W plastics WKO prn
Cardiothoracic Open chest wound Pneumothorax with air leak Massive haemothorax Chest stab
D/W CT surgery WKO, T/F there or TGA as arranged
Immediate discussion with and T/F to CT surgery WKO if stable and thoracotomy likely, else TGA or local management as indicated
Vascular Avascular or threatened limb
T/F vascular surgery TGA; if not available, then WKO
Thoracic aortic injury
T/F vascular surgery WKO
Abdominal General abdominal injuries
Immediate surgical management locally if indicated. Consider T/F / bypass to TGA if delays locally and safer to do so
Possible solid organ injury
D/W surgery TGA
Significant liver injury
D/W hepatobiliary surgery WKO, manage / T/F as indicated
Stable, high risk
CT if positive, immediate T/F to TGA, or WKO if tertiary service needed
Perineal injury
Transfer TGA
Major Multisystem Trauma
Trauma Service W if tertiary services needed (e.g. neurosurgery, plastics, emergency angio-embolisation, cardiothoracic, multisystem and SCI); else TGA
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Rotorua Trauma Referral Matrix 1. These criteria should prompt bypass or immediate transfer to definitive care facilities. 2. Activate transfer process as soon as the decision to transfer is made. 3. All transfers must be safe and confer clinical benefit to the patient. 4. Notification between senior transferring and accepting medical staff precedes all transfers. KEY W
Transfer to Waikato Hospital
(W)
Transfer to Waikato after Cardiothoracic (CTS) consultation
S
Transfer to Star ship
T/F
Transfer
D/W
Discuss with Condition
Transfer to
Recommended Actions
GCS >= 13, KO > 5mins
(W)
CT
GCS >= 13 not resolving
(W)
CT, D/W Waikato neurosurgeon
GCS 9-12
(W)
CT, D/W Waikato neurosurgeon
GCS < 9
W
Intubate, consider mannitol, T/F ASAP
Open brain injury
W
T/F to W ASAP
Open brain injury + awake
W
T/F to W ASAP
Skull base #
(W)
CT, D/W Waikato neurosurgeon
<2 yrs old and GCS<13
S
D/W S (can go direct to W if in extremis)
(W)
CT, ortho review, +- D/W W
Traumatic Brain Injury
Spine Spinal fracture
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Spinal cord injury
W
CT + do ASIA Score. Ortho to D/W SCI Centre: direct transfer if isolated SCI (as per definition in SCI Plan) and safe for transport If multi-trauma, treat injuries in ROT or WKO, then T/F to SCI Centre when safe to do so
Cervical spine injury
(W)
Ortho Open or complex pelvic #
(W)
CT, ortho review, +- D/W W
Bleeding pelvis
(W)
If no angio, transfer to W ASAP if safe
Acetabulum #
CT, ortho review, +- D/W W
Maxillofacial Jaw fracture
(W)
Facial fractures( minor)
CT then D/W W CT
Facial fracture (major)
(W)
CT then D/W W
Exsanguinating face
W
D/W W immediately, T/F ASAP if safe
Supraglottic airway threat
(W)
consider intubate, D/W W
Plastics Facial dog bite
W
Viable digit amputation
W
Partial limb amputation
(W)
D/W plastics/ortho/vascular
Burns
(W)
Refer Burns Plan
Soft tissue loss
(W)
D/W W
Open chest wound
W
D/W CTS W
Multiple rib #s
(W)
CT +- D/W CTS
Flail chest
(W)
CT +- D/W CTS
Chest
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Pulmonary contusions
(W)
CT +- D/W CTS
Air leak
(W)
CT and D/W CTS
Requiring VATS
W
CT and D/W CTS
Pneumothorax
(W)
CXR +- ICD +- D/W CTS
Haemothorax
(W)
CXR +- ICD +- D/W CTS
Chest stab (stable)
(W)
CXR +- ICD and D/W CTS
Chest stab (unstable)
W
OT for thoracotomy (surgeon must be skilled)
Avascular limb
W
D/W Waikato vascular
Threatened limb
W
D/W Waikato vascular
Thoracic aortic injury
W
CT angio and D/W Waikato vascular
Vascular
Abdominal Expansile abdomen
CT if stable; OT if unstable
Seat belt bruising
CT
Open abdomen
OT
Abdo penetrating
Local Wound Exam: if +ve, laparoscopy
Possible solid organ injury
CT
Peritonism
OT
Unstable, FAST +
OT
Stable, but hi risk
CT
Major liver injury
(W)
CT and D/W W gen surg
Urology
(W)
Assess in ED
Severe Multisystem Injury
(W)
Direct to W if: 1) High risk of deterioration or major occult injury 2) Potentially requiring angioembolisation.
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3) Need neurosurgery, plastics, max-facial, CTS, Trauma Service, Spine Service, Tertiary Service 4) Multiple casualties (>4)
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Taupo Trauma Referral Matrix 1. These criteria should prompt bypass or immediate transfer to definitive care facilities. 2. Activate transfer process as soon as the decision to transfer is made. 3. All transfers must be safe and confer clinical benefit to the patient. 4. Notification between senior transferring and accepting medical staff precedes all transfers. KEY R
Transfer to Rotorua Hospital
W
Transfer to Waikato Hospital
S
Transfer to Starship
R (W)
Transfer to Rotorua; direct to Waikato if severe or multiple injuries
W (R)
Transfer to Waikato unless patient is low risk
R (S)
Transfer to Rotorua for CT; D/W Starship
T/F
Transfer
Condition
Go To:
Consider these actions before transfer
GCS >= 13, KO > 5mins
R
CT
GCS >= 13 not resolving
R
CT
GCS < 13
R
CT
GCS < 9
W
Intubate, mannitol, T/F to W ASAP
Open brain injury
W
Open brain injury + awake
W
Possible skull base #
R
<15 yrs old and GCS 9-13
R (S,W)
<15 yrs old and GCS <9
S (W)
Traumatic Brain Injury
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Spine Spinal fracture suspected
R
CT
Spinal fracture on XR
R (W)
D/W W
Cervical spine injury
R (W)
CT
Spinal cord injury
W
Consult ortho to D/W SCI Centre: direct T/F if isolated SCI (as per definition in SCI Plan) and safe for transport If multi-trauma, treat injuries in ROT or T/F to Waikato, then T/F to SCI Centre when safe to do so
Ortho Pelvic #
R
CT
Open pelvic #
W
T/F ASAP
Closed pelvic #
R
Pelvic sling, CT +- D/W W
Bleeding pelvis
W
Pelvic sling, T/F ASAP
Acetabulum #
R
Compound limb #
R
IV a/b, splint, T/F ASAP
Jaw fracture displaced
W
Displaced jaw fracture direct to W
Jaw fracture un-displaced
R
Facial fractures( minor)
R
Facial fracture (major)
W
Consider intubation if airway threatened
Exsanguinating face
W
Pack, D/W W and T/F ASAP if safe
Supra-glottic airway threat
R (W)
consider intubation prior to T/F
Facial dog bite
W
D/W W prior to transport
Viable digit amputation
W
D/W W prior to transport
Maxillofacial
Plastics
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Partial limb amputation
W
D/W plastics/ortho/vascular
Burns
R (W)
Refer National Burns Plan
Minor soft tissue loss
R
Major soft tissue loss
R (W)
D/W WKO
Open chest wound
W
CXR +- ICD
Multiple rib #s
R
CXR
Flail chest
R (W)
CXR +- ICD (D/W cardiothoracic)
Pulmonary contusions
R
CXR
Pneumothorax
R
CXR +- ICD
Haemothorax
R
CXR + ICD
Chest stab (stable)
R
CXR +- ICD
Chest stab (unstable)
W
CXR +- ICD t/f ASAP (D/W cardiothoracic)
Thoracic
Vascular Avascular limb
W
Threatened limb
W
Thoracic aortic injury
W
Abdominal Expansile abdomen
R
Seat belt bruising
R
Open abdomen
R
Abdo penetrating
R
Possible solid organ injury
R
Peritonism
R
Unstable, FAST +
R
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Stable, but hi risk
R
Perineal injury
R
Urologic Injury Micro haematuria
R
Frank haematuria
R
Penile injury
R
Severe Multisystem Injury
W
Direct to W if: 1) High risk of deterioration or occult injury 2) Potentially requiring angio-embolisation 3) Need neurosurgery, plastics, max-facial, CTS, Trauma Service, Spine Service, other Tertiary Service 4) Multiple casualties (>4)
Paediatric Known or Suspected NAI
R
Trauma admissions
R
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Tairawhiti Trauma Referral Matrix 1. These criteria should prompt bypass or immediate transfer to definitive care facilities. 2. Activate transfer process as soon as the decision to transfer is made. 3. All transfers must be safe and confer clinical benefit to the patient. 4. Notification between senior transferring and accepting medical staff precedes all transfers. KEY W
Transfer direct to Waikato Hospital
(W)
Consider transfer to Waikato if high risk
High risk
Chance of deterioration or needing neuro Sx, CTS, max-facial, plastics, liver surgery, complex multisystem trauma, etc.
S
Transfer to Starship
T/F
Transfer
D/W
Discuss with
Condition
Go To:
Consider these actions before transfer
Traumatic Brain Injury GCS < 9
(W)
Intubate, CT ?mannitol, D/W neurosurgeon
Open brain injury
W
Consider T/F to W if survival possible
Open brain injury + awake
W
Direct T/F to W ASAP
GCS<13 and Age <2
S
D/W neurosurgery at Starship
N.B. Waikato neurosurgery will accept if SSH not accessible Spine Spinal fracture
(W)
CT +- D/W W spine service
Spinal cord injury
(W)
CT + do ASIA Score: D/W spine service W Consult ortho to D/W SCI Centre: direct T/F to SCI Centre if isolated SCI and safe for transport
Cervical spine injury
(W)
CT +- D/W ortho W
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Ortho Open or complex pelvic #
(W)
CT +- D/W W as required
Bleeding pelvis
(W)
Consider immediate T/F to W if angio indicated
Acetabular #
(W)
CT +- D/W W as required
Jaw fracture
(W)
CT then D/W max-facial W
Facial fracture (major)
(W)
CT then D/W max-facial W
Exsanguinating face
(W)
D/W W immediately, T/F ASAP if safe
Supraglottic airway threat
(W)
Consider intubation, D/W W max-facial
Maxillofacial
Plastics Facial dog bite
(W)
Viable digit amputation
(W)
D/W TDH ortho; T/F to W if plastics required
Partial limb amputation
(W)
D/W TDH ortho, gen surg
Burns
(W)
Consult National Burns Plan
Soft tissue loss
(W)
D/W gen/surg/ortho
Open chest wound
(W)
Gen surg review
Flail chest
(W)
CT
Chest stab (stable)
(W)
CXR +- ICD +- CT D/W W CTS
Chest stab (unstable)
(W)
OT for thoracotomy +- subsequent T/F
Avascular limb
(W)
Review by TDH surgeons; CTA +- W
Threatened limb
(W)
Review by TDH surgeons; CTA +- W
Thoracic aortic injury
(W)
CTA and D/W W
Chest
Vascular
Abdominal
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Major injury
(W)
CT gen surg D/W W as required
(W)
Consider direct to W if high risk (see below) liver surgery, complex multisystem trauma, etc.
Severe Multisystem Injury
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Taranaki Base Hospital Trauma Referral Matrix
1. These criteria should prompt bypass or immediate transfer to definitive care facilities. 2. Activate transfer process as soon as the decision to transfer is made. 3. All transfers must be safe and confer clinical benefit to the patient. 4. Notification between senior transferring and accepting medical staff precedes all transfers. KEY W
Transfer to Waikato Hospital
TBH
Taranaki Base Hospital
WLG
Transfer to Wellington Hospital
CCH
Transfer to Christchurch Hospital
M
Transfer to Middlemore Hospital
S
Transfer to Starship
(WKO)
Transfer to Waikato after specialist consultation
T/F
Transfer
D/W
Discuss with
Condition
Transfer to
Recommended Action
Traumatic Brain Injury GCS >=13, KO >5 mins
CT
GCS >= 13 not resolving
CT, D/W Wellington neurosurgeon
GCS 9-12
CT, D/W Wellington neurosurgeon
GCS <9
WLG
Intubate, consider mannitol, T/F ASAP
Open brain injury
T/F to Wellington ASAP
Open brain injury + awake
T/F to Wellington ASAP
Skull base #
(WLG)
CT, D/W Wellington neurosurgeon
<15 yrs old and GCS 9-13
(S)
D/W Starship
<15 yrs old and GCS <9
S
D/W Starship
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Spine Spinal fracture
Admit Taranaki Base
Spinal cord injury
CCH
CT + ASIA Score. Ortho to D/W SCI Centre: Direct T/F if isolated SCI (as per definition in SCI plan) and safe for transport If multiple-trauma, treat injuries in TBH or Waikato then T/F to SCI Centre when safe to do so As per direction of ortho service
Cervical spine injury Ortho Open or complex pelvic #
(M)
CT, TBH ortho review
Bleeding pelvis
(M)
If no angio, T/F to Middlemore ASAP if safe
Acetabulum #
(M)
Admit TBH ortho review
Maxillofacial Jaw fracture
CT
Facial fracture (minor)
CT D/W TBH max-facial
Facial fracture (major)
CT D/W TBH max-facial
Exsanguinating face
W
Supraglottic airway threat
D/W Waikato immediately, T/F ASAP if safe Consider intubate, D/W TBH ENT
Plastics Facial dog bite
W
Viable digit amputation
W
Initial assessment by TBH ortho team, D/W W if require reimplantation
Partial limb amputation
W
D/W plastic/ortho/vascular
Burns
M
Refer Nations Burns Plan
W
D/W CTS Waikato
Chest Open chest wound Multiple rib #
CT
Flail chest
CT
Pulmonary contusions
CT
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Air leak
CT
Pneumothorax
CXR +- ICD
Haemothorax
CXR +- ICD
Chest stab (stable)
CXR +- ICD
Chest stab (unstable)
W
OT for thoracotomy (surgeon must be skilled)
Vascular Avascular limb Threatened limb Thoracic aortic injury
W
Abdominal Expansile abdomen
CT if stable, OT if unstable
Seat belt bruising
CT
Open abdomen
OT
Abdo penetrating
Local Wound Exam: if +ve laparoscopy
Possible solid organ injury
CT
Peritonism
OT
Unstable, FAST+
OT
Stable, but high risk
CT
Major liver injury
CT
Urology Severe Multisystem Injury
(W)
Direct to W if: 1) High risk of deterioration or major occult injury 2) Potentially requiring angio embolisation 3) Need neurosurgery, plastics, max-facial, CTS, Trauma Service, Spine Service, Tertiary Service 4) Multiple casualties (>4)
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Appendices Appendix A – TMT / Midland Trauma System (MTS) A.1 Overview •
•
•
Trauma system development is growing steadily around the world as the true burden of trauma on the community is being recognised. Based on strong evidence of the effectiveness of trauma systems overseas and highly positive results from the few organised trauma services in New Zealand, the TMT / Midland Trauma System was initiated. It is being implemented on the minimum specification to be effective and sustainable. MTS is a collaborative network of clinicians in five TMT / Midland DHBs with special training in trauma care and trauma data collection. They are supported by a core specialist group at Waikato DHB, where the trauma registry is managed. The core group is comprised of the programme manager, data administrators, biostatistician and director. Each DHB has a dedicated trauma nurse specialist supported by a trauma-oriented consultant. These trauma services identify all patients admitted to hospital and collect standardised, detailed data on patient demographics, the mechanism and types of injury, pre-hospital transport and treatment, in-hospital care, and clinical progress along the trauma continuum from the point of injury through to discharge. A number of quality improvement variables and audit filters will continuously assess the adequacy of all parts of the system.
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Appendix B – Waikato Hospital Trauma Service B.1 Overview The Waikato Hospital Trauma Service has provided dedicated multidisciplinary care and consultative services continuously since it commenced in 2006. Aligned with the priority of ‘patients and whanau first’ the service is available for consultation during working hours in situations when optimal processes for individual patients are not covered in the Guidelines or if there are issues with transfers into and out of Waikato Hospital. B.2 Mission To ensure that trauma patients and their families receive the highest quality of trauma care throughout the trauma continuum from point of injury to optimal function. B.3 Trauma Service Personnel Clinical Director
Grant Christey
021 761 941
Deputy Director
Damien Ah Yen
021 100 4937
CNS Trauma
Bronwyn Denize
027 539 8205
CNS Trauma
Gina Marsden
027 224 6796
Trauma Fellow
Trauma Fellow
021 761 938
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Appendix C. Roles of Trauma Call Team Members The composition of the trauma response teams may vary depending on resources in the individual DHBs however the tasks and skills required should all be supplied by team members present, working to achieve the standards outlined in this document.
Team Member
Responsibility
Trauma Team Leader
• •
Decisions, direction, destination, documentation (The Trauma Team Leader (TTL) is an experienced consultant, trauma fellow or skilled, designated senior registrar who takes a “Hands Off” approach and orchestrates an effective and efficient response).
Wear the TTL jacket to identify your role. Ensure team members and equipment are ready prior to patient arrival and assign roles, ensuring an appropriate skill set for the assigned role. • Set a calm and efficient tone in the resuscitation room and ensure all team members are confident in their assigned roles. This includes crowd control. • Ensure appropriate equipment is present prior to patient arrival and stipulate placement which does not obstruct access. • Ensure appropriate products are available stipulate which drugs, fluids and blood products and which will be made ready. Order early antibiotic and tetanus prophylaxis. • Obtain essential history from pre-hospital personnel. • Ensure team members perform their roles in a timely fashion and delegate or intervene only when difficulty is encountered. • Prioritise investigations and interventions. • Ensure agreement with the trauma team members regarding management • Contact and request the presence of other specialties as required, • Facilitate passage of patient to definitive care, • Ensure documentation is completed by team members. • Ensure timely and full communication with the patient’s relatives. • Perform any of the other roles as required and supervise invasive procedures stepping in only if required. Debrief team if able, especially for difficult cases or where the patient dies (ensure coronal processes in this event).
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Team Member
Responsibility
Emergency medicine registrar (if available)
• Identify yourself to the trauma team leader (TTL) and accept role as allocated. Communicate clearly with TTL at all times during resuscitation. If allocated as A – Airway doctor: • Ensure familiarity with airway equipment and location in resuscitation room prior to patient arrival. • Establish patent airway and give oxygen. • Establish and maintain an adequate airway and ventilation. • Assess need for immobilisation of the cervical spine and clinically clear if possible. • Communicate with the patient. • Evaluate cerebral neurological status (GCS, pupils). • Initial investigation of face/eyes/ears/scalp. • Monitor ECG and vital signs. • Place a gastric tube if patient intubated. • Whilst airway management is the primary responsibility of DEM doctors, ICU or anaesthesia staff may be there to assist. The key outcome is that airway management is always swift, skilful and safe. The decision rests with the TTL who will determine the best person for the job at that time and for that patient. If allocated as BC – Breathing/Circulation doctor: • Complete primary survey of B and C. • Ensure control of external bleeding and assist with the search for concealed haemorrhage especially FAST. • Request immediate CXR and PXR if indicated. • Insert large bore cannulas (14-18g) into antecubital fossa. Consider EZIO if problematic • Insert intercostal chest drain, CVL and/or arterial line as directed to do so by TTL. • Take trauma bloods, cross-match, ethanol, VBG if unstable or actively bleeding. ABG is only done if an arterial line is inserted. • Supervise balanced fluid resuscitation with warm isotonic IV fluid. Ensure additional haemostatic measures applied as required e.g. SAM pelvic sling and traction splints. • Order appropriate analgesia and administer drugs such as morphine as discussed with TTL. • Consider other drugs as necessary such as IV antibiotics and tetanus prophylaxis if compound or contaminated wounds in consultation with TTL. • Ensure temporary treatment of peripheral fractures and dislocations including reduction if required and splinting. • Complete and document the secondary survey. Communicate clearly with the trauma team leader at all times.
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Anaesthesia
• Called as required by ED staff for routine trauma calls but mandatory attendance for a Code Red activation). • Introduce yourself to the TTL if not known). Can assist the EM doctor with A – Airway per role description above. Clear communication and understanding of roles throughout is or paramount importance. • Will accept handover at an appropriate time and manage the patient until the next phase of care begins. The TTL/resus team stays with patient (transport etc.) until definitive therapeutic destination identified at which point formal handover of care to appropriate specialty (anaesthesia/ ICU) occurs. Other roles specific to the anaesthesia registrar: • Discuss the patient with the duty anaesthetist early. • Provide clinical escort to other areas for investigation and treatment if required (shared role with ED, workload dependent; determined by TTL).
General surgery registrar
• • • • •
Introduce yourself to the TTL (if not known). Assist with the primary survey and engage in the search for concealed haemorrhage. Expedite appropriate emergency surgical and radiological interventions in consultation with the TTL. Confirm secondary survey findings. During logroll, examine back and perform rectal examination if indicated. Evidence or suspicion of any of the following: o Spinal cord injury o Trans pelvic penetrating injury o Perineal injury
Trauma room nursing roles
•
Liaise with the duty anaesthetist early if operative intervention likely to be required. Call off theatres as soon as possible if need for surgery discounted or delayed.
•
Perform invasive examinations and therapeutic procedures such as: o Intercostal drainage o Urinary catheterisation o Intra -osseous access o Communicate clearly with the trauma team leader at all times
In order to provide optimal care to trauma patients, clarity of roles are important to avoid cross over and confusion of duties/responsibilities. The goal is to provide efficient, focused, and timely care to be able to deliver patients to definitive care. Depending on nursing resources required and available, the below role descriptions are designed to ensure that patient care requirements are meet in an orderly and efficient way.
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ED Primary RN Primary nurse of this patient remains close to patient so is fully informed of plan, progress and patient changes, remains hands on assistant for procedures / investigations being carried out. Will continue and take responsibility for this patient through the journey of care. Should be close to airway and procedures trolley.
Prior to arrival: • Don personal protective wear (eye protection, gown, gloves, and lead gowns). • Prepare airway equipment (oxygen, suction, trolley, intubation drugs). • Patient slide board ready. • Rapid Infuser if required – need nominated person to run it. Arrival: • Ensure C-spine stabilisation if indicated. • Assist with patient transfer onto bed, cut off clothes on right side. • Assist with initial airway management as directed. • Ensure oxygen applied and flowing if required. • During intubation. • Assist with intubation as directed by team leader and/or airway lead. • Assist with insertion of gastric tube. • Ongoing care. • Continue with obs, IV fluids and drug administration and notify scribe nurse. • Monitor airway and ventilation. • Assist with procedures. • Record ECG. • Prepare underwater sealed drain/Art line/catheter equipment if required. • Assist with wound dressings and temporary splinting. • Communicate and provide updates to the nurse in charge of the shift. • Prior to transport. • Total drainage output from IDC and chest drain and informs scribe nurse. • Ensure portable oxygen, suction and transport monitor and transport bag is available.
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ED secondary/assist RN Secondary RN to assist where required will not be the primary nurse of this patient and will be directed by the TTL and primary nurse, to supply additional assistance with IV lines, drugs, monitoring, and equipment from store room as required. Take on scribe role also if third RN is not available.
Prior to arrival: • Don personal protective wear (gown and gloves). • Set up monitoring. • Prepare required fluids and drugs as directed from TTL.
Arrival: On patient’s arrival: • Assist with patient transfer onto bed, cut of clothes on left side. • Assist with exposing patient. • Attach multifunction monitor. • Perform initial vital signs and inform team: HR, NIBP, RR, Temp, SpO2. • Assist with control of any external haemorrhage or dressing of wounds. • Assist with or perform venous access and blood sampling. • Ensure bloods sent to laboratory ASAP. • Send off specimens. • Perform IV fluid and drug administration as required and as directed by Team Leader and document. During intubation • Assist with IV lines and fluid infusion Ongoing care • Continue with obs, IV fluids and drug administration and notify scribe nurse. • Set up arterial line if required. • Assist with application of splints and dressings. Prior to transfer • Perform final fluid balance and document. • Ensure necessary equipment and fluids available.
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Scribe (ED/CRN/Trauma CNS) If a third person is available they should commence to take on the scribe role, in close liaison with the TTL, this role is hands off and to document, organise and communicate extra support as required (specialities, attendants, HCA). Should be situated at foot of bed, to remain out of the way of clinical personal and clinical duties.
Prior to arrival: • Paperwork is prepared (chart, X-ray, blood form) • Identify team members Arrival On patient’s arrival (hands-off role). • Document: time of arrival, history of incident, patient status, baseline recordings. • Prepare forms for lab tests and trauma views. • Liaise with clerks re: patient details, valuables. Label and secure property. • Initiate calls to specialty registrars as required. During intubation • Document drugs, times, doses. Ongoing care • Provide team with regular updates. • Liaise with social workers and ED charge nurse for ongoing family care. • Arranging MTP (massive transfusion protocol) if requested by team leader. Prior to transfer • Liaise with ED charge nurse. • Ensure documentation complete. • Help with getting transport equipment. • Arrange attendant.
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Appendix D - Primary Survey <C>ABCDE (as per EMST TM) and adjuncts: D.1 Control catastrophic external haemorrhage D.2 Airway • Assess the airway • Create or maintain an airway by: o Looking - use suction o Chin lift or jaw thrust o Intubation naso/oropharyngeal; orotracheal; cricothyroidotomy, etc.
Relative Indications for Intubation •
Airway or breathing compromise (present or predicted)
•
Threatened airway
•
GCS<9
•
Combative and likely to injure self or others
•
Unco-operative patients (M5 or less) requiring CT, aortography etc.
D.3 Breathing • • • •
Administer high flow oxygen Assess the chest by clinical examination Recognise and treat: tension pneumothorax, massive haemothorax, flail chest, sucking chest wounds, pericardial tamponade Emergent CXR and treat as required D.4 Circulation
The patient with cold, pale peripheries has shock until proven otherwise. Assess circulation by: • • • • •
Looking for external haemorrhage Observing skin colour, temperature and capillary refill Feeling the pulse Taking the blood pressure Distended neck veins, hypotension, muffled heart sounds (pericardial tamponade)
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Interventions for Circulatory Management •
Arrest external haemorrhage by local pressure. Suture if possible.
•
IV Access. Insert at least 2 antecubital large-bore IV cannulas. Use femoral vein if necessary. Ultrasound scan (USS) may help this but should not delay progress. Unless the patient is exsanguinating this process should not hold up other team members in the Trauma Call process.
•
Blood Gases: Arterial Blood Gas (ABG) in unstable patients, preferably via an early arterial line; or by immediate femoral stab if an arterial line may delay definitive management. Venous blood gas is satisfactory for stable patients but becomes unreliable if the patient’s blood pH is <7.2. (Arch Surg. 2005;140:1122112).
•
Take trauma bloods: (FBC, Biochem, Ethanol, Coag, Cross-match) Pregnancy test if child-bearing age female.
•
Judicious infusion of warmed 0.9% saline.
•
Massive Transfusion Protocol if indicated (refer Appendix J)
•
Monitors: pulse oximeter, ECG, temperature probe, BP cuff.
•
Recognise hypothermia and give warmed fluids as appropriate. Replace cooled fluid pre-hospital fluids with warmed fluids.
•
Exsanguinating patients get Group O-Neg blood ASAP.
•
Be meticulous with fluid management in all patients, with special attention to the elderly or those with underlying cardiac disease.
D.5 Disability • • • • •
Estimate GCS Talk to the patient Painful stimulus = pressure on toes or fingers. Consider central stimulus to sternum, earlobe or forehead if unreliable peripheral response Assess papillary size and response Examine for lateralising signs (differing motor scores on each side) and signs of cord injury. (Evidence of tentorial herniation requires immediate neurosurgical assessment and consideration of measures to reduce ICP which may include Mannitol)
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Adult Glasgow Coma Scale Score
Eye Opening
Verbal Response
Motor Response to Pain
1
nil
nil
nil
2
To pain
incomprehensible
Extends limbs
3
To voice
inappropriate
Flexes limbs
4
Spontaneous
confused
Withdraws from pain
oriented
Localizes to pain
5 6
Obeys commands
TOTAL /15
Paediatric Glasgow Coma Scale Score
Eye Opening
Verbal Response
Motor Response to Pain
1
nil
nil
nil
2
To pain
Inconsolable, Agitated
Extends limbs
3
To voice
Moaning
Flexes limbs
4
Spontaneous
Cries, Consolable
Withdraws from pain
Interacts
Withdraws from touch
5 6
Purposeful Movements
TOTAL /15
D.6 Exposure/Environmental Control • Expose the patient fully for the initial surveys then keep covered • Measure core temp and repeat if warming underway • N.B. Hypothermia is a major barrier to successful surgical intervention D.7 Analgesia • Most trauma patients are in significant pain, therefore analgesia should be considered as soon as resuscitation has been initiated and the patient’s injuries and physiologic responses have been established. In general pain relief is aided by: establishing rapport Doc ID: Version: 02 Issue Date: MAR 2021 Review Date: MAR 2024 Facilitator Title: Clinical Director Department: MTS IF THIS DOCUMENT IS PRINTED, IT IS VALID ONLY FOR THE DAY OF PRINTING Page 95 of 136
• •
with the patient, splinting of injured extremities, gentle movement and handling, prevention of shivering, cooling of burns. Opioids should be given intravenously in severe trauma or if in significant pain: titrate in small increments until comfortable. Beware hypotension, respiratory depression and vomiting (Consider antiemetic if the patient is nauseated or vomiting). Local Anaesthetic allows wound exploration and minor suturing. Femoral block is used in femoral fractures.
D.8 Great Mistakes •
Inducing hypothermia from patient left in wet clothes or sheets.
•
Over-resuscitation can exacerbate bleeding causing haemo-dilution and “blowing off the clot” by raising systolic pressure excessively.
•
Under-diagnosis of intra-cavity injuries can be life-threatening. Clinical examination is not sensitive or specific enough to exclude significant injuries. Imaging is safe, rapid and cost-effective. Consider the risks of radiation alongside the risk of under-diagnosis. Remember that the mortality from uncontrolled body cavity bleeding in an unstable patient rises by about 1% per 3 minutes.
•
Underestimating the effect of any bleeding is dangerous. All haemostasis is a critical priority.
•
You cannot assume haemodynamic stability when fluid administration is underway.
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Appendix E - Secondary Survey Overall Schema in Secondary Survey E.1 Complete the History A
Allergies
M Medications P
Previous medical/surgical history
L
Last food
E
Events associated with the injury (what happened?) E.2 Examination
This assessment is a complete examination of the patient from top to toe, front to back. Be thorough and document your findings. Examine: • • • • • •
Head/neck/nerves Chest Back/Spine Abdomen/pelvis Limbs Neurology/GCS E.3 Make a Definitive Plan
• All members of the trauma team have a responsibility to ensure their actions, findings, names and roles are recorded in a legible fashion in the patient’s medical record. • Definitive care decisions may require further documentation: specialty, specialist, plans and prioritisation. When several teams are involved, explicit instructions (e.g. NBM, mobility, observation limits, etc.) are required. The TTL is responsible for making sure this task is completed. • It is expected that all appropriate speciality teams have been notified prior to the patient leaving the resuscitation room.
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E.4 Clinical Examination E.4.1 Head
• Look for posterior scalp lacerations and compound fractures. If the scalp is bleeding, stitch it immediately! Scalp dressings do not stop bleeding; they conceal it. • Beware progressive papillary changes or GCS fluctuations. • Injuries under the hard collar will be missed if you don’t look. • Adequate in-line stabilisation must be maintained when the collar is off. • Scalp bleeding can result in major blood loss. Suture or staple immediately. • Periorbital haematoma = blowout orbital fracture until proven otherwise. Call max-fac and ophthalmology if confirmed on CT. • For lid lacerations, call ophthalmology. • Remove glasses and contact lenses and store. • Neuromuscular blockade following intubation doesn’t alter autonomic pupillary signs but renders PR exam for neurology unreliable. • Avulsed tooth survival decreases 1% per minute out of the socket. Replace it only if it can be secured, and poses negligible aspiration risk. • Mid-face mobility is checked by a gentle wiggle of the maxilla. • Mid-face disruption can threaten the airway - sit the patient up and consider early intubation. • Facial bleeding can be massive. Consider early intubation, pharyngeal packing and angioembolisation. Refer immediately if early attempts at haemostasis are not definitive or if tertiary anatomic reconstruction is required. E.4.2 Neck • Maintain stabilisation until neck cleared • Assess but do not probe wounds that penetrate platysma. Determine fascial breach using local anaesthesia • Look for airway injury, distended neck veins, vascular signs (bruit, bleeding, expanding haematoma), nerve injury (Horner’s syndrome, brachial plexus deficit) E.4.3 Cervical spine • Extrication cervical collars are useful to stabilise a cervical bony injury from the point of injury, but should only stay on until an injury has been excluded or definitive treatment planned. Rigid collars restrict the ability to do emergency intubation or other neck examinations and procedures, cause local pressure damage, increase the risk of aspiration and not least of all they are painful to wear (try one for 30 minutes). • Cervical spine clearance by early clinical assessment, and appropriate radiological examinations should be complete within 1 hour of patient arrival in the Emergency Department. Extrication collars should be removed or replaced by Philadelphia or Aspen collars. The following management algorithm incorporates the Canadian Cervical Spine Clearance Guidelines into a sensible schema for early assessment of the cervical spine. • Please note that the algorithm primarily addresses evaluation of suspected isolated cervical spine injuries. In patients with severe, multiple injuries and competing clinical priorities, CT of head and neck should be performed at the index scan. So, in an awake, non-intoxicated patient with no distracting injuries, proceed with clinical clearance (Refer Appendix Q Cervical Spine Clearance). Doc ID: Version: 02 Issue Date: MAR 2021 Review Date: MAR 2024 Facilitator Title: Clinical Director Department: MTS IF THIS DOCUMENT IS PRINTED, IT IS VALID ONLY FOR THE DAY OF PRINTING Page 98 of 136
E.4.4 Chest General examination • Rib and sternal fractures may be easily missed on clinical exam and X-ray • These injuries may significantly compromise the patient • Do CT chest if CXR is abnormal and more information is required e.g. haemothorax vs pulmonary contusion; wide mediastinum; etc. • Remember that CT of the abdomen or CT of the head and neck to T4 level will show significant occult pneumothoraces Specific Injury Tips
Mechanism of injury, clinical signs and CXR are primary diagnostic tools. Key features •
Cardiac tamponade: penetrating mechanism, hypotension distended neck veins. FAST is 98% sensitive for penetrating injury
•
Aortic Rupture: high speed acc/deceleration; wide mediastinum; pleural effusion.
•
Ruptured diaphragm: abdominal compression, respiratory distress, vague diaphragm or bowel loops in chest
•
Oesopohageal Rupture: abdominal compression, mediastinal emphysema, pleural effusion
•
Pneumothorax: subcutaneous emphysema, may be absent on CXR but will show on CT, may become evident on positive pressure ventilation
•
Haemothorax: may be a subtle opacity on supine CXR. If in doubt consider CT chest.
•
Myocardial contusion: high speed acceleration/deceleration. Associated with anterior flail, non-specific cardiac signs and ECG, enzymes correlate poorly with injury, Echo is best test – get it early
•
Rib fractures: common and often occult to CXR, springing can localise the fractures, high and posterior = major energy transfer and associated thoracic injuries. If the patient cannot breathe comfortably, analgesia is inadequate. Consider epidurals for vulnerable patients
•
Pulmonary contusion: common, may not be obvious on initial CXR, associated with major chest wall deformity or blast, get worse over the first 24 hrs, best kept in HDU. May require PEEP or mechanical ventilation
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E.4.5 Abdomen General examination • Pain or tenderness or bruising requires further investigation, not guesswork. • The inaccessible abdomen with appropriate mechanism requires investigation: FAST (or DPL) in unstable patients; CT in stable patients. • Vaginal examination in female patients with pelvic ring fractures or non-menstrual vaginal bleeding. In pregnancy this may be deferred to an obstetric specialist. • A nasogastric tube is relatively contra-indicated in the presence of facial fractures. An orogastric tube should be inserted if gastric decompression is indicated. • A urinary catheter should only be inserted if there is no blood at the meatus, no perineal bruising, and rectal examination is normal.
Tips •
This is most likely body cavity to house occult massive bleeding. Have a high index of suspicion until injuries are definitively ruled out.
•
The mortality from uncontrolled intra-abdominal bleeding is 1% per 3 minutes. It is critical to find and stop the bleeding immediately.
•
Clinical examination alone is inadequate to rule out significant intra-abdominal injury. CT imaging is useful in stable patients only but can still miss subtle organ injuries.
•
FAST is only indicated and validated in unstable blunt trauma patients or those with suspicion of body cavity penetration. To improve skill levels, it should be performed by personnel gaining FAST credentialing in all trauma patients as long as it does not interfere with the process of definitive care.
•
Any breach of deep fascia over the abdominal cavity requires exclusion of a peritoneal breach. This means screening laparoscopy or laparotomy.
•
If a diaphragmatic laceration is possible it must be excluded by visual examination at laparoscopy or laparotomy. Negative imaging is not helpful. The only way to be sure is to look
•
The consequences of a single missed intra-abdominal injury can be severe and life-threatening. Diagnose or exclude all potential injuries thoroughly and deliberately.
•
Bowel perforation is disastrous but may be occult to clinical exam and CT until sepsis is well advanced. Consider early laparotomy if suspicious.
•
The force required to produce a seat belt bruise is enough to injure abdominal organs.
•
Beware occult stab wounds in the groin and axilla: always examine the back.
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E.4.6 Back • Log roll ideally takes 5 people: 3 body, one at the head, one examining • Inspection and palpation • Indications for rectal examination in trauma patients are evidence or suspicion of: o spinal cord injury o perineal injury o trans-pelvic penetrating injury E.4.7 Spine and Spinal Cord • • • • • • •
Cervical spine is best assessed with collar released and in-line immobilisation Thoracic and lumbar spine are assessed during logroll During logroll assess for steps, tenderness, boggy swellings Record motor power, reflexes and sensory levels Anterior wedge fractures may not manifest as posterior tenderness Rectal exam for anal tone and sacral sparing is mandatory for suspected spinal cord injury. Always remove gel from anal region when finished Priapism in spinal cord injury is autonomic and is not affected by neuromuscular blockade
ASIA Impairment Scale • • •
•
The ASIA Impairment Scale is an internationally recognised, validated scoring system for use in patients with spinal injury. It can be used for prognostic purposes and as a tool to accurately monitor patients through their early and late treatment for spinal injury. Why: Use of the ASIA Impairment Scale ensures rapid and accurate evaluation of patients with spinal injury in the acute setting. It also allows reproducible examinations to be carried out that document any change in a patient’s neurologic status. When: All patients with a spinal injury should have an examination carried out as soon as practical after their arrival in the emergency department. This examination should be documented using the ASIA Impairment Scale worksheet, and that worksheet should be filed in the patient’s clinical notes. Further examinations should be carried out at any time a deterioration in symptoms is suspected, or after any intervention related to the spinal injury. All spinal injuries should be assessed by the on-call orthopaedic registrar using the ASIA Impairment Scale
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ASIA Impairment Scale
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E.4.8 Extremities • Inspect and palpate each limb for tenderness, crepitation or abnormal movement. • If the patient is cooperative ask him or her to move the limbs in response to command in preference to passive movement in the first instance. • Adequately splint any injuries. • Reassess after splints, traction or manipulation. • Joint fracture/dislocations with potential skin necrosis require urgent relocation by personnel designated by the team leader. • All limbs should be carefully examined for contusions, laceration, deformity, crepitus and distal neurovascular status: any abnormality should prompt immediate referral to appropriate surgical teams. • Beware compartment syndromes associated with major soft tissue and vascular injuries: pain and sensory loss are early signs – don’t miss them. • Examine the hands and feet carefully – they are a prime source of debilitating missed injury that can be avoided by early identification and treatment. E.4.9 Pelvis and Perineum • Gently palpate the pelvis for pain and tenderness – do it once and do not “spring” the pelvis. This is painful and can exacerbate bleeding. • The possibility of blunt pelvic exsanguination with no pelvic fracture is very low. • The best screening test for pelvic bleeding is the pelvic X-ray (PXR): the best treatment for isolated pelvic bleeding is angio-embolisation. • Place a bed sheet binder or sling if not already applied pre-hospital. • Dislocated hips (e.g. from dashboard impact) may manifest as knee lacerations and flexed position on the gurney. Traumatic hip dislocation is an orthopaedic emergency. Immediate consultation and reduction is required. • Assess supine and during logroll. • Look for blood at meatus, scrotal haematoma, high-riding prostate on rectal exam. • Urethral injury is common with bilateral pubic ramus fractures, “open book” pelvis and vertical shear injuries. • Penetrating injuries of the perineum and lower parts of the buttocks should be assumed to have breached the pelvis, retroperitoneum or abdominal cavity until proven otherwise. E.4.8 Neurological examination • • • •
Repeat the GCS Re-evaluate pupils if abnormal Look for localising or lateralising signs Look for signs of cord injury
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E.4.9 Ethanol • •
All major trauma patients should have a hospital ethanol level taken as part of routine ‘major trauma” bloods. Police ethanol levels should be taken on all road crash drivers when: o Requested by police o Patient smells of alcohol o An urgent hospital ethanol is >3mmol/l
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Appendix F - Tertiary Survey What A tertiary survey is a comprehensive review of a major trauma patient which includes the review of the medical record, collation and review of all investigations combined with a complete head-to-toe physical examination. It is used to complete a comprehensive plan of care by identifying and catalogue all injuries after the initial resuscitation and/or operative intervention of a patient. Who It should be carried out within 24-48 hours and once the patient is awake and accessible of the patient’s admission and usually by the registrar of the admitting team although any clinician experienced in the assessment of major trauma may be suitable. The findings are documented on a check sheet then further investigations, communications or treatment are actioned immediately. The tertiary survey is repeated by the same clinician on weaning sedation, recovery of cognitive function or if there is any new sign or symptom suggesting a missed injury.
Why The incidence of missed injuries following primary and secondary surveys is variable but may be as high as 50% depending on how they are defined. Missed injuries can impact on patient morbidity and mortality and may lead to short and long term functional deficits, embarrassment of clinicians and litigation. Formal tertiary surveys have been shown to reduce these rates by about 35%. The remaining injuries are usually picked up within the following 2 weeks. The commonest missed injuries are extremity fractures, and the patients at highest risk of missed injuries are those with severe brain injury, alcohol intoxication or undergoing emergent surgery, all situations which may preclude a meaningful secondary survey.
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Appendix G - Emergency Procedures Includes: • • • • •
FAST DPA Chest drain insertion and removal Emergency Thoracotomy Cricothyroidotomy G.1 FAST (Focused Assessment by Sonography for Trauma)
This is a rapid ultra-sonographic assessment of the abdomen and pericardium done by a trained operator. The FAST scan should take between 1-3 minutes and has the advantage that it is repeatable and non-invasive. Key points about the indications and use of FAST Scanning: • • • • • • • •
FAST is a screening test that has a singular critical function: it determines the presence of free fluid in 3 areas of the abdomen, or the pericardium. Almost always this fluid is blood but beware the ruptured bladder. FAST is only clinically validated as a decision-making tool in unstable patients, to determine whether the patient should go to the operating room or the angiography suite for life-saving intervention. The exception to this rule is the patient with a penetrating truncal injury who has free intraabdominal or pericardial injury but maintains haemodynamic stability. A positive FAST scan must be consistent with the clinical setting of the patient. This means there must be enough fluid on the FAST scan to account for the patient’s instability. A sliver of free fluid is not a positive scan in this situation. The use of FAST is encouraged for all major trauma patients by experienced operators or those in training with an experienced instructor. It does not diagnose intra-abdominal injuries and cannot assess the retro-peritoneum, therefore should never be used to determine the requirement for CT scanning or not. FAST scans on stable patients are for practice and credentialing only and should not slow the progress of the patient to definitive imaging or care. Exams from inexperienced or un-credentialed operators should not be recorded in the notes or used for clinical decision-making (see ACEM and RACS guidelines). G.2 Diagnostic Peritoneal Aspirate (DPA)
• DPA is performed when FAST is equivocal or not available. The indications for its use are the same as for FAST. • Diagnostic peritoneal lavage (DPL) involves placement of an intraperitoneal catheter followed by lavage with 1 litre of warm saline. It is best used when the possibility of hollow viscous injury is suspected on clinical exam or CT.
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Technique for DPA This approach is identical to the incision used for placement of the umbilical Hasson cannula in laparoscopic surgery. • • • • • • • •
Ensure that the patient has a gastric tube and urinary catheter in place. Prep the abdomen with betadine and drape the umbilical region. Inject local anaesthetic with adrenaline in the midline sub-umbilical region (supra-umbilical if pelvic fracture present). Vertically incise the skin and subcutaneous tissue down to the fascia. Insert a small self-retaining retractor to hold the tissues open and stop any bleeding. Incise the fascia and identify the peritoneum. Insert a purse-string suture. Make a small hole in the peritoneum; if frank blood is evident, the test is positive. Close the purse string and take the patient immediately to the operating theatre for laparotomy. G.3 Intercostal Drain Insertion and Removal
Intercostal drains are associated with high rates of complications, largely related to inexperienced operators. Placement requires invasion of a sterile body cavity and therefore demands sterile technique performed with skill and precision. The anatomic approach is best. Safe Zone • • •
Anterior border of Lat Dorsi Lateral Border of Pect Major Nipple line (5th intercostal space in midclavicular line)
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Drains • • • • • •
32 Fr routinely for trauma patients. 28Fr for shorter people. No trocars. Single dose of Intravenous antibiotic (Fluclox or Kefzol) is appropriate. Sterile prep and drape. It is vital to understand the anatomy and visualise the direction of the drain before starting the procedure. Ensure local anaesthesia and be gentle. Consider sedation in consultation with Emergency Physician. Infiltrate 1% lignocaine with adrenaline to skin and into the intercostal spaces. Adrenaline aids haemostasis and prolongs action of LA. Pleura must be infiltrated in all conscious patients. For longer lasting anaesthesia consider adding Marcain 0.25% with adrenaline as well as Lignocaine.
Ideal Technique Three cm incision mid-axillary line in the 5th intercostal space (along the superior edge of 6th rib) identify it exactly and mark prior to incision. Incision • • •
Drain passes obliquely at 45º to the chest wall down a single hole. Consider using a placement guide if available. Sweep pleura down firmly with fingertip until the pleura gives way and you feel the slippery lung moving on your fingertip. Document the whoosh of air. Push the tip of drain into thorax with a fingertip. If it does not slide in smoothly it will be in the wrong place. Tip goes posteriorly and toward the apex, along the line of the rib. This drains the dependant part of the thoracic cavity. This means that the drain exits the chest going anteriorly.
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Secure the Drain • •
Connect immediately to underwater sealed drain at -20mmHg continuous suction. Single stitch to one end of the incision, tied at 10-14cm on drain. This ensures all holes are in the thoracic cavity. NB: crimp the drain at one point – no “Roman sandal ties” that climb up the drain. Drains are soft and are designed to be crimped. No purse string sutures: they are unnecessary and leave unsightly, painful scars.
Cut between two knots nearest to skin to remove drain. This leaves the skin stitch in place.
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Placement Problems • • • •
Any drains placed anteriorly, inferiorly or transversely risk hilar or parenchymal injury and may not drain the thoracic cavity adequately. Use local on skin, intercostal space and through the pleura (it is exquisitely sensitive to stretch). If drain placement is painful, anaesthesia is inadequate. Make one hole only down to pleura using long, straight forceps so you know where the tip is. If you make more than one the drain tip will always go down the wrong one (Law of Murphy). Pierce the pleura with your fingertip.
A practical approach to drain removal Remove when: 1. 2. 3. 4.
<200 mls/day Drain not bubbling Clinically improving Not for further IPPV
Do not clamp drain prior to removal. • • •
CXR within 1 hour after drain removal Be ready to put another one back in the right place immediately if a pneumothorax recurs Warn the patient of signs of recurrence: dyspnoea, sudden chest pain, and have a plan in place G.4 Emergency Thoracotomy
Performed in ED only if: • • • • • •
Agonal patient Penetrating chest trauma Vital signs within 5 minutes of ED Survivable associated injuries Trained staff with specialist consultation OT not immediately available
Remember that lighting, equipment, anaesthesia and experienced surgical assistance will be available in OT. If the patient will survive the trip, go straight to OT. The chances of survival are greatly increased. There is no role for personnel without experience and specific training to do this procedure.
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Emergency Thoracotomy Method • • • • • • • • •
Anterolateral or clamshell incision. Place Finocietto retractor and get lighting targeted. Evacuate clot with hands then pack the apex firmly. Open pericardium anterior to phrenic nerve. Temporary occlusion of cardiac injury (finger, foley, clamp, staples). Open cardiac massage if required. Haemostasis: pack apex, clamp hilum, tie intercostals. Cross-clamp thoracic aorta if sub-thoracic exsanguination. Proceed to definitive procedures in OT: heart, lungs, aorta, chest wall, vascular. G.5 Surgical Cricothyroidotomy (Adults)
Indication is inability to oxygenate by any other means. Consider the use of “front-of-neck’ kits if available. Relative contraindications are tracheal transaction or significant damage to larynx or cricoid. If the distal airway is visible in a penetrating injury, it is likely that it can be intubated directly. Method • • • • • •
Identify the cricothyroid membrane between the thyroid cartilage and the cricoid cartilage. (about 2cm below the “Adam’s apple”). Prep and local anaesthetic if patient awake. 3cm longitudinal skin incision over membrane, then 1cm stab through membrane. Enlarge with tissue forceps or use a specific tracheal dilator. Insert a specific tracheostomy tube or 6.0 endotracheal tube, inflate cuff, ventilate patient and secure tube. G.6 Needle Cricothyroidotomy (Children <12 years old)
Indications as above Method • • • • • • • • •
Use specific jet insufflation kit, or Attach 14 Ga cannula to 5ml syringe filled with saline Identify cricothyroid membrane Prep and local anaesthetic Puncture membrane perpendicular to skin and aspirate air bubbles Tilt needle 45 downward Aspirate air Feed plastic cannula off the insertion needle Intermittent insufflation: 1 second on, 4 seconds off
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G.7 Intraosseous Access Intraosseous (IO) access is a useful means of introducing crystalloids, colloids, medications, and blood products into the systemic circulation. The marrow cavity provides access to a noncollapsible venous plexus as blood flows from the medullary venous sinusoids into the central venous sinus and is then drained into the central venous circulation via nutrient and emissary veins. Indications Initiation of IO access is indicated in adults, children, infants, or new-borns in any clinical situation where vascular access is emergently needed but not immediately available via a peripheral vein. IO access provides a means of administering medications, glucose, and fluids, as well as (potentially) a means of obtaining blood samples. Such a situation would include any resuscitation; cardiopulmonary arrest; shock, regardless of aetiology; life-threatening status epilepticus; or lack of venous access resulting from burns, oedema, or obesity. IO needle placement does not constitute definitive therapy; rather, it allows the administration of life-saving medications and fluids in a context where intravascular access is vital. Often, definitive IV access is easier to obtain once a bolus of fluids and medications has been administered via the IO needle. IO needles may be left in place in the marrow for up to 72-96 hours; the needle is usually removed as soon as another means of vascular access (either peripheral or central) is available, ideally within 6-12 hours. Contraindications Contraindications to IO access include the following: • Ipsilateral fracture of the extremity, because of resulting extravasation and risk of compartment syndrome. • Previous placement or attempted placement in the same leg or site (e.g. sternum), because of consequent extravasation into soft tissue compartments through the previous puncture site. • Osteogenesis imperfecta, because of the likelihood that puncture of the bone may cause a fracture. • Osteoporosis, because of the risk of fracture. • Obvious overlying infection at the proposed puncture site, because of the risk of seeding infection (a relative contraindication). • Prosthetic joint near proposed insertion point. Intraosseous Catheter Placement Technique Potential uses are as follows: This should only be performed by, or in the presence of a skilled clinician. Local anaesthesia is not generally required for the EZIO device; however hand-drill devices should prompt adequate analgesia in awake patients. Potential insertion sites are as follows:
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Proximal tibia The insertion site of choice in children and infants is the proximal tibia; the distal tibia and distal femur are alternatives (see the images below). The proximal tibia provides a flat wide surface and has only a thin layer of overlying tissue, which allows easy identification of landmarks. Additionally, the proximal tibia is distant from the airway and chest, where cardiopulmonary resuscitation (CPR) is often in progress.
Distal Tibia With increasing age, the cortical thickness of long bones, particularly the tibia, increases, making penetration more difficult and forceful; thus, in older children and adults, using the distal tibia or the proximal humerus may be advantageous because it also provides reliable and evident landmarks, has a relatively thin cortex, and is distant from ongoing CPR (see the images below). The anterolateral proximal humerus is another site that may be used in adults.
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Alternate Site: Distal Femur The distal femur (see the image below) may also be used for IO access, but it generally has much denser covering layers of fat, muscle, and soft tissue, which make identification of landmarks and bony penetration more difficult. Paediatrics 3-39kg One finger width proximal to the upper margin of the patella and slightly medial to avoid the patella tendon, best for children under 6 years, may need to use a longer needle on older children.
Adult access
In adults, other insertion sites have included several different iliac sites; the sternum, the distal radius or ulna, and, as mentioned above, the humerus.
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Appendix H - Guidelines for Referral of Adult Patients with Head Injury from South Waikato Rural Hospitals to Waikato Hospital for CT Brain Purpose of guideline To provide a guideline for clinicians working in the South Waikato rural hospitals for the appropriate referral of patients with isolated head injury for CT brain to Waikato Hospital. • This guideline details the indications for CT in patients with Traumatic Brain Injury (TBI) with particular reference to patients with minor TBI who have risk factors for neurologic deterioration. • Patients with moderate to severe brain injuries (GCS <13) or multi-system injuries should be referred directly to the neurosurgical/trauma/ ED team as above , and not merely referred for CT. Management of a brain injured patient which should follow EMST™ principles. Guideline: When to refer a patient for CT brain 1. Immediate Scanning Adult patients should be transferred immediately for CT scanning if any of the following features are present: • • • • • •
Eye opening only to pain or not conversing or not obeying commands (GCS 12/15 or less). Confusion or drowsiness (GCS 13/15 or 14/15) followed by failure to improve within one hour of clinical observation or within two hours of injury (whether or not intoxicated from drugs or alcohol). Focal neurological signs. Base of skull or depressed skull fracture or penetrating injuries. Deteriorating level of consciousness. Full consciousness (GCS 15/15) with no fracture but other features, e.g. a. severe and persistent headache. b. history of coagulopathy or anticoagulants (e.g. Warfarin, Clopidigrel) and any clinical evidence of brain injury.
These patients should be retrieved or transported with appropriate nurse, paramedic or medical escort. Depending on severity of injury they should be referred to ICU/ ED, neurosurgery and /or the Trauma Team at Waikato Hospital (see Major Trauma Transfer Criteria). All patients must have meticulous, regular brain injury observation. 2. Urgent CT Brain (within 8 hours of injury) CT scanning should be performed within eight hours in an adult patient who does not fulfil criteria for immediate scanning but has any of the following features: • • • •
Age>65 with any loss of consciousness or amnesia. Clinical evidence of a skull fracture (e.g. boggy scalp haematoma, open fracture). Any seizure activity. Significant retrograde amnesia (>30 minutes).
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• •
Suspicion of brain injury and dangerous mechanism of injury (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, significant fall from height) or significant assault (e.g. blunt trauma with a weapon) Coagulopathy or recent use of anticoagulant.
The ED consultant on duty must be made aware of these patients. The radiology registrar will contact the ED consultant if any intracranial lesion is seen.
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Appendix Ia – Adult Massive Transfusion Protocol (MTP) N.B. Waikato Version for reference – may soon be replaced by TMT/Midland regional version.
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Appendix Ib – Paediatric Massive Transfusion Protocol (MTP)
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Appendix J - Management of the haemodynamically unstable patient with a pelvic fracture with Angiography available
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Appendix K - Management of the haemodynamically unstable patient with a pelvic fracture without Angiography available
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Appendix L - Extremity Penetrating Algorithm
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Appendix M - Moribund penetrating chest trauma
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Appendix N - Penetrating abdominal wound Penetrating abdominal trauma Low Velocity Injuries (stab wounds) Traditionally the management of penetrating abdominal injury has been mandatory exploration via laparotomy. Studies have shown a complication rate of up to 25% as well as up to 5 day stay with these procedures. 50-75% of stab wounds breach the peritoneum and only 50-75% of these would cause an injury that requires an operative intervention. In the last decade, the approach has become more selective. Several modalities have been utilised to identify those with injuries that require a therapeutic intervention. CT imaging has a 94% sensitivity for hollow viscus injury. Another useful of diagnostic test is laparoscopy. In the past this carried with it a high rate of missed injury; probably related to early limited experience in the technique. Studies demonstrate that diagnostic laparoscopy is safe in the setting of penetrating injury, with a rate of missed injury of 0.4%. However, if there are any concerns about the quality of the laparoscopic examination, there should be a low threshold to convert to a laparotomy. Our approach to low velocity abdominal stab wounds takes into account the evidence available to date, our relatively low rate of penetrating injury and the resource availability, especially the feasibility and cost of frequent clinical serial assessment. This is therefore reflected in the following algorithm: •
Proposed algorithm for management of low velocity penetrating abdominal injury is as follows:
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Low velocity penetrating abdominal injury
Local wound exploration. If
Gunshot or Peritonitis or Evisceration
fascia
Thoracoabdominal1
or
Laparotomy other injuries
abdomen No +ve vascular laparotomy5
Laproscopy
or
Abdomen
abdomen
Breach
Laparotomy
discharge
colonic / major
speciality involved
1 2
operative management
Above coastal margin but below nipple line Exclude mediastinal injury
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Gun Shot Wounds (High Velocity Penetrating Injuries) These abdominal wounds should undergo mandatory exploration with a laparotomy unless there is clear evidence clinically or radiologically that the trajectory of the bullet is tangential and did not enter the abdominal cavity. Back/Flank wounds These wounds should be investigated with a CT scan if the patient is haemodynamically stable. Exploration is selective based on the findings of the CT. • • •
Low risk: Into subcutaneous tissue – patient can be discharged. Intermediate risk: Penetrates into the muscles, retroperitoneal haematoma, not near any critical structures – for observation. High risk: colonic or major renal injury, vascular injury, retroperitoneal gas – laparotomy.
Reference Biffl et al, Management guidelines for penetrating abdominal trauma, World Journal of Surgery (2015) 39: 1373-1380 Como et al, Practice Management guidelines for Selective non-operative management of penetrating abdominal trauma, Journal of Trauma 63 (3) March 2010 Uraneus et al, Laparoscopy in penetrating abdominal trauma, World Journal of Surgery (2015) 39: 1381-1388
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Appendix O - Suspected thoracic injury
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Appendix P - Suspected spinal cord injury
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Appendix Q – Cervical spine evaluation
Suspicion of Cervical Spine Injury
Altered LOC at time of Assessment Painful Distracting Injury * Midline Tenderness Dangerous Mechanism * Paresthesias in extremities >65 years Focal Neuro Deficits *
Yes
Phili Collar (within one hour) No
CT C-Spine CT brain required No
Currently able to cooperate with exam and intervention
Yes
Yes
Yes
Body habitus or other injuries preclude imaging with plain films No
No
Yes
Age >55 Remain in Phili Collar Delay evaluation until assessable
No
Decreased ROM No Yes
No
Plain films 3 view series Delayed flex/ext views # clinic in 10-14 days Dx in Phili Collar
Adequate Plain films (must visualise C7/T1) Yes
Yes
Midline tenderness or focal neuro deficits or decrease ROM No further intervention – Remove collar
No
Radiologic abnormality
No
* Definitions: 1. Distracting injuries: including but not limited to long bone fracture, visceral injury requiring surgical consultation, large laceration, degloving injury, crush injury, large burns, or any injury causing acute functional impairment. 2. Dangerous Mechanism: fall from >1m or 5 stairs, an axial load to head, high speed RTC (>100 kph), unprotected motorcycle collision >30 kph, vehicle rollover or ejection, recreational vehicle crash, bicycle collision. 3. Midline Tenderness: tenderness to palpation in an 2cm band from occiput to T1. 4 Decreased ROM: neck rotation past 45◦ causes pain.
Remain in Phili Collar, Ortho Consultation
5. Focal Neuro Deficit: any focal neurologic abnormality or motor or sensory examination.
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Appendix R - Suspected Urethral Injury
prostate No
Attempt IDC
Inform Urology
least 16Fr IDC with caution
No
imaging as appropriate
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Appendix S - Chest Wall Injury Guideline 1. •
•
Introduction Rib fractures are among the most traumatic injury found in 10%-20% of all those who are hospitalised for thoracic trauma. Other associated injuries include lung contusion, haemothroax, pneumothorax and blunt cardiac injury. Rib fractures are associated with significant morbidity with patients requiring admission to ICU and with mortality rates as high as 33%. Development of a pathway that integrates different modalities of care would benefit patients with blunt chest injury focusing on the following components: o Analgesia o Respiratory intervention o Surgical fixation This document excludes penetrating, cardiac, and aortic injury.
2. • • • • • • •
Who should be admitted to hospital? Frail Age >60 Multiple rib fractures (3 or more) Symptomatic injury (respiratory distress or pain) Respiratory co-morbidity Flail chest injury Multi-system injury
• • •
If appropriate for discharged then ensure: • Nurse led education/rib fracture brochure • Adequate analgesia 3.
Where the patient should be admitted?
ICU • Requiring invasive ventilation • Other injuries require ICU care HDU • Non-invasive ventilation • High oxygen requirement • Other injuries require HDU care WARD (trauma, cardiothoracic, or other specialty ward determined by the more significant system injury if the chest injury is deemed mild). Those not included in the above criteria.
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Management
Physiotherapy • Mobilisation and chest physiotherapy Nurse education • Deep breathing and coughing exercises • Education about rib fracture prognosis Analgesia (multi-modal) ladder Step 1 • Paracetamol • Oral short active morphine • Add NSAIDS were tolerated – significant reduction in pneumonia Step 2 • PCA • Gabapentin/Pregabalin • Infusion analgesia Step 3 • Regional anaesthesia o Serratus anterior catheter o Paravertebral block o Thoracic Epidural Intervention Intercostal drain (refer to trauma protocol) • Symptomatic haemothorax/pneumothorax • Moderate-large haemothorax/pneumothorax • Small pneumothorax in presence of positive pressure ventilation (NOT for occult pneumothorax – these are for expectant management) Consideration of Rib ORIF (Open reduction internal fixation) Recommend: • 5 or more rib flail requiring mechanical ventilation • Symptomatic non-union • Severe displacement found during thoracotomy (done for other reasons) Consider: • 3 or more rib flail not requiring mechanical ventilation • 3 or more rib fractures with severe displacement (bi-cortical displacement) • 3 or more rib fracture with mild-moderate displacement with 50% reduction in FVC despite optimal pain control
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Thoracotomy/VATS (video assisted thoracic surgery) • Significant haemothorax (massive haemothorax [1.5L] or persistent bleeding [200mls/hour for 2 hours]) • Persistent haemothorax despite intercostal drain • Septic complication (empyema or collection)
Cardiothoracic referral • Meeting criteria for rib ORIF • Open thoracic injury • Significant or persistent air leak from ICC • Non-resolving haemothorax • If any other concerns
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Appendix T - Pregnant trauma patient
Pregnant trauma patient Notify obstetrician Primary survey
Yes
No
CPR and normal left uterine displacement
Maternal cardiac arrest
Yes Haemodynamic instability
Return if circulation in 5 mins No
Yes
Foetus > 24 weeks FAST +ve No
Yes
No
Unstable pelvic fracture
Resuscitate and CT scan Yes
C-section
No Resuscitate
Yes
Angioembolisation and Csection (viable pregnancy*) Trauma laparotomy and Csection (viable pregnancy*)
Intervention determined by injury +/- C-section (viable pregnancy*)
Yes Fetal distress No Secondary survey and imaging as appropriate
* Viable pregnancy > 24 weeks
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