Major Trauma A standard approach

1. Major TraumaA standard approach Ballarat Health Services Emergency Medicine Training Hub

2. Learning objectives To be familiar with BHS protocols for trauma including trauma teams Management of suspected cervical spine injuries To understand the Victorian State Trauma System and the role of Ballarat Health Services in that system. Pre reading Hughes T & Cruickshank J. Adult Emergency Medicine at a Glance. Chichester, West Sussex, UK : John Wiley & Sons, 2011. Chapter 8 Trauma; primary survey. Chapter 9 Trauma; secondary survey. Chapter 10 Major head and neck injury. Chapter 11 Minor head & neck injury Ballarat Grampians Emergency Medicine Training Hub

3. Other learning resources http://www.health.vic.gov.au/trauma/links.htm http://www.health.vic.gov.au/trauma/triage.htm Relevant guidelines for Ballarat Health Services Trauma – General Approach BHS Intranet Linkhttp://webapps/airapps/Services/au/org/bhs/govdoc/HTMLViewer.php?id=-31766~intranet-search Trauma Team Activation BHS Intranet Linkhttp://webapps/airapps/Services/au/org/bhs/govdoc/HTMLViewer.php?id=-32235~intranet-search Cervical spine BHS Intranet Linkhttp://webapps/airapps/Services/au/org/bhs/govdoc/HTMLViewer.php?id=-32499~intranet-search All available viahttp://bhsnet/gov-doc-search Ballarat Grampians Emergency Medicine Training Hub

4. Introduction Trauma leading cause death 1-40yo Peak age 15-30 Cost in A$ 11 billion Up to 40% trauma deaths preventable Improvements largely due to social education Seat belts Speed limits Drink driving Helmets For each death estimated to be 10 serious non-fatal injuries Ballarat Grampians Emergency Medicine Training Hub

5. Essence of Trauma Care Right patient to the right resources as soon as possible Achieved by: • Integrated system - ‘Trauma Network’ • Seniority or experience of providers • Decision Pathways and education Ballarat Grampians Emergency Medicine Training Hub

6. Trauma Network Ministerial Taskforce on Trauma and Emergency Services - 1997 Victoria State Trauma Network – 1998 ROTES report (Trauma deficiencies) – 1999 Ongoing governance Ballarat Grampians Emergency Medicine Training Hub

7. Introduction Medical management has shown far less improvement Standardisation of approach has helped improve outcomes Concept of “Golden Hour” 50% deaths <1/24 due to major vessel, CNS, spinal injury benefit from prevention 30% deaths patients major truncal injuries causing respiratory & circulatory compromise benefit from prevention and timely intervention 20% die from sepsis, organ failure etc. benefit from prevention, timely intervention and possibly from integrated approach to recovery Ballarat Grampians Emergency Medicine Training Hub

8. Phases of care Pre-hospital Triage Primary survey Secondary survey Disposition Ballarat Grampians Emergency Medicine Training Hub

9. Prehospital Very little evidence to support major interventions in the field Oxygenation Immobilisation cervical spine Ventilation (unproven) Fluids (unproven) Lights and sirens (increases mortality and community risk) Ballarat Grampians Emergency Medicine Training Hub

10. Triage to trauma centre Associations with increased risk of death?? Demographics Age <5 >55 Know chronic cardiac/respiratory disease Vital signs BP <90 RR <10 >29 GCS < 13 Trauma score >14 Ballarat Grampians Emergency Medicine Training Hub

11. Triage to trauma centre Injuries Penetrating injury to chest, abdomen, head, neck or groin Significant injuries to two or more body regions Severe injury to head, neck or trunk Two or more proximal long bone fractures Burns >15% (?10%) or involving face or airway Ballarat Grampians Emergency Medicine Training Hub

12. Triage to trauma centre Mechanism (No longer used as part of trauma call decision) High speed >60 kph* Fall > 6m* >50 cm intrusion Ejection from vehicle* Death of other occupant Rollover* Pedestrian* Ballarat Grampians Emergency Medicine Training Hub

13. Trauma reception Prior warning Prepare Staff Area Paramedical services Ballarat Grampians Emergency Medicine Training Hub

14. Trauma teams Ballarat Grampians Emergency Medicine Training Hub Team leader • Overview • Resus • Assessment • Communication • Internal & external Airway team • Assess and secure airway • Control cervical spine • Ventilation • NGT Procedure team • IV access & bloods • IDC • ICC Scribe Scout Radiographers

15. Handover Patient should transferred to trauma trolley prior to hand over Parallel processing Airway and procedure teams commence assessment (?team – silent handovers) leader (?team – silent handovers) receives handover Assume the worst & protect against unforeseen injuries do not focus on obvious injuries – protocol of ATLS Ballarat Grampians Emergency Medicine Training Hub

16. Primary survey Airway & cervical spine Assess & secure airway Patency Look, listen, feel Jaw trust (no chin lift as cervical spine uncleared) Oropharyngeal airway, nasopharyngeal airway? RSI Maintain cervical protection until spine cleared In-line immobilization Consider NGT Ballarat Grampians Emergency Medicine Training Hub

17. Primary survey Ventilation/Breathing Oxygen is the most important drug in the trauma room Ensure adequate ventilation Assess adequacy Exclude pneumothorax, haemothorax Bag/mask, ETT if required to maintain ventilation Aim for normocarbia CXR Intervention may precede investigation if required Ballarat Grampians Emergency Medicine Training Hub

18. Primary survey Circulation Assess adequacy & effect of blood loss Conscious state Pallor Capillary return BP HR visual estimation of blood loss unreliable FAST scan – ‘rule in’ test Ballarat Grampians Emergency Medicine Training Hub

19. Primary survey Circulation • Control haemorrhage • pressure dressings • Tourniquets • Haemostatic dressings • Splinting • Thoracotomy (Cardiac manoeuvres/Aortic compression) • Theatre Ballarat Grampians Emergency Medicine Training Hub

20. Primary survey Haemorrhage classification Class Loss BP HR RR CR UFR CS Class I <15% N N/+ N N/+ N N Class 2 <30% N + + + anx Class 3 <40% ++ ++ ++ leth Class 4 >40% +/- +/- ++ coma Ballarat Grampians Emergency Medicine Training Hub

21. Primary survey Circulation Access 2x >16G peripheral IV’s Fluids initially crystalloid 20mlkg (repeat if required) warmed Crystalloid vs colloid (no proven benefit) Blood O negative Class III/IV haemorrhage Continuing need for crystalloid Consider need for clotting factors and plateletes ‘1:1:1’ Hypotensive resuscitation Ballarat Grampians Emergency Medicine Training Hub

22. Primary survey Disability Level of consciousness AVPU ALERT VOICE PAIN UNCONSCIOUS GCS – E4M6V5 Pupil response Don’t ever forget the glucose Ballarat Grampians Emergency Medicine Training Hub

23. Primary survey Exposure Remove Clothes Jewellery Avoid hypothermia Ballarat Grampians Emergency Medicine Training Hub

24. Primary survey Monitoring ECG, BP, SaO2, GCS +/- ventilator obs Analgesia Radiology CXR, Cx spine, AP pelvis IDC traditionally part of 1° survey but usually done later Ballarat Grampians Emergency Medicine Training Hub

25. Secondary survey AMPLE history Allergy Medications Past history Last food Event Ballarat Grampians Emergency Medicine Training Hub

26. Secondary survey Head to toe examination – ‘all over and all holes’ Look, feel, move, listen Log roll PR examination Consider Tetanus toxoid Antibiotic prophylaxis Ballarat Grampians Emergency Medicine Training Hub

27. Review Constantly reassess and review Any change repeat 1° survey After any corrective procedure repeat 1° survey Ballarat Grampians Emergency Medicine Training Hub

28. Disposition Parallel thinking from before patients arrival Direct to appropriate services Definitive care made aware of patient Discharge with appropriate support Ballarat Grampians Emergency Medicine Training Hub

29. Questions? Ballarat Grampians Emergency Medicine Training Hub

30. Summary • You are all part of a trauma network • Education saves lives • Reassess, reassess, and reassess again (and intervene if required of course . . .) Ballarat Grampians Emergency Medicine Training Hub

31. Thankyou Ballarat Grampians Emergency Medicine Training Hub