A Penetrating Injury

1. A Penetrating Injury ED Thoracotomy Dr Laura Attwood EM Consultant, RVI

2. Aim • Statistics • Case review • Discuss Pre-Hospital elements • Code Red • Roles within the Resus • Development of a Traumatic Cardiac Arrest Protocol

3. Statistics • TARN data • 3rd most common cause of trauma in North East • 1st RTC • 2nd Fall • Increasingly more common according to TARN • Often Interpersonal violence related

4. Statistics • Home Office • In 2009-10 • North East rate for violent crime = 3rd highest in all regions of England & Wales at 560 incidents per 1000 persons • 1st = London, 2nd = East Midlands • In 2012/13 • 5th highest • 725 offences

5. Statistics • Daily Mail!

6. Case Review

7. Background • RVI Emergency Department • ~ 2100 hours • x 1 Consultant • X 1 Reg • x 5 SHO’s • x 2 nurses in Resus.

8. Pre Hosp Info • Young male • Stab wound to the back • ETA 5 mins • Respiratory arrest but now breathing

9. Team preparation • Trauma Team call • ED Staff • Cardiothoracic surgeon contacted and set off for hospital • Orange on call contacted ICU consultant • Thoracotomy kit moved next to bed • Team briefed on potential for Thoracotomy

10. Handover • 30 mins on scene • Difficult to access due to Police present and perpretator still on scene • Respiratory arrest in ambulance • Unable to get IV access

11. On arrival • No external Catastrophic Haemorrhage • A: Intubate/Ventilate • Establish etCO2 • Monitoring attached • ECG = asystole • Sats = not recordable • Pulse check = no carotid/radial

12. On arrival • X1 posterior chest stab wound • = Thoracotomy Initiated

13. Thoracotomy Kit VS

14. Landmarks

15. View inside

16. What next • No wounds in the heart • No wounds in the lung • Aortic compression • With internal cardiac compressions

17. Moving on • Unable to obtain large IV access • IO line establish in tibia • Blood pushed through with 20ml syringe • Consultant General Surgeon arrives and extends the damage control trauma surgery to Laparotomy.

18. Laparotomy • Evidence of splenic disruption • ?gone through descending abdominal aorta also • Abdomen packed to control haemorrhage • Unable to regain output from patient • Decision taken as a team to stop resuscitation and patient pronounced dead.

19. Post Mortem • Verbal Report • Concludes above findings • Grade IV Splenic laceration • Wound through descending abdominal aorta

20. Discussion Points • Pre Hospital – stay and play vs scoop and run • Code Red call • Venous Access • How to get the MHP into the patient • Staffing • Development of a Traumatic Cardiac Arrest Protocol

21. Pre Hospital • Paramedics involved • Training and Education issues • Do the land paramedic crews understand what we want to do to the patients when they arrive and why it is so time critical? • ? Scoop and Play

22. Code red call • Who is alerted: • Blood transfusion for MHP to be activated • Porters to collect MHP form lab • Trauma Theatre • Trauma Team Personnel • Would this have helped? • ?More staffing – possible resource from ODP/Theatre Staff

23. Lines • Trauma Subclavian Line/Peripheral Access = ideal • If we can’t…. • Just lean towards IO’s • x2 yellow IO’s in humeral heads with Level1 attached • Significant success in Military Operations

24. MHP • Use of Belmont and Level 1 infusers • Can use with IO’s • Ensure the blood is also warmed

25. Ideal Staffing

26. Ideal Staffing

27. Level 1 = 1.5 nurses Belmont = 1.5 nurses ODP Nurse 1: Monitoring/Trauma Kit Nurse 2: Drug nurse TTL Anaesthetist B Doc C Doc General Surgeon Orthopaedic Surgeon Ideal staffing

28. Traumatic Cardiac Arrest Protocol

29. Summary • Trauma case that we may see more and more off • Lets be prepared • Plan what resources we need • Implement some simple changes • In hospital AND pre hospital