NewShockTraumaProtocol&TraumaCallCriteria

ByDrDSGillConsultant,EmergencyMedicine,MorristonHospital

InterimNa=onalCo-DirectorEMRTSCymru

DISCLAIMER:Changestoyourprac=cethatfollowapplyto...

“MAJORTRAUMAPATIENTSWITHSIGNIFICANT

MECHANISMSOFINJURY&MULTISYSTEMINVOLVEMENT”

Ra=onaleforchange...

Preventdevelopmentoflethaltriad:AcidosisHypothermia

CoagulopathyMortalityof47.8%LiXlechangeinmortalityofthisgroupEMJ2012;29:622-625

Howarewegoingtoachievethis?DamageControlResuscita<on(DCR)“TheTherapeu<cTriad”- Immediatetemporarycontrolofexternalhaemorrhage- Clotstabilisa=onbyhaemosta=cresuscita=on- Iden=fy&controlallsignificantsourcesofbleeding

DamageControlResuscita=onaimsto...STOPbleedingPREVENTfurtherbleeding

PREVENTdeathfrombleeding

What’sdifferentfrommyusualATLSprac=ce?

SIXTHINGSTOCHANGE!

CatastrophichaemorrhagecontrolcomesfirstAirway,secureitearly!Breathing,chestdecompressionwiththoracostomy&chestdrainCircula=on,haemosta=cresuscita=onusingwarmbloodproductsNOTcrystalloid!DisabilitysameasusualExposure,keeppa=entwarm,minimalhandling&movement

HAEMOSTATICRESUSCITATIONDON’TFILLTHEBATHBEFOREPLUGGINGTHEHOLE!

IfSystolicBP>90–NOFLUIDS

IfSystolicBP<90–GIVEBLOOD&FFP1:1(AIMforSBP90)

(PRESENCEORABSENCEOFRADIALPULSE)

Defini=vehaemorrhagecontrol(SURGERY)

Thenrefill

Revisedshocktraumaprotocol...Star=ngAugust

Immediatemeasuresfortemporarycontrolofobviousbleeding

DirectCompressionTourniquetImprovisedpelvicbinder

FASTScanCT

CXR:?decompression

APPelvicXR

Iden<fysourceofconcealedbleeding

TranexamicAcid1gstatRepeatforevery10unitsofbloodproductsIni<ateMassiveTransfusionpolicyAdministerallfluidsinrapid250mlaliquots,withaclearobjec=veinmind:-Ifthepa<enthasbeenorisnowhypotensive:-MaintainSBPat90mmHgun=lbleedingiscontrolled.Ifthepa<entistachycardicbutnormotensive:-Onlyrestorenormalhaemodynamicswhenon-goingbleedinghasceased/beencontrolled.Ini=atemassivetransfusionpolicy.AimtomaintainBPatconstantlevelun=ldefini=vecontrolofbleedingisachieved

Recognisesignificantbleedingintraumapa<ent:THERAPEUTICTRIAD

Immediatemeasuresfortemporarycontrolofobviousbleeding

Beginfluidresuscita<on&Clotstabilisa<on

DirectCompressionTourniquetImprovisedpelvicbinder

FASTScanCT

CXR:?decompression

TranexamicAcid1gstatRepeatforevery10unitsofbloodproductsAdministerallfluidsinrapid250mlalliquots,withaclearobjec=veinmind:-Ifthepa<enthasbeenorisnowhypotensive:-Ini=ateMassiveTransfusionpolicyBUTaimtomaintainSBPat90mmHgun=lbleedingiscontrolled.Ifthepa<entistachycardicbutnormotensive:-Onlyrestorenormalhaemodynamicswhenon-goingbleedinghasceased/beencontrolled.Ini=atemassivetransfusionpolicy.AimtomaintainBPatconstantlevelun=ldefini=vecontrolofbleedingisachieved

APPelvicXR

ITUviaCTifnotalreadyperformed

Iden<fysourceofconcealedbleeding

Theatre:Defini<vecontrolofbleedingDecompressionofextremitycompartmentsyndrome

Restorehaemodynamicnormality

Traumacallcriteria...

DISPLAYEDINRESUSONEANYONEcanac=vateatraumacallatANY=meIfindoubtspeaktoseniorEDdoctororshiqcoordinatorANDPUTCALLOUTLettraumateamleaderknowifac<vated!

PHYSIOLOGICAL • AIRWAY COMPROMISE • SIGNS OF LIFE THREATENING CHEST INJURY • SpO2 < 90%

• PULSE >120/MIN OR SYSTOLIC BLOOD PRESSURE <90mm Hg. IN ADULTS • A CHILD WITH ANY SIGNS OF RESPIRATORY DISTRESS, SHOCK OR ALTERED LEVEL OF CONSCIOUSNESS

AND/OR

HISTORICAL • AN INCIDENT INVOLVING A FATALITY • HIGH SPEED MOTOR VEHICLE CRASH • FALL FROM A SIGNIFICANT HEIGHT • WHERE THE PATIENT HAS BEEN EJECTED FROM A VEHICLE

• UNCONSCIOUSNESS >FIVE MINUTES • KNIFE WOUND ABOVE THE WAIST • ANY GUNSHOT WOUND • A CHILD PEDESTRIAN OR CYCLIST HIT BY A VEHICLE • AN INCIDENT WITH FIVE OR MORE CASUALTIES

Clinicalgovernanceframework...

RevisedSHOCKtraumaprotocol(Damagecontrolresuscita<on)

Traumadocument(toimprovedatacapture&actasanaidememoire)

Debrief&datacapture:- Traumateam‘hot’debrief- ‘Hot’debriefforms- MDTmee=ngs- TARNdatacollec=on

Newequipment:CommercialpelvicbindersTourniquetsScoopstretcherHighvolumetraumalinesTraumadrugpacksTransfusiondevices(Someofwhichwillbekeptinadedicatedtraumatrolley)

Training:- TREATS- Traumaanaesthesiacourse- Regularmocktraumacalls

EvidencebasedSOPSon:-Roles&responsibili=es- Massivehaemorrhagepolicy(ABMUwide)- Tranexamicacid- Traumaairwaymanagement&proceduralseda=on- Chest,abdominal&pelvictrauma- Openfracturepolicy- Externalhaemorrhagecontrol- Vascularaccess- Trauma=ccardiacarrest- Headinjury- Burns- Handling&packaging(discussedatcombinedtraumacommiXeemee=ngs)