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SEVERN TRAUMA ADULT GUIDELINE Manual
SEVERN MAJOR TRAUMA NETWORK
STAG Edition 1
SevernTraumaAdultGuidelineManual
Version:July2018ReviewDate:July2020
ProjectLead&LeadEditor:JimBlackburnEditors:RowenaJohnson,RichardTurck
GuidelineFormaon:RowenaJohnson
ApprovedBy:SevernMajorTraumaNetworkClinicalLeadDistribu>on:SevernMajorTraumaNetwork,TraumaTeamLeaders,TraumaTeam
�ii
STAGProjectLeads
DrBenjaminWalton-SouthmeadMajorTraumaCentreClinicalLeadMsSarahLapham-MajorTraumaCentreAdministrator
DrJamesBlackburn-ProjectLeadforSTAG,LeadreviewerandeditorDrRowenaJohnson-Editor,reviewer,documentproducMonandformaNng
DrRichardTurck-Editorandguidelinereviewer
GuidelineAuthorsandContributors
MsKayleeAllanDrJulesBlackhamDrChris>neBlaneDrAdamBrownDrAnthonyCareyMrTimChesserMsDebbieCleary
MrAlistairRMCobbDrGrahamCollinDrNeilCollin
DrKateCrewsdonMsLauraCrowleDrAmitGoswamiDrScoNGrierMrLukeHarriesMsHelenHarvey
DrKatyHillDrTimothyHooperDrNicholasHowesMrMikeKellyMrUmrazKhan
DrKatherineLivingstonProfessorDavidLockeyMrAnthonyMacquillan
MsJoannaMaggsDrPatrickMorganMrStephenMorrisMrWilliamNearyDrStevenNovakDrSimonOdum
DrAdrianPollen>neDrNicholasPrestonMissAnnePullyblankMrAndrewRiddickMrDavidSandemanMrDavidSandersMsVictoriaStanleyDrIanThomas
MissKatherineWarrenMrCrispinWigfieldDrTimWrefordBushDrNiroshaDeZoysa
Acknowledgements
ThankyoutoProfessorDavidLockey,ClinicalDirector,SevernMajorTraumaNetwork, forhisenthusiasm
and support for the project. AddiMonal thanks toMs Victoria Le Grys, NetworkManager, SevernMajor
Trauma Network, for coordinaMon and support of the teams involved in producing the guidelines and
manual.
�iii
WelcometoSTAGEdi>on1
Our trauma network has now been in operaMon for six years. It has been graMfying to see the
enthusiasmandhardworkofallof those involved inthecareoftraumapaMentstranslated into
improvementsincarethroughoutthepaMentpathway,welldocumentedbyregularTARNquality
data.
Manyoftheimprovementshavebeenrelatedtosystemdevelopmentratherthanmajorchanges
intheclinicalmanagementofpaMents. StandardoperaMngproceduresandguidelinesareakey
part of standardising pracMce, educaMng juniors and those new to our system and preparing
trauma staff for less common scenarios. Many are based on naMonal guidelines and describe
commonpracMceinmostUKtraumanetworks–othersareinfluencedbyourregionalgeography
andthelocaMonofourspecialityservices.
TheyareanessenMalcomponentofnetworkdocumentaMonbuttheyalsotakeawhiletostabilise
andembedthemselvesinourpracMce.Theauthorsoftheseguidelineshavedoneanexcellentjob
of collecMng, revising and presenMng the core operaMng material on which our major trauma
centre and trauma units depend. These guidelines and their successorswill posiMvely influence
trauma pracMce and ensure that our trauma paMents have the best chance of an improved
outcomea\erenteringanypartofourtraumanetwork.
ProfessorDavidLockey
ClinicalDirector,SevernMajorTraumaNetwork.
�iv
�Contents
Pa>entPre-alert Page2
MTCAutomaMcAcceptancePolicy Page3
PrehospitalBloodTransfusion Page6
ATMISTHandover Page8
Inter-hospitalTransferofAdultMajorTraumaPaMents Page10
MajorTraumaTriageTool AppendixA
MajorTraumaPhoneCalls AppendixB
Opera>onalGuidelines Page16
TraumaTeamRoles Page17
UnknownPaMentRegistraMon Page35
ED&ICUMajorTraumaDrugBags Page36
TranexamicAcid Page41
HEMSDirecttoCTPathway Page43
Death&BreakingBadNewsintheEDFollowingMajorTrauma Page45
Resus1Layout AppendixC
TraumaTeamMemberReferenceCards AppendixD
Inter-hospitalTransferFlowchart AppendixE
DetailsRequiredfor999CalltoSWAST AppendixF
Airway&Anaesthesia Page50
EmergencyAnaesthesiaforMajorTrauma Page51
EmergencySurgicalAirway Page60
Oral&Maxillo-FacialInjuries Page62
RSIChecklist AppendixG
DifficultAirwayAlgorithms AppendixH
ThoracicTrauma Page68
ManagementofChestInjuriesinMajorTrauma Page69
TraumaMcCardiacArrest AppendixI
ChestDrainSafetyChecklist AppendixJ
MajorHaemorrhage,Cardiac&VascularTrauma Page100
MajorHaemorrhage Page101
CardiacInjuries,includingresuscitaMvethoracotomy Page115
TraumaMcVascularInjuryManagement Page123
MajorHaemorrhageProtocol AppendixK
Intra-operaMveCellSalvage AppendixL
Idarucizumabreversalfordabigatran AppendixM
MajorHaemorrhageAuditForms AppendixN
�v
Abdomen&Pelvis Page132
AssessmentandManagementofMajorAbdominalTrauma Page133
PelvicandAcetabularFracturesManagementandReferral Page148
DamageControlSurgeryProtocol AppendixO
AbdominalTraumaDecisionAlgorithm AppendixP
AASTOrganInjuryGrades AppendixQ
RetrogradeUrethrogramandCatheterCystogram AppendixR
PelvicandAcetabularFractureReferralForm AppendixS
PelvicFractureChecklist AppendixT
Extremi>es Page158
CompartmentSyndrome Page159
ManagementofOpenFracturesforAdults Page163
ReferralGuidelinestoSpecialistPeripheralNerveInjuryUnit Page168
Head&Spine Page172
ManagementofSevereTraumaMcBrainInjury Page173
CareofHeadInjuryPaMents Page180
SpinalCordInjuryCarePathway Page185
SpinalCordInjuryAlgorithm AppendixU
ASIAClassificaMon AppendixV
SpinalCordInjuryCarePathway AppendixW
ReferraltoSpinalCordInjuryCentre AppendixX
TransfertoSpinalCordInjuryCentreChecklist AppendixY
Imaging Page196
ImaginginMajorTrauma Page197
RadiologicalPrimarySurveyChecklist AppendixZ
WholeBodyCTProtocols AppendixAA
Rehabilita>on Page206
DirectoryofRehabilitaMonServices Page207
TerMarySurvey Page209
SpecialistDieteMcManagementandNutriMonalSupport Page211
AmputeeReferralPathway Page213
ReferralGuidelinestoRehabilitaMonServices Page215
TerMarySurveyProforma AppendixBB
Appendices Page230
ContactNumbers Page297
IndexofGuidelines Page299
�vi
PATIENTPRE-ALERT
�2
� MajorTraumaCentreAutoma>cAcceptancePolicy
1. ThispolicywillrelatetopaMentsfromTraumaUnitsandLocalEmergencyHospitalswithin
TheSevernMajorTraumaNetworkareafollowingmajortrauma
2. The SevernMajor Trauma Network must accept all severely injured paMents in a Mmely
manner.
3. Thispolicyappliessevendaysaweek
4. Capacityconstraintscannotbeusedoverclinicalprioritytoturn-downordelaypaMents
5. The final responsibility for the implementaMon of this policy lies with the on-call Major
TraumaConsultant(TraumaTeamLeader)
6. TransferofthepaMentistobeorganisedbythereferringhospital.
�
Following the introducMon of Regional Major Trauma Networks, Major Trauma Centres are
requiredtohaveautomaMcacceptanceofpaMentsrequiringtreatmentformajortraumainjuries.
ThepurposeofthispolicyistoprovidedirecMonandguidanceforacMonsfromkeyindividualsand
organisaMonswithinTheSevernMajorTraumaNetworktoreducethechallengeandimprovethe
paMentpathwayandqualityofcare.Todothisitwill:
• Ensure the automaMc acceptanceof traumapaMentswithin the Severn Trauma Network
fromTraumaUnitstotheMajorTraumaCentre
• Ensure that all relevant parMes are aware of their specific roles and responsibility, and
preventtheacceptanceandtransferofpaMentsbeingdelayed
• DescribetheprocedurewherecapacitytoacceptseverelyinjuredpaMentsisexceeded.
MajorTraumaCentreAutoma>cAcceptancePolicy
Introduc>onandPurposeofthePolicy
�3
�
This policywill relate to paMents from TraumaUnits and Local Emergency Hospitalswithin The
SevernMajorTraumaNetworkareafollowingmajortrauma.ThispolicyappliestoreferringTrustshospitals,AmbulanceTrustsandlocalairambulances.Itisthe
responsibilityofNorthBristolNHSTruststafftoensurethatthatthispolicyisfollowedfromfirst
contactbyanoutsideagency.ThepolicywillbeimplementedbypersonnelinA&E,IntensiveCare,HighDependencyUnitsand
GeneralWards.
Thefinal responsibility for the implementaMonof this policy lieswith theon callMajor Trauma
Consultant(TraumaTeamLeader)whoacceptsthepaMent.Departurefromthepolicywouldhave
tobejusMfiedtotheExecuMveOncallwithclearandcompellingreasons.Anydeparturefromthe
policy must be documented in the paMent notes or failing that, in a leqer to the Director of
OperaMons.
�
Thispolicyapplies7daysaweek.
AllrelevantclinicalinformaMonistobegiventothereceivingTrust.
ThetransferofthepaMentistobeorganisedbythereferringhospital,providingnecessaryescort
arrangements, together with all necessary documentaMon including the Severn Major Trauma
NetworktraumapaMentrecord.
ThispolicyshouldbereadinconjuncMonwith:
• TheSevernTraumaNetworkrepatriaMonpolicy
• SWASFTMajorTraumaTriageTool
Applica>on:ToWhomThisPolicyApplies
Principles
�4
PATIENT
PRE-ALERT
�
Inthecaseofanemergencytransferthereferringhospitalmustcontacttheon-dutyMajorTraumaConsultant(TraumaTeamLeader)withdetailsofthepaMent.
Thereferringhospitalmustalso informtheAmbulanceServiceCoordinaMondeskofthetransfer
anddetailsofthepaMent.
ThetransferproceduremustbecarriedoutatTraumaTeamLeaderlevel.
FullpaMentdetailsincludingnameofreferringTraumaTeamLeadertoberecordedinthetrauma
booklet.
The Severn Major Trauma Network paMent trauma record follows the paMent to the receiving
hospital.
On arrival, the paMent must be taken to the resuscitaMon room and trauma call procedures
iniMated.
�
The SevernMajor Trauma Centre has a duty of care to the populaMon covered by The Severn
MajorTraumaNetworkandmustacceptallseverelyinjuredpaMentsinaMmelymanner.Timelyis
definedasaccordingtotheurgencyoftransferasdefinedbytheTraumaTeamLeaderonly.
TheNBTMajorTraumaconsultantoncallhas responsibility fordecisions regardingcapacityand
the ability to accept paMents from the Severn Major Trauma Network and from outside the
network.
Wherethereareproblemswithcapacity inspecificareasofNBT(suchascriMcalcare) toaccept
paMents from the Severn Major Trauma Network, it is the responsibility of the affected unit/
departmentto informtheMajorTraumaConsultant inaMmelymannerandtoworktogetherto
resolvethesituaMonexpediently.Capacityconstraintscannotbeusedoverclinicalprioritytoturn-
downordelaypaMents.
If a request forpaMent transferoriginates fromaTraumaUnitwithinThe SevernMajor Trauma
Network,itistheresponsibilityoftheNBTMajorTraumaConsultanttoensurethat,ifimmediate
major trauma centre care is not clinically required, then an alternaMve bed can be sourced in
anotherMajorTraumaCentre(inconjuncMonwiththeAmbulanceServiceCoordinaMoncentre).
The decision ofwhether a paMent requires immediatemajor trauma centre care and therefore
mustbeacceptedismadebytheTraumaTeamLeader.
IfnootherMajorTraumaCentrewithinareasonabletravelMmecanacceptthepaMentinaMmely
mannertheNorthBristolNHSTrustmustacceptthepaMent.
Automa>cAcceptanceProcessForEmergencyTransfers
Capacity&OverflowManagement
�5
�
Pre-HospitalBloodTransfusion1. SeveralprehospitalteamsrouMnelycarrypackedredbloodcellsand/orfreshfrozenplasma
orlyoplas.
2. Themajorityofpa>ents receivingprehospitalblood transfusionwillneed furtherbloodandbloodproductsonarrivalintheEmergencyDepartment.
3. All paMents who have received prehospital blood transfusion will arrive wearing specific
wrist bands for traceability. The paMent idenMfier should be used for all pathology and
imagingrequests.
4. Theprehospitalteamshouldprovideapre-transfusionbloodsample;thiswillbesentusing
the pod system to the transfusion laboratory. 2 further crossmatch samples should be
drawnandsentintheusualway.
�
Great Western, Wiltshire and Dorset & Somerset Air Ambulance teams rouMnely carry blood
productsandwillperformprehospitalbloodtransfusionswhenrequired.
EachAirAmbulancecarries2unitspackedredbloodcells. Theywillinthefuturealsocarryfresh
frozenplasmaorlyoplas.
�
• Prior toarrival, youwill receiveapre-alert (ATMIST) clearly staMng thatprehospitalblood
transfusionhasbeengiven.
• Any paMent receiving prehospital blood will have a unique paMent idenMfier (hospital
number,nameanddateofbirth)allocatedtothemintheprehospitalphase. Thiswillnot
be the paMents actual name or date of birth. The unique idenMfier allocated in the
prehospitalseNngshouldbeusedforallimagingandlaboratoryrequests.
• ThetraumateamleadershouldconfirmtheuniqueprehospitalidenMficaMonnumberatthe
MmeoftheATMISTcall:i.e beforethepaMentarrivesintheEmergencyDepartment:this
will facilitate use of the correct number for pre-requesMng laboratory and imaging
invesMgaMons.
Pre-HospitalBloodTransfusion
Background
Intheeventthatapa>entwhohasreceivedapre-hospitalbloodtransfusionistransferredtoyourhospital:
�6
PATIENT
PRE-ALERT
• Themajorityofpa>entswho receiveprehospitalbloodproduct transfusionwill requireaddi>onalbloodonarrivalintheEmergencyDepartment.
• The prehospital paMent idenMfiers and the actual paMent details will be merged by the
admissionsteamoncethepaMentarrivesatthelocaMonofdefiniMvecare. Theprehospital
teamwillprovidebloodtransfusionspecificaccompanyingdocumentaMon.
• Onarrival,apre-hospitalGroup&Savebloodsamplewillbehandedover;pleaseassistthe
prehospital team to ensure the prehospital pre-transfusion blood sample is sent to the
transfusion laboratory as quickly as possible. The South West Ambulance Service
Prehospital Blood Transfusion SOPwould normally expect this to be done using the pod
system.
�
On wristbands, paperwork and pre-transfusion blood sample you will find unique prehospital
idenMfiers.
HospitalNo:Unique7digitnumber(6139XXX)–compaMblewithNBTcomputersystemSurname:HEMS00001,HEMS00002etc.Firstname:UnknownDateofBirth:01-Jan-1900TheaboveinformaMonshouldhavebeenpassedtothetraumateamleaderwiththeiniMalATMIST
report.Allimagingandlaboratoryrequestsshouldberequestedusingthesedetails.
Even once the paMent details are known, the prehospital idenMfiers and all associated
invesMgaMonsshouldconMnuetobeusedunMlthepaMentarrivesatthelocaMonofdefiniMvecare
e.g. Intensive Care, at which point the prehospital idenMfiers will be merged with the known
paMentdetailsandalllinkedinvesMgaMonsandresultswillbetransferredtotheidenMfiedpaMent.
�
ThefollowingdocumentaMonwillarrivewiththepaMent:theprehospitalteamareresponsiblefor
ensuringitiscorrectlycompletedandcopieslodgedwiththetraumateam:
• Pre-hospitalBloodTransfusionRecord(includesprescripMon)
• BloodCompaMbilityForm
• Group&SaveRequestForm(withsample)
• SWASTPaMentCareReport(PCRorelectronicPaMentCarerecord)
Uniquepre-hospitaliden>fica>on(compa>blewithNBTcomputersystems)
Documenta>on
�7
� ATMISTHandover
1. TheATMISTapproachshouldbeusedtohandoveralltraumapaMents
2. Theprogram inappendixB (page232)mustbeused to record thepre-alert forallmajor
traumapaMents.
3. Alldetailsontheproformashouldbecompleted
�
• Themnemonic ATMIST amethod of clinical handover between pre-hospital and hospital
teams
• It offers a structured format for handover and its aim is to improve communicaMonwith
emergencydepartmentswhenpre-alerMnganduponarrivalofatraumapaMent.
• TheATMISThandoverisexpectedtotakelessthan60seconds
�
AnATMISTpre-alertisexpectedinthefollowingcircumstances:• AnypaMent triagedasmajor traumaby the ‘Major TraumaTriageTool’ – seeAppendixA
(page231)
• Any paMent where the trauma team is required outside the ‘Major Trauma Triage Tool’
criteriae.g.specificclinicalconcerns.
UponreceiptofanATMISTpre-alert,thehospitalteamshouldrecordthehandoverontheATMIST
handoverproformasMcker–seeAppendixB(page232).
Uponarrivalof thepaMent in theemergencydepartment, anATMISTapproach shouldagainbe
performedtohandoverclinicalinformaMon.
ATMISTHandover
Background
ATMIST
�8
PATIENT
PRE-ALERT
�
Pre-hospitalBloodTransfusion• If the paMent has received a prehospital blood transfusion this should have been clearly
statedduringanATMISTpre-alert.
• DuringthisATMISTpre-alert,thetraumateamleader(TTL)shouldconfirmtheuniquepre-
hospital idenMficaMon number (ie. Before arrival of the paMent in the emergency
department) – thiswill facilitate use of the correct number for pre-requesMng laboratory
andimaginginvesMgaMons.
�
�
1. SWASTCG05–ATMISTPaMentPre-alertandHandoverSystem–01/02/2013–ClinicalGuideline
hqps://www.swast.nhs.uk/Downloads/Clinical%20Guidelines%20SWASFT%20staff/CG05_ATMIST_PaMent_Pre-Alert.pdf
2. SWASTCG24–TraumaCare:AccessingTraumaServices–17/03/2017–ClinicalGuideline
hqps://www.swast.nhs.uk/Downloads/Clinical%20Guidelines%20SWASFT%20staff/CG24_Trauma_Care_Accessing_Services.pdf
SpecialCircumstances
AGE(INCLUDINGPATIENTNAMEIFKNOWN)
TIMEOFINCIDENT
MECHANISMOFINJURY
INJURIES
SIGNS–VITALSIGNS
TREATMENTSOFAR
ETA,modeoftransport(landvsair),specialistresourcesrequiredonarrival?
References
�9
https://www.swast.nhs.uk/Downloads/Clinical%20Guidelines%20SWASFT%20staff/CG05_ATMIST_Patient_Pre-Alert.pdf
�
Inter-HospitalTransferofAdultMajorTraumaPaMents
1. PaMentslikelytorequiretransfershouldbeidenMfiedearlyintheirEmergencyDepartment
admissiontofacilitateMme-efficienttransfer.
2. Incaseswhereuncertaintyexists,earlycommunicaMonwiththeTraumaTeamLeader(TTL)
atNorthBristolNHSTrust(NBT)isencouraged.
3. ResuscitaMonand stabilisaMonof thepaMent shouldoccur inparallelwithpreparaMon for
transfer
4. A dedicated team member should prepare and verify correct funcMoning of all transfer
equipment&drugs
5. ReferraltotheTTLatNBTshouldoccurinparallelwithpaMentpreparaMonwherepossible.
6. TheseniorcliniciancaringforthepaMentshouldmakethiscall,notnecessarilytheperson
undertakingthetransfer.
7. CriMcallyillpaMentsundergoinginter-andintra-hospitaltransfershouldbeaccompaniedby
twotrained,competentandexperiencedstaff.
8. EnsureallradiologyiselectronicallytransferredtoNBTsothatitisavailableasthepaMent
arrivesattheMTC.
9. The default locaMon for recepMon and handover will be Emergency Department
ResuscitaMonareaatNBT.
10. AformalhandovermustoccurbetweenthetransferteamandreceivingteamConsideraMon
shouldbegiventousingtheSBARorATMISTstructure.
11. AlltransferdocumentaMonshoulduseSWCCNdocumentaMonavailableinalltraumaunits.
Inter-HospitalTransferofAdultMajorTraumaPa>ents
�10
PATIENT
PRE-ALERT
!
AdultmajortraumapaMentspresenMngtoTraumaUnitswithintheSevernMajorTraumaNetwork
(MTN) frequently require inter-hospital transfer to facilitate specialist treatment at the Major
Trauma Centre. NaMonal guidance from the Intensive Care Society [1] and AssociaMon of
AnaestheMstsofGreatBritainand Ireland [2]hasbeenused to create regionalguidelines forall
criMcal care transfers within the South West CriMcal Care Network (SWCCN) [3], the northern
secMonofwhichcorrespondstotheSevernMTN.
TheseMTNguidelines shouldbe read in combinaMonwith theSWCCN ‘Guidelines for the inter-
andintra-hospitaltransferofcriMcallyilladultpaMents’.Standardsfortraining,equipment,clinical
governance,accompanyingpersonnelandriskassessment,monitoring,safety,documentaMonand
handoverarealldescribedandnotrepeatedinthisdocument.
�
Theseguidelines:• Apply primarily to the safe transfer of level 2 and level 3 criMcally ill adultmajor trauma
paMents
• Aim to ensure that transfer of these paMents occurs with minimal risk and in the best
interestsofthepaMent
• Provideaneasy-to-followflowcharttofacilitatesafeandMme-efficienttransfer
�
TheSevernMTNguidanceonpaMentsrequiringspecialisttreatmentintheMajorTraumaCentre
shouldbefollowed.PaMentslikelytorequiretransfershouldbeidenMfiedearlyintheirEmergency
DepartmentadmissiontofacilitateMme-efficienttransfer.PaMentswhomeetSWASTMajorTrauma
Bypass criteria will almost all require transfer. In cases where uncertainty exists, early
communicaMonwiththeTraumaTeamLeader(TTL)atNorthBristolisencouraged.
Introduc>on
PurposeofThisDocument
TransferDecision-Making
�11
�
SeeAppendixEforaddi>onalinforma>on(page251)
• IdenMfypaMentrequiringtransferonadmissionorassoonaspracMcable
• ResuscitaMonand stabilisaMonof thepaMent shouldoccur inparallelwithpreparaMon for
transfer
‣ Care should be taken to ensure paMents are safe to transfer (some paMents requiringtransfermaybeunstable)
‣ Unnecessary intervenMons thataddMmedelayshouldbeavoidedwherepossible.e.g.arterialaccessisrarelyessenMalbutfrequentlydelaystransfer.
‣ Ensureall tubes, linesdrainsetcarewell secured,protectedandaqempt tominimisetheriskofdisplacementduringtransfer.
‣ AdedicatedteammembershouldprepareandverifycorrectfuncMoningofalltransferequipment (including standard monitoring, portable venMlator, infusion pump(s),
transferbag,anddrugsandemergency/rescuemedicaMons).
‣ PrepareSWCCNtransferdocumentaMon(availableineveryEmergencyDepartment)• Contact TTL atNorthBristol; this should occur in parallelwith paMent preparaMonwhere
possible.TheseniorcliniciancaringforthepaMentshouldmakethiscall,notnecessarilythe
personundertakingthetransferitself.
• The senior clinician caring for the paMent should should then contact South Western
AmbulanceServiceNHSFoundaMonTrust(SWAST)viathe999service.
PaMentsrequiringaMmecriMcaltransferandspecialisttreatmentaspartoftheMTNwillreceive
an “Mme criMcal” 8minute response from SWAST [4]. Some paMents are not Mme criMcal but
require“immediate”ambulanceaqendancewithin30minutesofthecall. VeryfewpaMentsare
expectedtobesuitablefor“urgent”1-4hourresponse.
ThepersonmakingthecallwillrequirethefollowinginformaMon(seeAppendixF,page252)
• Typeoftransfer:MajorTraumaTransfer
• Urgencyofresponse:MmecriMcal(8minutes),immediate(30minutes),urgent(1-4hours)
• PaMentlocaMon[exactlocaMonwithinhospital]
• Receivinghospitalanddepartment
• Whetheraparamedicvehicleisrequired.Mostlevel2and3transfersareaccompaniedby2
non-ambulanceserviceescorts, sothereisnoabsoluterequirementforaparamediccrew
whichmayspeeduptheresponse.
• Detailsofescort(s)beingprovided(forinstance,doctorandnurse)
• PaMent’scurrentcondiMon(anaestheMsed,etc)
• Medicaldevicesbeingtransported(venMlator,monitor,syringepump(s),etc)
Prepara>onforTransfer
�12
PATIENT
PRE-ALERT
PackagepaMentonambulancetrolley
• ThepaMentmustbesecuredtothetrolley(askambulancecrewforhelp)
• Pay aqenMon to lines, tubes and drains to ensure their safety; these should be secured,
protectedandriskofblockage,displacementandremovalminimised.
• Ensuremonitor,venMlatorandinfusionpump(s)aresecurelyfastenedtothetrolley
• EnsurepaMent’sdignityisprotectedandpayaqenMontotemperaturemanagement
OndepartureupdateTTLwithesMmatedMmeofarrival(SWASTcrewareabletoesMmatethis)
EnsureallradiologyiselectronicallytransferredtoNorthBristolNHSTrustsothatitisavailableas
thepaMentarrivesattheMTC.
�
TheSWCCNexpectthemajorityofinter-hospitaltransferstobeundertakenbyroad. Withinthe
SevernMTN, air transportaMon of paMents will very rarely be quicker than road transportaMon
exceptinexcepMonalcircumstances.
�
CriMcally illpaMentsundergoing inter-and intra-hospital transfer shouldbeaccompaniedby two
trained,competentandexperiencedstaff.
ThemajorityofadultmajortraumapaMentsrequiringinter-hospitaltransferwillbelevel2and3
paMentswithsignificantriskofdeterioraMon,whorequireanurse(orotherregisteredhealthcare
professional) and medical escort (with the medical pracMMoner being from an anaestheMc or
intensivecaremedicinebackground).
�
ThedefaultlocaMonforrecepMonandhandoverwillbeEmergencyDepartmentresuscitaMonarea
inSouthmeadHospital. IfanalternatelocaMon(suchastheatres) isrequired,thiswillbeclearly
statedbytheTTLandarrangementsmadeforthepaMenttobemetonarrivalsothetransferring
teamdonotgetlost.
A formal handover must occur between the transfer team and receiving team led by the TTL.
Handovershouldbestructuredandconcise. ConsideraMonshouldbegiventousingtheSBARor
ATMISTapproachalongsidewriqendocumentaMon.
Selec>onofTransportMode
AccompanyingPersonnel
Recep>onandHandover
�13
�14
PATIENT
PRE-ALERT
�15
OPERATIONALGUIDELINES
�16
� TraumaTeamRolesandResponsibiliMes
1. AcMvaMonofthetraumateamisbasedonanatomicalandphysiologicalparameters
2. ThisteamshouldmanagetheiniMalassessment,resuscitaMon,imagingandco-ordinaMonof
disposalfortraumapaMentspresenMngtoNBT
3. ThedecisiontoacMvatethetraumateamismadebytheseniordoctorandBand7onduty
followingpre-alertfromtheambulanceservice.
4. ThetraumateamisacMvatedbyringing‘2222’andstaMng‘traumacall’
5. Thetraumateamleadersshouldbeavailablewithin5minutesofnoMficaMon
6. AllmembersofthetraumateamshouldinformtheirrespecMvespecialityteammembersof
incomingtraumaandaqendtheresusareaassoonaspossibleonreceiptofthetraumacall
7. All trauma team members must remain with the paMent unMl appropriate disposal is
achieved
TraumaTeamRolesandResponsibili>es
�17
Trauma Call Adult Team Contact Number
Trauma Team Leader Bleep: 9745
Anaesthetist 3rd On Call Bleep: 9034
General Surgeon Reg On Call Bleep: 9772 & 9656
Orthopaedic Reg On Call Bleep: 9750
Radiology Reg Bleep: 9746
Radiographer Bleep: 9740
Trauma Nurse Co-ordinators Bleep: 9747, 9748, 9749
ED Nurse 1 | ED Nurse 2 | ED Nurse 3
Porter Bleep: 9567
Matron ED Bleep: 9744
Senior Nurse ED Bleep: 9743
Receptionist Bleep: 9742
Other specialties may be called as clinically indicated:
Neurosurgery Reg Dial: 45726
Plastics Reg Bleep: 1311
Cardiothoracics BRI via switchboard
Haematologist Bleep: 9433
� GenericTraumaTeamRole
�
CollectSpecialityTraumableepandreceivehandover+relevantSpecialitysituaMonalreport.
�
InformrespecMveSpecialityteammembers/Consultant/Theatresof incomingTrauma–thereby
allowingforproacMveplanningofpersonnel,resourcesandtheatrespace. AqendResusareaoftheEmergencyDepartmentassoonaspossibleonreceiptofTraumacall.
The decision to acMvate the Trauma team is based on the expectaMon that the alerted team
memberswillbepresenttoreceivethepaMent.Thereisnorequirementforteammemberstoring
theEDtodiscussthecasepriortothepaMent’sarrival.
OnarrivaltotheEmergencyDepartment:• IdenMfyyourselftotheTraumaTeamLeader.• Givename,specialtyandgradetothescribe• FillinyouridenMficaMonsMckerandplaceinavisibleplace• Confirmexpectedrole• EnsureadequatepersonnelprotecMveequipment• On arrival of trauma team, all teammembers should be on the paMent’s le\ of the ED
trolley, except the airway nurse and anaestheMst. The paramedics will then be on the
paMent’sright.
Remainwiththepa>entun>lappropriatedisposalisachievedIfyouneedtoleavetheTraumaTeamenvironment–thismustbediscussedandbeagreedbytheTraumaTeamLeader
GenericTraumaTeamRole
StartofShil
TraumaCallAc>va>on
�18
OPERATIONAL
GUIDELINES
�
TraumaTeamAcMvaMon
AcMvaMonofthetraumateamisbasedonanatomicalandphysiologicalparameters.Mechanismof
injurydoesnotformthebasisoftheacMvaMontriagetool. AtraumateamcanbecalledatanystageofapaMent’sjourney. ThereisanautomaMcacceptancepolicy.AcopyofSouthWestAmbulanceServiceNHSTrustMajor
TraumaTriageToolcanbefoundintheappendix(seeAppendixA,page231).
�
• Unsafeairway• Flailchest• PenetraMnginjurytohead,neckortorso• Severepelvicinjury• Majorcrushinjurytotorsoorupperthigh• LimbamputaMon• Twoormorelongbonefractures• Paralysisfromspinalcordinjury• Burnsover20%orpotenMalairwayburns
�
• RespiraMons30orothersignsofrespiratorycompromise• Pulse<50or>120• Systolicbloodpressure<90mmHg• Systemicsignsofshock• HeadinjurywithMotorScore≤4• Anysignsofrespiratorydistress,shockorreducedconsciouslevelinpaediatrics
�
• MulMplepaMents• HEMSrequested
TraumaTeamAc>va>on
Anatomy
AbnormalPhysiology
SpecialCircumstances
�19
�
TheethosisthatthisteammanagetheiniMalassessment,resuscitaMon,imagingandco-ordinaMon
ofdisposalbeittheatre,ITUorwardforTraumapaMentspresenMngtoNBT.
Each teammemberwill have generic roleswithin this structure, aswell as, providing individual
experMse.TheaimisthataconsistentandpredictableTraumateamresponseisprovidedtoeach
trauma,whererolesandresponsibiliMesarewelldefinedandadheredtobyeachmemberofthe
team.
Thereisaswitchboardtestcallat10:00amandat16:00
�
• Following pre-alert from ambulance service the senior doctor and Band 7 on duty will
decide whether trauma team is acMvated: decision supported by the use of trauma
acMvaMonguidelines.
• Ringx2222
• StateTraumacall
• The Trauma Team leader and Senior Nurse will carry out a situaMonal appraisal of the
departmentwiththeDutyEDleadtoallocateappropriatebaysandresources.
• On arrival of paMent the Trauma Team Leader must idenMfy themselves to the Lead
Prehospitalclinicianandreceivehandover.
• The salient points of this handover will be wriqen on the Trauma Board to prevent
repeMMonofinformaMon,usingtheATMISThandoverformula–seeseparateguideline. A
sMckerforATMISThandovershouldbeavailableandcompletedbythescribe.
• Eachmemberof the traumateamshould fulfil their rolesunless the team leaderdictates
otherwise.
• Members of the trauma team must not leave resuscitaMon without discussion with the
TraumaTeamLeader(TTL).
TraumaTeam
CallAc>va>on
�20
OPERATIONAL
GUIDELINES
�
TraumaTeamLeader
PresentinEDoravailablewithin5minutesofno>fica>on.Start of Shil: Liaise with Lead Nurse, collect Trauma bleep and TTL folder, take DepartmentalsituaMonalreportandmeetwithTraumaTeamNurse1&2.
�
Pre-Hospital:AlertCall• Takecall/reviewcallasdetailstaken• TakepaMentidenMfiersasavailable• DecidewithEDnursingshi\leadwhethertoiniMateTraumaTeamAcMvaMon• CallSwitchboardtoiniMateTraumaCall–anETAisnotrequired• IfpaMentistransferredbyAirthenSecurityandClinicalsiteteamsneedstobeinformed.
In-Hospital:AlertCall• CanbeiniMatedatanystagebytheTraumaTeamLeaderforapaMentwithintheEmergency
Department.
• ThedecisiontoacMvatetheTraumateamisbasedontheexpectaMonthatthealertedteam
memberswillbepresenttoreceivethepaMent.ThereisnorequirementforteammemberstoringtheEDtodiscussthecasepriortothepaMent’sarrival.
• All teammembers receivingaTraumacallareexpected toalert their respecMvespeciality
teamsofanincomingTrauma.
• (Thus theatre, radiology, ITU beds and blood product availability can be planned for by
respecMveteams)
Consider:• EarlynoMficaMontoNeurosurgery,PlasMcSurgery, IntervenMonalRadiology,Cardiothoracic
Surgery,UrologyandVascularSurgeryasrequired.
• MassivetransfusionprotocolacMvaMon
�
Pre-arrival• AddAlertCalldetailstoTraumaBoard–updateTraumaTeam.• LeadresuscitaMon,coordinatestaffandresources.• EnsurepersonalintroducMonsbyTeammembersandconfirmroles.• EnsureteamwearpersonalprotecMveequipment.
TraumaTeamLeader
TraumaTeamAc>va>on
TraumaLead
�21
Pa>entRecep>on• EnsureResusclockandVideorecorderstarted.• Co-ordinateATMISThandoverfromPre-HospitalTeam–adddetailstoTraumaBoard.• Co-ordinatetransfertoResusTrolley.• ManageTraumaTeamresponse.• MakedecisionsinconjuncMonwithteammembersandrelevantspecialists.• PrioriMseinvesMgaMonsandtreatments.• Ensure imminent life threateningcondiMonsare treatedanddirect rapid transfer toCTor
Theatre.
PromoteanenvironmentofopencommunicaMonwithreviewofongoingmanagementprioriMes
andplans,ensuringinvolvementofallteammembers.
AimforCTwithin15minutesunlessreasonspreventthisConsiderCTinlieuofprimarysurveyx-raysinsomecasessee“ImaginginTraumaGuidance”
Considerearlyuseof:• ONegblood
• MassiveTransfusionPolicy
• Tranexamicacid1gover10mins. -Themaintenancedose,1gover8hrs(givenwithin3hoursofTrauma)shouldbegivenonreturn fromCT in order tominimise infusions needed in the CT scanner, and to focus theteamonprepara>onfortheCTscanner.
• CombatApplicaMonTourniquet–useandmanagement.
• ConsidereFAST–ifthiswouldenhanceandnotdelayongoingpaMentcare.
Pa>entTransferTeammembersmayberequiredtoremainwiththepaMentduringtransfertoCTorTheatre.
Whilst sliding the paMent up or down into the head cradle, the TTL should hold the trauma
maqressfixedinposiMonwhilstthetraumateamslidethepaMent.
TraumaTeammembersmustremainwiththepaMentunMlappropriatedisposalisachieved.
IfanyTeammemberneedstoleavetheTraumaTeamenvironment–thismustbediscussedand
agreedbytheTraumaTeamLead.
AnMbioMcs, urinary catheter, arterial lines, tetanus, pregnancy test need early consideraMon but
canbedelayediftransfertotheatreforemergencysurgeryisrequired.
ResuscitaMonismanagedasadynamicprocesswhichisnotdependentongeographicallocaMon.
Handover:TheTraumaTeamleaderdeterminestheSpecialitytoleadongoinginpaMentcare.InformBloodBank:WhenpaMenttransferredandlikelyongoingbloodproductrequirements.SpeaktoRela>vesDocumenta>on:ReviewcompletecasenotedocumentaMonandcompleteHotDebriefform. Debriefteam
�22
OPERATIONAL
GUIDELINES
� OrthopaedicRegistrar
�
• CatastrophicHaemorrhagecontrol
• CervicalSpineandPelvicstabilisaMon
• Venousaccess
• PerformSecondarySurvey
�
• Direct pressure Haemorrhage control as required, in extreme condiMons for extremity
bleeds–considertourniquetuse.
• EnsureC-spinecollarinsitu,correctsizeandplacement
• EnsurePelvicsplintinsitu,correctsizeandplacement
• EnsurelegsalignedwithinternalrotaMon–bandageanklestomaintainposiMon
�
• Venousaccess–sharedrole–asdirectedbyTeamLeader
• Confirmpatencyofi.v.access
• Unless thepaMenthas twopatent i.v.access sites -Gain i.v./ i.o.accesswith20mlsblood
samplesfor:-FBC,UE’s,LFT’s,Lipase,CloNngscreen,X-match,VenousbloodgasandBlood
Glucose
• Ifpossible,freecannulatobeplacedinthebackofthele\handforthe IVcontrast.
• If the paMent has two patent i.v. access sites then gain 20mls blood for samples from a
femoralarterialpuncture
• Ensuresamplesarelabelledcorrectlyanddispatchedtotheappropriatedepartments.
Performbaseline peripheral neurological examinaMon, if RSI planned or just prior to log roll, as
directedbyTeamLeader.
Splintanylongbonefracture
OrthopaedicRegistrar
KeyRoles
Pa>entManagement
VenousAccess
�23
Contribute to case discussion with the Team Leader, parMcularly where limb or lifesaving
intervenMonsarerequired.
Once the primary survey and immediate lifesaving intervenMons have been achieved, the
Orthopaedic Consultant must be informed of the likely case progression. This may require the
aqendanceoftheConsultanttotheResuscitaMonRoomortotheatreasappropriate.
�
Carry out secondary survey, when deemed appropriate and verbally report findings to Team
Leaderanddesignatedscribe.
• Documentallwounds,grazesanddegloving.• Evaluateeachjointandlong-bonefordislocaMon/stability/fracture.• NeurovascularexaminaMonofalllimbs.• Recordpresenceorabsenceofkeypulses&neurologicalfindings.• IdenMfyperipheralinjuriesthatneedtobeincludedintheCTscan• Splintfractures.• RepeatneurovascularexaminaMona\ersplinMng.
AnyaddiMonalimagingrequirementsinaddiMontoaCTTraumaseries(review“ImaginginTrauma
Guidance”)shouldbediscussed.RequesMngofdepartmentalfilmscanimpedetherapidprogress
ofpaMentstodefiniMveorstagingcare–andmustbeagreedamongstteammemberstoensure
co-ordinatedcare.
PaMentswhohaveanteriorpelvicinjuriesmayrequirearetrograde-urethrogrampriortoinserMon
ofurinarycatheters–thisistobeundertakenbytheOrthopaedicRegistrar.
Discuss Orthopaedic assessment / plan / needs / prioriMes with team leader. Case discussion
shouldalsoconsidertheneedforVascularorPlasMcSurgeryspecialtyaqendance,dependenton
injurypaqerns.
Liaise with theatres, anaestheMc colleagues, bed manager and consultant for paMents needing
theatreand/oradmission.
Assistwith sending/ordering tests, liaisingwith specialists or performing procedures as training
andabilityallowse.g.chestdrains,urinarycatheter.
�
DocumentallacMonsandfindingswithaclearplaninpaMentnotes.
Remainwiththepa>entun>lappropriatedisposalisachieved IfyouneedtoleavetheTraumaTeamenvironment–thismustbediscussedandbeagreedbytheTraumaTeamLeader.
SecondarySurvey
PostTraumaCall
�24
OPERATIONAL
GUIDELINES
�
SurgicalRegistrar
�
• AssessBreathingandCirculaMon.• PerformlogrollexaminaMon.• DetermineneedforimmediatesurgicalintervenMonintheatres.
�
B–Breathing:• Assessairentry,chestexpansion,percussionandtrachealposiMontoallowidenMficaMonof
significantchestpathology.
• ReportfindingstoTraumaLead,discuss,agreeandinsMtuteappropriateintervenMons.
C-Circula>on• Venousaccess–sharedrole–asdirectedbyTTL• Confirmpatencyofi.v.access• Unless thepaMenthas twopatent i.v.access sites -Gain i.v./ i.o.accesswith20mlsblood
samplesfor:-FBC,UE’s,LFT’s,Lipase,CloNngscreen,X-match,VenousbloodgasandBlood
Glucose Ifpossible,freecannulatobeplacedinthebackofthele\handforthe IVcontrast.
• If the paMent has two patent i.v. access sites then gain 20mls blood for samples from a
femoralarterialpuncture
• Ensuresamplesarelabelledcorrectlyanddispatchedtotheappropriatedepartments.
Performabdominalexamina>on
Performexamina>ononlogroll–ensurefullexposure.Assessforoccipitalheadtrauma,thoracic/lumbarspinalinjury,examineposteriorchestincludingauscultaMon,palpateflanks,performrectal
examinaMonandassessposterioraspectoflimbs.
ContributetocasediscussionwiththeTeamLeader.DiscussSurgicalassessment/plan/needs/prioriMesparMcularly:decisiononTransfertoCTorTheatre-CommunicaMonwiththeatresroleis
shared with ITU. Case discussion should also consider the need for Vascular or PlasMc Surgery
specialityaqendance,dependentoninjurypaqerns.
SurgicalRegistrar
KeyRoles
Pa>entManagement
�25
OncetheprimarysurveyandimmediatelifesavingintervenMonshavebeenachieved,theSurgical
Consultant must be informed of the likely case progression if paMent has iniMal SBP entun>lappropriatedisposalisachievedIfyouneedtoleavetheTraumaTeamenvironment–thismustbediscussedandbeagreedbytheTraumaTeamLeader.
PostTraumaCall
�26
OPERATIONAL
GUIDELINES
�
AnaestheMcs3rdOnCall
�
• EnsurepaMentoxygenatedandvenMlatedwithnoairwayobstrucMon.• Intubate when appropriate in discussion with the Team leader – ensuring baseline
neurologicalexaminaMonperformedbeforehand.
• ControlpaMentlogroll• EnsuresafepaMenttransfer
�
A-AirwayIntubatedpa>entsTake physical handover of ETT or LMA from pre-hospital team. Ensure end Mdal capnography
confirmsplacement.
Assess effecMveness of BMV/ Mapleson C venMlaMon in conjuncMon with surgical registrars
assessmentofBreathing
AqachtovenMlatorassoonfeasible–withconfirmaMonofeffecMvebilateralvenMlaMon.
Non-Intubatedpa>ents–requiringintuba>onIntubatewhenappropriateindiscussionwiththeTTL–ensuringbaselineneurologicalexaminaMon
performedbeforehand,orthopaedicregistrarwillassessperipherallimbresponse,anaestheMstto
assesspupilresponseandformalGCS.
Performco-ordinatedRSIwithNurse1.
EnsureendMdalcapnographyconfirmsplacement.
Assess effecMveness of BMV/ Mapleson C venMlaMon in conjuncMon with Surgical Registrars
assessmentofBreathing
AqachtovenMlatorassoonfeasible–withconfirmaMonofeffecMvebilateralvenMlaMon.
Non-Intubatedpa>entsCommunicateairwaypatencyandissuestoteamleader/scribe.
Assessrespiratoryrateandinformteamleader/scribe.
ItisusuallyappropriatefortheanaestheMsttotalktothepaMentandprovideongoingassessment
ofGCSandpupilsize.
Anaesthe>cs3rdOnCall
KeyRoles
Pa>entManagement
�27
Reassure paMent on arrival, explain what is happening, take AMPLE history and inform Team
leader/scribe
• AAllergies• MMedicaMons• PPastmedicalhistory• LLastmeal• EEverythingelserelevant
E-ExposureOnceprimarysurveycompletedandwhendirectedbytheTTLtheanaestheMstwillcontrolthelog
roll
Considerneedforendogastrictube(nasalororal).
Arterial linesmaybe indicated, to avoiddelay toCT this canusually bedonea\erCTor in the
operaMngtheatre.Itshouldnotdelayeither.
Contribute to case discussion with the TTL. Case discussion should also address ongoing fluid
management,bloodproductsand inotropicsupport.Discussmassive transfusionprotocoluse in
theEDandmanageitsimplementaMononceintheatre,informingbloodofanychangestocontact
nameandtelephonenumber.
Once the primary survey and immediate lifesaving intervenMons have been achieved, the ITU
Consultantmustbeinformedofthelikelycaseprogression.Thismayrequiretheaqendanceofthe
ConsultanttotheResuscitaMonRoomortotheatreasappropriate.
Communicate any requirements with theatres - role shared with surgical registrar. Liaise with
addiMonalanaestheMstasappropriateifcaretobehandedoverfortheatreetc.
Assistwith sending/ordering tests, liaisingwith specialists or performing procedures as training
andabilityallowse.g.chestdrains,urinarycatheter.
�
DocumentallacMonsandfindingswithaclearplaninpaMentnotes.
RemainwiththepaMentunMlappropriatedisposalisachieved IfyouneedtoleavetheTraumaTeamenvironment–thismustbediscussedandbeagreedbytheTraumaTeamLeader.
PostTraumaCall
�28
OPERATIONAL
GUIDELINES
�
NonAirwayNurse
LiaisewithTraumaTeamLead,SeniorEDNurseandotherTraumaTeamNurse.Reviewresusbays
andensureResuschecklistsarecompletedandsigned.Highlightandaddressanydeficiencies.
�
ResponsibleforsupporMngTraumaTeamLeader.infuser
Prepare for the traumacallwith levelone infuser run throughwhen indicated,warmed ivfluids
runthrough,chestdrainsetsout ifsuggested,scoopstretcherandpelvicbindertohand.Ensure
equipmentforgaininglargeboreIVaccessandtakingbloodsisavailable.
EnsureavailabilityofONegBlood.
MeetpaMentathelicopterifrequired–co-ordinateporters/transferequipment.
�
EnsureclockstartedwhenpaMentarrivesinResusBay
AssistintransfertotheResustrolley
PosiMonyourselftothepaMentsle\side
Havescissorsready,removeenoughclothinginiMallytoaqachmonitoring,
ClearlystatefirstobservaMonstoteamleader&scribeassoonasavailable.
ThenconMnuetoremoveallclothingincludingunderwearandstoresecurely.
Checktemperature
Coverwithforcedairwarmingblanket/blankets
HelpwithgeNngIVaccessandsendingbloodsoffifrequired,setupintraosseouskit(ez-IO)ifno/
difficultIVaccess.AqachpaMenttoleveloneinfuserifrequired.
Assistwithlogroll
Drawupdrugs/administerasprescribed
PreparefortransfertoCTASAP(within10minutesideally)and/ortheatre
HelpwithproceduresasidenMfiede.g.catheter,chestdrain,andarteriallineDressingsandsplints
ofopenfractures/significantwounds.
EnsurepaMentkeptwarm.
NonAirwayNurse
PriortoPa>entArrival
Pa>entArrival
�29
�
EnsureyouhavedocumentedallyourinteracMonsinthenotes
Ensureyouhavesignedforanydrugs
OnlyleavethepaMenta\erliaisingwiththeTraumateamleader
PostTraumaCall
�30
OPERATIONAL
GUIDELINES
� AirwayNurse
LiaisewithTraumaTeamLead,SeniorEDNurseandotherTraumaTeamNurse.ReviewResusbays
andensureResuschecklistsarecompletedandsigned.Highlightandaddressanydeficiencies.
�
• ResponsibleforassisMngwiththeiniMalassessmentandmanagementofairwaysupporMng
anaestheMst.
• AssistinpreparinganydrugsrequestedbyanaestheMst.• Checkallappropriateairwayequipmentisavailableandworking• ChecksucMonavailableandworking
�
• PosiMonyourselftopaMent’srightside• Assistintransfertoresustrolley• ReassureandestablisharapportwithpaMent• AssistanaestheMstwithairwaypatencyandvenMlaMonpassingadjunctsasnecessary• PrepareanydrugsneededbyanaestheMst(checkdrugswiththemorNurse2)Assistduring
logroll
• Preparearteriallineequipmentifrequested
�
• EnsureyouhavedocumentedanyofyourinteracMons• Ensureyouhavesignedforanydrugs• OnlyleavepaMenta\erliaisingwiththeTraumateamleader
AirwayNurse
PriortoPa>entArrival
Pa>entArrival
PostTraumaCall
�31
� RadiographerMSK
PlacecasseqesunderthetrolleytospeedupiniMalx-rays.
LiaisewithTTLornurseinchargeifteammembersarenotwearinglead.Liaisewithteamleaderif
teammembersareobstrucMngyourchancetox-raytoprioriMseacMons.
�
Radiologist
LiaisewithCTradiographertocleartheCTScannerandcommunicatewithResuswhenscanneris
likelytobeavailable.
Aqend the traumacallwheneverpossible as yourexperMsewill be valuable in reviewing x-rays,
eFAST scans and early recogniMon of intervenMonal radiology requirements and planning of
imaging(CTvsUS).
MosttraumapaMentswillneedearlyCT,naMonalguidelinesare=completetheCTandhavethe
iniMalreportwithin30minsofarrivalinED.
AstandardisedreporMngproformaisusedtoensurerapidreporMng.
RadiographerMSK
Radiologist
�32
OPERATIONAL
GUIDELINES
�
SCRIBE-emergencyNurseAssistant(eNA)
Acomplex jobbutvital.Ensureyouarebeinggiventhe informaMonyourequireand informtheteamleaderifnot.
�
EnsureRecep>onistison-handforrapidpa>entregistra>on• EnsurepaperworkisavailablefordocumentaMon• Ensurebags/documentaMonavailableforpaMentproperty• Ensureteamsignontowhiteboardonarrival• Document teammember’spresenceonTraumaBoard: includingspeciality,gradee.g.ST3
andsupervisingconsultant.
• Ensuretabards/rolelabelsavailable–encouragememberstoplacelabelsvisiblyincenterof
chest.
�
EnsureclockhasbeenstartedwhenpaMentarrivesintheResusBay.GetPaMentCareRecord(PCR)
handoverfromParamedics. EnsureallpaMentdetailscorrectandNOKinformaMonisdocumented. EnsurepaMentwristlabels
aresecuredonthepaMent.ListandstoresafelyanypaMentbelongings
ResponsiblefordocumentaMonofobservaMons,eventsandintervenMons
• Documentallprehospitaldrugsandfluids–Mmesandamounts.
• Document iniMal vital signs and then every 5 mins in unstable pt and every 15 mins
otherwise.ThisroleconMnuesintoCTandunMldischargedfromED.
• Maintainachronologicalrecordofalleventse.g.Mmeofvenflon,CXR,FAST,movetoCTetc.
InformtheteamleaderifkeyobservaMonshavenotbeentakene.g.TemporGCS.
Inform the team leader every 15mins that pass, the aim is to be in CT within 15mins when
appropriateaskanddocumentreasonsforanydelays.
Keepalogoftherunningtotalofbloodproductstransfused–thisrolemaybedonebyaspecified
nursememberresponsiblefortheleveloneinfuser.Inamassivetransfusiona\erevery4-5units
prompttheTTLofneedforadjuncts(suchascalciumorinsulin/dextrose).
SCRIBE-emergencyNurseAssistant(eNA)
PriortoPa>entArrival
Pa>entArrival
�33
�
• EnsurealldocumentaMoniscomplete
• Liaisewithpoliceifanypropertyhandedoverforevidence
• Ensurealldrugs/fluidssignedforbyappropriateperson
• OnlyleavethepaMenta\erliaisingwiththetraumateamleader
PostTraumaCall
�34
OPERATIONAL
GUIDELINES
� ConvenMonfortheRegistraMonofPaMentswithUncertainDetails
1. MRNandpaMentidenMfiersareissuedusingthemodeofarrival,dateandMmeinformaMon
inaspecificformatdetailedwithintheguideline.
2. DeviaMonfromthisprocesscouldleadtosignificantpaMentharm
3. Even once paMent informaMon is known, the MRN, name and DOB from the ED should
remaininuseunMlthepaMenthasreachedthelocaMonofdefiniMvecare.
�
AnypaMentwhoaqendstheEmergencyDepartmentMajorTraumaCentreatSouthmeadHospital
forwhomtheirdemographicdetailsareunknownoruncertaininanyway,shouldberegisteredas
anunknownpaMent.
ThenamingconvenMonforunknownpaMentsshouldfollowtheform:
• (Surname)MODEOFARRIVALDATEOFARRIVALTIMEOFARRIVAL• (Forename)UNKNOWN
(wheremodeofarrivalis“Air,Land”whicheverisapplicable,anddateand9mehavenocolonsorbackslashesin).
• DateofBirth:01/01/1900
Thus,apaMentarrivingon10thMarch2015at14:37hoursbyhelicoptershouldberegisteredas:
AIR100320151437,UNKNOWNDOB01/01/1900
ThiswillallowanMRNtobegeneratedwhichwillalsoensurethepaMentisfoundinICE,allowing
theorderingofpathology,bloodandx-rays/CTscans.
It is imperaMvethatthepaMentremainsregisteredasanunknownunMlsuchMmeasthepaMent
moves to an area of definiMve care, eg Intensive Care Unit, ward environment, EVEN IF THE
PATIENTDETAILSBECOMEAVAILABLE.
FullmergerofpaMentdetailsfromunknowntoknownwillbeaccompaniedbyfullmergerofthe
ICEdetails,bloodtransfusionrecord,andradiology.
FailuretoadherethispolicywillcausethepotenMalforextremepaMentjeopardy,thepossibilityof
“NEVEREVENT”occurrence,oratleasttheneedtoinappropriatelyre-bleedthepaMent.
Conven>onfortheRegistra>onofPa>entswithUncertainDetails
UnknownPa>entRegistra>onGuidelines
�35
�
EmergencyDepartment&CriMcalCareMajorTraumaDrugBags
1. ThedrugbagsshouldbekeptinthelocaMonsidenMfiedinthefollowingpages.
2. Thedrugbagsshouldbesealedwithatamperproofsealoncerestocked
3. Wherecontrolleddrugsareusedfromwithinthedrugpouches,itistheresponsibilityofthe
individual using those drugs to ensure they are appropriately prescribed, signed for in a
controlleddrugregisterandcommunicatetheneedtoreplaceorrestock.
4. It is theresponsibilityofeachclinicalservicetoensurecontentsarereplacedasusedand
drugswithindateprior toeachuse.Themechanismstoachievethismayvarybutshould
include the ability to audit restock and expiry status of contents as well as trace those
individualsresponsibleforeachrestockormaintenanceofthebags.
5. The drug bags should be available on acMvaMon of the trauma team in allmajor trauma
calls,priortoarrivalofthepaMent.
6. ThebagsshouldbeavailableduringthetransferormovementofanypaMentwithinorfrom
theEDorcriMcalcareenvironments.
�
DrugbagshouldbestoredinthelockedcontrolleddrugcupboardinResus1and/or2
EmergencyDepartment&Cri>calCareMajorTraumaDrugBags
EmergencyDepartmentMajorTraumaDrugBag
�36
OPERATIONAL
GUIDELINES
Ketamine10mg/ml1x20mlvial
Midazolam1mg/ml1x5mlampoule
Morphine10mg/ml2x1mlampoule
TheEDdrugbagcontentsmaychangeoverMme,butshouldcontainallkeydrugstosafelyperform
emergencyanaesthesiaforalltypesofmajortraumapaMents.
NotetheEDalsohaveaseparateSOPcoveringthemanagementofcontrolleddrugswithinthe
drugbagintheED-cliniciansshouldfamiliarisethemselveswiththis.
�37
Fentanyl50µg/ml1x10mlampoule
Propofol10mg/ml1x20mlampoule
Metaraminol10mg/ml1x1mlampoule
Rocuronium10mg/ml2x5mlampoule
Suxamethonium50mg/ml2x2mlampoule
Lorazepam4mg/ml1x1mlampoule
TranexamicAcid100mg/ml2x5mlampoule
�
EmergencydrugbagkeptinthePodDfridge
IntensiveCareUnitDrugBag
�38
OPERATIONAL
GUIDELINES
Adenosine3mg/ml3x2mlampoule
Adrenaline1:100002xpre-filledsyringe
Adrenaline1mg/ml2x1mlampoule
Amiodarone300mg1xpre-filledsyringe
Atropine600µg/ml2x1mlampoule
CalciumChloride10%10mg1xpre-filledsyringe
Chlorphenamine10mg/ml1x1mlampoule
Glucose50%1x50mls
�39
Ipratropiumnebuliser250µg/ml2x1ml
Magnesiumsulphate5g/10ml1x10mlampoule
Naloxone400µg/ml2x1mlampoule
Salbutamol2.5mgin2.5ml2
SodiumBicarbonate8.4%1
TranexamicAcid100mg/ml2x5mlampoule
Propofol1%2x20mlampoule
Suxamethonium50mg/ml2x2mlampoule
�40
OPERATIONAL
GUIDELINES
Rocuronium10mg/ml2x5mlampoule
Metaraminol10mg/ml1x1mlampoule
Atracurium10mg/ml2x5mlampoule
Ephedrine30mg/ml1x1mlampoule
0.9%saline10mg4x10ml
� TranexamicAcid(TXA)inMajorTrauma
1. Tranexamic Acid (TXA) is indicated in the majority of seriously injured paMents and allpaMentswithsuspicionof,orclinicalsignsofmajorhaemorrhage.
2. Itshouldbeadministeredasearlyaspossibleandwithinthefirst3hoursinallcases.
3. ComplicaMons associated with TXA administraMon are rare, but include risk of venous
thromboembolism,hypotensiononrapidbolusadministraMon,anaphylaxis(rare).
4. ContraindicaMons include: established disseminated intravascular coagulopathy, known
allergy,knownuretericobstrucMon.
�
TranexamicisasyntheMcderivaMveoflysinethatinhibitsfibrinolysisbyblockingthelysinebinding
sitesonplasminogeninthecloNngpathway.
The2010ClinicalRandomisaMonofanAnMfibrinolyMcinSignificantHaemorrhage2(CRASH-2)was
an internaMonal study of 20,207 trauma paMents with or at risk of significant haemorrhage.
PaMents were randomised to double-blind treatment with either tranexamic acid or matching
placebo, given within 8 hours of presentaMon. Tranexamic acid was associated with a 1.5%
absolutereducMoninmortalitycomparedtoplacebo,withnoincreaseintheriskofvaso-occlusive
events.
ThegreatestbenefitisseenwhenTXAisadministeredwithinthe1sthoura\erinjury,butbenefit
remainsupto3hoursa\erinjury.
ManypaMentsarrivingathospitals in theSevernTraumaNetworkwill have receivedTXA in the
prehospital seNng. Theminority thathavenot should receiveTXA,wherenocontraindicaMons
existasearlyaspossibleintheEDadmission.
�
• TXA should be given to ALL seriously trauma paMents with blood loss as evidenced by
systolicbloodpressureof<90mmHgorheartrate>110bpm.
TranexamicAcid(TXA)inMajorTrauma
Background
Indica>ons
�41
• Major trauma paMentswith normal physiology should be administered TXAwheremajor
injury is assumed to be present on mechanism, clinical examinaMon and radiological
findings.
• ThebestpaMenttariffrecommendsTXAwithin3hoursofinjury
• ForanypaMentat riskof significantblood lossaqendingNorthBristolNHSTrustwithin8
hoursofinjuryTXAshouldbeadministeredifnotalreadyreceived.
�
• IniMalloadingdose: Tranexamicacid1gisdilutedin100mls0.9%saline. Itisadministered
byintravenousinfusionover10minutes.Infusionpumprateof600ml/houroraslowbolus
over10minutes.
• Seconddose:Tranexamicacid1gdilutedin400mls0.9%salineover8hours.Infusionpump
rateof50mls/hour.
�
Cau>onshouldbetakenwhenusingTXAinpa>entswith:• Knownallergytotranexamicacid
• KnownuretericobstrucMon
• EstablishedDIC
�
1. NICEGuidance:Significanthaemorrhagefollowingtrauma:tranexamicacid
hqps://www.nice.org.uk/advice/esuom1/chapter/Key-points-from-the-evidence
2. Gruen Russell L, Reade Michael C. Administer tranexamic acid early to injured paMents at risk of substanMal bleeding
BMJ2012;345:e7133
hqp://www.bmj.com/content/345/bmj.e7133
3. TheimportanceofearlytreatmentwithtranexamicacidinbleedingtraumapaMents:anexploratoryanalysisoftheCRASH-2randomised
controlledtrial.TheLancet2011;377:9771,p1096-1101
hqp://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(11)60278-X.pdf
4. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in traumapaMentswith significant haemorrhage
(CRASH-2):arandomized,placebo-controlledtrial.TheLancet2010;376:9734p23-32
hqp://www.thelancet.com/crash-2-2010
Dose&Administra>on
Cau>ons
References
�42
OPERATIONAL
GUIDELINES
https://www.nice.org.uk/advice/esuom1/chapter/Key-points-from-the-evidencehttp://www.bmj.com/content/345/bmj.e7133http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(11)60278-X.pdfhttp://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(11)60278-X.pdfhttp://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(11)60278-X.pdf
� HEMSDirecttoCTPathway
1. HEMS teams familiarwith SevernMTCmay choose to accompanymajor traumapaMents
requiringafulltraumascanasperoftheirarrivalprocedure.
2. The pathwaymust be followed to minimise delays between paMent arrival, imaging and
handover
3. HEMS should idenMfy any paMents for the direct to CT pathway and contact the Trauma
TeamLeader/EMRedPhone
4. ThepaMentremainsundertheclinicalcareoftheHEMSteamunMlformalhandoverinthe
resuscitaMonbayfollowingimaging.
DirecttoCTappliestothefollowingemergencyaNendances:
• FASTposiMvepaMentsthroughtheStrokeThrombolysisProtocol(notcoveredfurtherinthis
document)
• IsolatedCTHeadfornon-traumapaMents(HEMSaccompanied)
• FulltraumascaninstablemajortraumapaMent(HEMSaccompanied)
The‘DirecttoCT’pathwayisaseriesofstepsthatshouldbefollowedtoensureseamlesspaMent
arrival,imagingandhandoverandtominimisedelays.
�
HEMSshouldiden>fyanypa>entswheredirectaccesstoCTisappropriate
HEMSmust contact the Trauma Team Leader (TTL) or ED Red Phone and inform of need fordirectaccesstoCT
• HEMSshouldconfirmthatthepaMentisstableforscan• PaMentnameandDOB,accurateETAandrouteoftransfermustbeprovided
ThedoctorwhoreceivestheHEMSpre-alertmust:• InformrecepMonstafftobook-inpaMentandorderrequiredimaging• InformCTradiographerandon-callRadiologyRegistrarthatthedirecttoCTpathwayisin
place
HEMSDirecttoCTPathway
BeforePa>entArrivesatEmergencyDepartment
�43
�
HEMScrew/paramedicswillproceeddirecttoCTthroughthe‘fardoor’.
HEMScrewcanacknowledgethereceivingclinician(normallytheTTL),butnohandoveristooccur
inpitstop.Wristbandswillbeapplied,butnootherintervenMonsshouldbeundertakenbytheED
traumateamatthisMme.
HEMSstaffwilltransferpaMentoffstretchertoCTscan(weightlimit200kg)
ThepaMentremainsundertheclinicalcareoftheHEMSteambefore,duringandimmediatelya\er
thescanunMltheformalhandoveroccursintheEDTraumaresusbay.Thereceivingclinician(TTL)
mayobservetheCTtoenablecontactoffurtherstaffifrequired.
ThehandoverprocessshouldnotbeginunMlpaMentinResusbay; interferencemustbeavoided.
NomembersofthetraumateamexcepttheTTLandanytraumateammembersspecificallyinvited
bytheTTLshouldaqendCT.
HEMSstaffwillloadthepaMentfromscannertoEDstretcherfollowingcompleMonofCTimaging.
AporteristobeavailabletodrivetrolleyfromCTtoResusbayandleavethroughthe‘frontdoor’
andproceedtoexpectedpaMentresuscitaMonbay.
HEMSwillformallyhandover(ATMIST)thepaMenttothereceivingclinician/TTLinEDResuscitaMon
bay.
FollowingPa>entArrivalAtEmergencyDepartment
�44
OPERATIONAL
GUIDELINES
� Death&BreakingBadNewsintheEmergencyDepartmentFollowingTraumaMcInjury
1. EffecMve&Mmely communicaMonwithpaMents and their relaMves is a crucial elementof
effecMvetraumacare.
2. A single point of contact should convey informaMon to relaMves and paMents to avoid
conflicMnginformaMonandmixedmessages.
3. UseofanamednurseandaprivatespacewithinwhichtoholdmeeMngsisbestpracMcefor
alltraumapaMents.
4. NBT supports theprincipleofwitnessed resuscitaMonand family shouldbeoffered this if
appropriate.
5. RelaMves, includingchildrenshouldbeencouragedtospendMmewiththepaMentpriorto
transfertoICUortheatre.
6. AllpaMentswithaperceiveddevastaMngbraininjurywherenoneurosurgicalintervenMonis
planned should be discussed with the ICU Consultant regarding admission to ICU for a
periodofneuro-prognosMcaMon.
7. WhereICUadmissionforneuro-prognosMcaMonisplannednodiscussionregardingorganor>ssuedona>onshouldtakeplaceinED.AspecialistnurseinorgandonaMon(SNOD)shouldbecontactedtoinformthemoftheadmissiontoICU.
8. IntheraresituaMonofadecisionbeingmadetowithdrawlifesustainingtreatment inED,
two senior cliniciansmust agree that this is appropriate. In these circumstances, prior to
discussing organ donaMonwith the paMent’s relaMves, a SNODmust be contacted by thetraumateamleader.
9. Any discussion about organ donaMon should be undertaken as a collaboraMve approach
involvingtheseniorclinician,SNODandanamedlinknurse
10. TissuedonaMonshouldbeconsideredfollowingthedeathofanypaMentintheED.
Death&BreakingBadNewsintheEmergencyDepartmentFollowingTrauma>cInjury
�45
�
Effec>veand>melycommunica>onwithrela>vesiscrucial.Keypointsinclude:ConversaMonswith familymembersshould takeplace ina roomofferingprivacyandspacewith
refreshment faciliMes available. InformaMon should be provided in a Mmely and open manner
including details of their relaMves condiMon, possible outcomes, assurances their relaMve is not
experiencing pain or distress and an indicaMon when death is imminent. Regular updates of a
paMent’scondiMonshouldbeprovided.Whereindicated,interpretersshouldbeused
CommunicaMon between staff members is essenMal to prevent conflicMng informaMon being
provided. A named link nurse to support relaMves and act as an advocate for the relaMve(s) is
essenMal
NBTsupportstheprincipleofwitnessedresuscitaMon;thisshouldbeofferedwhereappropriate.
Offer relaMves theopportunity to spendMmewith thepaMentbefore transfer to ITUor theatre,
even if this is only for a brief period. Children should not be excluded as theymay imagine a
situaMonfarworsethanthereality.
Followingdeath,relaMvesshouldbeallowedto‘saygoodbye’.Offersupportfromappropriatefaith
or religious leaders (available via switchboard). Thismayprovide support to relaMveswhilst the
paMentisintheatreorfollowingdeath
�
Wherewithdrawaloflifesustainingtreatmentisconsideredthefollowingstepsshouldbetaken:AnypaMentwherewithdrawalof life sustaining therapy isbeingconsideredshouldbediscussed
with the on call ICU Consultant so that an appropriate management plan and locaMon can be
agreed.
All paMents with a perceived devastaMng brain injury where no neurosurgical intervenMon is
planned should be discussed with the on call ICU Consultant regarding admission to ICU for a
periodofneuro-prognosMcaMon.
Where ICU admission for neuro-prognosMcaMon is planned this should be explained to relaMves
but no discussion regarding organ donaMon should take place. A SNOD should be contacted to
informthemoftheadmissiontoICU.
No discussion about organ dona>on should take place in the ED when an ICU admission isplanned.RarelyaSNODmayiniMatethisdiscussionintheEDiffeltappropriatebytheSNODandseniorclinicianresponsibleforthepaMentintheED.
Communica>onwithRela>ves
PlannedWithdrawalofLife-sustainingTreatment
�46
OPERATIONAL
GUIDELINES
In the rare situaMon of a decision beingmade towithdraw life sustaining treatment in ED, two
seniorcliniciansmustagreethatthisisappropriate.ThiswillnormallybetheTraumaTeamLeader
andICUConsultant.
Whenwithdrawal of life sustaining treatment is planned to take place in ED, a SNODmust becontacted by the Trauma Team Leader prior to discussing organ donaMon with the paMent’s
relaMves. Every reasonable effort must then be made to wait for the SNOD to aqend before
iniMaMngadiscussionaboutorgandonaMonwithapaMent’srelaMves.
A SNOD should be contactedon the followingpager - 07659591 642, in all caseswhereorgan
donaMon is being considered. TheOrgan DonaMon Register should also be checked (01179 757
580).If an approach for organ donaMon is undertaken in the ED a planned, collabora>ve approachinvolvingtheseniordoctor,SNODandnamedlinkednurseshouldbeundertaken.
AnydiscussionregardingorgandonaMonmustbeseparatedfrominformaMonregardingprognosis.This ‘de-coupling’ of ‘breaking bad news’ and an approach regarding organ donaMon allows
relaMvesMmetobegintounderstandtheposiMontheirrelaMveisin.OrgandonaMonmustnotbe
raisedunMlitisclearthatrelaMveshaveunderstoodandacceptedtheclinicalsituaMon.
Agreen foldercontaining informaMon relaMng toorganandMssuedonaMoncanbe found in the
officebehind‘seeandtreat’.InformaMonisalsoavailableontheintranetorfromtheSNOD.
TissueDonaMon (corneas, heart valves)must be considered in all paMents a\er death (24 hour
NaMonalReferralCentre–08004320559).
�
VerificaMonofdeathmustbecompletedasperNBTpolicyanddocumentedonNBTverificaMonof
deathpaperwork
All deathsmust be reported to the coroner byway of a hospital death reportwhich should be
completedbytheTTL.RecepMonstaffwillfaxthistothecoroner.
Nursing staff must complete a deceased paMent record which ensures GP’s are noMfied and
informaMoncollatedforfollow-upandaudit
In the event of a paediatric trauma/death, ‘Form A’ - noMficaMon of child death, must be
completed.Theconsultantcommunitypaediatrician(contactedviaBRIswitchboard-76100)and
AnnFry(namednurseforchildprotecMon-01173232363)mustbecontacted
RelaMves shouldbegiven the ‘WhenSomeoneDies’ leaflet.This containspracMcalguidanceanddetailsofsupportservices.Amemberofthebereavementteamwillcontactadeceased’sfamily
forfollow-upandsupport
Any further informaMon or guidance required please speak to the ED nursing team who are
experiencedandtrainedinEDbereavementcare.
FollowingDeath
�47
�
1. EndofLifeCareforAdultsintheEmergencyDepartment,RoyalCollegeofEmergencyMedicineBestPracMceGuidance,March2015
2. OrganDonaMon and the EmergencyDepartment: A Strategy for ImplementaMon of Best PracMce,OrganDonaMon and the Emergency
DepartmentStrategyGroup,NHSBloodandTransplantService,November2016
References
�48
OPERATIONAL
GUIDELINES
AIRWAY&ANAESTHESIA
�50
� EmergencyAnaesthesiaforMajorTrauma
1. Emergency anaesthesia for themajor trauma paMent is a high risk intervenMon that has
significantpotenMalbenefits.
2. TheanaestheMstaqendingamajor traumawillbeaminimumofST5 intheir trainingand
willhavereceivedappropriateorientaMontothisdocumentandtheresuscitaMonbays.
3. RSIisindicatedwhenthebenefitsoutweighthepotenMalrisks–thisisaclinicaljudgement.
The decision to RSI will be made by the Trauma Team Leader and the trauma team
anaestheMst(s).
4. ItisstronglyrecommendedthatketamineisusedastheinducMonagentofchoiceinmajor
trauma.
5. Vasopressors should be avoided in the acute phase ofmajor trauma in all but themost
excepMonal circumstances; preference is for blood product transfusion and balanced
anaesthesia.
6. Inalmostall traumapaMents, itwillnotbeappropriateorpossibletowakethepaMentor
reversemusclerelaxantsonceadministered. Intheeventofairwaydifficulty,Therelevant
DASalgorithmsshouldbeadheredto.
7. In addiMon to standard intubaMng equipment, consideraMon of videolaryngoscopy and
equipmentforPlanB&PlanDCICVmustbeconfirmedinallcases.
�
RapidsequenceinducMonofanaesthesia(RSI)inmajortraumaisperformedtopreventaspiraMon
of gastric contents in paMents who are inadequately starved; to stabilise physiology; and to
facilitate invesMgaMon and treatment. The essenMal features of RSI are safety, pre-oxygenaMon,
intravenous inducMon(usingapre-determinedinducMondose), inserMonofatrachealtubeprior
tomechanicalvenMlaMonofthelungsandtransfertoradiologyordefiniMvecare.ItisimperaMveto
avoidhypoxia,hypercarbia,hypotensionandaspiraMonduringtheprocedure.
EmergencyanaesthesiaforthemajortraumapaMentisahighriskintervenMonthathassignificant
potenMalbenefits.Ifperformedpoorly,anaesthesiainthenon-theatreenvironmentforapaMent
populaMon that o\en have unstable cardiovascular and respiratory systems can result in
unnecessarymorbidityandmortality.
EmergencyAnaesthesiaForMajorTrauma
Background
�51
The purpose of this standard operaMng procedure is to provide a consistent, standardised
approachtoemergencyanaesthesiainmajortrauma,reducingthecogniMveloadandthepotenMal
forhumanerrorandavoidingsignificantpaMentharm.
TheanaestheMstaqendingamajortraumawillbeaminimumofST5intheirtrainingandwillhave
receivedappropriateorientaMontothisdocumentandtheresuscitaMonbays.Theyarepartofthe
majortraumableep,butcanbecontactedonbleep9034iftheyhavenotaqendedoratraumacall
hasnotgoneout.
�
RSI is indicatedwhenthebenefitsoutweighthepotenMalrisks–this isaclinical judgement.The
decisiontoRSIwillbemadebytheTraumaTeamLeaderandthetraumateamanaestheMst(s).
PossibleindicaMonsforRSIinclude,butarenotlimitedto,thefollowingcategories:
A. Airway–ObstrucMonor impendingobstrucMon. Thiswould includea reduced consciouslevel with loss of airway reflexes, seizures resistant to treatment or head injuries. AGlasgow Coma Score (GCS) less than 15 is an indica>on to consider RSI to op>miseoxygena>onandven>la>on.AGCSonalofcases.
B. Breathing–OxygenaMonandvenMlaMonareinadequateorpotenMallyinadequate.C. Clinical course–e.g. thepaMentwithmulMple contaminatedopen fractures thatwill be
heading to theatre imminently; anaesthesia will facilitate further invesMgaMon and
management.
Inmassivehaemorrhage,anaesthesiawillallowconMnuedresuscitaMon,butconsideraMonshould
begiventoadministraMonofbloodproductstocounteracttheinstabilityofinducMon.
In some circumstances anaesthesia canbe administered for humane reasons, e.g. extremepain
fromsignificantburn injuries,orhighlyagitatedorcombaMvepaMents inwhomanaesthesiawill
facilitatefurthermanagement.
InmakingthedecisiontoperformanRSI,numerousrisksmustbeconsidered:
• An>cipatedDifficultAirway:anyindicaMonofadifficultairwaypre-inducMonwillhavetobecarefullyconsidered.
• Anxiety of the Intubator:anxiety for any reason can affect judgement and performance;thiswillclearlyhampertheRSIprocessandfurtherincreasethepossibilityofharm.
• Personnel-Arethemostappropriatepersonnelavailabletoperformtheprocedure?IfnothowlongunMltheyareavailable?
• Resources–AreanyaddiMonalresourcesessenMaltotheprocessthatarenotpresent?
Indica>onsforRSI
�52
AIRWAY
&
ANAESTHESIA
�
Briefing:• Whenrespondingtoamajortraumathetraumateamleaderwillprovideabriefingofthe
inboundpaMent.
• Itmaybepossiblea\ertheiniMalbrieftodetermineifanaesthesiaisrequired.AtthisMme
theRSIchecklistcanbeusedtoguidepreparaMon(AppendixG,page253).
• ItistheresponsibilityoftheanaestheMsttocheckthepresenceofequipmenttheymaywishtouse.
Environment:• The majority of major trauma paMents are received into a resuscitaMon bay in the
EmergencyDepartment. (AppendixC,page233)Ensure there is360-degreeaccess to the
paMenttoallowforfurtherintervenMonsasrequired(e.g.thoracostomy)
• Lownoiselevel–allowseffecMveteamcommunicaMon.
Iden>fyroles:• Manualin-linestabilisaMon,ifsuspectedcervicalinjury.• 1stIntubator• 2ndIntubator(EitherBleep9030anaestheMcconsultantorTTL)• AirwayNurse–airwayequipment,cricoidpressureandexternallaryngealmanipulaMon.• Drugdelivery
Monitoring:• Fullmonitoring(ECG,NIBP,SpO2,EtCO2).Ensuremonitoringisswitchedon,parMcularlythe
EndMdalCO2moduleasittakes1-2minutestowarmup.
• DonotdelayRSIforinserMonofarterialline.
�
Suc>on:• ConfirmsucMonisworkingwithappropriatesized“yankauer”sucMoncatheteraqachedand
placedontherighthandsideofthepaMents’head. Itmaybeappropriatetoarrangefora
second sucMon unit to be available if significant, hard to manage, airway soiling is
anMcipatede.g.maxillofacialtrauma.
Prepara>on
Equipment
�53
Ven>lator:• ThetraumaresuscitaMonbayshaveaDrägerOxylog3000venMlator.• ThevenMlatorshouldbetestedpriortouse.• ConfirmsuitableiniMalseNngsforthepaMent:e.g.Mdalvolumesof400mL,respiratoryrate
18breaths/minute,PEEP5cmH20,onaConMnuousMandatoryVenMlaMonseNng.Theaim
is to achieve Mdal volumes of 6mL/kg (ideal body weight) with a minute venMlaMon
appropriatetothedesiredEtCO2.
• Note the peak pressure at commencement of venMlaMon, adjusMng pressure alarms
accordingly.Change inpeakpressure isanearly indicaMonofexpandingpneumothoraces,
orspontaneousbreathaqempts.
• Ensurecorrecttubingisaqachedandthecircuittestedforanyleaks.• Ensureaself-inflaMngbagwithoxygentubingisimmediatelytohand,incaseofvenMlator
failure.
Videolaryngoscope:A CMAC videolaryngoscope is available; if it is not immediately available in the emergency
department contact the anaestheMc co-ordinator (Bleep9666) toborrow fromLevel 2 theatres.
Arrangeearlytoavoiddelay.
Airwayequipment:shouldbeplacedontopoftheairwaytrolleyreadyforuse.
Minimumlayout:• Laryngoscopex2[size3and4blade]• Bougie-rouMnelyusedinallemergencydepartmentintubaMons.• Tracheal tube with subgloNc sucMon port, endotracheal cuff tested (7.0mm ID ETT for
femaleand8.0mmIDETTformale).• CathetermountandHMEfilter• 10mlsyringe• AlternaMvesmallertrachealtube.• 2xnasopharyngealairways• 1xoropharyngealairway• Bag-maskconnectedtoO2tubing,sidestreamEtCO2aqached.• (Mapleson“C”circuitavailableifdesired)• Nasalcannula
Confirmavailabilityof:• Airway“PlanB”–SupragloNcAirwaydevice(I-gel)• AlternaMvelaryngoscope[alternaMvebladesize/type].• AnMcipateddifficultairwayequipmente.g.C-Mac.• Airway“PlanD”-Difficultairwaykit[surgicalairway]
�54
AIRWAY
&
ANAESTHESIA
�
InducMondrugsanddosewillbebasedonclinicalassessmentandpracMMonersexperienceoftheir
use.ThismustincludeconsideraMonofdrugsrecentlygivenforanalgesiaandproceduralsedaMon
inthepre-hospitalphaseofcare.
ItisstronglyrecommendedthatketamineisusedastheinducMonagentofchoiceinmajortrauma
duetoits’relaMvehaemodynamicstabilityandwidetherapeuMcmargin.A10-20%contextspecific
overdoseisunlikelytocauseharm.
Thefollowingregimesarestronglyrecommended:
• Standard“3:2:1”-Fentanyl3mcg/kg,Ketamine2mg/kgandRocuronium1mg/kgConsideraMon to slight delay (approx. 30-60 seconds) between drugs (dependent on the
paMent’s clinical condiMon) to allow the drugs to achieve maximal effect at the point of
intubaMon
• Hypovolaemic“1:1:1”-Fentanyl1mcg/kg,Ketamine1mg/kgandRocuronium1mg/kgIfseverehypovolaemiaissuspectedfentanylmaybeomiqed,insomecircumstancesitmay
be appropriate to administer a paralysing agent alone. Simultaneous administraMon of
blood products to support blood pressure is strongly recommended rather than
vasopressor/inotropeuse.
RescuedrugsVasopressorsshouldbeavoidedinfavourofappropriateinducMon/maintenancedosesandblood
products. The use of vasopressors for themanagement of hypotension due to hypovolaemia in
trauma is associated with increased mortality. In excepMonal circumstances vasopressors and
inotropesareavailableintheemergencydepartment.
Suggamadexisavailablefromlevel2theatresifanaphylaxistorocuroniumissuspected.
SpecificcircumstancesOnoccasionitmaybeappropriatetouseapropofol/opiatebasedinducMonregime.E.g.Isolated
headinjuries.
Proceduralseda>ontofacilitateinduc>onSome paMents may be agitated and uncooperaMve. They will require incremental sedaMon to
facilitatepre-oxygenaMonandinducMon.SmalldosesoftheplannedinducMondruge.g.10-20mg
Ketamine boluses Mtrated to effect. 1-2mgMidazolam can be used, parMcularly in head injured
paMents. In all cases cauMonmust be exercised and youmust be in a posiMon to immediately
maintaintheairwayandprovidevenMlaMon.
Drugs
�55
MaintenanceConMnued fentanylbolusesandPropofol infusionsareavailable formaintenanceofanaesthesia.
TheCTscannerisclosetotheresuscitaMonbays:Donotdelayatransfertoscantoawaitinfusions
to be commenced. If not immediately available maintenance can be achieved with ongoing
boluses of ketamine (10min intervals) and opiate. AlternaMvely, a fentanyl midazolam “bolus”
regimecanbeused.
Regularadministra>onofmusclerelaxantsisappropriateinmajortraumapa>ents.
�
Op>malposi>oningforpa>ent:• InthetraumapaMentwithpossibleC-spineinjurytheheadshouldbeplacedintheneutral
posiMonwithmanualinlineimmobilisaMon,andanyspinalimmobilisaMon(includingcollars)
removed.
• TheobesepaMentmayrequire“ramping”withheadandchestelevatedabovethelevelof
thepaMent’snavel.
IV/IOAccess:• Ensure two large bore intravenous access are inserted, patent, flushed and accessible.
Intraosseous devices can be used for all anaestheMc drugs in the event of inadequate IV
access.Ensurealldrugsareflushedin.EnsureIOinserMonsiteisappropriatetothepaqern
of injury. e.ghumeral inpresenceofpelvic injury. AnalternaMveopMon is inserMonofa
wideboresubclavianline.
• Simultaneous resuscitaMon with blood products may be required for haemodynamically
compromisedpaMents.
History&Examina>on:Any history and examinaMon are ideally performed before anaesthesia, but in some cases the
urgencyforairwaycontrolwilltakeprecedence.MinimuminformaMonpriortoRSIshouldinclude:
• GlasgowComaScore• Pupillarysizeandresponse• Anyevidenceofchestinjuries.(AnMcipaMngtheneedforthoracostomies).• Abdominaltendernessandguarding• NeurologicalfuncMondistaltosignificantlimbinjury• Limbmovement
Pa>entPrepara>on
�56
AIRWAY
&
ANAESTHESIA
Predic>ngadifficultairway:• History of Ankylosing spondyliMs, Rheumatoid arthriMs, previous head and neck cancer/
surgery
• Morbidobesity,prominentupperincisors,recedingmandible.• Facialtraumaorexcessivebleeding• Necktrauma(haematoma),burnstoneckorface.
Pre-oxygena>on:• For3minutes,bybagvalvemask(BVM)orWaterscircuit.• Ifagitated:facemaskwithreservoirbag+/-incrementalsedaMon(midazolamorketamine,
followedbysubsequentreducMonininducMondrugdoses).
• IninstancesofrespiratorydistressaugmentaMonofvenMlaMonwithBVMcanbeused,butis
o\endifficult.
• Pre-oxygenaMon with significant maxillofacial injuries should be done in a comfortable
posiMon for the paMent, but such that they can rapidly be re-posiMoned to facilitate
intubaMon.
• ApnoeicoxygenaMonvianasalcannulae.OninducMonofanaesthesiaflowisincreasedto15
l/min.
�
DecisiontoRSI• Appropriatepeoplealerted• Pre-oxygenaMoncommenced• Equipmentassembled• Challengeresponsechecklist(AppendixG,page253)• InducMondrugsadministered• Nasalcannulato15l/min• Cricoidpressure(ifused)• LaryngoscopyandintubaMon• Confirmtrachealtubeplacementandsecure• Cricoidpressurereleased• PaMentassessmentperformed• Preparefortransfer
Conduct-PredictedStepsinProcess
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Performarapidre-assessmentofAirway,Breathing,Circula>onandDisability.Thefollowingshouldbeac>onedandcommunicatedtotheTTLandscribe:• ConfirmaMonof tracheal tubeposiMon:Bilateral chestmovement, auscultaMon, conMnued
CO2traceonmonitoranddirectvisualisaMonattheMmeofintubaMon.
• Monitorvalues:SpO2,NIBP,ECG,EtCO2,peakvenMlaMonpressuresandminutevenMlaMon.• SetNIBPtoa1to2.5minutecycle.Thiso\enrequiresrepeaMngasthemonitorresetswhen
disconnectedfromthebaseunit.
• ANYsubsequentchangestovenMlatorseNngsormaintenancedrugs• CompleteRSIauditform.
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An>cipatedorUnan>cipatedDifficultIntuba>on:• Asperthedifficultairwaysocietyguidelines(AppendixH,page254)
• InthemajorityoftraumapaMentsreversalofthemusclerelaxantisnotanopMon.
• “Can’tintubate,CANvenMlate”:asupragloNcdevicecanbeusedtemporarily. “Can’tintubate,CAN’Toxygenate”:ASURGICALAIRWAYisanappropriatesoluMon.
• AnyaddiMonal“difficultairway”equipment,isavailableviathetheatreco-ordinatororon-
callanaestheMcassistantlead.Delayinprocuringequipmentneedstobebalancedagainst
theurgencyoftheanaesthesiarequirement.
Desatura>on:• Confirmoxygensupplybytracingfromcylindertotrachealtube.
• ConfirmcorrecttubeplacementwithEtCO2andauscultaMonofthechest
• Confirmadequatecardiacoutput–NIBP,pulse,EtCO2
• Exclude/treatpathology:
‣ Pneumothorax +/- tension (O\en predictable, peak pressures/ minute venMlaMon onvenMlatormaysuggestaproblem)
‣ Anaphylaxis‣ Bronchospasmofothercausee.g.asthma‣ Malignanthyperpyrexia
PostIntuba>onChecks
EmergencyAc>ons
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AIRWAY
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ANAESTHESIA
Hypotension:ExcludethefollowingcausesofhypotensionpostinducMon:
• DruginducedvasodilaMon.
• TensionPneumothorax.
‣ Treatment involves finger thoracostomy anterior to themid axillary line in the fourthintercostalspaceontheaffectedside.
‣ Ifsuspectedandunilateraldecompressiondoesnotrelievetheproblemrepeatontheoppositesideofthechest.
‣ Ifperformedinasterilemannerwithskinprepthethoracostomymaybeconvertedtoaformalchestdrain.
• HypervenMlaMon
In low cardiac output states raised intrathoracic pressure impedes venous return and
hence a hypotensive state ensues. The effect can be reducedwith reducMon of PEEP,
earlybolusofbloodproducts,andpressurelimiMngthevenMlator.• Myocardialimpairment
Directinjury,hypovolaemia,pericardialeffusion.
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EmergencySurgicalAirway
1. ThisguidelineistobeusedinconjuncMonwiththeEmergencyAnaesthesiaSOPtoprovidea
consistent,standardisedapproachtoperforminganemergencysurgicalairway.
2. Emergency surgical airwaymay be needed either following failed intubaMon in the “can’t
intubate can’t oxygenate” situaMon or where iniMal intubaMon is not possible and
oxygenaMonisnotpossiblebyothermeans.
3. Surgicalairwayequipmentshouldberemovedfromthedrawerinthedifficultairwaytrolley
whenitisanMcipatedthatanairwaywillbeparMcularlydifficult.
4. TheDASunanMcipateddifficultintubaMonalgorithmshouldbefollowedincallcases.
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ThepurposeofthisstandardoperaMngprocedure,inconjuncMonwiththeemergencyanaesthesia
SOPistoprovideaconsistent,standardisedapproachtoperforminganemergencysurgicalairway.
This may need to be performed either following failed intubaMon in the “can’t intubate can’t
oxygenate”situaMonorwhereiniMalintubaMonisnotpossibleandoxygenaMonisnotpossibleby
othermeans.
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Thesurgicalairwayequipmentshouldberemovedfromthedrawer inthedifficultairwaytrolley
whenitisanMcipatedthatanairwaywillbeparMcularlydifficult.Forexample:
• Airwaytrauma
• Difficultanatomy
• Burnstofaceandneckprecludingjawmovement
• Possibleairwayburns
• Severemaxillo-facialtrauma
Thetechniquesuggestedminimisestwocommonlyencounteredproblemsnamelybleedingfrom
the incision and loss of the incision into the airway before or during tube inserMon. It differs
slightlyfromtheDASalgorithm.
EmergencySurgicalAirway
Background
SurgicalCricothyroidotomy
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AIRWAY
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ANAESTHESIA
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• Extend thepaMentsneckasmuchas feasible. In this seNngairwaymanagement should
takeprecedenceovertheriskofcervicalspineinstability.
• Insert a number 22 scalpel blade horizontally into the cricoidmembrane using a “stab /
rocking”technique
• Leave theblade inposiMonunMl theMpsof a tracheal dilator arepushed into the airway
incisiononeithersideofthebladeandopenedaswidelyaspossible.
• Remove the scalpel blade, rotate the tracheal dilators 90 degrees (handle caudally, jaws
cranially). Keep the jaws wide open throughout. This will facilitate easier passage of the
endotrachealtube.
• Inserta6.5mmcuffedtrachealtube(overalubricatedintubaMngbougieifnecessary) intotheholeheldopenbythedilators.
• Inflatethecuff,confirmtubeposiMoninthenormalwayandcommencevenMlaMon
• FixthetubeintoposiMonwithaMeorElastoplast.
• Theprocedureshouldtakearound30seconds
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Method
Cricothyroidotomy technique. Cricothyroidmembrane palpable: scalpel technique; ‘stab, twist, bougie, tube’.
(A) IdenMfy cricothyroid membrane. (B) Make transverse stab incision through cricothyroid membrane. (C)
Rotatescalpelsothatsharpedgepointscaudally.(D)Pullingscalpeltowardsyoutoopenuptheincision,slide
coudeMpofbougiedownscalpelbladeintotrachea.(E)Railroadtubeintotrachea.
Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adultsC. Frerk, V. S. Mitchell, A. F. McNarry, C. Mendonca, R. Bhagrath, A. Patel, E. P. O’Sullivan, N. M. Woodall and I. Ahmad, Difficult Airway Societyintubation guidelines working groupBritish Journal of Anaesthesia, 115 (6): 827–848 (2015) doi:10.1093/bja/aev371
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ManagementofOralandMaxillofacialInjuries
1. IniMalassessmentofmaxillofacialinjuryshouldbedonebyEmergencyDepartmentstaff
2. Theremustbeanassessmentforcervicalspineinjury.Thismustbeclearlydocumentedin
themedicalnotesanddischargesummary.
3. Specific imaging is required for maxillofacial injuries. Full imaging requirements are
describedintheguidelinesbelow.
4. The on-call maxillofacial surgical team, based at the BRI, are available 24/7 through
sw