Professional Documents
Culture Documents
ETC Manual 2018 Edite Marques Mendes
ETC Manual 2018 Edite Marques Mendes
European
Trauma
Course
THE TEAM APPROACH
Personal copy of Edite Marques Mendes (ID: 338160)
Edition 4.0
The European Trauma Course Manual
Personal copy of Edite Marques Mendes (ID: 338160)
Introduction 7
Glossary 8
Chapter 5 Shock 67
Personal copy of Edite Marques Mendes (ID: 338160)
CONTENTS | 3
The ETC Course Management Committee would like to express their gratitude to the following organisations for
their support in the development of both the ETC and this manual:
European Resuscitation Council (ERC)
European Society for Trauma and Emergency Surgery (ESTES)
European Society for Emergency Medicine (EuSEM)
European Society of Anaesthesiology (ESA)
Editorial team
Karl-Christian Thies, Greifswald, Germany
Al Mountain, Stoke-on-Trent, UK
Peter Goode, Newcastle, UK
Disclaimer
No responsibility is assumed or accepted by the authors or publisher for any injury and/or damage to persons
or property as a matter of product liability, negligence or otherwise, or from use or operation of any methods,
products, instructions or ideas implied or contained in the material herein. Because of the rapid advances in
medical science and practice, the editors recommend that independent verification of diagnosis should be made.
© European Trauma Course Organisation ivzw. All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior
written permission of the ETCO.
CONTRIBUTORS | 5
Paola Perfetti Markus Roessler Eshan Senanayake
Consultant in Emergency Medicine Lead Clinician for Prehospital Specialist Registrar in Cardiothoracic
Ospedale Civile Maggiore Emergency Medicine Surgery
University Hospital of Verona Department of Anaesthesia University Hospital Birmingham
Verona University of Goettingen Birmingham
Italy Goettingen UK
Germany
Peter A. Oakley Karl C. Thies
Retired Consultant in Anaesthesia and Simon Scott Consultant in Anaesthesia and
Trauma Consultant Orthopaedic & Trauma Critical Emergency Medicine
Royal Stoke University Hospital Surgeon University Medical Center
Major Trauma Centre Aintree University Hospital & MTC, Greifswald
United Kingdom Liverpool Germany
UK
Marcus Rall Eric Voiglio
Consultant in Human Factors, CRM, Dare Seriki Médecin Inspecteur
Emergency Medicine Consultant in Vascular Radiology Direction de l’Action Sanitaire
InPASS University Hospitals of South Division de Santé
Reutlingen Manchester Monaco
This edition of the ETC manual, on the 10th anniversary instructors in providing an ever increasing
of the formal introduction of the course, has been an number of courses for candidates. At the time
opportunity to build on the previous good work of of writing, ETC is now being offered in over
a number of contributors and revise the information 20 countries with 120 courses annually.
and guidance in line with up to date practice.
The editors are grateful to their families for their
This would not have been possible without a lot of support over the last few months as they spent
hard work by a number of members of the Course time reviewing submissions, editing, re-editing and
Management Committee of the ETC and the editors discussing the content in numerous conference calls.
are grateful for their contributions. We would also
like to express our thanks to Ingrid Van der Haegen of We hope that the ETC manual and subsequent course
Studio Grid for undertaking the layout and formatting will provide you with the confidence and skills (both
of the manual. Many thanks to Camilla and Bibiana technical and non-technical) to maximise your ability
Personal copy of Edite Marques Mendes (ID: 338160)
Metelmann for cross-reading and correcting the to look after trauma patients and provide a strong link
manuscript. Copyright Landesklinikum Neunkirchen. in the chain of survival from serious injury.
We thank YourView (www.yourview.at) and the
emergency team of LK Neunkirchen for the cover This manual is dedicated to the victims of trauma
photographs. and their families who entrust us with their care at a
difficult and stressful point in their lives and to the ETC
This is an opportunity to also thank the ETC instructors who freely give of their time to improve
Course Directors, Course organisers and the trauma care in Europe and beyond.
Peter Goode
Al Mountain
Karl Thies
INTRODUCTION | 7
Glossary
The World Health Organisation (WHO) has identified and geography, the spectrum of responses and a
trauma as the major health care challenge of our lack of scientific data. These are addressed by the
century; worldwide, trauma claims more productive course retaining an element of flexibility; where
life years than any other disease. Although prevention effective local variations in management exist, they
is key to tackling this problem, the WHO estimates are acknowledged and recognized as an alternative
that the mortality of major trauma in Europe could approach.
be decreased 30% by improving the chain of care for
major trauma patients. The European Trauma Course On the course, you will be expected to work through
(ETC) has been developed to address this problem a series of trauma cases of varying complexity; in the
and teaches a system of care for managing trauma majority of cases, the patient’s survival is dependent
victims that reflects the reality we experience on a on the trauma team working effectively rather than
daily basis. As a person dealing with these patients, the abilities of any one individual. As in real life, your
you may already have some knowledge and skills, role in the team will change depending on the needs
Personal copy of Edite Marques Mendes (ID: 338160)
and experience of working in a team. However, these of the patient. Our goals are that by the end of the
attributes might differ from those of other people course you will have improved your knowledge, skills
that you are working with, and this can impair the and abilities as a team member and team leader. In
efficiency of the team. The ETC aims to address this by turn you will then understand how all of these enhance
enhancing your clinical skills, whilst at the same time team performance and ultimately contribute to
enabling you to become effective both as a trauma improving patient outcome. To maximise the learning
team member and team leader. opportunities available to you as a participant on the
ETC, it is essential that you read this manual; it contains
The contents of the ETC are based upon the working the very essence of what we are trying to achieve. Each
practices of the relevant specialties that treat chapter explains the processes that form the basis of
trauma patients within Europe (European Society of the workshops and the final chapter explains the roles
Anaesthesiology (ESA), European Society for Trauma you will be expected to play. Prior assimilation of this
and Emergency Surgery (ESTES), European Society for information will enable you to gain a great deal more
Emergency Medicine (EuSEM), European Resuscitation from the course than if you arrive unprepared.
Council (ERC)) and, where it exists, evidence of best
practice. In addition, the authors have tried to take Finally, we sincerely hope you enjoy your time as a
a pragmatic approach to improving trauma care by participant on the ETC. If you have, tell your friends and
recognizing that across Europe there are areas of colleagues, if you have not, tell us so we can continue
both commonality and differences in clinical practice. to improve for future participants.
The latter can be a result of variations in resources
INTRODUCTION | 9
Personal copy of Edite Marques Mendes (ID: 338160)
n T
he importance of communication in non-technical skills
Personal copy of Edite Marques Mendes (ID: 338160)
n T
he role of non-technical skills in the performance of medical interventions
n T
he use of non-technical skills in the European Trauma Course
n T
he key points of crew resource management in trauma care
Figure 1.1 The integration of non-technical skills and communication During the resuscitation
All personnel need to participate in the exchange of
Communication information by communicating effectively, by both
listening and speaking. The team leader facilitates this
Communication is an interpersonal process that by providing informative and complete feedback as
of verbal communication, body language also plays names and eye contact
an important role. Therefore care must be taken to n g
ive short focused facts and information (repeat if
n after the patient leaves (team debriefing) There is the potential for communication to fail at a
number of points and it is essential that the loop is
Team briefing closed at all stages. This is summarised in figure 1.2.
For the team to be able to work effectively together the
first aim is to ensure that everyone is introduced by name.
Close the loop
This supports communication throughout immediate and is not said
future encounters, improves situational awareness (see
later) and reduces distractions. Clear legible name tags
help addressing individual team members in a personal Close the loop
is not heard
manner. A key requirement of the briefing is for the team
leader to ensure that all personnel have the same idea of
the patient’s condition and requirements. Achieving this Close the loop
is not understood
common mental model requires two-way communication
so that team members can question and clarify issues.
By doing so a clear initial plan can be developed and
is not done!
appropriate tasks allocated according to individual
competences. However, pre-arrival information is often Figure 1.2 The Stairway of communication. All team members
limited, and the patient may arrive with more severe are responsible for how messages are delivered, understood and
injuries than expected. It is therefore useful to develop acted upon. In a complex situation of a trauma resuscitation where
an alternative strategy (Plan B, C) to cover this eventuality team members constantly exchange information conversations
(chapter 2). How and when this alternative plan will be must be unequivocal and concise in order to facilitate close loop
implemented needs to be clear to all personnel. communication. There is no place for informal conversation,
which only raises the noise level unnecessarily and distracts from
essential tasks.
Leadership is defined as ‘the process whereby n assimilating (i.e. understanding) the information
CHAPTER 1 HUMAN FACTORS, NON-TECHNICAL SKILLS AND THE PRINCIPLES OF CREW RESOURCE MANAGEMENT | 13
Decision making The ‘STOP’ procedure
This is the process whereby an individual assimilates
information, both from personal observation and (10 seconds for 10 minutes)
other team members, to allow them to carry out Resuscitation of trauma patients can be very busy,
appropriate interventions. The key decision-maker is tense situations with fast rates of activity. This can result
the team leader. in the team leader getting lots of information in a short
time. Processing this information and making focused
Medical decisions are usually not ’black or white’; decisions can be jeopardized by the team leader being
the advantages and disadvantages of a situation ‘hands on’ rather than taking a strategic overview of the
or a treatment need to be calculated. A solution situation. A technique to deal with information over-
is chosen after identifying the advantages and load is by ‘slowing down’ as it gives the team capacity
disadvantages of the options. Once made, the to organise the next steps. This procedure is most
decision has to be communicated clearly to all the beneficial in critical situations such as the beginning of
team members, followed by appropriate checks to the diagnostic process, treatment, planning treatment
confirm understanding and implementation. The priorities with an unexpected deterioration in patients
patient’s physiological response then needs to be condition or if the team feels ‘stuck’. The procedure
evaluated; ‘did what I think would happen, occur?’ is for the team leader to announce a ‘TIME OUT’,
The answer to this question directs the planning of collect again the findings in a structured way (e.g.
Summary of non-technical skills and integration of relevant equipment and should also use manuals and
the STOP procedure other cognitive aids to learn to use the equipment and
as a backup source of information during patient care.
Non-technical skill Key point in healthcare Therefore all members of a trauma team must know
Process Actions their specific roles and responsibilities within the team.
Team working Coordination Effective communication
Exchanging information ‘STOP’ procedure n Anticipate and plan
Authority and assertiveness Exercise leadership and Anticipation is crucial for goal-directed behaviour.
followership Trauma team professionals must consider the
Assessing Anticipate and plan requirements of a case in advance and plan for the
Call for help early key milestones. They must prepare for all eventualities
Supporting others Listening and empathy and plan ahead for possible difficulties. Savvy trauma
Task management Planning and preparing Anticipate and plan professionals expect the unexpected, and when it does
Know your environment strike, they can fall back on an alternative ‘Plans B or C’ if
Prioritising Exercise leadership required. All team members should try and proactively
Set priorities dynamically “stay ahead of the game” instead of passively “falling
Providing and maintaining Use cognitive aids behind”. Using “action cards” with role descriptions
standards helps planning who in the trauma team is doing
Identifying and using Allocate tasks what; no discussion about role allocations and always
resources Distribute the workload everything ready to go.
Mobilize all available
resources n Call for help early
Call for help early Knowing one’s own limitations and calling for help is
‘STOP’ procedure not a sign of weakness. In opposite, trying to handle
Situational Gathering information Use all available information everything alone or ‘toughing’ out a critical situation
awareness Re-evaluate and share is dangerous behaviour. In general, help should be
information called early rather than late. It is important to know in
Recognizing and Allocate attention advance who is available and how to call for help and
understanding ‘STOP’ procedure to plan for how best to use the help when it arrives.
Anticipating Anticipate and plan Typical triggers for calling for help are:
Decision making Identifying options Planning and preparing - when there are too many tasks to do
‘STOP’ procedure - when the situation is already serious (e.g., cardiac
Balancing risks and Prevent and manage errors arrest, difficulty securing the airway)
selecting options ‘STOP’ procedure - when serious problems are getting worse or not
Re-evaluating Re-evaluate repeatedly responding to the usual manoeuvres
Set priorities dynamically
n E xercise leadership and followership with
assertiveness
A team needs a leader. Someone has to direct, distribute
tasks, collect information, and make key decisions.
However, leadership does not mean knowing more
CHAPTER 1 HUMAN FACTORS, NON-TECHNICAL SKILLS AND THE PRINCIPLES OF CREW RESOURCE MANAGEMENT | 15
than everybody else, doing everything alone, or putting ambulance service, which ensures that blood products
other people down. Leadership is co-ordination, are available on patient arrival at the hospital. Similar
planning, deciding, and distributing tasks through clear protocols exist for other trauma emergencies e.g. the
communication. Good followership requires excellent need for immediate operating room or airway disasters.
NTS; trauma team members need to be open minded,
know their environment and the care processes involved; n Communicate effectively—speak up
they need very good communication skills to keep up Communication is key in complex team situations. Good
with a dynamic management plan, which can change teamwork depends on everybody being on the same
without warning. To a certain extent team members page. Clear and concise communication helps to ensure
need to ‘go with the flow’ and follow directions. that the team ‘shares the same mental model’ throughout
the resuscitation and consequently works into the
On the other hand this does not mean that team members same direction. This requires a continuous exchange
should shut down their brains. As the team leader, they of information between all team members, which can
also need to stay proactively ahead of the game; they are easily lead to communication overload with essential
the operational element of the trauma team fulfilling their information being lost. Verbal communication during a
allocated tasks and supporting other team members at resuscitation must be concise and to the point. To ensure
the same time. It is not good enough if nothing gets done that a message is understood and acted upon the SBAR
unless it is explicitly ordered. The TTL remains ‘hands format has been introduced in health care (Table 1.5).
this” -sometimes also called “cognitive tunnel fact, “assumptions” are a very common cause of errors
vision.” In this type of error, attention is focused on and failures in team performance, with catastrophic
only one possibility and other (possibly or actually effects. Example: The team leader assumes that the
correct) alternatives are not taken into account. blood glucose was checked by the ambulance team,
Example: Placing a tourniquet on the thigh to stop and that they would have told if it were low. Or the
bleeding from an open fracture/amputation and not assumption that we all share the same mental model…
considering additional pelvic fracture and not placing Always check your assumptions!
a pelvic sling. Or treating the trauma patient and not
considering underlying heart disease (e.g. myocardial n Use cognitive aids
infarction), which could have triggered the accident. Cognitive aids—such as checklists, handbooks,
2) Another fixation error is “everything but this,” the calculators, online information and smart phone
persistent search for irrelevant information and failure apps—come in different forms but serve similar
to treat a probable cause with serious consequences. functions. They make knowledge “explicit” and
Example: Assuming a bad bronchospasm after “in the world” rather than only being implicit, in
aspiration, and not considering esophageal intubation someone’s brain. Memory and cognitive functioning
as a cause. are vulnerable to error or complete failure, especially
3) Perhaps the most insidious fixation error is the in stressful situations or in phases of low human
persistent claim that “everything is OK,” in which all performance levels (after a long day, in the middle
information is attributed to artifact and possible signs of the night, in emotionally challenging situations).
of a catastrophic situation are otherwise dismissed. Cognitive aids offload memory and safeguard the
Another form of “everything is OK” is the failure to recall of critical items. (e.g. RSI-Checklist, Chapter 3;
transition from “routine mode” to “emergency mode” TRAUMATIC Algorithm, Chapter 5). They also help
when the situation demands it. This leads to a critical ensure the use of current best practices because
loss of precious time at least. Example: Assuming the during a crisis, people sometimes revert to what they
blood pressure readings are low, because the cuff is originally learned as the best, not what is the latest
too large, ignoring hypovolaemic shock as the most recommendation. Sharing the aids helps to share
likely cause of hypotension in trauma. mental models about what to do when.
CHAPTER 1 HUMAN FACTORS, NON-TECHNICAL SKILLS AND THE PRINCIPLES OF CREW RESOURCE MANAGEMENT | 17
n I mplement principles of good teamwork—coordinate between focusing on details and focusing on the big
with and support others picture and to offload certain responsibilities, tasks, or
Teamwork in multidisciplinary and multi-professional information streams to other qualified team members,
teams is at the heart of trauma care. Coordination provided that they periodically update the team leader
within a team begins before a team gathers. Knowing about the situation.
the members of a team, ideally by name, is critical. If all Multitasking should be avoided; we have to organise
members know their tasks and their roles, coordination ourselves to reduce the demand for multitasking
is easier. Team briefs before the patient arrives should episodes. Team members might “not hear” each other,
be standard. This is described in detail in chapter 2. if they are doing (or thinking) something else. “Hearing”
During the resuscitation, the TTL more or less frequently requires allocation of attention to ensure “listening”!
calls stop procedures to update all team members on
the progress of the resuscitation and to coordinate the n Set priorities dynamically
team’s activities (10-for-10). “Dream teams” support each Dynamic situations demand dynamic measures with
other continuously, with everybody looking after each decisive, purposeful preliminary decisions and actions
other. Professional team members do not need to “like that are constantly re-evaluated and modified as
each other”, to perform as best for the patient as possible. new information becomes available or the results of
treatment are apparent. What was not a right move at
n Allocate attention wisely one time may become the right move at another. In
InPASS InPASS
CRM Key Points
PATIENTENSICHERHEIT
FOR-DEC
PATIENTENSICHERHEIT
Dynamic Decision Making (Lufthansa CRM-Course) From Rall & Gaba in Miller‘s Anesthesia 7th edition
Opt
assertiveness.
tio
ks
www.inpass.de www.inpass.de
Figure 1.5 Pocket cards containing the 15 key points of CRM are helpful to facilitate learning
Further information
n A
naesthetists’ Non-Technical Skills (ANTS) System
http://www.abdn.ac.uk/iprc/ants/
n F
lin R, Patey R, Glavin R, Maran N. Anaesthetists’
CHAPTER 1 HUMAN FACTORS, NON-TECHNICAL SKILLS AND THE PRINCIPLES OF CREW RESOURCE MANAGEMENT | 19
Personal copy of Edite Marques Mendes (ID: 338160)
The composition of the trauma team can vary than large centres;
considerably depending on the regional system and n an influx of large number of casualties requires
able to secure a compromised airway and provide (e.g. entrapment, vehicle roll-over, ejection from vehicle,
anaesthesisa, if required. fall from height)
Injuries suspected
n A third clinician, (B-person), who is able to assess
Signs and symptoms
the chest including ventilation and competent to n Respiratory rate, SpO2
insert a chest drain. n Heart rate, blood pressure
n A fourth practitioner (C-person), who is capable of n GCS, focal neurological deficits
Preparation
TABLE 2.2 The equipment in the trauma resuscitation bay must
be checked on a daily basis. In addition, the TTMs,
cABC both doctors and TSP, are responsible for checking the
The cABC approach helps to prioritse and structure resuscitation
of trauma victims towards the most preventable causes of death, availability and functionality of the equipment they
which are require for planned and unplanned interventions:
Personal copy of Edite Marques Mendes (ID: 338160)
available
B = chest injuries n s
uction to hand and functional
C = circulatory shock n v
entilator tested and ready for immediate use
n s
emi-rigid collars, blocks and tape
n e
scape-plan: supraglottic airway device, surgical
● a mutual awareness of limitations (of both TTL n l arge bore vascular access including large central
Intensive Care Unit (ICU) of possible needs. intraosseous), plan for catastrophic haemorrhage
n Identify if a standard primary survey is to be
followed, and formulate ‘Plan A’ together with the Finally, the TTL must:
team. Check with individual team members to ensure
n
n Ensure that TTMs are aware of an alternative that the equipment is complete and functioning
strategy, ‘Plan ’B’, e.g.: and that TTM know how to summon senior
● n eed for immediate transfer to the operating support if required.
theatre n E
nsure that the room and fluids are pre-warmed.
c ritical care
●
TTL remains ‘hands-off’. The best position for the TTL n ensure ECG and peripheral oxygen saturation
is at the foot end of the patient’s bed, which gives (SpO2) monitors are attached
him the best overview, helps retaining situational n examine the chest
awareness and maximising bandwith. n perform a lateral thoracostomy and insert ICD as
The TTL should stand next to the recording TSP (scribe) necessary
to allow for optimal communication between the two n inspect and palpate the neck
intervention is required.
Prior to the Primary Survey the patient must be
exposed to allow a complete examination and access Circulation
to vital structures. Circulation personnel:
Personal copy of Edite Marques Mendes (ID: 338160)
depending on the response, they will: (BP) and capillary refill time (CRT)
n give oxygen if the SpO is decreased; n start fluid resuscitation or give blood products
2
n provide basic and advanced airway management n examine the abdomen, pelvis and long bones
Figure 2.4 The standard views of eFAST (with the kind permission
Dieter von Ow, Kantonsspital St.Gallen, CH)
Ideally the trauma receiving area and the CT scanner Angiography and interventional radiology
should be co-located as this enables imaging to be All trauma centres should have access to angiography
performed within the first few minutes of arrival, whilst and interventional radiology services 24 hours a
resuscitation continues. When the scanner is remote, day within 30-60 minutes of request. Ideally, an
well-rehearsed procedures need to be in place to ensure interventional radiologist should be immediately
CT imaging is possible within the first hour of admission. available if the CT scan reveals active bleeding as the
Administrative delays should also be minimized by source may be amenable to treatment.
having a standardised request and protocol understood
by all departments. In some advanced systems early
whole body CT scan is carried out as part of the primary Analgesia
survey. This requires the CT scanner to be located in the
trauma bay or the shock room (fig 2.5). From both a humane and therapeutic point of view,
all trauma patients should receive appropriate pain
When scanning occurs shortly after arrival there is relief. This can be achieved using a combination of
no need to perform plain radiographs of the spine, psychological, physical and pharmacological methods.
(particularly cervical) or pelvis. However, if CT scanning
is not immediately available, plain x-rays of the chest Psychological methods
and pelvis remain part of the primary survey. Plain films Stress will make the perception of pain more acute and
of the extremities can be taken as required but again, disturbing and a combination of the following should
should not unduly delay the transfer for scanning. be used to minimise this:
n make eye contact with the patient;
Planning Round
Figure 2.6 T he patient pathway. Before the patient leaves the Emergency Department all findings need to be summarised and the priorities
established
Quantifying the intensity of pain is an essential part of The decision making process required to initiate an
initial and ongoing pain assessment. A number of tools are individual patient pathway can be quite complex and
available to assess pain. In the Emergency Department, usually requires senior multispecialty input.
whichever tool is used needs to be quick, accurate and
flexible for varying situations and ages. A commonly used Ultimately, all patients will require transfer out of the
system is the verbal rating scale where patients are asked Trauma Bay regardless of the care pathway planned.
to score their pain on a scale ranging from 0 (no pain) to The transfer should follow the concepts described in
10 (worst pain imaginable). This is repeated to assess the chapter 12.
effectiveness of the analgesia given.
It is the responsibility of the TTL to make contact with
Although regional anaesthesia can be used, it has staff in the immediate receiving unit (e.g. operating
limited applicability during the primary survey. Nerve room, ICU) to ensure that an appropriate handover is
blocks and local anaesthesia can play an important given.
role in preventing pain in invasive procedures, e.g.
chest tube insertion. Time spent by the patient in the Trauma Bay should be
minimised. Those in need of time critical interventions
(e.g. damage control surgery) should be transferred at
Summary and planning round the earliest opportunity. However this need for speed
should not be at the expense of safety. These patients
The primary survey concludes with a summary and must be packaged and moved so that resuscitation
planning round which must take no longer than 5 and monitoring by appropriately trained individuals
minutes. Its purpose is to collate all findings, review all can continue. The TTL should ensure that all relevant
measures taken so far and to establish an individual documentation remains with the patient at all times.
patient pathway (figure 2.6). A number of factors have Handovers of care are crucial moments in the patient’s
a common influence on the pathway. pathway.
They must be carried out in line with hospital guidance
Patient factors: to avoid loss of critical information.
n actual or suspected injuries
n C T scans
Summary
The initial resuscitation of the trauma patient is
best achieved by a well trained, multidisciplinary
team of Clinicians, and Trauma Support
Practitioners in a shock room environment.
Each member of the team must understand
their responsibilities and role within the team
and work within their competencies. Any
response of a critically injured patient to the
team’s interventions is dynamic and therefore
resuscitation during the primary survey is a
continuous cycle of assessment, intervention
and reassessment.
movement
n Soft tissues: bruising, pain and tenderness, swelling,
surgical emphysema
n Trachea: deviation
Chest
n Chest wall: bruising, lacerations, penetrating injury,
wheezing, crepitations
n Heart: Apex beat, heart sounds
Limbs
n ruising, lacerations, muscle, nerve or tendon
B
damage. tenderness, deformities, open fractures,
n Joint stability/mobility
n Sensory and motor function (muscle strength) of
any nerve roots or peripheral nerves that may have
been injured
Back
n Log roll, inspect the entire length of the back and
Injuries 20
FLUID LOSS BLOOD LOSS
Signs Planning Injuries
URINE
Treatment Round
CHEST DRAIN
Diagnostics: US ; CXR ;
Interventions:
Chest drain ;
Diagnostics: US ; Pelvic XR ;
Interventions:
n B
asic airway management and the use of simple airway adjuncts
n T
he use of supraglottic airway devices
Personal copy of Edite Marques Mendes (ID: 338160)
n T
echniques for ventilation of the patient’s lungs
n R
ecognising the potential for a difficult airway
n T
he use of surgical airways in the resuscitation room
the airway personnel must complete a final check of Normal breathing should be quiet, noisy breathing
equipment while waiting for the patient to arrive. indicates partial airway obstruction;
n FEEL for airflow at the mouth and nose.
On arrival at hospital, the patient’s airway must be
assessed immediately, as part of the 5-second round. If Patient’s airway is clear
there is evidence of compromise, clear and secure the Breathing should be quiet with no abnormal noises
airway using simple techniques while simultaneously and with good airflow at the mouth and nose. A clear
immobilising the head and neck. This may be with airway is associated with a normal pattern of chest
Although the patient may have a clear airway, this Basic techniques for opening the airway
does not guarantee adequate ventilation as there If there is evidence of foreign material in the airway
may be other injuries e.g. to the chest. If ventilation is it should be removed. Small amounts of blood and
inadequate, it must be supported. secretions need to be cleared from the oral cavity by
using a suction catheter. Large amounts of blood or
An obstructed airway vomit are best removed using a rigid, wide bore sucker
Obstruction may be partial or complete and sited at (Yankauer). Solid debris such as food or teeth is best
any level from the upper airway (nose/mouth) down to removed with forceps (Magill) or similar device.
the lower airway (bronchi). Common causes include:
n loss of upper airway muscle tone, usually due to a Initial manoeuvres to relieve obstruction of the airway
reduced conscious level include chin lift and jaw thrust. Assess the effectiveness
n the presence of blood, vomit or foreign bodies of these manoeuvres using the look, listen and
n trauma to the face or neck feel approach described above, whilst at all times
patients who are not deeply unconscious. It may also oxygen via a good fitting facemask with a reservoir at
be life-saving in patients with maxillofacial injuries or 15 l/min. The reservoir needs to be full before the mask
trismus. is applied and should inflate and deflate with each
breath. If spontaneous ventilation is inadequate, or
Insertion of nasopharyngeal airway (see skills section) the patient remains apnoeic despite a patent airway,
they will need to be ventilated.
KEY POINTS
Bag-mask ventilation
Indications: partial or complete airway obstruction,
particularly when trismus is present This is the simplest and most widely used device to
Procedure: insertion of a nasopharyngeal airway
oxygenate and ventilate a patient whose own efforts
are inadequate or absent. The mask covers the mouth
Complications: vomiting due to gag reflex if too long,
and nose, the bag is squeezed and its contents are
bleeding, do not use if there is a known
or suspected base of skull fracture delivered to the lungs. On release, the expired gas is
diverted to the atmosphere and the bag refills with
Common failure to insert as pushed ‘up’ the
pitfalls: patient’s nose, rather than along the floor air and oxygen if attached. When used alone, the
of the nose lungs are inflated with air (21% oxygen). This can be
increased to a maximum of around 80% if high flow
oxygen and a reservoir are attached.
Cervical spine immobilisation
At all times while managing the airway, consideration The use of a bag-mask apparatus by a single person
must be given to the possibility of injury to the cervical requires considerable skill because it is difficult to
vertebrae and spinal cord. If a patient arrives without achieve a gas-tight seal, and maintain a patent airway
their cervical spine being immobilised, this should with one hand whilst squeezing the bag with the
be achieved initially by a member of the team using other. Any significant leak will cause hypoventilation
MILS. Once the airway has been assessed and any and if the airway is not patent, gas may also be
intervention required completed, MILS should be forced into the stomach. This will reduce ventilation
replaced with a semi-rigid collar, blocks and tapes further and greatly increase the risk of regurgitation
or a well moulded vacuum mattress according to and aspiration. There is a natural tendency to try to
local policy. In patients who arrive with cervical compensate for a leak by excessive compression of the
immobilisation already applied, this will need to be bag, which causes high airway pressures and forces
removed temporarily to allow airway management, more gas into the stomach. Most of these patients will
in particular tracheal intubation or a surgical airway. ultimately need an advanced airway; a supraglottic
In these circumstances, MILS must be applied before device, tracheal tube or surgical airway depending on
any of the immobilising devices are removed and the urgency and the skills available within the team
maintained until they are fully reapplied. Tracheal members. Once an advanced airway device is in place,
intubation should not be attempted with a semi-rigid the bag can be connected to ventilate the patient.
collar in place as the procedure is made much more If there is any possibility of injury to the cervical
difficult and puts the patient at risk of oesophageal vertebrae or spinal cord, all airway interventions
intubation, failed intubation and hypoxia. must be performed while maintaining alignment and
immobilisation of the head and neck.
as a result of either ‘A’ or ‘B’ problems as well as saturation as the haemoglobin decreases (but is
‘C’ (e.g. haemorrhagic shock), and ‘D’ problems not affected by polycythaemia)
(e.g. high spinal cord injury). The oximeter probe n It is affected by extraneous light and unreliable
is attached to the tip of a digit or earlobe and the when there is excessive movement of the patient
Figure 3.1 Difficult Airway Algorithm (with permission of the Difficult Airway Society) http://das.uk.com
have generally been adopted. The main flow diagram and an emergency surgical airway is required.
of the DAS guideline is shown in figure 3.1 Although That said, practice of advanced airway management
ETC recommends the use of the DAS algorithm, it varies considerably, both in the equipment used and
is not the only difficult airway algorithm. ETC also application of the technique. Countries with physician-
recommends to verify which algorithms are in use in based pre-hospital systems will often use drugs-
your own system to assure everyone follows the same assisted tracheal intubation at an early stage, whereas
protocols in an emergency. Independent of which in other systems this will not occur until reaching
exact algorithm the Emergency Department and an anaesthetist is
Figure 3.2 Shaping the mind set; The Vortex Approach (with kind permission of Nicholas Chrimes, www.vortexapproach.org)
Insertion of a SGA device (see skills section) All patients who require tracheal intubation require
a rapid assessment to try and predict difficulty. If the
KEY POINTS assessment suggests difficulty, tracheal intubation
Indications: need for advanced airway and limited should only be undertaken by those experienced in
skills available, failed tracheal intubation managing difficult airways and with the appropriate
and failed ventilation with bag-mask equipment to deal with the possible problems. The
Procedure: insertion of a SGA device only exception is an immediate threat to life.
Complications: leak, gastric insufflation, trauma to the
airway Recognising a potentially difficult airway
Common unrecognised inadequate ventilation
A difficult airway can be divided into two main types:
pitfalls: when using the device, patient’s level of
consciousness prevents insertion 1. Difficult or impossible to oxygenate the patient with
a mask and simple adjuncts alone, which may be due
to:
Tracheal intubation n facial trauma, e.g. unstable bony injuries, lacerations;
This involves the insertion of a tube into the patient’s n cervical immobilisation
trachea via the mouth (orotracheal intubation). n upper airway obstruction, e.g. blood, vomit
The tube is placed under direct vision using a n abnormal anatomy, e.g. dysmorphic or asymmetrical
their mouth. The team leader should ensure that the n prominent upper incisors
team member tasked with airway management has the n receding mandible
q Muscle relaxant
q Vasopressor
Reference: NAP4 Report and findings of the 4th National Audit Project of the Royal College of Anaesthetists
n acroglossia
m Surgical airway
n previous surgery causing scarring This will be required when ventilation has failed using
b. Trauma: the techniques described above and the patient is
n swelling, e.g. burns becoming increasingly hypoxic. This may be the result
n facial trauma, particularly if excessive bleeding of complete airway obstruction e.g. oedema due to
n neck trauma burns or trauma to the larynx. Before proceeding to
n reduced mouth opening, e.g. presence of a cervical a surgical airway it is highly recommended to take a
collar time out (10-for 10) and discuss options with the team
briefly. The decision to create surgical airway should
Insertion of a tracheal tube (see skills section) be clearly communicated and actioned immediately.
The technique used will depend upon the skills of the
KEY POINTS team members. All team members must be trained
Indications: n eed for advanced airway, inadequate to progress to front-of-neck access, and trained
airway with basic techniques, airway at to perform a didactic scalpel technique (surgical
risk, inadequate ventilation with basic airway), by placing a wide-bore tracheal tube (6 mm)
techniques through the cricothyroid membrane into the trachea,
Procedure: insertion of tracheal tube facilitating normal minute ventilation with a standard
Complications: h ypotension (drugs), hypoxia, trauma to breathing system. Those lacking the training and
the airway, failure proposed skills of surgical airway may proceed with
Common u nrecognised oesophageal intubation, needle cricothyroidotomy, by inserting a large bore
pitfalls: bronchial intubation, hyperventilation cannula through the cricothyroid membrane into the
trachea. However, high-pressure oxygenation through
a narrow-bore cannula is associated with serious
Once an advanced airway has been inserted, morbidity. Both are temporising measures that allow
oxygenation and ventilation should commence using oxygenation and ventilation while more skilled airway
a self-inflating bag with high flow oxygen and reservoir personnel are assembled to assist the trauma team,
attached. Whilst the adequacy of oxygenation must e.g. anaesthetist or surgeon.
be checked with a pulse oximeter, ventilation is
confirmed with capnometry and ultimately by arterial
blood gas analysis.
informed, so that he amongst other team members can n be able to support ventilation using a bag-mask
be re-assigned tasks in the most appropriate manner. device with supplementary oxygen;
The most complex reorganisation of the team will be n recognising the potential for a difficult airway;
required if the patient requires tracheal intubation. n recognise the need for, and be able to create a
Once this decision has been reached, team members surgical airway.
will need to be allocated key tasks by the team
leader, appropriate to their skills and knowledge; one These cognitive abilities will be integrated with
person applies MILS, one person removes the collar the practical skills during the course workshops.
and any stabilising devices, e.g. tapes, blocks (and
subsequently applies cricoid pressure if appropriate),
one person draws up and gives the anaesthetic drugs.
These actions will be directed by the person carrying
out tracheal intubation to ensure they are coordinated
to facilitate the procedure; this person is in effect
temporarily taking control with the team leader
standing back and remaining ‘hands-off’ to retain
overview and situational awareness. In addition, prior
to any attempt at intubation, the airway personnel
must also clearly identify an escape plan with the team
leader in case of failed intubation/ventilation, e.g. use
of a supraglottic airway device or a surgical airway,
again clearly identifying the team members’ roles in
these circumstances.
Mechanical ventilation
A mechanical ventilator is usually used in
conjunction with a tracheal tube to prevent hyper-
or hypoventilation. In addition, their use will free-up
the airway personnel to assist others. However, they
should only be used by those who are trained and
competent to do so. The settings used need to be
tailored to each individual patient and guided by
frequent arterial blood gas analysis.
n d
ifficulty with access to the airway
Procedure:
n C
hoose a tube of the appropriate diameter, 7-8mm Bag-mask ventilation
for adults. Indications:
n C
heck for patency of the right nostril; some designs
n i nadequate or absent ventilation
require a safety pin to be inserted through the
flange to provide an extra precaution against the Procedure:
airway disappearing beyond the nares.
n C hoose a facemask that covers the patient’s nose
n L
ubricate the airway using water-soluble jelly,
and mouth.
insert the airway bevel end first, vertically along
n W ith one hand, apply the mask ensuring a good
the floor of the nose with a slight twisting action
seal with the patient’s face. At the same time, apply
(figure 3.7). The curve of the airway should direct it
a jaw thrust, lifting the patient’s face into the mask.
pressure if it is being applied. patient’s height; size 5 when >180 cm, size 4 when
n H olding the LMA like a pen, insert it into the mouth. 155-180 cm, size 3 when <155 cm.
n A
dvance the tip behind the upper incisors with the n P lace the patient’s head in a neutral position.
upper surface applied to the palate until it reaches n L ubricate the tip of the LT with water-soluble gel.
the posterior pharyngeal wall (figure 3.9). n M aintain MILS unless there is no risk of cervical
n P
ress the mask backwards and downwards around spine injury – in this case, flex the patient’s neck
the corner of the pharynx until a resistance is felt as slightly and extend the head.
it locates in the back of the pharynx. n I ntroduce the LT behind the incisors, and along the
n I f possible, get an assistant to apply a jaw thrust hard palate, down the centre of the mouth until
Personal copy of Edite Marques Mendes (ID: 338160)
after the LMA has been inserted into the mouth - resistance is felt or the device is fully inserted.
this increases the space in the posterior pharynx n T he cuffs are then inflated to a pressure of
with air (40 ml for a size 5 LMA and 30 ml for a size chest during inflation and observing bilateral
4 LMA); alternatively, inflate the cuff to a pressure chest movement. A large, audible leak suggests
of 60 cmH2O. malposition of the LT but a small leak is acceptable
n I f insertion is satisfactory, the tube will lift one to two provided chest rise is adequate.
centimetres out of the mouth as the cuff finds its n I nsert a bite block alongside the tube if available and
correct position and the larynx is pushed forward. secure the LT with a bandage or tape.
n I f the LMA has not been inserted successfully after
n C
onfirm a clear airway by listening over the chest during n t rauma
n o
bstruction of the airway, partial or complete, not
Complications: relieved with basic techniques
n i nadequate seal and lack of ventilation; n n
eed for respiratory support to treat hypoxia or
n a irway obstruction. n n
eed for targeted pCO management in traumatic
2
brain injury
n c
ardiac arrest
● The
induction drug produces unconsciousness,
and is followed immediately by a neuromuscular Figure 3.10 RSI in trauma patients is a complex team task that needs
meticulous preparation, clear role allocations and well rehearsed
blocking drug, using a pre-calculated dose. Both
escape strategies. Up to four persons are required to for a trauma RSI;
drugs are injected rapidly into a functioning 1st as airway operator, 2nd to maintain MILS, 3rd to administer drugs,
intravenous line with an infusion running to 4th to apply cricoid pressure. (Photograph: Grissom TE. Trauma airway
n h
ypertension due to inadequate sedation/
n Tie and adhesive tape
n
analgesia
Equipment for exhaled CO2 detection
n u
nrecognised oesophageal intubation
n Ventilator
n h
ypoxaemia (prolonged attempt, endobronchial
Failed intubation equipment
n S econd generation Supraglottic airway devices
intubation)
n t
rauma to the airway and bleeding
n S calpel cricothyroidotomy set
n r
egurgitation and aspiration
n Needle cricothyroidotomy kit with high-pressure injector
n t
ension pneumothorax
Drugs
Recent studies demostrated that combined use of fentanyl,
Scalpel cricothyroidotomy (stab – twist –
ketamine and rocuronium effectively attenuates acute hyperten-
bougie – tube technique):
sion during pre-hospital intubation, without causing significant
Indications:
hypotension in patients with major trauma. However, the choice
n l ife-threatening hypoxia and the inability to
should be guided by the operators experience and local practice
but will consist of: oxygenate by any other means
n A naesthetic induction drug/hypnotic
dioxide detector), however, this will not distinguish solution and, if appropriate, infiltrate the skin over
Figure 3.11 Scalpel cricothyroidotomy (with permission from the Difficult Airway Society)
combination of biteblocks and mandibular n Make sure to pad the nose tissue with gauze to
support from a c-spine collar, then baloon prevent pressure necrosis.
Personal copy of Edite Marques Mendes (ID: 338160)
tamponade of the mid-face is the next priority. n I f haemostasis is not achieved a Vaseline gauze can
This can be achieved with a commercial device if be inserted to pack the anterior nasal cavity.
available or a 12-Fr Foley catheter may be used. n I f there is ongoing haemorrhage from the oral
Insert the catheter into the affected nasal cavity cavity the oral cavity also can be packed with gauze
until the balloon is well into the posterior nasal
cavity. Inflate the balloon with 5 to 7 mL of saline Complications:
(posterior balloon tamponade). Pull the partially n r
isk of pneumocephalus
Nasal Intraoral
If Persistent Bleeding
Trans Arterial
Embolization OR
ECA ligation
Figure 3.12 treatment algorithm for severe bleeding in maxillo-facial trauma (with permission from Ajoy Roychoudhury)
n d
istension of the hemithorax
thoracocentesis) should be considered a technique of sufficient time for the insertion of a chest drain via a
last resort if there is no competent physician and/or separate route and the wound to be formally redressed.
equipment available.
Massive haemothorax
Tube thoracostomy (see skills section) This condition is defined as greater than 1500 ml
blood in the thoracic cavity. It is usually secondary
KEY POINTS to a laceration of either the intercostal or internal
thoracic arteries. Less commonly it results from injury
Indications: pneumothorax (simple and tension);
haemothorax to a mediastinal great vessel (e.g. pulmonary hilum)
or spillage into the pleural space from a cardiac
Procedure: open procedure; blunt dissection; 5th
intercostal space, 1cm anterior to the
laceration. Accumulation of blood in the pleural cavity
mid-axillary line compresses the lung, impairs ventilation and causes
Complications: haematoma; intercostal neurovascular
hypoxia, while at the same time causing hypovolaemia.
injury; thoracic and abdominal visceral In addition those with ongoing drainage of more
injury; infection than 200ml/hour will require urgent surgical review
Common t ube malposition (i.e. not in pleural regarding the need for thoracotomy. The signs of a
pitfalls: cavity) or slippage massive haemothorax are shown in table 4.3.
TABLE 4.3
Lateral thoracostomy
Signs of a massive haemothorax
This consists of carrying out the initial stages of a
tube thoracostomy procedure, but not inserting
n ypovolaemic shock
H
the chest drain. The technique allows rapid
n Dull to percussion over the affected hemithorax
chest decompression and is diagnostic as well
n Decreased breath sounds over the affected hemithorax
as therapeutic. A repeated finger sweep can be
n Hypoxia
performed to exclude re-accumulation of the tension
n Radiologically, in the supine position, a massive haemothorax
will result in a unilateral whiteout. This will obscure any
should the patient deteriorate again.
underlying, co-existing pneumothorax
Needle thoracocentesis (see skills section)
Diagnosis is confirmed readily by plain x-ray (figure 4.3)
KEY POINTS or sonography (figure 4.4).
Indications: d ecompensating tension pneumothorax
in a non intubated patient
Procedure: 1 4g cannula, 2nd intercostal space,
midclavicular line
Complications: lung injury, pneumothorax, bleeding from
intercostal vessels, cannula blocks or
kinks, failure to reach pleural cavity with
needle
Common misinterpreting the absence of air leak as
pitfalls: a sign that the pneumothorax has been
treated
overload/pulmonary oedema
n a nalgesia, usually in the form of intravenous
Figure 4.3 Plain chest x-ray showing a massive haemothorax Intercostal blocks, epidural analgesia and opioid/
ketamine infusions or patient–controlled analgesia
Cardiac tamponade
This should be suspected in any victim with a
penetrating wound of the chest, neck or upper
Figure 4.4 Ultrasound of the chest abdomen. A particularly dangerous site is the central
(Massive) haemothorax: Fluid (blood, hypo echoic) between chest area from clavicles to xiphisternum and between
diaphragm and thoracic wall, with an atelectatic lung section (‘half
moon’) ‘swimming’ inside. the right nipple and left lateral chest wall, anteriorly and
posteriorly, (sometimes referred to as ‘the danger box‘,
figure 4.5). Much less commonly cardiac tamponade is
Flail chest seen after blunt trauma particularly in patients who are
A flail occurs when two or more adjacent ribs are taking anticoagulants or antiplatelet drugs.
fractured, at two or more places. If conscious, the
patient will present with severe pain and rapid, shallow
breathing. Examination of the chest wall may reveal
tenderness, crepitus, bruising/abrasions or paradoxical
movement of the flail segment. Diagnostic difficulties
ventricular filling during diastole and therefore reduce equipment available. The commonest approach is
stroke volume. Initially compensatory mechanisms through a median sternotomy ideally performed in
maintain cardiac output (by increasing heart rate) the operating theatre. However this is dependent
and perfusion pressure (by increasing peripheral on the clinical urgency and status of the patient. A
vascular resistance). If the obstructive pressure thoracotomy performed in the Emergency Department
within the pericardial cavity is not released, cardiac can be effective in relieving cardiac tamponade. Only
output falls further and compensatory mechanisms when this expertise is not immediately available, and
will fail. Profound hypotension results, which in turn the patient is dying, should pericardiocentesis be
causes further myocardial injury as a consequence of considered.
reduced coronary perfusion. If not relieved promptly,
the patient will die from grossly inadequate cardiac Emergency Department thoracotomy
function and perfusion. A resuscitative thoracotomy (i.e. one performed as
an integral part of the primary survey) is potentially
The clinical signs of cardiac tamponade are shown in indicated in three groups of patients:
table 4.5, but are only seen in approximately one-third n c
ardiac arrest after penetrating trauma and less
of trauma patients. In the resuscitation room diagnosis than 15 minutes of CPR
is therefore best confirmed by sonography (Figure 4.6). n c
ardiac arrest after blunt trauma and less than 10
minutes of CPR
n r
efractory hypotension (systolic pressure <60mmHg
thoracotomy
n the patient is in extremis (i.e. about to die)
to organs (myocardium, lung, stomach, bowel, Figure 4.7 Chest x-ray showing a pneumomediastinum
oesophagus, spleen, and kidney) and laceration of
a coronary artery. Treatment of these injuries is almost always surgical
n A formal pericardial exploration will still be so an urgent consultation with a thoracic surgeon is
required irrespective of the perciardiocentesis necessary in all cases. In the short term, with suitable
findings because: expertise and equipment, intubating the patient with
● the
blood clots in the pericardial sac so there is a the tracheal tube extending past the rupture may help
significant chance of having a negative tap even stabilise the patient.
when a tamponade exists
The injury is managed using the principles already Many of these injuries are asymptomatic at
described. About 5% of these patients will require presentation so the most suggestive sign of a
formal thoracotomy, especially if there is persistent diaphragmatic injury is the proximity of the injury.
bleeding, air leakage or haemoptysis. Occasionally there are ipsilateral decreased breath
sounds. Another clue is peritoneal fluid leaking
Blunt cardiac injury through a chest drain. Typically the first suspicion
Blunt cardiac injury represents a spectrum of conditions, comes from the appearance of the chest x-ray (table
which range from minor ECG and/or lab abnormalities 4.11 and figure 4.9). Subsequently a CT of the thorax
to septal, free wall or valvular rupture. It is therefore will be required to identify the extent and site of the
a pathological diagnosis, which lacks an accurate tear.
clinical definition. The key clinical issues are; identifying
patients at risk of clinically significant blunt cardiac TABLE 4.11
injury, detecting the consequences (e.g. arrhythmias,
Chest x-ray features of a ruptured diaphragm
myocardial dysfunction) and management to prevent
adverse outcomes. These patients have usually been
n L oss of the diaphragmatic contour
exposed to major forces (e.g. a road traffic collision) and
n Stomach, naso-gastric tube or bowel gas pattern projected
so often have other injuries. within the chest
A leak from an oesophageal injury will give rise to As the clinical signs may not be clear cut, a chest x-ray
mediastinitis. This often presents as shock and severe should be taken when a pneumothorax is suspected
pain out of proportion to the apparent injuries. This (table 4.13). A typical apico-lateral pneumothorax is
is an important diagnostic clue. Pain on swallowing often invisible on the initial supine chest x-ray in up
also suggests oesophageal injury and must be to 30% of cases because the air will be lying anterior
investigated. A left-sided pneumothorax, effusion or to the lung (figure 4.11a). Consequently CT is playing
pneumo-mediastinum in the absence of rib fractures an increasingly important role in the diagnosis of
should also raise suspicions. Depending on the site pneumothorax (figure 4.11b). However its greater
of rupture, surgical emphysema or signs of peritonitis sensitivity needs to be balanced against detecting
may develop with time. small pneumothoraces which may not be clinically
due to pain and the patient cannot adequately cough, and absence of lung markings peripheral to this (figure 4.11a)
n
which increases the risk of pulmonary infection. A rim of about 1 cm on the radiograph corresponds to a pneu-
mothorax of 10% of total lung volume
Fracture of the first three ribs indicates a high-
energy transfer and should prompt a search for Supine film:
n
other underlying trauma e.g. an aortic injury, severe Deep, asymmetrical finger-like costophrenic sulcus on the
affected side
pulmonary contusion or airway rupture. Fractures of n Sharp hemidiaphragmatic border
the lower ribs increase the risk of injury to the liver and n Sharp mediastinal border
spleen. Other fractures (e.g. sternum, clavicle and or
scapula) may suggest the presence of a flail segment
so should prompt a reassessment of the ribs. In doing
this, remember that it is possible that only 50% of rib
fractures are evident on initial chest x-rays.
n
occurring either in blunt or penetrating trauma, in crush trauma patients: Different mechanism,
particularly after a blast injury to the lung. Patients different management. Injury 2013;44:60-65.
with a patent foramen ovale may have paradoxical n B
urlew CC, Moore EE, Moore FA et al. Western Trauma
systemic embolism following right-sided air embolus. Association Critical Decisions in Trauma: resuscitative
Treatment until a thoracotomy can be organised thoracotomy. J Trauma 2012;73:1359-1363.
include nursing the patient head down, expansion n S imms ER, Flaris AN, Franchino X, Thomas MS, Caillot
of the intravascular space by fluid resuscitation, J-L, Voiglio EJ. Bilateral Anterior Thoracotomy
increasing systemic arterial pressure by inotropes (Clamshell Incision) Is the Ideal Emergency
(and/or vasopressors), ventilation with 100% oxygen Thoracotomy Incision: An Anatomic Study. World J
and reduction of tidal volume of the ventilator to Surg 2013 Feb 23 [Epub ahead of print].
reduce intra-thoracic pressures. Even with these n W ise, D et al. Emergency thoracotomy: ‘How to do
interventions mortality remains high, particularly with it’. Emerg Med J 2005;22:22-24.
the neurological consequences of air entering the n A ll ultrasound images courtesy of Dr. Dieter von
cerebral vascular system. Ow, Kantonsspital St. Gallen, Switzerland. First
published in EUROPEAN HOSPITAL Vol. 25, Issue
5/16, www.healthcare-in-europe.com.
Summary
Thoracic trauma is common and contributes directly
to death in about a quarter of all trauma deaths.
Most are due to hypoxaemia and hypovolaemia.
85% of thoracic injuries can be managed with
simple measures of oxygenation, fluid and blood
resuscitation and chest tube placement. Surgical
intervention is only necessary occasionally.
n p
neumothorax (simple and tension), haemothorax. site for insertion if immediately available. This
minimises the risk of placing the tube sub-
Procedure: diaphragmatic.
n C
heck presence and function of all equipment ● when
sonography is not available or possible,
(table 4.14). identify the sternal angle and the medial end of
the 2nd costal cartilage. Count down to the correct
TABLE 4.14 level and make a mark 1cm anterior to the mid-
Equipment for tube thoracostomy axillary line.
n L ocal anaesthetic, needle and syringe ● if
it is not possible to identify the ribs, use the width
n Skin cleansing solution of the patient’s hand (i.e. the distance across the
n Artery forceps 2nd–5th metacarpophalangeal joints) below the
inferior anterior axillary border to estimate the 6th
n T he chest drain is then secured by tape, and/or when no scalpel is available to perform a thoracostomy.
anchoring sutures, and an appropriate dressing.
Knots tend to slip on the plastic tubing so use tape Procedure:
as well as sutures unless you are proficient in this n I f conscious inform the patient about the procedure
deteriorated. thoracostomy.
n R epeat the chest radiograph to confirm correct n A ttach a 14 or 16g extra-long thoracocenthesis
tube placement with all the side holes inside the cannula onto a 10ml syringe, with the needle still
pleural cavity, no kinking and resolution of the within the cannula.
pneumothorax (figure 4.13). If required, remove the n F ill the syringe with a few ml of air or saline.
dressing and/or sutures and reposition the drain. n I n view of the urgency of the situation when this
n D o not clamp the drain when there is a massive procedure is carried there will not be time for using
haemothorax; this does not reduce bleeding but local anaesthetic, but the skin should be quickly
does reduce lung expansion. cleaned.
n G ive prophylactic antibiotics (a cephalosporin or n I dentify the mid-clavicular line at the 2 intercostal
nd
clindamycin depending on local policy), at the time space (just above the upper margin of the lower
of insertion and for the first 24 hours afterward. This (3rd) rib).
will reduce the incidence of both empyema and all n A n alternative site is the 5 intercostal space, in the
th
tap attached.
n T he pericardial sac can be re-aspirated should the
signs of tamponade recur.
n E
nsure arrangements are being made for a thoracotomy. ● abdominal
viscera
n C onnect a 20ml syringe containing 10ml saline to n c ardiac arrhythmias, arrest and tamponade
n S
oft tissues:
Indications: ● central
(mediastinum):
n v ictims of polytrauma or localised thoracic ❍ size and shape
● lateral
(lungs):
Procedure: ❍ size
n A
h!: ❍ density
● use
the first 10 seconds to simply look at the ❍ edge
n A
dequacy and Accuracy: ❍ clarity of the angles
● patient’s
personal details ❍ gas under the diaphragm
● projection
of the x-ray beam (PA or AP) ❍ gas and foreign debris in the lateral chest
● exposure
of the film wall and neck
● area
of the chest on the film ● extrathoracic
soft tissues:
● degree
of inspiration ❍ foreign bodies
n A
lignment: ❍ air
● compare
the distance between the medial
edge of the clavicle and sternum on the left and Complications:
right sides n a
bnormalities missed on inspection, most commonly:
n A
pparatus: at
the apices
●
● location
behind
● the heart
● c
omplications under
● the diaphragms
in
the peripheral soft tissues and breast shadows
●
ate
Adequ
uate
Inadeq
saturation haemoglobin
haemoglobin arterial oxygen
➞ ➞
Adequacy of
cardiac output saturation
oxygen delivery
CHAPTER 5 SHOCK | 67
TABLE 5.1
Classification of shock
Type of shock Examples of causes Effect on cardiac output
Hypovolaemic Haemorrhage, interstitial (third space) losses, burns, dehydration Decreased
Obstructive Tension pneumothorax, cardiac tamponade, massive pulmonary embolus Decreased
Cardiogenic Myocardial injury or ischaemia Decreased
Distributive:
n Neurogenic Spinal cord injury (usually above T6) Decreased
n Septic Pneumonia, bowel perforation, infection (late complication of trauma), Decreased, normal or
delayed resuscitation increased
n Anaphylactic Acute allergic reaction (type I hypersensitivity) Normal or decreased
oxygen delivery. These are classified in table 5.1. All can On their own, these changes are not accurate enough
eventually lead to cellular hypoxia, microcirculatory to estimate the reduction in blood volume because of
n b
lood pressure; Pre-existing medical conditions
n r
espiratory rate; The response to trauma in these patients can vary.
n c
apillary refill time; Those with a reduced cardiorespiratory reserve due to
n s
kin colour and temperature; myocardial ischaemia, valvular disease or sympathetic
n u
rine output; neuropathy (e.g. diabetics) have a restricted ability to
n c
onscious level. compensate for acute hypovolaemia. As a result, blood
pressure can fall when relatively smaller volumes
Metabolic disturbances (blood gases) of blood are lost, leading to an overestimation of
n p H; blood loss. Alternatively, if the patient is normally
n l actate; hypertensive, haemorrhage may only lower the BP
n b ase deficit. into the normal range for that age group, leading to
an underestimation of blood loss.
CHAPTER 5 SHOCK | 69
Management of shock
Recognise the Vascular access
presence of shock (or IO) Coagulation Consider
Control
assay need for
external
Send trauma (including tranexamic
haemorrhage Identify Identify bloods &
calcium & acid
non-haemorrhagic source(s) of blood gas
causes of shock haemorrhage fibrinogen)
Fluid
resuscitation
Plan and prioritise
Give
Haemostatic/
Control Treat tranexamic
Consider balanced
haemorrhage coagulopathy acid
applying Treat as transfusion
pelvic appropriate appropriately
binder Monitor response to
guide further use of
blood/blood products
simultaneously. Specific features that the circulation there is significant lower limb trauma. The aim should
personnel will have to address are summarised in be that a tourniquet is left on for the shortest time
figure 5.3. Each of these will be considered in turn. possible, (certainly not for more than two hours), until
the source of bleeding has been controlled surgically
Haemorrhage control in the resuscitation room or by interventional radiology.
The techniques available to control haemorrhage in
the resuscitation room include: Splinting a limb is an effective way of limiting further
n direct pressure and elevation at the point of blood loss. A pelvic binder can also be life-saving
haemorrhage; when applied to severe pelvic fractures as it stabilises
n topical haemostatic dressing; the bone fragments, and decreases the pelvic volume
n tourniquets for limb haemorrhage; thereby reducing the risk of major hemorrhage. A
n splints to minimize further blood loss from long number of devices are available to temporarily bind
bone fractures; a fractured pelvis in a haemodynamically unstable
n application of a pelvic binder in a patient until surgical stabilization can be achieved (see
haemodynamically unstable patient with a chapter 7).
suspected pelvic fracture (chapter 7).
Vascular access
Having identified any external haemorrhage, one of the Peripheral venous access
circulation personnel should apply direct pressure over With overt bleeding controlled, vascular access should
the wound with an antiseptic dressing supplemented be obtained by inserting two large bore peripheral
with elevation if practical. When the bleeding stops IV lines (14 or 16g). If peripheral venous access is
or is significantly reduced, a compression bandage unavailable or fails, the alternatives are cannulation of
can be applied. If this fails to control the bleeding, a central vein (subclavian, internal jugular or femoral)
as demonstrated by bleeding through the dressing, or intraosseous (IO) access.
a further one should be applied. The next step is to
consider using a haemostatic dressing and tourniquet. Intraosseous access
Once in place these should be left until there is time to This technique can be used in patients of all ages
gain definitive control of the bleeding source. when it is not possible to cannulate a peripheral vein
and as an alternative when time or expertise limit the
Tourniquets are becoming increasingly used in the use of central access. It is simple to learn and has a low
pre-hospital environment, particularly in areas where incidence of complications.
CHAPTER 5 SHOCK | 71
1. Penetrating trauma blood pressure is an indication of raised intracranial
Patients with penetrating trauma and minimal tissue pressure and an attempt by the body to maintain
damage may have ongoing haemorrhage into a body cerebral perfusion. No action should be taken to
cavity that cannot be controlled externally. Although lower it. Isotonic fluids should initially be given
aggressive resuscitation with rapid infusion of a large at a normal maintenance rate. Otherwise, the
volume of fluid tends to raise arterial blood pressure, aim should be for a SBP > 110mmHg, a MAP of
there may be adverse effects, such as dislodgement of > 90mmHg, or normotension for the patient if known
an effective thrombus and a dilutional coagulopathy, to be hypertensive. The same targets apply to patients
leading to further haemorrhage. The priority in with isolated spinal cord injury.
these patients is emergency haemostasis either
surgically (damage control surgery) or radiologically, Assessing the patient’s response to fluid
depending on the site of haemorrhage and local resuscitation
facilities. Only essential investigations should be Essentially, there are three possible outcomes:
performed in order to minimize any delay in starting
surgery/interventional radiology, thereby reducing The patient is improving
the period of shock. Providing there is no head injury, This suggests that the combined effect of the body’s
fluid resuscitation prior to any intervention should compensatory mechanisms and the rate of fluid input
be limited to achieving a blood pressure sufficient to are greater than the rate of blood loss. Such patients
Once appropriate imaging has located the source have a head injury, but is not indicated if this is the only
of bleeding a decision should be made as to the injury. The adult loading dose of 1g is given over 10
best way to proceed; non-operative management, minutes followed by an infusion of 1g over eight hours.
interventional radiology, damage control surgery, or a
combination (table 5.3). It is essential that the members Coagulopathy in trauma
of the trauma team (including the interventional The significance of coagulopathy in trauma is often
radiologist and surgeon) decide upon the best underestimated with over one-third of civilian and
management for the patient based on all the available military trauma patients having deranged clotting on
information, both clinical and logistical. admission to the resuscitation room. All trauma patients
TABLE 5.3
CHAPTER 5 SHOCK | 73
Major Trauma?
Major Haemorrhage? Then...
T
trauma patient if within 3 hours of injury, or continued
hyperfibrinolysis:
n 1
g bolus, followed by
n 1
g infusion over 8 hours
Resuscitation n A ctivate Major Haemorrhage Protocol
Initial Transfusion Ratio 1:1:1 and consider:
R
n
n R
apid infuser and cell salvage
n T
ime-Limited hypotensive resuscitation
n P
elvic binder / splint fractures / tourniquet
n A void crystalloid use
Avoid Hypothermia n T arget temperature > 36°C
A n R
emove wet clothing and sheets
U Surgery
n A
n H
aemorrhage control, decompression,
decontamination and splintage
im surgery time < 90 minutes and conduct regular
‘surgical pauses’
Metabolic P erform regular blood gas analysis
M
n
A
Avoid n Inappropriate use of vasoconstrictors doubles mortality
Vasoconstrictors n H owever, use may be required in cases of spinal cord or
traumatic brain injury
Test Clotting n C
heck clotting regulary and target transfusion:
T
n L aboratory or point of care (TEG/ROTEM)
n A
im platelets > 100x109 /L
n A
im INR & aPTTR ≤ 1.5
n A
im fibrinogen > 2g/L
Imaging C onsider:
I
n
C
Calcium n M
aintain ionised Ca2+ > 1.0 mmol/L
n A
dminister 10mls of 10% Calcium Chloride over 10 mins
as required
must have their PT, aPTT, platelets and fibrinogen The targets to achieve in the bleeding trauma patient
measured, along with an arterial blood gas, serum include:
lactate and ionised calcium. Increasingly, point of care n Hb 7 – 9g/dl;
Coagulopathy
CHAPTER 5 SHOCK | 75
the laboratory for routine bloods and used for
Summary bedside glucose estimation.
n Inject a small volume of local anaesthetic to ease
All members of the trauma team must recognize the pain caused by injection.
and initiate treatment in shocked patients as early n F lush the system with 20ml saline to clear any
as possible. In trauma, the cause of the shock is debris or clot.
frequently multifactorial but will invariably have n F luids need to be given in boluses. This is easiest
a hypovolaemic component. Tissue hypoxia to achieve using a syringe and three-way tap.
is minimized by early assessment, constant
monitoring and appropriate interventions. The flow rates under gravity alone are not high enough
Regular reassessment is essential as any for resuscitation.
subsequent deterioration needs to be detected n Intraosseous lines need to be replaced by venous
Technique:
n The patient’s hand should rest palm down on the
all large burns should be cared for in burns centres, n f acial burns;
the management of the patient must start from the n s inged nasal hair;
initial contact because early treatment can have a n s oot in saliva or sputum;
Disability
Reduced level of consciousness, confusion and
restlessness may occur with hypoxia secondary to an
inhalation injury. However, the possibility of alcohol or
drug ingestion and the presence of other injuries must
also be considered.
Initial treatment
Dressing the wound can be achieved by loosely covering
the burn with plastic film. Hands can be placed in plastic
bags. The patient should then be kept warm with dry
blankets. Further accurate assessment of the wound
can take place at the burns centre after transfer. Topical
Personal copy of Edite Marques Mendes (ID: 338160)
Escharotomy
A circumferential full thickness burn can act like a
tourniquet and compromise the distal circulation.
Surgical division of the constriction is known as
Area Age 0 yr 1 yr 5 yr 10 yr 15 yr Adult escharotomy. There is rarely a need to perform this
A=½ head 9 ½ 8½ 6½ 5½ 4½ 3½
procedure within the first few hours, the exception
being a full thickness burn of the entire trunk that is
B=½ thigh 2 ¾ 3¼ 4 4½ 4½ 4¾
compromising ventilation. If this is carried out, note
C=½ leg 2½ 2½ 2¾ 3 3¼ 3½ that the wounds can bleed excessively as the incision
is down to areas of vascularity. Crossmatching blood
Figure 5b.2 Lund and Browder chart allows accurate calculation of for the patient, if not already done, is essential.
the % TBSA burned adjusted for age
Other initial interventions
Fluid resuscitation Ensure immunity against tetanus. In the absence of any
Any burn greater than 10% TBSA in a child, or 15% TBSA specific indications such as associated contaminated
in an adult, will require intravenous fluids to prevent wounds, there is no requirement for antibiotic
the development of burn shock. There are various prophylaxis at this stage. In contrast a nasogastric
formulae available to calculate fluid requirements, the tube and urinary catheterisation will be needed
Parkland formula is commonly used: in all patients with complex burns. As superficial
and deep dermal burns are painful, adequate pain
2-4ml Hartmann’s solution x % TBSA burned relief is a priority from an early stage. In addition to
x humanitarian reasons, pain leads to catecholamine
body weight (kg) release and may increase peripheral ischaemia and,
potentially, burn depth. Intravenous opiates should be
Use the higher value of 4ml initially. Weigh the patient given until the patient is comfortable.
or ask his/her weight as estimates are often inaccurate.
A child’s weight can be obtained by using a recognized Transfer to definitive care
formula (see chapter 11) or a Broselow tape. Half this In all cases, early contact should be made with a burns
calculated volume is given in the first eight hours from centre so that advice on initial management and
the time of injury and the second half over the next transfer can be given. The team leader needs to be
sixteen hours. Consequently many patients will already aware of the guidelines for referral taking into account
be behind with requirements by the time they arrive in the size of the burn, other indicators of complexity and
the resuscitation area. In addition, allowance has to be local policies. In most countries, all complex burns are
made for deficit due to other injuries and the patient’s managed in specialised burns centres. The following
normal maintenance fluids. A guide to the adequacy of is a guide to the types of complex burns that should
fluid resuscitation is the patient’s urine output (usually receive specialist attention.
requiring urinary catheterisation) which should be:
n 1ml/kg/h in adults
n 2ml/kg/h in children
burn of the limbs, torso or neck. n the burn wound to be cleaned and a specific
● high
voltage electrical injury; Summary
● chemical
injury >5% TBSA burnt; Although burns patients comprise a small
● hydrofluoric
acid injury (>1% TBSA burnt); proportion of trauma patients, they can be
● s uspicion of non-accidental injury, adult or distressing to the inexperienced and distract
paediatric. from other serious underlying injuries. For this
n p re-existing medical conditions: reason, management begins with a full primary
● cardiac
disease; survey to identify and treat life-threatening
● r
espiratory disease; injuries, whether or not caused by the burns.
● diabetes
mellitus; Subsequently a more detailed assessment of
● pregnancy;
the burns can be made along with discussion
● immunosuppression
of any cause; with burns experts. Appropriate management of
● hepatic
impairment, cirrhosis. those requiring transfer can then be organised.
n a ssociated injuries:
● crush
injuries;
● major
long bone fractures;
● head
injury;
● penetrating
injuries.
fluid resuscitation;
n cover burns;
Trauma care systems throughout Europe vary with elevation, direct or indirect pressure, pressure
considerably and regional guidelines for treatment dressings, tourniquets and topical haemostatic
of TCA may help tailoring patient pathways to agents.
infrastructure and resources. n Non-compressible haemorrhage is more difficult and
Resuscitative
ROSC? Thoracotomy
YES NO
Pre-hospital: immediate transport
to appropriate hospital Consider termination
In-hospital: damage control surgery of resuscitation
/ resuscitation
Figure 5c.1 T he TCA algorithm focuses on the simultaneous treatment of reversible causes
Recent evidence suggests that Resuscitative about 4 times higher in cardiac stab wounds than in
Endovascular Ballon Occlusion (REBOA) improves gunshot wounds.
survival in exsanguinating torso injuries. REBOA as
a temporary damage control procedure is a bridge
to surgical repair. REBOA can be carried out with
an embolectomy catheter advanced into the aorta
through a groin access to the femoral artery. Reduction
in blood flow below the balloon reduces perfusion
to the hemorrhagic focus. Thoracic aortic occlusion
(Zone I) can control bleeding from an abdominal
source, whereas infra-renal occlusion (Zone III) can
help controlling pelvic hemorrhage. REBOA is high-risk
procedure with the potential to cause fatal ischemic
damage to organ systems below the occlusion. Zone I
occlusion should not be longer than 30 minutes whereas
Zone III occlusion can be tolerated up to two hours.
operating theatre. RT should not be carried out if n direct control of exsanguinating thoracic
there is inadequate physical access to the patient, haemorrhage; open cardiac compression;
or if the receiving hospital is not easy to reach. n c ross clamping of the descending aorta to maintain
n Elapsed time: the time from loss of vital signs to cardiac and brain perfusion by stopping blood loss
commencing a RT should not be longer than 10 below the diaphragm;
minutes n direct repair of exsanguinating pulmonary
If any of the four criteria is not met, RT is futile and haemorrhage;
exposes the team to risks that outweigh the benefits n c ross clamping of the pulmonary hila in
cases of massive pulmonary haemorrhage or
Figure 5c.3 T he ten top tips illustrate procedural key points of resuscitative thoracotomy (with kind permission from the ‘The Secret
Chest Cracker’, Jonathan Carter)
haemorrhage protocol;
n understand how medical conditions can
Suggested Readings complicate shock management;
n how to assess, manage and monitor burned
A, Bierens JJ, Brattebø G, Brugger H, Dunning the practical skills during the course workshops.
J, Hunyadi-Antičević S, Koster RW, Lockey DJ,
Lott C, Paal P, Perkins GD, Sandroni C, Thies KC,
Zideman DA, Nolan JP; Cardiac arrest in special
circumstances section Collaborators. European
Resuscitation Council Guidelines for Resuscitation
2015: Section 4 .Cardiac arrest in special
circumstances. Resuscitation. 2015 Oct; 95:148-201.
n Kleber C, Giesecke MT, Lindner T, Haas NP,
Buschmann CT Requirement for a structure
algorithm in cardiac arrest following major
trauma: Epidemiology, management errors,
and preventability of traumatic deaths in Berlin.
Resuscitation. 2014 Mar;85(3):405-10
n Manzano Nunez R, Naranjo MP, Foianini E, Ferrada
P, Rincon E, García-Perdomo HA, Burbano P,
Herrera JP, García AF, Ordoñez CA. A meta-analysis
of resuscitative endovascular balloon occlusion of
the aorta (REBOA) or open aortic cross-clamping
by resuscitative thoracotomy in non-compressible
torso hemorrhage patients. World J Emerg Surg.
2017 Jul 14;12:30
CHAPTER 5 SHOCK | 85
Personal copy of Edite Marques Mendes (ID: 338160)
n The role of surgery and interventional radiology in managing patients with abdominal trauma
injuries are suspected further investigations (mainly CT) n peritoneal irritation caused by blood or intestinal
can be minimal. The pattern of injuries can sometimes haemodynamic state and subsequently deteriorate
be predicted from the entry site, but organs can be due to rupture of a subcapsular haematoma;
damaged even though they apparently lie away from n signs of hollow viscus rupture may take a few hours
Assessment and management Is the abdomen (or its boundaries) the likely
Having accepted that clinical examination of the cause?
abdomen in trauma is unreliable, it is not surprising The abdomen must be considered as a cause of
that it can become very insensitive in the presence of haemorrhage if the mechanism of injury is appropriate or
when dealing with penetrating injuries. effusion and left lobe liver injuries
n longitudinal view of the right upper quadrant:
A rectal examination may be required to detect rectal assess for right liver injuries, right kidney injury,
or anal blood, displaced pelvic bony fragments, anal and Morison pouch
sphincter tone, perianal sensation and in males, the n longitudinal view of the left upper quadrant: assess
position of the prostate. This can be done supine or for splenic injury and left kidney injury
Personal copy of Edite Marques Mendes (ID: 338160)
during the log roll. Vaginal examination is indicated in n transverse and longitudinal views of the suprapubic
the presence of perineal blood and when the source is region: assess the bladder and pouch of Douglas
unknown. Where there is frank blood loss per vagina,
examination should be deferred until the patient is
in the operating room. If examination of the rectum
and external genitalia does not suggest urethral
injury a catheter should be passed to measure urine
output, decompress bladder and detect haematuria. A
nasogastric tube helps decompress the stomach since
most patients will have some degree of gastroparesis
after trauma.
How can haemorrhage be controlled? Figure 6.2 a Haematoperitoneum: Fluid (blood, hypoechoic) in
It is safest to consider intra-abdominal haemorrhage the lesser pelvis, with the uterus and full bladder, separated by the
as uncontrollable and requiring urgent surgical bladder wall (on the right in image) ‘swimming’ inside.
assessment. Haemodynamically unstable patients
will require immediate surgical intervention and as
a result, the primary survey may not be completed
due to need for surgery. In the meantime controlled
resuscitation should commence using blood
products and tranexamic acid according to the local
major haemorrhage protocol and prevention of
hypothermia. In those in whom there is no immediate
indication for laparotomy, but a high degree of
suspicion, early CT scanning should be carried out. This
can also act as a precursor to interventional radiology.
In more advanced trauma systems it is possible to
simultaneously resuscitate and perform a CT scan with
very early access to haemorrhage control surgery.
positive FAST scan or fails to have a sustained response n accurate localisation of arterial bleed;
patients, damage control resuscitation (chapter 5) n technically difficult in cases of obesity, hypotension,
should be started before surgery commences; opening degloving injury, atherosclerotic disease;
the abdominal wall will cause significant hypotension n complications reported: haematoma, thrombosis,
Definitive care
Definitive care is provided after complete resuscitation
of the patient. It will be based upon the response to
treatment, the results of all the investigations, the
extent of all the abdominal injuries identified and the
surgical resources available. Most haemodynamically
stable patients with solid organ injury from blunt
and penetrating trauma may be managed without
operation. This is only possible if there is high
quality CT available to accurately assess and stage
the injuries. Once a non-operative approach is
decided upon, observation of vital parameters in a
ward with continuous monitoring and assessment
by an experienced team is mandatory. Frequent
measurement of the haemoglobin and haematocrit
is necessary as well as repeated imaging. Surgical
intervention must be possible at any time.
n How these changes affect the management of the pregnant trauma patient
The obstetrician who will care for the patient should Peri-mortem caesarean section
perform a vaginal examination. In addition to Data in trauma are lacking. In the context of ‘medical’
assessment of fetal position, the presence of vaginal cardiac arrests, it is relatively well documented that if
bleeding, amniotic fluid and any dilatation and/or resuscitation is not effective after 5 minutes, delivery
effacement of the cervix are important elements to of the fetus if over 20 weeks, is the only management
evaluate. Vaginal bleeding is present in up to 70% that will allow adequate CPR in the mother and
Personal copy of Edite Marques Mendes (ID: 338160)
of cases of placental abruption. Additional signs are possible restoration of her circulation. A decision to
uterine tenderness, contractions, and uterine irritability perform a peri-mortem caesarian section must be
(contractions induced by palpation of the uterus). made in close collaboration with the obstetrician.
their cause;
n frequent attendance at the Emergency
Department;
n self-blame for the cause of the injuries;
n delayed presentation;
harm;
n a partner insisting being present at all times;
n substance abuse;
of abdominal trauma;
n what investigations to request in a patient with
abdominal trauma;
n the role of surgery and interventional radiology
Unstable Patient
YES
Haemodynamics Stabilize?
NO
NO Intra-peritoneal or external YES
haemorrhage
Operating Room
Angio available < 30 mins?
NO
Extra-Peritoneal Pack
YES Damage Control Laparotomy
Angio-embolization
ICU
Definitive Imaging
Definitive Fixation
Pelvic binders reduce the pelvic volume and Management of acute hemorrhage in pelvic
reduce mechanical instability. trauma: an overview. Europ J Trauma Emerg Surg
2010;36:91-99.
Having worked through this chapter you are now n B
ottlang M, Krieg JC, Mohr M, Simpsom TS, Madey
ready to apply the following knowledge in the SM. Emergent management of pelvic ring fractures
abdominal and pelvic trauma workshop: with use of circumferential compression. J Bone
n understanding the different types of pelvic Joint Surg Am 2002;84A Suppl 2:43-47.
fractures; n G
anz R, Krushell RJ, Jakob RP, Küffer J. The antishock
n the signs of pelvic injury; pelvic clamp. Clin Orthop Rel Res 1991;267:71-78.
n the principles of examining the pelvis; O
sborn PM, Smith WR, Moore EE, Cothren
Personal copy of Edite Marques Mendes (ID: 338160)
n interpretation of pelvic imaging; CC, Morgan SJ, Williams AE, Stahel PF. Direct
n plan further treatment that may be required. retroperitoneal pelvic packing versus pelvic
angiography: a comparison of two management
These cognitive abilities will be integrated with protocols for haemodynamic unstable pelvic
the practical skills during the course workshops. fractures. Injury 2009;40:54-60.
n T ile M. Acute pelvic fractures: 1. Causation and
Classification. J Am Acad Orthop Surg 1996;4:143-151.
n H aemorrhage in fragility fractures of the pelvis.
●check
the name and the date of the x-ray for In Type C, (figure 7.3a,b) there is rotational and vertical
accuracy, to ensure it is the correct x-ray of the instability. Vertical shear injuries belong to this group.
patient; They can be unilateral, combined with a contralateral
an adequate pelvic x-ray should include the rotational instability or bilateral. These represent
whole pelvis and the proximal 1/3 of femurs with major trauma, which are a threat to life if not managed
an overall exposure that allows for interpretation. early and aggressively.
n A
lignment:
●t here are three rings to be checked. The sacrum Application of a pelvic binder (figure 7.9):
and the pelvic brim form the main pelvic inlet Indication:
(large ring). The two small ones are the obturator n p
atients with rotational or vertically unstable
is in line with the spinous processes. Deviation remove all objects from patient’s pockets and
from this alters the relative shape of the right and pelvic area.
left hemipelvises; n r
emember to check for the 5 p’s
fracture, which may show up as a lucency, slide upwards to the level of trochanters.
density or trabecular disruption; n W
ith the legs in slight flexion and internal rotation
● interruptions
of the ilioischial and iliopubic line close binder. The closing mechanism depends on
are hallmarks for an acetabular fracture; the various models.
● check
the acetabular margin for fractures.
n C
artilage and joints: Complications:
● the
sacroiliac joints and the symphysis pubis n increased blood loss;
Complications:
n f ailure to recognize injury to the posterior pelvis.
to resuscitation. External fixation is not used symphysis pubis. Through this incision, lesions of
as a definitive treatment, but a provisional the abdomen can also be treated, when needed.
one and is performed in the operating theatre Alternatively, a Pfannenstiel incision can be used.
under sterile conditions by an experienced n A
fter incision of the linea alba, the infero- and
n S
everal pins are inserted percutaneously into is released and the patient’s blood pressure can
Personal copy of Edite Marques Mendes (ID: 338160)
the iliac wing or in the iliac bone above the fall dramatically.
acetabulum (figure 7.10). n T
he void, which has been created by the
n T
he pelvic ring is reduced carefully. disrupted soft tissues and the haematoma, is
n T
he pins are connected to each other with bars, packed with sterile gauze bandages. The counter
which bridge the pelvic ring anteriorly. pressure provided by the stabilized pelvis on the
n T
his creates good anterior stability, additional traumatized soft tissues and torn small vessels
stabilization of the posterior pelvic ring is needed arrests bleeding.
in vertically unstable pelvic ring lesions. n T
he abdominal wall is closed over the gauzes. A
n p
in tract infection. Complications:
n d amage to organs within the true pelvis;
n i nfection.
Figure 7.10 Application of an external pelvic fixator Figure 7.11a,b Pelvic packing
Evidence base: Consensus meeting BOA and BAUS 2015. www.nice.org.uk/guidance/ng37 PTO
n Use of the correct terms when describing the severity of head injury
represents the body’s attempt to maintain cerebral deteriorate and may require a painful stimulus to elicit a
perfusion in the face of raised ICP. response. It is important to recognize that the minimum
total score is 3; no eye opening (1), no verbal response
Patient in shock. (1) and no motor response (1). Both sides of the patient
IV fluid should be used to restore blood pressure to an should always be assessed and the best response
appropriate level for the patient until haemorrhage recorded along with a note of the difference.
is controlled (chapter 5). Following this, aim for a
MAP >90mmHg to prevent the adverse effects of TABLE 8.2
hypotension on cerebral perfusion. Initially a bolus
Glasgow Coma Scale
of warmed isotonic crystalloid or colloid is given,
according to local protocols, with further fluid type Eye opening:
dictated by the patient’s response. Spontaneously 4
To speech 3
It is vital that all fluids given are recorded accurately;
To pain 2
consideration should be given to early monitoring of
the status of the circulation (e.g. CVP) to guide fluid None 1
management. Motor response:
Obeys commands 6
In head trauma, glucose-containing fluids (5% glucose, Localises to pain 5
4% glucose plus 0.18% saline) are avoided because they:
Flexion (withdraws) to pain 4
n reduce plasma sodium, thereby lowering the plasma
a minimal disturbance of conscious level (GCS 14–15). n a ny cervical injuries have been detected;
n t here is on-going monitoring of all the vital signs.
In addition, to be in this category, they must not have
any of the following:
n a mnesia >10 minutes duration; Referral to a neurosurgeon
n n eurological signs or symptoms at the time of
examination; Any patient with potential or actual need for neurosurgical
n s kull fractures, clinically or radiologically; intervention should be referred to a neurosurgeon. This
Treatment strategies
Severe head injuries The following are recognized treatments for head
These patients are in coma (GCS <9) even after full injuries, but should not be used routinely and ideally
resuscitation. All require urgent neurosurgical referral, only after neurosurgical referral.
along with patients who have any of the following:
n a skull fracture and neurological signs; Mannitol
n a compound or depressed skull fracture; This is an osmotic diuretic agent that has a dual
n b asal skull fracture; effect in reducing ICP. Its early effect is due to an
n p ost traumatic epilepsy; improvement in cerebral blood flow by altering red
n drop of GCS >2 points regardless of initial cell deformability and size. It also reduces interstitial
presentation; brain volume by establishing an osmotic gradient and
n neurological disturbance lasting more than six hours; movement of water between brain tissue and blood.
n a mnesia >10 minutes; In areas where the blood brain barrier is damaged it
n a ny abnormality on their head CT scan. can however leak into the brain tissue and increase
the local water content. Initially, 0.5g/kg, of mannitol
TABLE 8.6
Medical and neurological disorders complicating
trauma
n ypoglycaemia, hyperglycaemia
H
n Non-traumatic subarachnoid haemorrhage
n Seizures
n Acute coronary syndromes
n Cardiac arrhythmia
n Cerebrovascular accident (stroke)
n Vasovagal attack
n Medications (in particular anticoagulant and antiplatelet drugs)
n Alcohol, recreational drugs
CHAPTER 8 HEAD TRAUMA | 113
Head trauma – skills Indication:
The indications for performing a head CT are given in
How to read a head CT scan table 8.3.
A head CT needs to be interpreted in a systematic
fashion in order that any significant abnormalities Procedure:
can be detected and mistakes avoided. The system n A
h!:
●start
with the scout view, this may give you a
TABLE 8.7 clue that there is a fracture. Look for breaks in
the continuity of the bone;
Different tissues and appearance on CT ●check
for soft tissue swelling, this is an indicator
Tissue Hounsfield Units Colour of a high risk of a fracture;
Bone 1000 Bright white ●base
of skull fractures are most common in the
Grey matter 37 – 45 Grey petrous ridges, look for blood in the mastoid
air cells. Intracranial air (appears black) is also
Blood 40 Grey
an indication of possible base of skull fracture;
White matter 20-30 Grey ●check
the ethmoid, sphenoid and maxillary
CSF 15 Black sinuses are all aerated. Remember, the patient
Water 0 Black will have been lying supine during the CT so a
Fat -10 Black fluid level is therefore dependent (i.e. parallel
with the floor). If you see blood check for other
Air -1000 Very black
indications of base of skull fracture.
Blood:
n
●the
appearance of blood will be determined by
its age; an acute blood clot appears hyperdense
(white), becoming isodense between 4-14 days
and finally hypodense (darker than brain tissue)
after two weeks;
●where
there is active bleeding (no clot, as
may be seen in an acute extradural) the blood
appears black, only turning white as the iron in
haemoglobin is reduced as a clot forms.
Figure 8.1 (a) CT showing normal brain matter and CSF spaces in a After trauma, blood tends to be either extradural,
n
40 year old; (b) CT showing atrophy of brain matter and expansion subdural, intracerebral, subarachnoid or a
of CSF spaces in an 80 year old.
combination. Look for signs of an:
● acute
subdural haematoma (Fig 8.3), usually ● the
position of the falx cerebri;
caused by venous bleeding, crescentic in ● any
unilateral discrepancies.
shape over the surface of the cortex and
crosses suture lines. It may also extend along Soft tissues:
n
(intraventricular); trauma;
● subarachnoid
haemorrhage. This presents as ●signs
of a fracture necessitate a review of the
hyperdense areas outlining the CSF spaces, underlying brain images.
typically into the sulci and basal cisterns. It is
often associated with hydrocephalus;
● look
for mass effect of the haematoma; midline
shift away from the haematoma, compression
(effacement) of the ipsilateral lateral ventricle
and dilatation of the contralateral ventricle;
● look
for evidence of oedema of the adjacent brain;
this appears as a darker (hypodense) region.
●definition
and symmetry of the sulci;
●differentiation
between grey and white matter;
●hyperdensity;
from blood, contrast leak,
calcification;
●hypodensity;
from air, fat, ischaemia, active
bleeding; Figure 8.2 Extradural haematoma
●presence
of the third ventricle and basal cisterns;
●compare
the cerebellar and cerebral
hemispheres, the former is usually darker
(hypodense) than the cerebral hemisphere. If
this is reversed, (the ‘reverse cerebellar sign’)
it may indicate cerebral oedema, usually as
a result of generalised hypoxia. The cerebral
hemispheres are more sensitive and develop
oedema more than cerebellum.
●third
ventricle;
●lateral
ventricles;
●fourth
ventricle;
●basal
cisterns;
●midline
shift and presence of blood; Figure 8.3 Subdural haematoma
●symmetry
of the lateral ventricles and presence
of calcified choroid plexus.
vehicle at impact, the victim’s position and the collars, spinal boards and vacuum mattresses have
presence or absence of seat belts and airbags. The been the standard of care for decades. However,
next most common causes are falls, acts of violence, there is no evidence to support this practice, and
and sports-related injuries. Children have a higher procedures around immobilisation have become
percentage of spinal cord injury compared to adults less rigid as explained below.
due to sports and water recreational activities.
Initial reception
Up to 60% of patients suffering from spinal cord trauma The goal of in-hospital management of VCI and SCI is
will have other injuries; 25-50% will have an associated to preserve neurological function while maximising the
head injury and conversely, 5-10% of patients with chances of recovery. This requires:
n intoxication
Most patients in whom VCI or SCI is suspected will n neck and/or back pain
arrive at hospital fully immobilised. However, for those n neurological deficit
patients who are not, there are two ways of transferring n severe facial injury
the patient onto an Emergency Department trolley:
The effect of spinal immobilisation on Emergency drug assisted tracheal intubation should
mortality, neurological injury, spinal stability be performed with the semi-rigid collar released and
and adverse effects in trauma patients remains replaced with MILS; this requires a team approach,
uncertain. Airway obstruction is a major cause usually under the direction of the airway doctor. After
of preventable death in trauma patients, and successful intubation of the trachea, the cervical collar
immobilisation, particularly of the cervical should be re-fastened. Supraglottic airway devices are
spine, can cause airway compromise, the useful alternatives for airway management, particularly
Personal copy of Edite Marques Mendes (ID: 338160)
possibility that immobilisation may increase in the case of difficulty with intubation. Therefore these
mortality and morbidity cannot be excluded devices, according to local protocol, should always be
available when intubation is attempted.
other injuries. The classical log roll is performed if no Do not forget to test for perianal sensation, its
immediate imaging is available and meant to detect presence may be the first indication of an incomplete
superficial lacerations, wounds, bruising, swelling spinal cord injury (see spinal cord injury below).
and deformity as external signs of vertebral column
injury. Palpation of the entire spine from occiput Myotomes
to coccyx is performed to identify any tenderness, Although strictly speaking most muscles are innervated
steps, deformations and gaps between the spinous by more than one nerve root, the functions that can
processes. Finally, if indicated, a rectal examination is be regarded as being performed predominantly by
carried out to rule out sacral sparing. Any indication muscles with one spinal root value are shown in figure
of the potential presence of vertebral column injury 9.2. The power of the muscle supplied by the spinal
mandates appropriate radiological investigation, nerves is evaluated using either the MRC (UK) scale or
according to local protocols. the ASIA scale.
Figure 9.2
Incomplete = Any sensory or motor function in S4-5
LEVEL OF INJURY
Steps 1-5 for classification
2. MOTOR (NLI) 5. ASIA IMPAIRMENT SCALE (AIS) PRESERVATION MOTOR
as on reverse Most caudal level with any innervation
This form may be copied freely but should not be altered without permission from the American Spinal Injury Association. REV 11/15
Unconscious patients ● type
III through the vertebral body of the axis.
The key to recognizing the presence of a spinal cord n Mechanism: combination of flexion/extension
injury in unconscious patients is a continued high index and rotation. In elderly patients often due to a
of suspicion and checking for features listed in table 9.1. ground level fall.
When there is spontaneous movement it is important to n S ymptoms: variable, from isolated neck pain to
note if it was voluntary or a response to pain and whether high cervical paralysis.
there is any difference between limbs. Unconscious
patients will require a detailed reassessment. Posterior element fracture of C2
n D
efinition: bilateral fractures of the posterior
TABLE 9.1 elements (pars interarticularis or pedicles) are
referred to as a hangman`s fracture.
Features suggesting spinal cord injury in an
n M
echanism: forced extension with distraction.
unconscious patient
Despite their eponym, common in deceleration
n ypotension with a bradycardia
H
injuries in which the patient’s face hits an object
n Flaccid areflexia
leading to forced cervical spine extension.
n Diaphragmatic breathing
n S
ymptoms: dependent on the degree of
n Loss of response to pain below an identified dermatomal level
dislocation. Spectrum ranges from death due
n Absence of reflexes below an identified level
to medullary compression, stroke symptoms in
Personal copy of Edite Marques Mendes (ID: 338160)
n Priapism
cases of dissection of either or both vertebral
arteries and isolated neck pain.
Types of vertebral column injuries Injuries to the lower cervical spine (C3-C7)
In spinal trauma the following injuries may be encountered: n D
efinition: vertebral fractures, subluxation and
n D
efinition: internal decapitation in which the n S
ymptoms: neurological impairment is dependent
skull becomes separated from the spinal column. on the degree of fracture displacement and has a
n M
echanism: usually results of high energy trauma high incidence in uni- or bilateral facet dislocation.
with severe flexion and distraction.
n S
ymptoms: mostly fatal due to brain stem Fractures of the thoracic and lumbar spine
destruction, apnoea or severe neurological n D
efinition: fractures are divided into the following
compromise. Survivors usually arrive at hospital entities; compression fractures, burst fractures,
intubated and ventilated. transverse fractures (Chance fractures) and
fracture-dislocations.
Atlas fracture (C1 fracture) n M
echanism: compression and burst fractures are
n D
efinition: isolated fracture of the bony ring or mainly caused by axial loading. Chance fractures
a burst fracture of C1 (Jefferson fracture) with are a result of violent forward flexion. Fracture-
involvement of the anterior and posterior arches dislocations are due to severe flexion or multi-
of the vertebra. directional forces.
n M
echanism: axial loading of the spine due to a n S
ymptoms: in thoracic fractures (apart from pure
fall onto the top or back of the head e.g. diving compression fractures) there is a high incidence
in shallow water. of neurological impairment due to the narrow
n S
ymptoms: variable from isolated neck pain to fatal. vertebral canal. In adults fractures below L2 have
n A
ssociated injuries: high incidence of a low incidence of complete neurological deficit
combination injuries with fracture of the axis and since they can only involve the cauda equina.
lower cervical spine injuries. n A
ssociated injuries: Chance fractures have a high
n M
echanism: variable (atraumatic, minor or major Spinal cord injury
trauma to head). Spinal cord injuries can be classified as either complete
n S
ymptoms: torticollis (rotation of the head). or incomplete according to ASIA. The former should
be suspected when there has not been any recovery of
Axis fractures (C2 fractures) sensory or motor function within 48 hours. However,
Odontoid fractures during the first few weeks, this diagnosis cannot be
n D
efinition: fractures of the odontoid process of made with certainty due to the presence of spinal
C2 are subdivided into: shock. This is a condition where there is a complete
type
● I extends through the tip of the dens; but transient loss of sensation, muscle tone (including
type
● II through the base of the dens; rectal tone), muscle power and reflex activity (flaccid
an accurate prognosis for the patient cannot be given functional motor recovery.
in the first days and statements as such should not be
issued in the Emergency Department. Brown-Séquard syndrome
n A
rare injury resulting from a hemi-transection of the
Incomplete spinal cord injury has a much better spinal cord and associated unilateral spinal tracts.
prognosis for some functional motor recovery. The n T
he mechanism of injury is most commonly
presence of sacral nerve root function may be a more the result of a penetrating wound from either a
stable and reliable indicator of the incompleteness gunshot or stabbing.
of an injury as it represents at least partial structural n O
n examination:
blood flow to the centre of the cord. about 75% of those with complete spinal cord
n R
esults in damage to the corticospinal and injury showing no root deficit at the level of
spinothalamic tracts, with preservation of injury or having a functional return.
the sacral spino-thalamic and peripheral n T
hose with higher cervical injuries have a 30%
n T
he chance of some functional motor recovery pneumonitis are common complications;
has been reported to be about 75%. n t ake measures to prevent hypothermia and
hyperthermia;
Anterior cord syndrome n i nstitute measures to prevent respiratory
n D
ue to the loss of function of the anterior two- complications (e.g. atelectasis, muscle fatigue,
thirds of the spinal cord. increased breathing effort and ventilation-
n U
sually the result of a flexion injury or an axial perfusion mismatch);
loading leading to a burst fracture and damage n c onsider antiemetics and analgesics;
n M
ay also be seen after a period of profound n r emoval of immobilization devices at the earliest
● loss
of motor function (flaccid paralysis), sharp a target blood glucose level within the normal
pain and temperature sensation below the lesion; range (4.0–7.0mmol/l);
● proprioception,
vibration and deep pressure n e arly contact with a specialist/spinal
sensation are all retained in the trunk and lower rehabilitation unit.
NO YES
or
Personal copy of Edite Marques Mendes (ID: 338160)
or NO RADIOGRAPHY
■ Ambulatory at any time
or
■ Delayed onset of neck pain***
or
■ Absence of midline cervical spine
tenderness
UNABLE
YES
* Dangerous mechanism:
- Fall from elevation >1m (5 stairs)
- Axial load to the head
3. Able to actively rotate neck? - RTC high speed (>100km/hr, 60 mph),
450 left and right rollover, ejection
- Motorized recreational vehicle
- Bicycle collision
** Simple rear-end RTC excludes:
ABLE - Pushed into oncoming traffic
- Hit by bus/large truck
- Rollover
- Hit by high speed vehicle
*** Delayed onset of neck pain
NO RADIOGRAPHY - i.e. not immediate onset of neck pain
Figure 9.3 Canadian C-Spine Rule. For use with alert (GCS 15) and stable trauma patients where cervical spine injury is a concern.
ED=Emergency Department
inconclusive and routine use of steroids is not supported. suspected spinal injury;
Investigations spine;
In patients suffering from major trauma and/or multiple n i nterpretation of spinal imaging.
generally reserved for patients in whom life-threatening n Connor D, Greaves I, Porter K et al on behalf of the
injuries have been excluded and/or treated. consensus group, Faculty of Pre-Hospital Care. Pre-
hospital spinal immobilisation: an initial consensus
Plain x-rays statement. Emerg Med J 2013;30:1067-1069.
A lateral cervical spine x-ray is the most common type n Moss R, Porter K, Greaves I on behalf of the
of vertebral column x-ray. A number of errors can be consensus group. Minimal patient handling: a
made when evaluating these films that can result in faculty of prehospital care consensus statement.
injuries being missed. These include: Emerg Med J 2013;30:1065-1066.
n an inadequate x-ray; n Kornhall DK, Jørgensen JJ, Brommeland T et al.
n a ssuming that a ‘normal x-ray’ rules out spinal The Norwegian guidelines for the prehospital
injury. A good quality lateral cervical spine x-ray management of adult trauma patients with
is only 85% sensitive; potential spinal injury. Scand J Trauma Resusc
n S CI due to a vascular event with no bony Emerg Med 2017;25:2.
injury. (spinal cord injury without radiological
abnormality - SCIWORA);
n f ailure to appreciate the severity of the abnormality;
CT
CT is indicated in the following situations:
n G CS ≤13 on initial assessment;
n p atient anaesthetised;
spinal x-rays;
n o ther requirement for CT scan;
n d ementia;
Indication:
n p
atients identified by either the Canadian C-Spine
Procedure:
n A
h!:
●use
the first 10 seconds to simply look at the
image and note any immediately obvious
abnormalities. Then explore the image in more
detail using the AAABCS systematic review.
n A
ccuracy and Adequacy: Figure 9.5 Lateral cervical spine film showing the four longitudinal
curves
●correct
film for the patient and personal details
correct;
●are
all 7 cervical vertebrae, the occipito-cervical n Bones:
junction and the C7-T1 junction visible? ● check
the cortical surfaces of all vertebrae for
n A
lignment: steps, breaks, or angulation;
●check
the contours of the four longitudinal ● check
C1: the laminae and pedicles, think about
curves (figure 9.5): a Jefferson fracture;
❍ anterior
– along the anterior aspect of the ● c
heck C2: the outline of the odontoid and
vertebral bodies from the skull base to T1; pars interarticularis, think about a hangman’s
❍ posterior
– along the posterior aspect of the fracture.
vertebral bodies from the skull base to T1; ● C3–T1
start at the anterior inferior corner of
❍ the
spinolaminar line – this should be the vertebral body and proceed clockwise,
smooth except at C2 where there can be checking body, pedicles, transverse process,
slight posterior displacement (2mm); laminae and spinous process. The height of the
❍ the
tips of the spinous processes – these anterior and posterior bodies should be the
should trace out a tighter curve and same. More than 2mm difference suggests a
projection of the tips should converge to a compression fracture.
point behind the neck. n C
artilages and joints:
● Check
the disc spaces, facet joints and
A break in any of these lines indicates a fractured interspinous gaps.
vertebra or facet dislocation until proven Disc spaces should be of uniform height and
otherwise. Divergence of the spinous processes similar in size to those between adjacent
is also abnormal. In some patients there is a vertebrae. Facet joints have parallel articular
pronounced loss of the normal curve of the cervical surfaces, with a gap less than 2mm. Widening
spine (lordosis). This may be due to muscle spasm, of the gap and visibility of both facets suggests
age, previous injury, radiographic positioning or unifacetal dislocation. There will also be
the presence of a hard collar. Its presence therefore anterior displacement of less than half the
only indicates that the patient may have sustained width of the vertebral body and associated soft
a cervical spinal injury. tissue swelling. If there is displacement greater
than 50%, both facets are dislocated. There will
If the film is not adequate, it must be repeated also be narrowing of the disc space, widening
with the patient´s arms pulled down to remove the (fanning) of the spinous processes and soft
shoulders from the field of view or take a ‘swimmer´s tissue swelling.
view’. If these fail, then perform CT scan.
CHAPTER 9 TRAUMA TO THE VERTEBRAL COLUMN AND SPINAL CORD | 127
● Check
the gap between C1 and the front of the Log roll
odontoid peg. Indications:
The distance between the posterior surface of n t o allow examination of the patient’s back;
the anterior arch of C1 and the anterior surface of n r emoval of the spine board;
the odontoid should be less than 3mm in adults, n i f indicated, rectal examination.
and one third by the spinal cord’). assigned as in charge and it is essential that all
n S
oft tissues: the others follow his/her orders.
●Check
the soft tissue shadow anterior to the n I f conscious, the patient should be warned what
injury will result in a haematoma that is seen as control of the patient’s head, either with the
an increase in the width of the soft tissue shadow cervical collar in place or by MILS.
adjacent to the injury. In some subtle injuries this n T hree assistants stand to the side of the patient
downwards this increases to about 21mm, or one hand and places their second hand under
the width of the vertebral body. Occasionally, the patient’s knee;
this may be seen as anterior displacement of a ● the
third places one hand under the patient’s
tracheal tube. thigh and the other under the patient’s lower leg.
It must be remembered that the stability of the As a result, the assistants’ hands are placed such
cervical spine is dependent on the ligaments that are that the three hands on the torso will be facing
not revealed on a plain x-ray. Therefore, the lateral palms down, whereas the three hands supporting
cervical film must be examined not only for signs of the leg will be palms up.
bony trauma but also clues of ligamentous damage as n T he person at the head will then identify the
this may indicate the presence of an unstable injury. command to be given that indicates the team
Markers include facet joint widening, facet joint should turn the patient towards them e.g. “I will
overriding, widening of the spinous processes, >25% count to three and we will turn the patient on three”.
compression of a vertebral body, >10° angulation n E nsure that the whole team understands and is
signs
● of ligamentous injury. at the head will control the turn of the patient
supine. The same command structure is used as
for the initial turn; “I will count to three and we
will return the patient supine on three”.
n T he count is made and the patient returned
supine on ‘three’.
n I f the cervical collar has been removed for the
Complications:
n lack of coordination and risk of injury;
n tubes and lines being displaced;
n f atigue of team members.
n Prioritizing the treatment principles of extremity injuries in the primary and secondary survey
n Assessing common fractures and soft tissue injuries by the ‘Look - Feel - Move’ approach
Personal copy of Edite Marques Mendes (ID: 338160)
n Management of common fractures and soft tissue injuries in the resuscitation room
significant morbidity;
n a relatively common source of litigation. Care should be taken however to reduce any pain
caused by clinical examination to a minimum. Many
patients with limb injuries will require x-rays but these
Assessment of soft tissue injuries requires an adequate If an injury to a major limb artery is suspected, urgent
understanding of the anatomy of the injured area. In all vascular opinion is necessary. With direct vascular
cases of penetrating trauma, clinical assessment must trauma in penetrating injuries the need for referral
be made of all structures underlying the area of the is usually obvious, however following blunt trauma
wound. When making the assessment of the damage, the clinician must maintain a high index of suspicion
consider the patient’s posture at the time of injury. and seek expert opinion if there is any doubt. The
aim is to minimise warm ischaemic time to reduce
If it is not possible to exclude underlying tissue damage, ideally to less than five hours. These
damage the patient should be referred for a patients are likely to require angiography, pre- or
specialist opinion and a formal exploration of intraoperatively.
the wound.
Tendons
Details of the wound should be quantified and Tendon injuries occur frequently in lacerations
documented. This includes: to the limbs, in particular the wrist and hand. An
n s
ite and dimensions of the wound and depth if this understanding of the anatomy is vital along with
is apparent; a systematic way of examining each body area.
n t
he state of the wound edges, e.g. ragged or Simple inspection of wounds is often misleading, as
contused; the tendon ends may retract out of sight. If there is
n p
resence of any obvious contamination; any suspicion of tendon injury, referral for a formal
n p
resence of devitalised tissue. exploration is required.
Extensive wounds
If a wound cannot be closed, and it is not suitable
to be left to heal by second intention (e.g. extensive
area, cosmetically important, risk of contracture),
The classical signs and symptoms of a fracture are: examination of the whole affected bone is undertaken
n p ain; to determine any tenderness or other features that
n d eformity; suggests damage. In doing this the clinician should be
n s welling; mindful of common fracture patterns such as:
n t enderness; n injury of the medial malleollus and/or diastasis
restricted use and in the lower limb weight bearing is with a dislocation of the distal radio-ulna joint
impaired. Some fractures, e.g. femoral shaft fractures, (e.g. Galeazzi fracture).
may be associated with significant blood loss,
requiring appropriate resuscitation and stabilisation of Interpretation of radiographs
the fracture during the primary survey. Gross fracture Increasingly, radiographs are digitalised and made
displacement can compromise surrounding soft available for viewing electronically. These images
tissues including skin and neurovascular structures. should be viewed on a screen with appropriate
For this reason, following the primary survey and resolution. Hard copy films should always be examined
provision of analgesia, the fracture should be realigned on a light box. Fractures are identified by:
by manual in-line traction to restore congruity with n a
break in the cortex of the bone on one or more
the uninjured limb without awaiting radiographs of the views;
of the injury. Only when the diagnosis is uncertain, n a
ngulation of bone, especially in children;
e.g. in fractures near joints (which can be difficult to n a radiolucent line (in the case of a distracted fracture)
differentiate from fracture- dislocations), should x-rays or a radiodense line (in an impacted fracture) across
be undertaken prior to limb realignment. However part or all of the bone at the injury site;
when the diagnosis is certain, e.g. fracture-dislocation n s
oft tissue swelling adjacent to the suspected site
of the ankle, reduction should preceed x-rays. of the fracture;
n s
oft tissue evidence of fractures (e.g. the fat pad
Fracture realignment achieves reduction of: sign in radial head fractures or a lipohaemarthrosis
n p
ain; in intra-articular knee injuries).
n b
lood loss;
n p
ressure on the soft tissues; Once a fracture is spotted on the x-ray and correlated
n r
isk of neurovascular compromise; to clinical symptoms there are a number of important
n r
isk of fat emboli. features which need to be noted:
n L
ocation: is it in the diaphysis, metaphysis or
Before obtaining x-rays, temporary splintage or support epiphysis? This predicts the healing potential and
should be applied. In the upper limb the use of a sling is important for planning what sort of fixation to
may be sufficient or it may be necessary to use a plaster use, if any.
back slab, box or vacuum splint. In the lower limb a back n Pattern: is the fracture transverse, oblique or
slab, box splint, vacuum splint or traction splint may be spiral? This indicates the stability of the fracture
appropriate depending on the site of injury. Such simple to axial loading after splinting/reduction and may
measures will help minimise pain from the fracture and determine whether operative treatment is required.
during any movement, while the x-ray is taken. n I nvolvement of a joint surface: if so, is there
https://aotrauma.aofoundation.org
Dislocations are painful and are an orthopaedic n B
OAST 4 The Management of severe open lower
emergency. They are often dealt with in the emergency limb fractures (BOA & BAPRAS consenscus 2009)
department. In any dislocation, the neurovascular n B
OAST 10 Diagnosis and management of
status of the dislocated limb should be documented compartment syndrome of the limbs (BOA &
pre & post manipulation. A typical dislocation is BAPRAS 2016)
anterior dislocation of the shoulder. It usually follows n K
ey Clinical Topics in Trauma 2016 Porter, Greaves
Limitations:
There is inconclusive evidence to the best method of skeletal stabilisation.
Personal copy of Edite Marques Mendes (ID: 338160)
Recommended incisions for fasciotomy and wound extensions. (a) Margins of subcutaneous bor-
der of tibia marked in green, fasciotomy incisions in blue and the perforators on the medial side arising
from the posterior tibial vessels in red. (b) line drawing depicting the location of the perforators. (c) mon-
tage of an arteriogram. The 10cm perforator on the medial side is usually the largest and most reliable
for distally-based fasciocutaneous flaps. In this patient, the anterior tibial artery had been disrupted fol-
lowing an open dislocation of the ankle; hence the poor flow evident in this vessel in the distal 1/3 of the
leg. The distances of the perforators from the tip of the medial malleolus are approximate and vary
between patients. It is essential to preserve the perforators and avoid incisions crossing the line between
them.
Cross-section through the leg showing incisions to decompress all four compartments
How to apply a Thomas Splint n elect the correct sized Thomas splint and take
S
all the equipment to the patient. If the splint is a
A Thomas splint can be applied as a temporary measure half ring construct, ensure that the medial side is
prior to definitive fixation of a femoral fracture or for shorter than the lateral.
transport of patients abroad (as seen in evacuation of n After the analgesia has been given, ensure patient
UK military patients from Iraq and Afghanistan) is comfortable.
n Apply skin traction taking care to protect the
Procedure malleoli and head of fibula with padding.
n Inform patient about fitting of the splint and n Apply the bandage snugly but do not make it too
traction tight.
n Provide adequate analgesia
After care:
n ne of the slings should be placed directly under
O n Check for tightness of the ring from swelling.
n The slings should be sagging and not tight. n Check Achilles tendon and malleoli for pressure
areas.
n Check for new weakness of ankle dorsiflexion
lace upper thigh strap high into groin with the poles
P
on the outside of the leg. Measure pole against leg.
The bottom of the pole should extend 1 section below
the foot. The pole can be shortened or lengthened.
NB maintain inline traction of limb
pply the ankle strap with the padded bit behind the
A
ankle. Tighten using the green strap. The yellow strap
fits over the pole and traction applied with the red
following points apply to all children: team leader and pre-hospital team. If the child’s age
n t
raumatic brain injury is the leading cause of death is known, their weight can then be approximated
and disability in all age groups followed by chest to enable the relevant equipment, drugs and fluids
injuries; to be prepared in advance (table 11.1).
n Ensure adequate immobilization of the cervical n The airwary personnel carries out the neurological
spine until a spinal injury is ruled out. Up to 75% assessment, which is mainly based on the social
of cervical spinal cord lesions are incomplete at interaction of the child with its environment and
presentation with the potential for deterioration the child's response to external stimuli. This can be
if handled incorrectly. If in doubt, assume cervical difficult at times, especially in autistic children or
spinal injury. There is no evidence to support the children with a low pain threshold. The presence
use of cervical collars for immobilisation in children. of a parent is helpful to calm the child and to help
Immobilisation of the cervical spine should be interpreting the child's behavior. The neurological
maintained with manual in-line stabilisation. assessment consists of: the paediatric GCS (table
Alternatively, children a vacuum splint can be used 11.6), pupillary response to light, and assessment
to immobilise the whole child, including head and of the motor response between all four quadrants.
neck. Involving the parents or carers may enable This is of particular importance if the child is
better immobilization. Forced immobilisation is to be anaesthetised, which makes a through
likely to cause harm and should not be applied. If neurological assessment impossible.
a C-spine injury is suspected MILS or head-blocks
should be applied if tolerated by the child. Breathing personnel
n P
rovide analgesia after discussion with the n ssess breathing pattern. This can be difficult if the
A
team leader. This should be given at the earliest child is crying but with reassurance and analgesia
opportunity to allow a more effective assessment a more accurate assessment is possible. It is
of the child. The IV route is the most appropriate important to assess the respiratory rate, symmetry
in major trauma, but if this fails, the intranasal of movement, work of breathing (whether there is
route can be used. Intranasal Fentany is ideal to any accessory muscle use) and if it is effective.
CHAPTER 11 TRAUMA IN CHILDREN | 145
n Ensure ECG and SpO2 monitors are attached, if haemorrhage protocol (MHP). The use of crystalloids
not already done so. It can be difficult at times to and colloids should be limited to avoid dilution of
assess pulse oximetry if the child is unsettled or clotting factors and aggravation of trauma induced
upset but usually with persistence and reassurance coagulopathy (TIC). As in adults, PRBC, platelets and
an accurate reading is possible. The ECG leads are FFP should be transfused in a ratio of 1:1:1. in 1-10 ml/kg
usually tolerated well. aliquots depending on the severity of hemodynamic
n Inspect, palpate, percuss and auscultate the chest. instability. TXA and factor concentrates should be
Despite minimal external evidence of injury, there given according to local protocol.
can still be significant internal injury. Pulmonary n Aim for normal blood pressure. The compensatory
contusions are the commonest thoracic injury in mechanisms for blood loss in children are different
children, and can be present even in the absence from adults. Children respond with tachycardia and
of hypoxia and hypoventilation. Most significant massive vasoconstriction, allowing them to keep
contusions will be seen on the initial chest x-ray their bloodpressure relativley stable until abrupt
but may be delayed and only seen after 48 hours. circulatory collapse ensues (Fig 11.1). Hypotensive
n Inspect and palpate the neck. Resuscitation is therefore not applicable in children.
n Perform lateral thoracostomy and chest tube The principles of damage control resuscitation in
insertion as necessary. The indications are the children are outlined in Fig. 11.2.
same as in adults. n Examine the abdomen, pelvis and long bones
n Support other team members if no chest even if there is little external evidence of injury.
intervention is required. The pelvis needs assessing only once to determine
pain or instability. The perineum should also be
T
n
R
n
n C ell salvage
n N o hypotensive resuscitation (unless post-pubertal)
n P elvic binder / splint #s / tourniquet
n L imit crystalloid and colloid use
Avoid Hypothermia n T arget temperature > 36°C
A n
n
R
W
W
emove wet clothing and sheets
arm fluids
arming blanket / mattress
U
perform damage control surgery
Personal copy of Edite Marques Mendes (ID: 338160)
Damage Control
A im surgery time < 90 minutes
Surgery
n
M
n B ase excess guides resuscitation
n If lactate > 5mmol/L or rising, consider stopping surgery,
splint and transfer to ICU
n M onitor blood glucose
A
Avoid n Inappropriate use of vasoconstrictors doubles mortality
Vasoconstrictors n H owever, use may be required in cases of spinal cord or
traumatic brain injury
Test Clotting n C
onsider TEG
T
n C
heck clotting every 15ml PRBC / kg BW
n A
im platelets > 75x109/L
n A
im INR & aPTTR ≤ 1.5
n A
im fibrinogen > 1.5g/L
Imaging n C onsider:
I
n S upine CXR and e-FAST
n C T: Most severely injured / haemodynamically unstable
patients gain most from CT
n Interventional radiology
Calcium M
aintain ionised Ca2+ > 1.0 mmol/L
C
n
n A
dminister 0.2ml/kg 10% Calcium Chloride over 10 mins
as required
n G
ive routinely after MHP Pack One
priority
of
there is over
traumatic CT-scanning.
brain
a strong injury
suggestion Onlyoffunctional
exhibit ifathere
C-spine isdifficulties
ainjury
stronga maximum acceptable time target of 4 hours from the
suggestionshould
persisting
CT-scan of a C-spine
beyond injury a Common
bechildhood.
considered. CT-scan should
Consideration be
findings injury.
considered.
include
should poor
be Consideration
school
given to should
as performance,whether be itemployment
given as to
is justified
whether it is
difficulties,
depending onjustified
poor quality
the depending
of life, and
mechanism onincreased
of the mechanism
injury andmental
the Thoracic trauma
of injuryclinical
health
child’s and thecondition
problems. child’s
The best clinical condition
or outcome
can be focused or can
after be
head
on Serious chest injuries in children are rare, but can present
focused
injury
specific on
isbody specific
achieved
regions. body
by rapidregions.
access to definitive care without visible external signs and are associated with
and minimisation of ‘secondary injury’, including significant morbidity and mortality. The high flexibility
Planning
avoidance Round of hypoxaemia, hypotension, and hypo- of the paediatric ribcage explains why even fatal chest
or hypercapnia.
The primary survey Twenty percent of
concludes withall the
children
planning
with injuries can occur without any bony lesions. Rib fractures
traumatic
round, the brain
the purposeinjuries
purpose of require
which
of which isemergency
to collate
is to all craniotomy
findings,
collate all occur only if exceptional force is involved and if present
review
for evacuation
findings, allreview
measuresofallsub-
taken
measuresor soextradural
far, and so
taken haematoma.
establish
far, andan should raise suspicion regarding further underlying
individual
This should
establish patient
an be undertaken
pathway
individual (figure
patient as fast 2.5).possible,
pathway Depending
(figurewith ona
2.6). serious injuries. A chest x-ray is the first imaging
the local infrastructure
maximum
Depending acceptable
on the local timethe target
majority of 4 of
infrastructure hours
the from
the severely
the
majority modality for thoracic trauma in children, but if there is
injury.
injured
of children injured
the severely will need to be will
children transferred
need totobea suspicion of an intra-thoracic injury a chest CT should be
children’s trauma
transferred to a centre.
children’s trauma centre. obtained. As in adults, the majority of thoracic injuries in
Thoracic trauma children rarely require surgical intervention, apart from
Serious chest injuries in children are rare, but can present placing a chest tube for a pneumothorax.
Secondary survey
without visible external signs and are associated with
significant morbidity and mortality. The high flexibility Abdominal injury and pelvic fracture
A
secondary
ofn the survey is
paediatric ribcage performed
explains in anfatal
why even identical
chest Abdominal injuries are the third most frequent injuries
waycan
injuries to an
occuradult with any
without a detailed ‘headRib
bony lesions. to fractures
toe’ and after head and extremity trauma in children and are
occur‘front onlytoif back’ examination.
exceptional force is involved and if present the primary cause of circulatory shock. The history and
n Whilst
Whilst
should raisecarrying
suspicion out regarding
the examination,
further remember,
underlying understanding the mechanism of injury are both key
eveninjuries.
serious minimalA external
chest x-ray marking
is the may indicate
first imaging in diagnosing abdominal injuries. The solid organs are
significant
modality injury internally.
for thoracic trauma in Make a detailed
children, record
but if there is proportionally larger and the abdominal wall is thin,
including
suspicion of andiagrams and photographs.
intra-thoracic injury a chest CT should be offering relatively little protection. The diaphragm is
n ItIt is extremely
obtained. rarethe
As in adults, to perform
majorityaofrectal examination
thoracic injuries in more horizontal than in adults, causing the liver and
in a child.
children rarely Ifrequire
it is indicated, it must be done
surgical intervention, by a
apart from spleen to lie lower and more anteriorly. In addition the
paediatric
placing a chestsurgeon
tube forand not repeated.
a pneumothorax. ribs, being very elastic, offer less protection to these
n During
During the examination, although complete organs. This exposure leads to a higher incidence of
Abdominal
exposure is injury and pelvic
necessary, fracture
it is essential to keep the spleen and liver injuries than in adults. Fortunately,
child as injuries
Abdominal warm as arepossible. Children
the third most cool injuries
frequent quickly 90% of these injuries can be managed conservatively
afterand infants
head andeven more rapidly.
extremity trauma in children and are or with interventional radiology alone. The bladder is
n Request
the Rprimary
equest cause
any further investigations
of circulatory shock.or Theinterventions
history and intra-abdominal, rather than pelvic, and is therefore
as needed. the mechanism of injury are both key
understanding more exposed when full. Respiratory compromise
Review
Review all abdominal
inndiagnosing patient documentation;
injuries. The solid it isorgans
essential
are can complicate abdominal injury as a result of
to be as accurate
proportionally larger and as possible.
the abdominalThis is wall
evenismore
thin, diaphragmatic splinting/irritation.
significant
offering in child
relatively littleprotection
protection. cases.
The diaphragm is
n Maintain
more Maintain
horizontal ongoing
than indialogue with the
adults, causing parents/
the liver and
carers,
spleen to lielisten
lowertoand their
more concerns
anteriorly.and information
In addition the
ribs,they canvery
being provide.
elastic, offer less protection to these
organs. This exposure leads to a higher incidence of
spleen and liver injuries than in adults. Fortunately,
CHAPTER 11 TRAUMA IN CHILDREN | 143
149
90% of these injuries can be managed conservatively
or with interventional radiology alone. The bladder is
Road traffic collisions often involve rapid decelerations present with absent pulses and pallor of the affected
which cause abdominal compression. This can result in limb. They are easily overlooked in the polytrauma
damage to the liver, spleen and kidneys and rupture of patient and they must be actively searched for in order
the duodenum at the duodenojejunal flexure; direct to save the limb.
blows can readily injure the same solid organs. Injuries
to the pancreas or duodenum are a classic sequel of Non-accidental injuries
bicycle handlebar trauma. It is important when dealing with any child to have an
awareness of non-accidental injury. There are clues
Fractures of the elastic immature pelvis are relatively in the history; an unexplained delay in presentation,
rare in children, and generally have a good prognosis. injury incompatible with history or a change in the
However, if they are associated with other serious story over time. In the resuscitation room there are
injuries (head injury, long bone fractures, intra- sometimes indicators of possible concern revealed
abdominal injuries), mortality can increase to 15%. by watching the interaction of the parents with the
Most pelvic fractures in children can be treated child and the parents’ behaviour. Occasionally the
conservatively. In adolescents, fractures of the pelvic appearance of the child can be cause for concern
ring can lead to severe life-threatening retroperitoneal or the child may disclose physical abuse if given the
haemorrhage, which requires external splinting in the opportunity.
Emergency Department.
Limb injuries
The mortality of isolated limb injuries in children and
adolescents is low. If associated with trauma to other
organ systems, the mortality seems to depend on these
injuries rather than on the extremity. In the context
of damage control resuscitation, definitive repair is
postponed until the patient is fully stabilised. However,
temporary stabilisation of long bone fractures is part of
the resuscitative efforts because it reduces blood loss, Non-Accidental Injury Accidental Injury
pain and the incidence of multiple organ dysfunction
syndrome. Temporary measures include external
Figure 11.3 Non-Accidental Injuries often exhibit a typical pattern.
fixation or casting for more distal fractures.
children.
cannula.
Procedure:
n The most common sites used for intraosseous
debris or clot.
n Fluids need to be given in boluses. This is easiest
Complications:
n extravasation;
n subperiosteal infusion;
n osteomyelitis;
n compartment syndrome.
Your place of work will dictate how you interact distraction from parameter changes on the monitor
with your trauma network. If you work in a smaller and loss of situational awareness can and commonly
Trauma Unit, you may have cases that warrant care do occur. Movement between departments means
in a MTC self present to you, or brought in due to life that access to emergency drugs and equipment is
threatening injuries that require stabilisation. You will limited to what the team can carry in grab bags or on
need to resuscitate this patient and then plan where the transport platform.
the most appropriate destination is. If you work in a
MTC as a trauma team leader, you may be contacted by Inter hospital transfers will involve decisions about
a trauma unit to discuss patient transfers, or potentially the most appropriate transport modality (Table 12.1)
asking for advice and assistance with complex decision and the make-up of the accompanying transfer team.
making. If the patient arrives in your facility direct from Logistical considerations may require attention to
scene (a primary transfer), they will need resuscitating prevent it the transfer being to the detriment of the
by your team before you agree where the next most ongoing resuscitation, and the team must consider
appropriate destination for the patient is: imaging, strategies to mitigate this risk. Pre planning of as many
interventional radiology, theatres, intensive care or aspects of personnel and equipment as possible is
a trauma ward? What are the risks associated with essential. The requirements to arrange a transfer,
moving them to these departments and how might potentially arrange for a transfer team, who have not
these risks be mitigated? Might the plan have to been involved in the patients care so far, and decide on
change and if so is your team aware of the alternatives? the transport modality carries risks of distraction and
loss of situational awareness. Good communication
The risks and benefits of transfer is essential at all times. The team must consider how
Alongside the technical risks of physiological best to tackle all these elements of the transfer based
deterioration, equipment malfunction, failure and on the resources available to them.
dislodgement of drips, drains or tubes, physically
moving the patient adds a significant dynamic for The mechanism and pattern of injury should be
the team. Communication loops are easily broken, considered to advise precautions that should be
that can be referred back to at a later date, but this affect the hospitals response to major trauma.
relies on clear “closed loop” communication from team
members and not being overloaded with too much Human Factors
information at the same time. A trauma booklet for The sicker and more unstable the patient, the more
recording all the information from observations, the focus will be required by yourself to immediate
team leader and team members, radiologist and other active decisions. Your capacity to forward plan will
specialists is very useful in ensuring all the information therefore at best be limited, and at worse risks you
is in one place and events are properly recorded. becoming distracted and missing important clinical
These structured proformas and handover tools, (e.g. considerations, with risk of patient harm and poor
ATMIST) help to ensure that important information overall team performance. Predicting injury pattern
is not forgotten, is clearly documented and can be based on pre-alert information and mechanism of
referred back to at a later date. If the patient is being injury can help to ensure that you have the correct
transferred to a different hospital it is important that a people attending or en route to you and minimising
copy of this documentation accompanies the patient. the number of calls that need to be made in the midst
It is increasingly common that radiology images can of managing the resuscitation.
be electronically transferred between hospitals – it is
important to confirm that this has occurred. In complex polytrauma cases this may not always be
possible and so calling in a senior colleague as co-
Many polytrauma patients are likely to exceed the ordinator will help to offload some of these tasks. This
resouces available in the Trauma Unit to provide will mean you can focus on what is going on in the
definitive care and transfer to a Major Trauma Centre immediate resuscitation whilst the coordinator liaises
is therefore inevitable. This transfer should take with other specialties/the MTC or Ambulance service
place as soon as possible. At the local hospital only and retains the ability to plan ahead and to make
immediately life saving procedures should be carried critical decisions (Fig. 12.2)
out; diagnostics should be deferred unless they
can be completed without delaying the transfer
process. Within a trauma network, there should be clear
transfer arrangements and guidelines that describe the
indications and procedures for safe and fast transfer.
TABLE 12.1
Mode of Transport
Road Ambulance available, relatively cheap, quick to
activate, can cope with most weather
conditions, reasonable access to patient
Helicopter quicker, expensive, may require a
secondary transfer by land ambulance,
limited space, limited patient access,
limited communication in flight, limited
by weather/ light
Table 12.2 a summary of some of the key considerations of the team leader and team members, and some solutions to improve team
performance. Note the overlap between the considerations for team leader and the team members.
Debrief and improving and non-technical skills further in the future. Feedback
from the MTC to the TU that first dealt with the patient
performance is essential to inform good trauma audit.
You will become accustomed throughout the European There should be a governance system in place for all
Trauma Course to debriefing scenarios and discussing inter-hospital transfers to be reviewed and any learning
some of the issues that the team has encountered. points disseminated back to the teams involved, and
In clinical practice this is something that we can all practitioners who may be involved in subsequent
improve on: the clinical workload in your respective transfers. Enhanced Care teams will have a separate
departments does not pause and time pressures are governance structure but there should be positive
ever present within healthcare. The only way that you interaction between these teams and the hospital
will develop and improve as a team however is if you teams they handover and/or receive patients from.
re-group and discuss how a resuscitation and transfer These feedback loops will draw out positive practice
went. This will not only improve the overall team points and areas for future development. For this
dynamic, but will give individuals reflections points system to work effectively leadership and positive team
that they can take forward to develop their technical membership are required from everyone involved.
CHAPTER 12 INTER AND INTRA-HOSPITAL TRANSFER OF THE TRAUMA PATIENT | 157
Summary
This chapter summarises the complex Human
Factor aspects related to the acute transfer of
major trauma patients; there are multiple levels of
communication, which need to be coordinated to
ensure that no information is lost and all members
of the wider team work into the same direction.
Further information
n Fanara B et al. Recommendations for the intra-hospital
transport of critically ill patients. Critical Care. 2010; 14:
R87
n Brown JB et al: Helicopters improve survival in seriously
Personal notes
Personal notes
Personal notes