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Inpatient trauma care

Joseph Mathew
Consultant, Trauma Services

Trauma Registry
Trauma Service
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Odds of in-hospital death of major trauma patients
since introduction of the Victorian State Trauma System
Adjusted for injury severity, age and head injury
Source: Victorian State Trauma Registry

Hobart July 2017

Trauma Registry
Trauma Service
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Case Scenario
46 yo Male. Driver HS MVA v’s tree. Impact on driver’s side.
At scene:
A: Grunting, resolves with jaw thrust.
B: Decreased air entry on left. RR 28. O2 saturation 90%.
C: HR 134bpm. SBP 80mmHg.
D: GCS E1 V2 M5 = 8
Management:
• Supplemental O2 via Hudson mask initially. Cervical hard collar.
• Pneumocath to left side
• 14G iv both cubital fossae. Crystaloid 1.5 litres.
• RSI for airway protection and safe air transportation.

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3000 Trauma Team Activations

1 pt every 3 hours

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Trauma Service
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The Resuscitation Team
1. Team Leader: ED Consultant or Senior
Registrar
2. Airway: Anaesthetist Consultant or Registrar
3. Airway Nurse
4. ED Registrar (in conjunction with Trauma
Registrar): Primary Survey, adjuncts,
Secondary Survey, referral for definitive care.
5. Trauma Registrar (as above)
6. Circulation Nurse: assistant to ED and trauma
Registrars
7. Scribe: member of the nursing staff
8. Orderly
9. Radiographer
10. Ward Clerk

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Additional Personnel

1. Trauma Surgeon or Physician
2. Orthopaedic registrar or Consultant
3. Intensive Care Registrar
4. Cardiothoracic Registrar or Consultant
5. Neurosurgical registrar or Consultant
6. Theatre Scrub Nurse

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Trauma Service
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Major trauma by admission time of day

22%
51% 27%
100
2009-2010 2010-2011 2011-2012
80

60

40

20

0
00 0 0 0 0 00 00 0 0 0 0 00 00 0 0
: 00 : 00 :0
0
: 00 : 00 :0
0
:0
0
: 00 : 00 :0
0
:0
0
: 00 : 00 :0
0
0: 1: 2: 3: 4: 5: 6: 7: 8: 9: 10 11 12 13 14 15 16 17 18 19 20 21 22 23

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Major Trauma Admissions by day of week

250
200
150
100
50
0
y
ay

y

ay
ay
y

y
da

da
da

a
nd

id
d

rd
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rs
on

Fr

tu
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Sa
Th
ed
W

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Surgery / Operative Care
Pre-Hospital
Care

Emergency / Critical Care

Physical / OT/ Rehab
Care

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Trauma – a quaternary speciality

Surgery / Operative
Care
Injury evolution, timing of presentation,
timeliness of intervention, time
management & coordination of resources

Physical / OT/ Rehab
Care
Emergency / Critical
Care
Pre-Hospital
Care

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Trauma Registry
Trauma Service
As a clinician ………

Damage Control Resuscitation
(Pohlman et al 2015)

• Permissive Hypotension

• Haemostatic
Resuscitation (Massive
Transfusion Protocol)

• Haemorrhage Control
(Damage Control Surgery)

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Trauma Service
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Case Scenario (cont)

On arrival in Trauma Centre:
A: Intubated. Cx collar in situ.
B: Decreased air entry on left. O2 saturation 92%.
Crepitus along left lateral chest wall.
C: HR 105. BP 95 after 1.5 liters crystalloid.
FAST negative.
Right femur deformed
D: E1 VETT M1

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Case Scenario (cont)

Continue mechanical ventilation with 100% O2 until initial
ABG results available
Decompression of left chest:
Improve ventilation
Treat any degree of tension
Accurate measure of blood loss
Continue intravenous resuscitation:
Warmed crystalloid
O-negative or group-specific blood
Reduce and splint right femur

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Case Scenario (cont)
Progress:
A: stable.
B: ICC left hemithorax: 150ml haemoserous fluid.
pH 7.20. pCO2 50. pO2 71. HCO3 20.
C: HR 105-115. SBP 95-100.
Traction and splinting to right femur and tib-fib.
3 litres crystalloid. 2 units O neg RBC.
Secondary Survey:
Laceration right forehead
Deformed right distal lower leg
Deformed left great toe
LIF bruising

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Summary of injuries:
• CHI: supratentorial SDH
• Bilateral rib # with flails, pulmonary contusions and PTHx:
• Left 1-11 with flail 2-7 and displaced 8-11
• Right 3-8 with flail 3-7
• Sternal # with cardiac contusion
• Aortic intimal tear at T6
• Retroperitoneal fluid with thickened duodenum
• Splenic laceration with 2 small pseudoaneurysms
• Mesenteric contusion
• Right femoral shaft fracture
• Comminuted and displaced right distal tibia and fibula fractures
• Dislocated left 1st MCP joint
• Bilateral C4/5, C5/6 and C6/7 facet widening without ligamentous injury
on MRI
• T4 superior end plate fracture with acute discoligamentous disruption at T4/5
• L1-2 vertebral body fractures with ligamentum flavum tear

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Case Scenario (cont)
Initial Management:
CHI: ICP monitor and medical management.
Chest:
Ventilation. Right and Left ICCs on suction.
Angiography and stenting of aortic injury
Abdomen:
Splenic embolisation at time of aortic stenting
No operative intervention.
Femur and lower leg:
External fixation on day of arrival
Spine:
Initially nursed flat, as chest injuries precluded brace for sitting

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Trauma Service
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Case Scenario (cont)

Management Day 2:
CHI:
ICP<15.
Continued with medical management
Chest:
pO2 140; pCO2 40. pH 7.39; HCO3- 24. Sat 95% 50% FIO2. PEEP 10.
Blood stained sputum suctioned intermittently.
Abdomen:
Hb 112
Repeat CT scan with oral contrast to further assess duodenum
Tertiary survey
Left foot fracture identified – radiology ordered
-management plan made

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Trauma Service
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Case Scenario (cont)
Management Day 2: (continued)

Right leg:

• Concerns regarding internal fixation via femoral rod in the setting of
pulmonary contusions and pO2 140.
• Internal fixation of femur not vital though preferable prior to thoracic
spine fixation (patient required to be laid prone for surgery)
• ORIF of femur and lower leg day 2 (VAC dressing applied to lower leg)
• Foot fracture ORIF and 1st MCP fixation
• Physio/nutrition input

Management Day 3:

Spine: T3-6 posterior fixation

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Management Day 4-10

Extubated Day 4

• 2 more days in ICU
• Daily Physio /nutrition/ occupational therapy input
• Early physio mobilisation of patient

Neurocognitive assessment/Management of PTA

Transfer to ward

IM nail femur Day 6

Managing discharge planning Rehab assessment
- Needs neuro rehab
- Ongoing physiotherapy for non weight bearing status

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Case Scenario (cont)
Key points:

• Follow EMST/ATLS principles during resuscitation to identify life-
threatening injuries in a timely manner

• Injury patterns: look for associated injuries

• Shaft of femur fractures can kill: bleeding and fat emboli

• Aim for definitive management as early as possible, though only
when physiology allows

• Aim to sit the patient as early as possible:

• Early spine fixation

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Management Day 10 - 6 weeks

• Ongoing neuro rehab /daily physiotherapy
• Partiai weight bearing by 4 weeks
• Full weight bearing
• OPD visits:
• Vascular
• Multitrauma unit
• Neurosurgery
• Spine unit
• Outcome at 4 months :
• Back to work as a bank teller 2 days a week
• Outcome at 6 months: back at work full time

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The inpatient team
1. Inpatient Leader: Trauma Service

2. Intensive care team- trauma ICU

3. Trauma surgery

4. Trauma Physicians

5. Intensive care nurses/Ward nurses

6. Vascular surgeon

7. Interventional radiologist

8. Neurosurgeon

9. Orthopaedic surgeon

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Inpatient team

1. Plastics surgery

2. Residents/registrars/interns/fellows

3. Physiotherapist

4. Occupational therapist

5. Neuropsychology assessment

6. Nutrition

7. Social work

8. Above all, family

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The Alfred Trauma Service

Surgical Specialty Units

Emergency Research Medical Speciality Units
Trauma Surgery

Trauma
Director
Imaging
Allied Health
Pathology
Rehabilitation
Blood Bank HITH

Anaesthetics & Peri- Education
operative Medicine Intensive Care

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What is required- Inpatient Trauma Unit

• Parent unit- Trauma Service

• Initiation of resuscitation

• Involvement in the trauma continuum

• Co-ordinates and organises assesment and treatment
planning for multitrauma patients

• Unit comprises of general surgeons, critical care
physicians, specialist nurses,allied health staff

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Daily organisation

• Starts with multi unit trauma meeting
(Ortho, Neurosurgery,ICU)

• Previous 24 hour admissions discussion and radiology review

• Day’s spinal plans, surgical plans,c omplicated case
discussions

• Ward rounds (critical care physicians)

• Completion of tertiary surveys

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Daily organisation

• 24 hour consultant / specialist cover (ward and surgical)

• Radiology/Interventional radiology 24 hour cover

• Senior nurse attendance during rounds( discharge
planning)

• Daily physiotherapy/occupational therapy/social work
input for discharge planning

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Trauma Service
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Systems

Multidisciplinary meetings

Family meetings

Weekly trauma audits (M&M)– quality improvement

Education sessions ( medical/nursing)

Protocols/guidelines
o Spinal clearance protocol
o splenic injury guideline
o Trauma ICU guidelines
o ICC removal guidelines
o Nursing guidelines

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Education

Trauma resuscitation ( medical and nursing)

Damage control surgery ( cadaveric courses)

Procedural courses for trauma
physicians/Intensivists/anaesthetist (Cadaveric)

Trauma nursing courses

Ward patient management( modular)

Masters in Trauma Practice/Fellowship in Trauma

Trauma Registry
Trauma Service
Outcomes at 6,12 and 24 Months Post Injury

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Trauma Service
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Thank you

joseph.mathew@monash.edu

Trauma Registry
Trauma Service