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Trauma

Reception & Resuscitation
Professor Mark Fitzgerald ASM
MBBS MD FACEM AFRACMA

Director of Trauma Services The Alfred Hospital Melbourne
Director National Trauma Research Institute Australia
Professor Department of Surgery Central Clinical School
Monash University
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Priorities for TAEI for major trauma

Pre-Hospital Notification
Trauma Reception
Tamil Nadu State Trauma Plan
TN Trauma Registry
Sentinel sites/Networks
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By 2020 Trauma (physical injury) will be
No. 3 on the WHO list - Global Burdens
of Disease

• 1.25 million died globally from
road trauma alone in 2013
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In India, road crashes are the commonest cause
of death for people under the age of 35.

The estimated cost of road crashes in
India is 2% of the GNP

~USD $37,540,000,000

>150,000 killed in road crashes annually
In India, road crashes are the commonest cause
of death for people under the age of 35.

76% of road trauma
deaths after hospital
admission considered
unexpected
Goel A, Kumar S, Bagga MK.
Epidemiological and Trauma Injury and
Severity Score (TRISS) analysis of trauma
patients at a tertiary care centre in India. Natl
Med J India. 2004 Jul-Aug;17(4):186-9.
Lucknow
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When is the major trauma patient most at
risk from preventable morbidity/mortality?

The role of the trauma team is to
provide organization out of
chaos
55-91%1,2 of preventable deaths
occur at reception
Most of the reported errors during
reception relate to resuscitation
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Trauma – a quaternary speciality

Surgery

Injury evolution, timing of presentation,
timeliness of intervention, time management
and coordination of resource

Emergency / Critical
Care
Trauma

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Good team communication is linked to expeditious care and patient outcome.
In the first 30 minutes of reception and resuscitation a critical decision linked
to a life-saving intervention is made every 72 seconds.
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The major variable in resuscitation
relates to human factors.
At your
Trauma
Service

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27 June 2017

Trauma Team Time Out

• The Trauma Team consists of
combinations of Medical, Nursing,
Paramedical and technical staff.

• One member acts as Team Leader.
Others are assigned primary roles
in Haemorrhage Control, Airway
Patency, Ventilation and Circulation
Support.

• It is the responsibility of each team
member to ensure they are wearing
appropriate personal protective
equipment.

• Compliance should be checked by
the Team Leader.
Who?

Team introduction

• Most Trauma Centres within
organized trauma systems have pre-
hospital notification of inbound,
seriously injured patients.

• Whenever possible the Trauma Team
should assemble prior to patient
arrival.

• The Team Leader is responsible for
briefing the team, ensuring PPE,
clarifying roles and set-up.
Why?
Patient arrival and paramedic
Handover

• Mechanism, Injuries,
Signs, Treatment (MIST)

• Life Saving Interventions
(LSIs)

• Primary Survey

• Chest X-ray, Extended
FAST
What?

• 5-minute MIST situation report

• Repeating the Mechanism

• Repeating the principal Injuries

• Indicating to the Team the abnormal
Vital signs (including GCS)

• Assigning priorities for Life Saving
Interventions including
Haemorrhage Control, Airway
patency, Ventilatory support and IV
access

• Ensuring notification of Specialist
services, Surgery, Blood Bank
Where?

• 20-minute summary and
disposition decision

• Summary

• Diagnoses

• Treatments
Trauma Team Time Out

Time Out Who
Handover Why
5’ MIST What
20’ Summary When
Disposition

Debrief Whew!
For thousands of years the art of trauma care
had rarely gleamed, with treasures accumulated
through hard learned experiences often lost to
subsequent medical generations.

Hua Tuo 华佗,
CE 145-220
Roman Surgical Instruments
The current digital era has revolutionized the care of the
injured (just as the introduction of the printing press and
the adoption of oil based pigments catalysed the Early
Renaissance) with knowledge and ideas rendered
immediately accessible in new perspectives.

Carpaccio 1514
‘The Disputation of St Stephen

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The implementation of standardised, evidence based,
protocolized systems and computer assisted decision
support have revolutionized the art of trauma management.

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Romanesque ‘Christ in Majesty’
Westminster 13th Century

Vertical alignment lacking dimension
An expression of Faith
Accepted unquestioned as ordained
Death and disability an Act of God
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Current Medieval Trauma Care?

Vertical alignment lacking dimension
An expression of Faith
Accepted unquestioned as ordained
Death and disability an Act of God
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Johannes Gutenberg 1440

The development of the printing
press enabled 3,600 copies per day
compared to a few hand made
copies from the previous centuries
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Trauma management
Risk reduction and error avoidance

James K Styner
Nebraska 1976

Journal of Trauma Nursing
June 2006, Volume :13
Number 2, page 41- 44
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Trauma management
Risk reduction and error avoidance

Crew Resource management grew
out of the 1977 Tenerife airport
disaster where two Boeing 747
aircraft collided on the runway
killing 583 people
Medical error
Report finds 10% of patients in Victorian Hospitals experienced a
medical mishap/error.

A Victorian Auditor General's report has estimated that medical
mistakes are made on ten percent of people admitted to the
state's public hospitals.

The 2008 report found 135,000 public hospital patients were
subjected to medical errors in the last financial year*.

*Source: abc.net.au.

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Trauma care versus the Airline industry

risk

time
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Omission v Commission

Medical training and practice
focuses on intervention and
acts of commission

Little emphasis on acts of
omission
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Prehospital Interventions performed in a combat zone:
A prospective multicenter study of 1,003 combat
wounded. Lairet JR et al, J Trauma 2012.

Image U.S. Department of Defense
Protocolization

•Studies demonstrate that operational and clinical protocols improve
consistency, reduce error rates and improve outcome.

•Improvements in pre-hospital care have streamlined access for the
severely injured to sophisticated, specialist Trauma Centre reception
and resuscitation.

•As trauma systems evolve, patients with severe, but potentially
survivable injury are surviving to reach hospital.
ATLS and trauma resuscitation

Significant deterioration in knowledge and skills within
months of ATLS training1,2

53% overall protocol compliance when measured
prospectively3

1 Ali J, Cohen R, Adam R et al. Attrition of cognitive and trauma management skills
after the advanced trauma life support (ATLS) course. J Trauma 1996;40:860-6.
2 Blumfield A, Ben Abraham R, Stein M et al. Cognitive decline after Advanced
Trauma Life Support courses. J Trauma 1998;44; 513-`16.
3 Spanjersberg WR, Bergs EA, Mushkudiani N et al. Protocol compliance and time
management in blunt trauma resuscitation. Emerg Med 2009; 26;23-27.

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A single intervention in a mature Trauma System or…?

the TR&R hypothesis

‘..The greatest improvements in
resuscitation will come with improved
team communication, standardization of
interventions, improved physiological
monitoring, adherence to algorithmic
treatment pathways and the associated
reduction in errors of omission…’
(TRR©) Decision Support System & TAEI

 TRR© aims to assist in trauma
team coordination, assisting in
efficient intervention delivery,
reduction of errors and
morbidity as well as
resuscitation procedure record
keeping and training.
The TRR system provides the Trauma Team with
access to computerised clinical decision support
for the management of major trauma patients.
Fixation Error and Cognitive Workload

Consider the nature of the
trauma management
environment . . .

 A significant number of tasks

 Tasks need to be performed
efficiently and effectively

 Resources may be limited
Background of TRR©
 The TRR© system was implemented as a
research trial between 2005 and 2008.

 The primary aim was to test the hypothesis
that computer-aided decision support during
the first 30 minutes of trauma resuscitation
reduced errors in clinical management.

 It was an open randomised controlled
interventional study which recruited a total
of 1171 trauma patients who met Trauma
Callout criteria
Why is it used in the Trauma Centre?
 This study demonstrated that computer-aided clinical decision support reduced
errors during the initial resuscitation of major trauma patients. When the system
was used:
 Error free resuscitations were increased from 16% to 21.8%
 Errors in the management of shock were reduced by 26%
 The need for blood transfusion was significantly reduced

 Since 2008 the system has been installed in the four trauma bays and is used for
all major trauma patients who attend the Trauma Centre

 Detailed information regarding project results can be found in Fitzgerald et al
Trauma Resuscitation Errors and Computer-Assisted Decision Support Arch
Surg. 2011;146(2):218-225.
Benefits of the TRR System

 The prompts in the TRR system provide
guidance in what can be a chaotic, disruptive
overcrowded work environment1

 The TRR system improves diagnostic thinking for
clinicians by reducing reliance on memory.

 The use of clinical decision support tools such as
the TRR system can free up thinking to focus on
diagnostic processes2
Trauma Resuscitation Errors and Computer-Assisted
Expert Decision Support
[Fitzgerald M, Cameron P, Mackenzie C et al, Arch Surg 2011;
146(2):218-225]

• In the first 30 minutes a critical resuscitation decision is
required every 72 seconds and the prospectively gathered
critical error incidence is 2.3 errors per patient.
• Without real-time decision support 16% of patients have
an error free first 30 minutes of resuscitation.
• Real time computer assisted decision support improves
protocol compliance, increases cognitive capacity and
decreases errors of omission by 20% [p=0.004].
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The impact of inclusive, integrated Trauma
Systems

People with life-threatening - but
potentially treatable - injuries are up
to six times more likely to die in a
country with no organized trauma
system than in one with an
organized, resourced trauma
system.

Mock CN, Adzotor KE, Conklin E, Denno DM,
Jurkovich GJ. Trauma outcomes in the rural
developing world: comparison with an urban level I
trauma center. Journal of Trauma 1993;35:518-23.
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Priorities for TAEI

Pre-Hospital Notification
Trauma Reception
Tamil Nadu State Trauma Plan
TN Trauma Registry
Sentinel sites/Networks
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m.fitzgerald@alfred.org.au