1. Major Trauma A standard approach
Ballarat Health Services
Emergency Medicine Training Hub

2. Ballarat Grampians Emergency Medicine Training Hub
Learning objectives
To be familiar with BHS protocols for trauma including trauma teams
Management of suspected cervical spine injuries
To understand the Victorian State Trauma System and the role of Ballarat Health Services in that system.
Pre reading
Hughes T & Cruickshank J. Adult Emergency Medicine at a Glance. Chichester, West Sussex, UK : John Wiley & Sons, 2011. Chapter 8 Trauma; primary survey. Chapter 9 Trauma; secondary survey. Chapter 10 Major head and neck injury. Chapter 11 Minor head & neck injury
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

3. Other learning resources
Relevant guidelines for Ballarat Health Services
Trauma – General Approach
BHS Intranet Link
Trauma Team Activation
BHS Intranet Link
Cervical spine
BHS Intranet Link
All available via
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

4. Ballarat Grampians Emergency Medicine Training Hub
Introduction
Trauma leading cause death 1-40yo
Peak age 15-30
Cost in A$ 11 billion
Up to 40% trauma deaths preventable
Improvements largely due to social education
Seat belts
Speed limits
Drink driving
Helmets
For each death estimated to be 10 serious non-fatal injuries
What improvement?
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub 4

5. Ballarat Grampians Emergency Medicine Training Hub
Essence of Trauma Care
Right patient to the right resources as soon as possible
Achieved by:
Integrated system - ‘Trauma Network’
Seniority or experience of providers
Decision Pathways and education
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

6. Ballarat Grampians Emergency Medicine Training Hub
Trauma Network
Ministerial Taskforce on Trauma and Emergency Services
Victoria State Trauma Network – 1998
ROTES report (Trauma deficiencies) – 1999
Ongoing governance
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

7. Ballarat Grampians Emergency Medicine Training Hub
Introduction
Medical management has shown far less improvement
Standardisation of approach has helped improve outcomes
Concept of “Golden Hour”
50% deaths <1/24 due to major vessel, CNS, spinal injury
benefit from prevention
30% deaths patients major truncal injuries causing respiratory & circulatory compromise
benefit from prevention and timely intervention
20% die from sepsis, organ failure etc.
benefit from prevention, timely intervention and possibly from integrated approach to recovery
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

8. Ballarat Grampians Emergency Medicine Training Hub
Phases of care
Pre-hospital
Triage
Primary survey
Secondary survey
Disposition
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

9. Ballarat Grampians Emergency Medicine Training Hub
Prehospital
Very little evidence to support major interventions in the field
Oxygenation
Immobilisation cervical spine
Ventilation (unproven)
Fluids (unproven)
Lights and sirens (increases mortality and community risk)
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

10. Triage to trauma centre
Associations with increased risk of death??
Demographics
Age <5 >55
Know chronic cardiac/respiratory disease
Vital signs
BP <90
RR <10 >29
GCS < 13
Trauma score >14
Ask Jason where this is from
Last updated: 2 Nov 2012
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11. Triage to trauma centre
Injuries
Penetrating injury to chest, abdomen, head, neck or groin
Significant injuries to two or more body regions
Severe injury to head, neck or trunk
Two or more proximal long bone fractures
Burns >15% (?10%) or involving face or airway
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

12. Triage to trauma centre
Mechanism (No longer used as part of trauma call decision)
High speed >60 kph*
Fall > 6m*
>50 cm intrusion
Ejection from vehicle*
Death of other occupant
Rollover*
Pedestrian*
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

13. Ballarat Grampians Emergency Medicine Training Hub
Trauma reception
Prior warning
Prepare
Staff
Area
Paramedical services
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

14. Ballarat Grampians Emergency Medicine Training Hub
Trauma teams
Airway team
Assess and secure airway
Control cervical spine
Ventilation
NGT
Team leader
Overview
Resus
Assessment
Communication
Internal & external
Procedure team
IV access & bloods
IDC
ICC
Scribe
Scout
Radiographers
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

15. Ballarat Grampians Emergency Medicine Training Hub
Handover
Patient should transferred to trauma trolley prior to hand over
Parallel processing
Airway and procedure teams commence assessment (?team – silent handovers)
leader (?team – silent handovers) receives handover
Assume the worst & protect against unforeseen injuries do not focus on obvious injuries – protocol of ATLS
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

16. Ballarat Grampians Emergency Medicine Training Hub
Primary survey
Airway & cervical spine
Assess & secure airway
Patency
Look, listen, feel
Jaw trust (no chin lift as cervical spine uncleared)
Oropharyngeal airway, nasopharyngeal airway?
RSI
Maintain cervical protection until spine cleared
In-line immobilization
Consider NGT
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

17. Ballarat Grampians Emergency Medicine Training Hub
Primary survey
Ventilation/Breathing
Oxygen is the most important drug in the trauma room
Ensure adequate ventilation
Assess adequacy
Exclude pneumothorax, haemothorax
Bag/mask, ETT if required to maintain ventilation
Aim for normocarbia
CXR
Intervention may precede investigation if required
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

18. Ballarat Grampians Emergency Medicine Training Hub
Primary survey
Circulation
Assess adequacy & effect of blood loss
Conscious state
Pallor
Capillary return BP HR
visual estimation of blood loss unreliable
FAST scan – ‘rule in’ test
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

19. Ballarat Grampians Emergency Medicine Training Hub
Primary survey
Circulation
Control haemorrhage
pressure dressings
Tourniquets
Haemostatic dressings
Splinting
Thoracotomy (Cardiac manoeuvres/Aortic compression)
Theatre
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

20. Ballarat Grampians Emergency Medicine Training Hub
Primary survey
Haemorrhage classification
Class Loss BP HR RR CR UFR CS
Class I <15% N N/+ N N/+ N N
Class 2 <30% N anx
Class 3 <40% leth
Class 4 >40% /- +/ coma
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

21. Ballarat Grampians Emergency Medicine Training Hub
Primary survey
Circulation
Access 2x >16G peripheral IV’s
Fluids initially crystalloid 20mlkg (repeat if required) warmed
Crystalloid vs colloid (no proven benefit)
Blood O negative
Class III/IV haemorrhage
Continuing need for crystalloid
Consider need for clotting factors and plateletes ‘1:1:1’
Hypotensive resuscitation
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

22. Ballarat Grampians Emergency Medicine Training Hub
Primary survey
Disability
Level of consciousness
AVPU
ALERT
VOICE
PAIN
UNCONSCIOUS
GCS – E4M6V5
Pupil response
Don’t ever forget the glucose
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

23. Ballarat Grampians Emergency Medicine Training Hub
Primary survey
Exposure
Remove
Clothes
Jewellery
Avoid hypothermia
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

24. Ballarat Grampians Emergency Medicine Training Hub
Primary survey
Monitoring
ECG, BP, SaO2, GCS +/- ventilator obs
Analgesia
Radiology
CXR, Cx spine, AP pelvis
IDC traditionally part of 1° survey but usually done later
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

25. Ballarat Grampians Emergency Medicine Training Hub
Secondary survey
AMPLE history
Allergy
Medications
Past history
Last food
Event
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

26. Ballarat Grampians Emergency Medicine Training Hub
Secondary survey
Head to toe examination – ‘all over and all holes’
Look, feel, move, listen
Log roll
PR examination
Consider
Tetanus toxoid
Antibiotic prophylaxis
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

27. Ballarat Grampians Emergency Medicine Training Hub
Review
Constantly reassess and review
Any change repeat 1° survey
After any corrective procedure repeat 1° survey
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

28. Ballarat Grampians Emergency Medicine Training Hub
Disposition
Parallel thinking from before patients arrival
Direct to appropriate services
Definitive care made aware of patient
Discharge with appropriate support
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

29. Ballarat Grampians Emergency Medicine Training Hub
Questions?
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

30. Ballarat Grampians Emergency Medicine Training Hub
Summary
You are all part of a trauma network
Education saves lives
Reassess, reassess, and reassess again (and intervene if required of course . . .)
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub

31. Ballarat Grampians Emergency Medicine Training Hub
Thankyou
Last updated: 2 Nov 2012
Ballarat Grampians Emergency Medicine Training Hub