1. A Penetrating Injury ED Thoracotomy Dr Laura Attwood
EM Consultant, RVI

2. Aim Statistics Case review Discuss Pre-Hospital elements Code Red
Roles within the Resus
Development of a Traumatic Cardiac Arrest Protocol

3. Statistics TARN data 3rd most common cause of trauma in North East
1st RTC
2nd Fall
Increasingly more common according to TARN
Often Interpersonal violence related

4. Statistics Home Office In 2009-10 In 2012/13
North East rate for violent crime = 3rd highest in all regions of England & Wales at 560 incidents per 1000 persons
1st = London, 2nd = East Midlands
In 2012/13
5th highest
725 offences

5. Statistics
Daily Mail!

6. Case Review

7. Background RVI Emergency Department ~ 2100 hours x 1 Consultant
X 1 Reg
x 5 SHO’s
x 2 nurses in Resus.

8. Pre Hosp Info Young male Stab wound to the back ETA 5 mins
Respiratory arrest but now breathing

9. Team preparation Trauma Team call ED Staff
Cardiothoracic surgeon contacted and set off for hospital
Orange on call contacted ICU consultant
Thoracotomy kit moved next to bed
Team briefed on potential for Thoracotomy

10. Handover
30 mins on scene
Difficult to access due to Police present and perpretator still on scene
Respiratory arrest in ambulance
Unable to get IV access

11. On arrival No external Catastrophic Haemorrhage A: Intubate/Ventilate
Establish etCO2
Monitoring attached
ECG = asystole
Sats = not recordable
Pulse check = no carotid/radial

12. On arrival
X1 posterior chest stab wound
= Thoracotomy Initiated

13. Thoracotomy Kit VS
Unable to use surgical kit as not enough nursing staff availabel to deal with opening and handing kit etc…

14. Landmarks

15. View inside

16. What next No wounds in the heart No wounds in the lung
Aortic compression
With internal cardiac compressions

17. Moving on Unable to obtain large IV access
IO line establish in tibia
Blood pushed through with 20ml syringe
Consultant General Surgeon arrives and extends the damage control trauma surgery to Laparotomy.

18. Laparotomy Evidence of splenic disruption
?gone through descending abdominal aorta also
Abdomen packed to control haemorrhage
Unable to regain output from patient
Decision taken as a team to stop resuscitation and patient pronounced dead.

19. Post Mortem Verbal Report Concludes above findings
Grade IV Splenic laceration
Wound through descending abdominal aorta

20. Discussion Points Pre Hospital – stay and play vs scoop and run
Code Red call
Venous Access
How to get the MHP into the patient
Staffing
Development of a Traumatic Cardiac Arrest Protocol

21. Pre Hospital Paramedics involved Training and Education issues
Do the land paramedic crews understand what we want to do to the patients when they arrive and why it is so time critical?
? Scoop and Play

22. Code red call Who is alerted: Would this have helped?
Blood transfusion for MHP to be activated
Porters to collect MHP form lab
Trauma Theatre
Trauma Team Personnel
Would this have helped?
?More staffing – possible resource from ODP/Theatre Staff

23. Lines Trauma Subclavian Line/Peripheral Access = ideal If we can’t….
Just lean towards IO’s
x2 yellow IO’s in humeral heads with Level1 attached
Significant success in Military Operations

24. MHP Use of Belmont and Level 1 infusers Can use with IO’s
Ensure the blood is also warmed

25. Ideal Staffing

26. Ideal Staffing

27. Ideal staffing Level 1 = 1.5 nurses Belmont = 1.5 nurses ODP
Nurse 1: Monitoring/Trauma Kit
Nurse 2: Drug nurse
TTL
Anaesthetist
B Doc
C Doc
General Surgeon
Orthopaedic Surgeon

28. Traumatic Cardiac Arrest Protocol

29. Summary Trauma case that we may see more and more off Lets be prepared
Plan what resources we need
Implement some simple changes
In hospital AND pre hospital