new shock trauma protocol & trauma call criteria · new shock trauma protocol & trauma call...
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NewShockTraumaProtocol&TraumaCallCriteria
ByDrDSGillConsultant,EmergencyMedicine,MorristonHospital
InterimNa=onalCo-DirectorEMRTSCymru
DISCLAIMER:Changestoyourprac=cethatfollowapplyto...
“MAJORTRAUMAPATIENTSWITHSIGNIFICANT
MECHANISMSOFINJURY&MULTISYSTEMINVOLVEMENT”
Ra=onaleforchange...
Preventdevelopmentoflethaltriad:AcidosisHypothermia
CoagulopathyMortalityof47.8%LiXlechangeinmortalityofthisgroupEMJ2012;29:622-625
Howarewegoingtoachievethis?DamageControlResuscita<on(DCR)“TheTherapeu<cTriad”- Immediatetemporarycontrolofexternalhaemorrhage- Clotstabilisa=onbyhaemosta=cresuscita=on- Iden=fy&controlallsignificantsourcesofbleeding
DamageControlResuscita=onaimsto...STOPbleedingPREVENTfurtherbleeding
PREVENTdeathfrombleeding
What’sdifferentfrommyusualATLSprac=ce?
SIXTHINGSTOCHANGE!
CatastrophichaemorrhagecontrolcomesfirstAirway,secureitearly!Breathing,chestdecompressionwiththoracostomy&chestdrainCircula=on,haemosta=cresuscita=onusingwarmbloodproductsNOTcrystalloid!DisabilitysameasusualExposure,keeppa=entwarm,minimalhandling&movement
HAEMOSTATICRESUSCITATIONDON’TFILLTHEBATHBEFOREPLUGGINGTHEHOLE!
IfSystolicBP>90–NOFLUIDS
IfSystolicBP<90–GIVEBLOOD&FFP1:1(AIMforSBP90)
(PRESENCEORABSENCEOFRADIALPULSE)
Defini=vehaemorrhagecontrol(SURGERY)
Thenrefill
Revisedshocktraumaprotocol...Star=ngAugust
Immediatemeasuresfortemporarycontrolofobviousbleeding
DirectCompressionTourniquetImprovisedpelvicbinder
FASTScanCT
CXR:?decompression
APPelvicXR
Iden<fysourceofconcealedbleeding
TranexamicAcid1gstatRepeatforevery10unitsofbloodproductsIni<ateMassiveTransfusionpolicyAdministerallfluidsinrapid250mlaliquots,withaclearobjec=veinmind:-Ifthepa<enthasbeenorisnowhypotensive:-MaintainSBPat90mmHgun=lbleedingiscontrolled.Ifthepa<entistachycardicbutnormotensive:-Onlyrestorenormalhaemodynamicswhenon-goingbleedinghasceased/beencontrolled.Ini=atemassivetransfusionpolicy.AimtomaintainBPatconstantlevelun=ldefini=vecontrolofbleedingisachieved
Recognisesignificantbleedingintraumapa<ent:THERAPEUTICTRIAD
Immediatemeasuresfortemporarycontrolofobviousbleeding
Beginfluidresuscita<on&Clotstabilisa<on
DirectCompressionTourniquetImprovisedpelvicbinder
FASTScanCT
CXR:?decompression
TranexamicAcid1gstatRepeatforevery10unitsofbloodproductsAdministerallfluidsinrapid250mlalliquots,withaclearobjec=veinmind:-Ifthepa<enthasbeenorisnowhypotensive:-Ini=ateMassiveTransfusionpolicyBUTaimtomaintainSBPat90mmHgun=lbleedingiscontrolled.Ifthepa<entistachycardicbutnormotensive:-Onlyrestorenormalhaemodynamicswhenon-goingbleedinghasceased/beencontrolled.Ini=atemassivetransfusionpolicy.AimtomaintainBPatconstantlevelun=ldefini=vecontrolofbleedingisachieved
APPelvicXR
ITUviaCTifnotalreadyperformed
Iden<fysourceofconcealedbleeding
Theatre:Defini<vecontrolofbleedingDecompressionofextremitycompartmentsyndrome
Restorehaemodynamicnormality
Traumacallcriteria...
DISPLAYEDINRESUSONEANYONEcanac=vateatraumacallatANY=meIfindoubtspeaktoseniorEDdoctororshiqcoordinatorANDPUTCALLOUTLettraumateamleaderknowifac<vated!
PHYSIOLOGICAL • AIRWAY COMPROMISE • SIGNS OF LIFE THREATENING CHEST INJURY • SpO2 < 90%
• PULSE >120/MIN OR SYSTOLIC BLOOD PRESSURE <90mm Hg. IN ADULTS • A CHILD WITH ANY SIGNS OF RESPIRATORY DISTRESS, SHOCK OR ALTERED LEVEL OF CONSCIOUSNESS
AND/OR
HISTORICAL • AN INCIDENT INVOLVING A FATALITY • HIGH SPEED MOTOR VEHICLE CRASH • FALL FROM A SIGNIFICANT HEIGHT • WHERE THE PATIENT HAS BEEN EJECTED FROM A VEHICLE
• UNCONSCIOUSNESS >FIVE MINUTES • KNIFE WOUND ABOVE THE WAIST • ANY GUNSHOT WOUND • A CHILD PEDESTRIAN OR CYCLIST HIT BY A VEHICLE • AN INCIDENT WITH FIVE OR MORE CASUALTIES
Clinicalgovernanceframework...
RevisedSHOCKtraumaprotocol(Damagecontrolresuscita<on)
Traumadocument(toimprovedatacapture&actasanaidememoire)
Debrief&datacapture:- Traumateam‘hot’debrief- ‘Hot’debriefforms- MDTmee=ngs- TARNdatacollec=on
Newequipment:CommercialpelvicbindersTourniquetsScoopstretcherHighvolumetraumalinesTraumadrugpacksTransfusiondevices(Someofwhichwillbekeptinadedicatedtraumatrolley)
Training:- TREATS- Traumaanaesthesiacourse- Regularmocktraumacalls
EvidencebasedSOPSon:-Roles&responsibili=es- Massivehaemorrhagepolicy(ABMUwide)- Tranexamicacid- Traumaairwaymanagement&proceduralseda=on- Chest,abdominal&pelvictrauma- Openfracturepolicy- Externalhaemorrhagecontrol- Vascularaccess- Trauma=ccardiacarrest- Headinjury- Burns- Handling&packaging(discussedatcombinedtraumacommiXeemee=ngs)