Contents:

Protocol for paging Trauma team The Trauma Team Primary Survey Secondary Survey Radiology Placement Head injuries Spinal Injuries Chest Injury Blunt abdominal Trauma Penetrating abdominal Trauma Urological Injuries Eye Trauma

Hand Injuries Burns Carbon monoxide poisoning Obstetric Trauma Paediatric Trauma Paediatric resuscitation chart Hypothermia Universal Precautions Blood Alcohol Testing Patient transfers into Liverpool Patient transfers out of Liverpool Telephone numbers Acknowledgments

   All spinal injuries should be assessed by the orthopaedic registrar on call. They will then be discussed with the orthopaedic VMO and/or the neurosurgical VMO depending on the clinical situation.

   Should transfer be necessary, injuries with neurological deficit should be discussed with Prince Henry Hospital or Royal North Shore. Injuries involving only the bony spine only may be kept at Liverpool Hospital or transferred to any accepting Orthopaedic Unit, commencing at Westmead.

SUSPECT SPINAL INJURIES WHEN:

• There is pain or a haematoma in the midline posteriorly, aggravated by movement.
• Unexplained hypotension with or without bradycardia
• Inappropriate vasodilatation with dry warm skin.
• Obvious flaccid paralysis in the awake patient.
• Always suspect spinal injuries in the head injured.
• Priapism.
• Patulous anus.
• Horners syndrome with high lesions.

SPINAL INJURIES SHOULD ALSO BE SUSPECTED IN THE FOLLOWING TRAUMATIC INSTANCES

• Head injuries.
• Hanging.
• Gunshot wounds to head, face & neck.
• Diving injuries or football injuries when scrum collapse has occurred.
• Falls greater then 6 metres.
• MVA where the patient has been ejected or there has been rapid forward-backward movement of the head.
• Any neurological signs following a traumatic event.
• The cervical spine should be stabilised with a stiff neck collar

The principles of the primary and secondary survey still apply

   Hypotension in spinal injuries must be carefully assessed to exclude haemorrhage. If haemorrhage is suspected, a diagnostic peritoneal lavage should be performed.

   Hypotension not due to haemorrhage is most likely due to spinal shock and is managed in the same way as other forms of shock, paying careful attention to urine output.

   It is essential to insert a urinary catheter during the secondary survey to assess adequacy of fluid resuscitation and to prevent bladder distension.

   During the secondary survey a full neurological assessment and a complete examination of the back is requireed. One person should be placed at the top of the bed to stabilise the head during lifting. At this time all clothing and any objects such as glass etc. should be removed and the patient placed on spinal rnattress and a Jordan lifting frame. The trauma team leader must contact the spinal registrar at the receiving hospital after the secondary survey.

MANAGEMENT

   Stabilise whilst arranging transfer.

   Immobilise cervical spine fractures with a hard collar and sand bags.

   Thoracic and lumbar spine fractures are stable with the patient supine. If it is necessary to move the patient, log-roll using at least three assistants whilst an experienced medical officer supports the cervical spine in the long axis of the body. The Jordan frame will facilitate patient movements.

   The spinal injured patient should be carefully lifted with in-line neck traction every two hours for pressure area care to prevent bed sores. Ischaemia can develop within two hours following spinal injury. The slats of the Jordan Frame must not be left underneath the patient.

   Administer continuous high flow oxygen.

   Volume replace the patient remembering that a mean arterial pressure greater than 70mm Hg. may be difficult to achieve.

   A silastic urinary catheter should be inserted at an early stage to avoid damage to the bladder.

   Treat bradycardia with atropine only if pulse rate is below 35 or BP <80 systolic.

   Pass a naso-gastric sump tube and apply continuous suction.

   Administer Metaclopramide.

   High spinal injuries may result in hypoventilation and these patients should be intubated and ventilated whilst longitudinal traction is applied. Neck movement may be avoided during intubation by the use of silastic introducers. (Contact ICU consultant on call).

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