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October 1997 Vol 2 Issue 3 Contents:
Introduction. It has been an exciting year in trauma in Australia, with enthusiasm for trauma education at an all time high. In Tasmania, Dr Ras Simpson and colleagues have been promoting Rural Trauma education with an excellent video, similar work from our unit in Alice Springs, EMST courses remaining as popular as ever and now the launch of the Australian Trauma Society. In Victoria Frank McDermott and colleagues have identified some of the problems in Victorian Trauma Care. Challenges in our trauma care in Liverpool Hospital are currently being presented by our trauma fellow Dr Janjua. It is only through critical analysis of trauma care and the current systems that Australian trauma victims will receive optimal care. In this issue Ian Civil ,Director of Trauma at Auckland Hospital, outlines the development of trauma services in New Zealand. For years at Liverpool Hospital we strove to provide a genuine friendly and efficient interhospital trauma transfer mechanism. I am concerned that we need to look in detail at what we are offering. The current issue deals with a new look interhospital transfer guidelines. Registration for SWAN V is filling up quickly so if you have not registered please send in your registration forms. We all looking forward to sharing experiences with our guest speakers, Professor Larry Marshall (San Diego), Dr Anne Kolbe (Auckland), Professor Danny Cass (Sydney) and Mrs Trish McDougall (Sydney). Dr Damien McMahon, who has just returned from 2 years in trauma in Philadelphia, will join our guests. If you would like to preview one of the cases on the SWAN meeting have a look at our web site www.med.unsw.edu.au/livtrauma. Michael Sugrue Inter-Hospital Trauma Transfer - A Challenge Interhospital trauma transfers aim to provide a rapid means of transferring trauma patients to definitive care at the Major Trauma Service. In line with EMST principles it is important to achieve early definitive care. The need for interhospital transfer arises from the fact that certain hospitals do not have the resources to look after seriously injured patients. The process of transfer should be simple. This is particularly important as often resources are tied up in managing life threatening injuries and resources at the urban or rural hospital do not allow for detailed phone conversation. Often it is not simple, because of inadequate transfer systems or inter personal issues between the referring and receiving doctor. There are two sides to a transfer and each medical officer has different perspectives. The referring officer is often stressed by the serious nature of the injuries coupled with limited human and physical resources. The doctor may feel that the accepting doctor is condescending, with unreasonable expectations and may feel they are unhelpful. The receiving doctor may on the other hand find the referring doctor difficult to deal with and slow to accept suggestions. The art of accepting interhospital transfer must be supplemented by a system that will work. In South West Sydney we believed that we had such a good system for 2 years but recently two cases highlighted the need for us to produce clearer guidelines to both accepting and referring staff. This article includes our recent guidelines and we hope that this will help in future transfers. We would welcome your comments or suggestions in relation to the issue of interhospital transfer and our proposed guidelines. These guidelines are at an early stage of development and may need significant alteration over the coming few months. In the near future we hope to look at Trauma Fax incorporating a standard form to be located and completed by the referring Emergency Departments and group faxed by them to the receiving ICU,ED, retrieval co-ordination center and retrieval service. Nadia Nocera has been appointed as our regional trauma co-ordinator and follows up every Trauma Hotlines request for interhospital transfer. If you have any queries contact her on 98283000 page 48552 . INTERHOSPITAL TRAUMA TRANSFER GUIDELINES GOAL : Quickest route to definite care (EMST - Golden Hour!) The first step on receiving a major trauma patient who you feel might need HDU or ICU bed ring Liverpool Hospital Trauma Hotline 98283666 as soon as possible (preferably within 20 min of patients arrival). The ICU registrar will accept your patient if the patient may need HDU or ICU, even if there is no bed at Liverpool. Suggested times to achieve best outcome in line with EMST
In the event of serious life threatening injuries occurring, the referring doctor may not be able to get to the phone to speak to the receiving doctor. In this situation the referring hospital will classify the transfer as a code red and provide information 10-20minutes later once the patient has been stabilized. We anticipate this code red call with little information to be the exception rather than the rule. TRAUMA TRANSFER INFORMATION Pre Hospital Information (M.I.S.T.) Mechanism _____________________________________ Injury _____________________________________ Signs _________________________________________ Treatment _______________________________________ Resuscitation Information Primary Survey A (Don't forget C spine info) _____________________________________ B RR SaO2 Plus Examination _____________________________________ C P BP T Fluids given _____________________________________ D AVPU Pupils _____________________________________ Secondary Survey + GCS _____________________________________ Detail specific injuries. Remember the log roll and PR. Definitive Care Information Airway Treatment + Results of C Spine Xray Breathing Intervention + Result of CXR Circulation Any signs of bleeding + Result of pelvic Xray Documentation must be clear especially drugs, fluids administration Regular obs are important (15-30min) : Temp
/ O2 Sat/ RR / BP / P / GCS 1 Concise transfer of information on phone should shorten telephone time 2 Ring early (<20min) and ring the right person Trauma Hotline for ICU patient 3 Ensure Hard Cervical Collar is kept on, Take off any earrings before Xray 4 Prior to transfer of a multisystem trauma patient ensure that there is no major abdominal bleeding and if there is operate before transfer 5 Check CXR post intubation, check position of ET Tube etc 6 Have urinary catheter in place with hourly reading if indicated 7 Have all tubes fully secured 8 Apply splintage to any limb fracture. Jordan Frame if any suspicion of spinal injury 9 Have your 3 Xrays ready on viewing screen. Don't forget the pelvis if you have time. Leave the C collar on even if you think the x-ray is normal. 10 Keep the patient warm and document all vital signs regularly TRAUMA TRANSFER REQUESTS *Liverpool Hospital accepts all trauma transfers for definitive care. If an ICU bed is required and no beds are available at Liverpool, a bed will be found after definitive management. *Exceptions Pediatric, Spinal injuries with cord lesions and Burns patients. *All interhospital transfers require a trauma team activation (Up to 2 weeks post injury) *Interhospital Trauma Transfer patients must be assessed in the resus room *During your conversation with the referring doctor please try and stick to the information format that we like with transfers Tips *Make sure that the patient has a C Collar in place even if "the c-spine is normal" *Always encourage "packaging" of the patient ( bearing in mind resources can be limited)
*To decide if patient needs medical retrieval or paramedic ambulance consult the guidelines for inter-hospital transfer in SWSAHS *After accepting a referral, the following persons must be informed.
WHAT'S NEW IN TRAUMA: Diagnosis of Injuries after Stab Wounds to Back and Flank - Edward Boyle and colleagues, Harbour view Medical Centre, Washington, John Hopkins, Baltimore Historically patients with deep stab wounds to the back and flank underwent a formal laparotomy to rule out injury. This study evaluated the experience of the authors with selective management to identify areas of improvement. They looked at 203 patients with a flank or back stab wound over a ten year period. By IR changing the policy from mandatory laparotomy to selective management the total laparotomy rate decreased from 100% to 24% and the therapeutic laparotomy rate increased from 15% to 80%. Selectively managed patients were subdivided into 5 groups based upon diagnostic techniques used. Patients with signs of haemodynamic instability and evisceration or acute abdominal symptoms had one shot IVP's in the Emergency Department followed by an immediate laparotomy. Stable patients, without obvious signs suggesting internal injury, had either observation alone, a diagnostic peritoneal lavage alone , a CT scan after negative DPL or CT scan alone. All CT scans were triple contrast using oral, intravenous and rectal contrasts. Diagnostic peritoneal lavage used a red cell count of 1,000mm3 (which is significantly less than we use for blunt trauma). 203 patients with stab wounds to the back and flank were identified. 11 patients required immediate laparotomy, 34 were managed by observation alone, 32 had DPL, 18 underwent exploration of which 11 were truly positive. There were 7 false positive DPLs, 37 had CT scanning of which 2 required an exploration. There were 2 false negatives on CT scanning. 28 patients had CT alone, 3 of these gave rise to exploration of which 1 was positive. Of patients with injuries at laparotomy, Boyle found that 32 of the 44 had intra-peritoneal injuries as well as extra peritoneal injuries supporting the use of DPL as the initial diagnostic study. Based upon false positive DPLs they have recommended changing their peritoneal lavage count in penetrating trauma from 1,000 to 10,000 red blood cells (remember we use 100,000mm3 red cells for blunt trauma). They concluded that all patients with haemodynamic instability, evisceration or symptoms of acute peritoneal irritation should proceed to laparotomy. Stable patients with no obvious signs of internal injury should have their wounds explored in the Emergency Department to determine if the wound is superficial or penetrates the muscular fascia. Patients with superficial wounds can be discharged home. If the wound penetrates the fascia, DPL is the best initial examination and patients with a negative DPL should undergo triple contrast CT scanning. When reviewing the CT scan the surgeon or the radiologist should look forthe completeness of the examination, specifically looking for paracolic air or haemorrhage. In the 44 patients with significant injuries, 32 of these had injuries to both intraperitoneally and extraperitoneally. This supports the use of DPL as an initial study. Thoracoscopic Pericardial Window and Penetrating Cardiac Trauma Journal of Trauma 1997, Volume 42, page 260 - 265 Carlos Orales and colleagues from Hospital San Bincente de Paul, Columbia, South America. The authors report a study between 1991 and 1996 of 108 patients with penetrating wounds near the heart with no obvious signs of cardiac injurywho underwent the creation of a diagnostic thoracoscopic pericardial window to rule out cardiac injury. All these patients were stable, normotensivee or had mild hypotension that responded to crystalloids. Thoracoscopy was performed under a general anaesthetic using a rigid laparoscope. They made a 3cm incision over the cardiac silhouette (chest wall) and using an Alice Clamp the pericardium was grasped and divided. 70% of the injuries were due to stab wounds, 28% due to firearms and 2% to blunt trauma. In 33 patients the procedure identified a haemopericardium. The sensitivity of the procedure was 100%, specificity 96% with an overall accuracy of 97%. They found that thoracoscopic pericardial window was a precise, safe and rapid method for diagnosing wounds to the heart in patients with no clear symptoms or signs. It also allowed evaluation of other thoracic injuries. They recommend this procedure as a standard diagnostic approach for cardiac injuries in the stable patient. In their discussion the author's comment that for non-operative management of stable patients with stab wounds to the chest they recommend an active diagnostic approach, although Au....and colleagues in 1994 have observed a large number of patients with stab wounds to the heart with only 4 deaths in the series and 2 of these were due to cardiac injuries. The authors feel, however, justified in approaching this aggressively. In their hands they have not found pericardiocentesis useful and have found echo cardiography to be approximately 96% accurate, but in patients with a haemothorax it is only 56% accurate. Laryngeal Masked Airway in air transport when intubation fails - A Case Report From the Journal of Trauma 1997, Volume 42, Page 273 - 275. Sharon Martin et al, Lifestar Medical Services, Savannah Georgia. Martin and colleagues report a 76 year old woman where the Emergency Physician had experienced difficulty with laryngoscopic visualisation and oral intubation. On arrival the flight doctor inserted a laryngeal mask on first attempt without difficulty ensuring that transport to hospital from an airway viewpoint was maintained. Martin goes on to review the use of laryngeal masks in trauma patients and identified some advantages of a laryngeal mask which includes:
As with many alternative techniques potential complications exist. Gastric aspiration has been suggested but not documented in the emergency setting. In an analysis the public literature reports the incidence of aspiration is low, occurring in 3 in 12,901 patients. Martin suggests that because multiple studies show the use of insertion and successful ventilation with a laryngeal mask in anaesthetised patients that they should be considered more widely in the emergency pre-hospital setting. Martin goes so far as to suggest that the solution for the "can't intubate, can't ventilate" scenario before surgical intervention with cricothyroidotomy is a laryngeal mass.
RECOMMENDATIONS FROM THE TRAUMA AUDIT: ISSUE 1 : Multi system trauma in an intubated patient with a significant head injury,(GCS <8). How should one approach abdominal evaluation for intra-peritoneal haemorrhage and organ injury? In line with EMST, priorities must be dealt with and treated as they arise in order of importance, i.e. airway, breathing, circulation and then disability. If the patient is haemodynamically stable, i.e. with a blood pressure above 110 systolic requiring less than 8 litres of crystalloid or colloid, then in the presence of a proven head injury, dealing with disability comes before any potential circulatory problem, unless the circulatory problem is extremely obvious, such as a tourniquet around a partly amputated leg that has been applied for over one hour. In terms of stable patient evaluation the preferred approach within the Liverpool Hospital Trauma Unit is immediate head CT. If the head CT is positive for intracranial haematoma that requires drainage, then the patient should be transferred urgently to the operating theatre for craniotomy. Ifthe head CT is negative or shows only intracerebral oedema the patient should proceed with an abdominal CT with oral and intravenous contrast (nasogastric tube removed, arms up by the side to improve image). The patient requiring urgent intracranial haematoma drainage will need a DPL in theatre. Do not proceed with and abdominal or cervical CT scan. In the event of haemodynamic instability prior to CT scanning a DPL using the umbilical approach will provide a rapid answer as to whether intraperitoneal haemorrhage is the contributing factor to hypotension. It is vital that an unstable patient not be sent to CT scan as the mortality will increase by a factor of 6, 10 - 15% to 60% in patients with a significant head injury. ISSUE 2 : Radiology of Trauma Patients - In a patient with a blown pupil - what is appropriate in terms of x-rays Ideally the Trauma Team should be lead-gowned, having received accurate pre-hospital information of the arrival of an impending multi system trauma. The chest x-ray cassette should be in place on the trolley with the radiographer primed to shoot sequential chest x-ray followed by c-spine and pelvis. Ideally the chest x-ray should be shot at approximately 5 minutes into the resuscitation followed by the c-spine at 8 - 10 and the pelvis at12 minutes. The three basic x-rays should be complete by 15 minutes at which time the patient will have been intubated, assessed for the need for a chest tube, IV cannulas inserted, urinary catheter placed, the CT scanner alerted, the Neurosurgeon alerted, the operating theatre alerted and the patient transferred for CT scanning at approximately 20 - 25 minutes. ISSUE 3 : Secondary rise in intracranial pressure - the time to elicit the underlying lesion. In general a sustained rise of intracranial pressure beyond 20mmHg should prompt an immediate response from the attending ICU Team. Specific manoeuvres to decrease the pressure, such as elevation of the bed by 15 - 20 degrees, removal of c-collar with application of sand bags and review of sedation. Mannitol may be required. Should these manoeuvres fail, then it is possible that further intracranial haemorrhage is occurring and an urgent CT scan should be arranged within a time period of 15 minutes. The patient should be in CT within 20 minutes and if necessary back in the operatingtheatre, if there is another collection, within 40 - 45 minutes. ISSUE 4 : Drugs and Trauma: Does the patient have a head injury or is he drunk. The patient must ALWAYS be assumed to have a head injured. THE HISTORY OF TRAUMA SERVICE DEVELOPMENT IN NEW ZEALAND Dr Ian Civil , Director of Trauma Services , Auckland Hospital. Trauma care has long been a feature of health care delivery in New Zealand. Unfortunately accidental falls, workplace injuries, domestic violence, and road crashes all feature prominently as causes of injury in NZ. Throughout the 60s and 70s road crash related injuries were amongst the highest in the so-called developed world. In 1985 the road crash fatality rate was 21/100,000 per year which placed NZ ahead of the US, Canada, and Australia as one of the more dangerous places in the work to drive. Although recent initiatives have lowered this rate, our position in relation to other motorised countries has not substantially altered. Assault and domestic violence result in a steady stream of hospital admissions with 4.7% of all injury admissions in the 80s being the result of assault. Although New Zealand would have to rate as an "unarmed" society, gun ownership is nevertheless very high. While we are not prone to many assaults involving firearms, the recent worldwide trend to mass murders has seen New Zealand stake three claims with killings of 12, 6 and 5 people in single events. Injury care in NZ has traditionally been delivered in individual hospitals by clinical teams with expertise in the area of the major injury sustained. Patients have always been transferred between institutions when the relevant service was not available but there has been no formal development of a trauma network. Thus, patients with severe head injuries have always been transferred to a neurosurgical service but there has been no cognisance of severity of injury as a whole being an indication for patient transfer. Because of specific patient related incident in 1992 the Ministry of Health commissioned the RACS NZ Trauma Committee to write a set of guidelines that might steer the delivery of trauma care through the 90s. Utilising work already done in the USA and the NRTAC report in Australia the Trauma Committee produced a document that outlined a trauma system for NZ. "In formulating guidelines which attempt to ensure that the needs and requirements of injured patients are matched, the NZ Trauma Committee is essentially describing a trauma system. It is not describing what resources named institutions must have but rather outlining the range of personnel and facilities which must be available to provide optimum care for injured patients of a given severity." This document by itself would probably have had little effect on the delivery of care. However, at this same time the Accident Compensation and Rehabilitation Insurance Corporation (ACC) was reaching the opinion that improved pre- and in-hospital trauma care might result in better outcomes and lower costs for the Corporation. It instituted a pilot study in Wellington and the Hawkes Bay (Hastings and Napier) to test this theory and utilised the Trauma Committee's guidelines for the basis of the system that was being tested. Thus the following recommendations were put into effect in this region: Prehospital care The participation of general practitioners in the process of prehospital care be encouraged, in appropriate geographic areas. Triage Where the patient is regarded as having potentially major trauma with immediate threat to life they be taken directly to a facility identified as having a capability to stabilise or definitively manage severe trauma. Transport Emergency ambulances staffed by two crew members be standard and ongoing training and financial support be aimed at ensuring that where case volume is adequate at least one of the crew members is an Intermediate Care Officer (ICO) or Paramedic. Hospital Management Procedures be developed for the coordination of the various surgical and non-surgical specialists, not only in the initial assessment and early definitive care phases, but also in the intensive care units and surgical wards. Trauma System Coordination Regional emergency care committees, based on advanced trauma services and integrated at a national level, be established Data Collection A national minimum data set on injury be instituted and more comprehensive trauma registries piloted in several areas. Thus trauma teams, trauma services and trauma systems were set up in this region. Recognising various deficiencies in systems of care in the other Regional Health Authority areas, these bodies have also moved within the general direction of the Trauma Guidelines to consolidate and improve their systems of care. Thus there is now a general movement towards an integrated system of care with the possibility of a national trauma registry achievable. One ongoing concern rests with the results of the trauma pilot study. All those practising in the area of emergency care would be aware of the lack of evidence based medicine that supports our actions. In the trauma system area there are few methodologically sound papers that confirm the benefits of trauma systems and the same would be said for ATLS (EMST) training worldwide. There are numerous possible explanations for this. One of the most common reasons for lack of valid results is the inability to isolate the intervention in a true controlled fashion. Once trauma care begins to be measured, behaviours change. Whether the trauma pilot will be able to demonstrate any benefit over a three year period is dubious. Strenuous efforts are being made to ensure that lack of short term proof does not get interpreted as an overall lack of benefit for an integrated trauma systems approach. Ian Civil TRAUMA MCQ's Question 1 : Which of the following are the least likely to contribute to making an outstanding Team Leader:
Questions 2 : Patients with penetrating injury should have implements left in place until they arrive in the Operating Theatre because:
Question 3: In young children intra-osseous needles should be considered under the following circumstances.
Question 4: In patients with penetrating neck and chest trauma which of the following statements would you consider the most appropriate.
Question 5: The patient shown has sustained a multi system trauma in a high speed motor vehicle accident into a tree. On primary survey in the Resuscitation Room his airway in intact and he has had prehospital intubation. Breathing is O.K. Circulation: blood pressure 80 mmHg pulse 120/m. Disability: he has a fixed dilated right pupil and bruising over his right temporal region. You are the Team Leader, you are going to choose which of the following:
Question 6: You are the ICU registrar at a major trauma service. You receive a telephone call from a rural hospital 100 kms away. The patient has been intubated because of a GCS of 4, his breathing is O.K., he is hypotensive with a blood pressure of 90, has received 1.5litres of fluid and has a fixed dilated right pupil. Your would request:
ANSWER 1: 3 - the hands on Trauma Team Leader is not in a position where he can manage or direct the trauma unless he is extremely skilled. It is better for the Team Leader to stand back and observe from a distance once the primary survey has been completed. ANSWER 2: 2 - knives can actually lie in a major vessel and partly tamponade the bleeding whilst still present. Removal can lead to sudden collapse and exanguination. ANSWER 3: 2 - intra-osseous insertion of needles is vital and should bean early part of resuscitation of shocked children. It must be done early as often 5-10 minutes can be delayed accessing small IV's in children. ANSWER 4: 3 - MAST suits in penetrating chest trauma delay the time to hospital, increase venous bleeding and may aggravate a diaphragmatic rupture which has been shown in International theories to have a negative outcome, increased mortality and should never be used in penetrating trauma. ANSWER 5 : You are going to choose diagnostic peritoneal lavage which, if positive will proceed to an immediate laparotomy. This will help prevent secondary brain injury. The patient can then undergo an emergency CT scan following laparotomy or a blind burr hole, although blind burr holes are not ideal as they can miss the lesion or the lesion can be on the other side. ANSWER 6: 5 is the correct answer you would perform a diagnostic laparoscopy as interhospital transfer patients, bleeding from the abdominal cavity is extremely hazardous and if the patient survives from a haemorrhage point of view he may have secondary significant brain injury. Management of Head Injured Patients. The management of multisystem trauma patients with serious head injuries has always posed a dilemma for the attending team. The dilemma or challenge relates to attending doctors predominant desire not to miss a life threatening head injury, which could have been readily treated if recognised early. This may result in lack of attention to circulatory instability which if persistent will significantly increase mortality and have an adverse effects on outcomes. The aim of management is
The goal of treatment is to identify and treat life threatening injuries as they occur. Airway must be maintained with intubation. Anaesthetic agents used should take into account the patients blood pressure and avoid and marked swings in ICP or cerebral perfusion pressure. It may for example be better to induce with Ketamine rather than Thiopentone if the patient is hypotensive. Patients with a serious head injury invariably have sustained multisystem trauma and require careful assessment. In the two year period 1995- 1996 we had 108 patient present to our emergency with a GCS <8. Of those 108, 14 (13%) had a subdural and 6 (6%) had an extradural. The relative probability of a patient with a pre-hospital GCS of having a drainable intra-cranial haematoma approached 20%. Is important that the patient's management plan Is clear from the moment of arrival right. The trauma team function Is vital in ensuring a rapid response. The decision tree shown below outlines tow paths, one for the stable head injured patient and the other for the unstable. It can be difficult in practical terms to define stable but in general fluid requirement of >2litres, pulse.111/min, or BP<110 mmHg constitute instability. Other factors such as age, medication and co-morbidity have an important role in determining this as well. In relation to unstable patients, it Is unusual for the instability to becaused by neurological problems and the five major sources of bleeding must be assessed and bleeding stopped before and move to CT Is made. The CXR should be performed in less than 8 min followed by the C Spine and Pelvis all shot in under 15 minutes. If there Is no sign of external bleeding and the CXR Is clear DPL should be undertaken( within 15min). We use an umbilical approach and use a large bore tubing ( BBC Catheter Cooke Australia) coupled with a TURP give set and warm saline. An unstable patient should not be brought to CT scan. For the stable patient we would like to have the patient in CT at 25min, with 3 series of plain xrays complete, urinary catheter and orogastric tube. In general Head CT take us 20 minutes to complete and we like to have the patient with an intra-cranial lesion in the operating theatre in under 65 minutes. In a stable patient if the head CT does not show a drainable intra-cranial haematoma then an abdominal CT scan should be performed. Remember
If you suspect that the patient has a possible small bowel injury remember CT will NOT pick the injury and that patient should have a DPL. Our care plan shown below Is what we believe to be ideal management . We do not for one moment believe that we can achieve this in every case but it acts as template for care. Case of the Month: Guidelines for CT's in Blunt Trauma Patients The aim of these guidelines is to recommended the manner in which CT scans are to be undertaken in Trauma Patients so as to:
Indications in Blunt Abdominal Trauma
Contra-indications
Tips
Guidelines for CT's in Penetrating Trauma Patients The aim of these guidelines is to:
Indications In Penetrating Abdominal Trauma
Contra-indications
Tips
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