SEVERN TRAUMA ADULT GUIDELINE Manual

SEVERN MAJOR TRAUMA NETWORK

STAG Edition 1

SevernTraumaAdultGuidelineManual

Version:July2018ReviewDate:July2020

ProjectLead&LeadEditor:JimBlackburnEditors:RowenaJohnson,RichardTurck

GuidelineFormaon:RowenaJohnson

ApprovedBy:SevernMajorTraumaNetworkClinicalLeadDistribu>on:SevernMajorTraumaNetwork,TraumaTeamLeaders,TraumaTeam




�ii

STAGProjectLeads

DrBenjaminWalton-SouthmeadMajorTraumaCentreClinicalLeadMsSarahLapham-MajorTraumaCentreAdministrator

DrJamesBlackburn-ProjectLeadforSTAG,LeadreviewerandeditorDrRowenaJohnson-Editor,reviewer,documentproducMonandformaNng

DrRichardTurck-Editorandguidelinereviewer

GuidelineAuthorsandContributors

MsKayleeAllanDrJulesBlackhamDrChris>neBlaneDrAdamBrownDrAnthonyCareyMrTimChesserMsDebbieCleary

MrAlistairRMCobbDrGrahamCollinDrNeilCollin

DrKateCrewsdonMsLauraCrowleDrAmitGoswamiDrScoNGrierMrLukeHarriesMsHelenHarvey

DrKatyHillDrTimothyHooperDrNicholasHowesMrMikeKellyMrUmrazKhan

DrKatherineLivingstonProfessorDavidLockeyMrAnthonyMacquillan

MsJoannaMaggsDrPatrickMorganMrStephenMorrisMrWilliamNearyDrStevenNovakDrSimonOdum

DrAdrianPollen>neDrNicholasPrestonMissAnnePullyblankMrAndrewRiddickMrDavidSandemanMrDavidSandersMsVictoriaStanleyDrIanThomas

MissKatherineWarrenMrCrispinWigfieldDrTimWrefordBushDrNiroshaDeZoysa 


Acknowledgements

ThankyoutoProfessorDavidLockey,ClinicalDirector,SevernMajorTraumaNetwork, forhisenthusiasm

and support for the project. AddiMonal thanks toMs Victoria Le Grys, NetworkManager, SevernMajor

Trauma Network, for coordinaMon and support of the teams involved in producing the guidelines and

manual.

�iii

WelcometoSTAGEdi>on1

Our trauma network has now been in operaMon for six years. It has been graMfying to see the

enthusiasmandhardworkofallof those involved inthecareoftraumapaMentstranslated into

improvementsincarethroughoutthepaMentpathway,welldocumentedbyregularTARNquality

data.

Manyoftheimprovementshavebeenrelatedtosystemdevelopmentratherthanmajorchanges

intheclinicalmanagementofpaMents. StandardoperaMngproceduresandguidelinesareakey

part of standardising pracMce, educaMng juniors and those new to our system and preparing

trauma staff for less common scenarios. Many are based on naMonal guidelines and describe

commonpracMceinmostUKtraumanetworks–othersareinfluencedbyourregionalgeography

andthelocaMonofourspecialityservices.

TheyareanessenMalcomponentofnetworkdocumentaMonbuttheyalsotakeawhiletostabilise

andembedthemselvesinourpracMce.Theauthorsoftheseguidelineshavedoneanexcellentjob

of collecMng, revising and presenMng the core operaMng material on which our major trauma

centre and trauma units depend. These guidelines and their successorswill posiMvely influence

trauma pracMce and ensure that our trauma paMents have the best chance of an improved

outcomea\erenteringanypartofourtraumanetwork.

ProfessorDavidLockey

ClinicalDirector,SevernMajorTraumaNetwork.

�iv

�Contents

Pa>entPre-alert Page2

MTCAutomaMcAcceptancePolicy Page3

PrehospitalBloodTransfusion Page6

ATMISTHandover Page8

Inter-hospitalTransferofAdultMajorTraumaPaMents Page10

MajorTraumaTriageTool AppendixA

MajorTraumaPhoneCalls AppendixB

Opera>onalGuidelines Page16

TraumaTeamRoles Page17

UnknownPaMentRegistraMon Page35

ED&ICUMajorTraumaDrugBags Page36

TranexamicAcid Page41

HEMSDirecttoCTPathway Page43

Death&BreakingBadNewsintheEDFollowingMajorTrauma Page45

Resus1Layout AppendixC

TraumaTeamMemberReferenceCards AppendixD

Inter-hospitalTransferFlowchart AppendixE

DetailsRequiredfor999CalltoSWAST AppendixF

Airway&Anaesthesia Page50

EmergencyAnaesthesiaforMajorTrauma Page51

EmergencySurgicalAirway Page60

Oral&Maxillo-FacialInjuries Page62

RSIChecklist AppendixG

DifficultAirwayAlgorithms AppendixH

ThoracicTrauma Page68

ManagementofChestInjuriesinMajorTrauma Page69

TraumaMcCardiacArrest AppendixI

ChestDrainSafetyChecklist AppendixJ

MajorHaemorrhage,Cardiac&VascularTrauma Page100

MajorHaemorrhage Page101

CardiacInjuries,includingresuscitaMvethoracotomy Page115

TraumaMcVascularInjuryManagement Page123

MajorHaemorrhageProtocol AppendixK

Intra-operaMveCellSalvage AppendixL

Idarucizumabreversalfordabigatran AppendixM

MajorHaemorrhageAuditForms AppendixN

�v

Abdomen&Pelvis Page132

AssessmentandManagementofMajorAbdominalTrauma Page133

PelvicandAcetabularFracturesManagementandReferral Page148

DamageControlSurgeryProtocol AppendixO

AbdominalTraumaDecisionAlgorithm AppendixP

AASTOrganInjuryGrades AppendixQ

RetrogradeUrethrogramandCatheterCystogram AppendixR

PelvicandAcetabularFractureReferralForm AppendixS

PelvicFractureChecklist AppendixT

Extremi>es Page158

CompartmentSyndrome Page159

ManagementofOpenFracturesforAdults Page163

ReferralGuidelinestoSpecialistPeripheralNerveInjuryUnit Page168

Head&Spine Page172

ManagementofSevereTraumaMcBrainInjury Page173

CareofHeadInjuryPaMents Page180

SpinalCordInjuryCarePathway Page185

SpinalCordInjuryAlgorithm AppendixU

ASIAClassificaMon AppendixV

SpinalCordInjuryCarePathway AppendixW

ReferraltoSpinalCordInjuryCentre AppendixX

TransfertoSpinalCordInjuryCentreChecklist AppendixY

Imaging Page196

ImaginginMajorTrauma Page197

RadiologicalPrimarySurveyChecklist AppendixZ

WholeBodyCTProtocols AppendixAA

Rehabilita>on Page206

DirectoryofRehabilitaMonServices Page207

TerMarySurvey Page209

SpecialistDieteMcManagementandNutriMonalSupport Page211

AmputeeReferralPathway Page213

ReferralGuidelinestoRehabilitaMonServices Page215

TerMarySurveyProforma AppendixBB

Appendices Page230

ContactNumbers Page297

IndexofGuidelines Page299

�vi

PATIENTPRE-ALERT

�2

� MajorTraumaCentreAutoma>cAcceptancePolicy

1. ThispolicywillrelatetopaMentsfromTraumaUnitsandLocalEmergencyHospitalswithin

TheSevernMajorTraumaNetworkareafollowingmajortrauma

2. The SevernMajor Trauma Network must accept all severely injured paMents in a Mmely

manner.

3. Thispolicyappliessevendaysaweek

4. Capacityconstraintscannotbeusedoverclinicalprioritytoturn-downordelaypaMents

5. The final responsibility for the implementaMon of this policy lies with the on-call Major

TraumaConsultant(TraumaTeamLeader)

6. TransferofthepaMentistobeorganisedbythereferringhospital.

�

Following the introducMon of Regional Major Trauma Networks, Major Trauma Centres are

requiredtohaveautomaMcacceptanceofpaMentsrequiringtreatmentformajortraumainjuries.

ThepurposeofthispolicyistoprovidedirecMonandguidanceforacMonsfromkeyindividualsand

organisaMonswithinTheSevernMajorTraumaNetworktoreducethechallengeandimprovethe

paMentpathwayandqualityofcare.Todothisitwill:

• Ensure the automaMc acceptanceof traumapaMentswithin the Severn Trauma Network

fromTraumaUnitstotheMajorTraumaCentre

• Ensure that all relevant parMes are aware of their specific roles and responsibility, and

preventtheacceptanceandtransferofpaMentsbeingdelayed

• DescribetheprocedurewherecapacitytoacceptseverelyinjuredpaMentsisexceeded.

MajorTraumaCentreAutoma>cAcceptancePolicy

Introduc>onandPurposeofthePolicy

�3

�

This policywill relate to paMents from TraumaUnits and Local Emergency Hospitalswithin The

SevernMajorTraumaNetworkareafollowingmajortrauma.ThispolicyappliestoreferringTrustshospitals,AmbulanceTrustsandlocalairambulances.Itisthe

responsibilityofNorthBristolNHSTruststafftoensurethatthatthispolicyisfollowedfromfirst

contactbyanoutsideagency.ThepolicywillbeimplementedbypersonnelinA&E,IntensiveCare,HighDependencyUnitsand

GeneralWards.

Thefinal responsibility for the implementaMonof this policy lieswith theon callMajor Trauma

Consultant(TraumaTeamLeader)whoacceptsthepaMent.Departurefromthepolicywouldhave

tobejusMfiedtotheExecuMveOncallwithclearandcompellingreasons.Anydeparturefromthe

policy must be documented in the paMent notes or failing that, in a leqer to the Director of

OperaMons.

�

Thispolicyapplies7daysaweek.

AllrelevantclinicalinformaMonistobegiventothereceivingTrust.

ThetransferofthepaMentistobeorganisedbythereferringhospital,providingnecessaryescort

arrangements, together with all necessary documentaMon including the Severn Major Trauma

NetworktraumapaMentrecord.

ThispolicyshouldbereadinconjuncMonwith:

• TheSevernTraumaNetworkrepatriaMonpolicy

• SWASFTMajorTraumaTriageTool

Applica>on:ToWhomThisPolicyApplies

Principles

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PATIENT

PRE-ALERT

�

Inthecaseofanemergencytransferthereferringhospitalmustcontacttheon-dutyMajorTraumaConsultant(TraumaTeamLeader)withdetailsofthepaMent.

Thereferringhospitalmustalso informtheAmbulanceServiceCoordinaMondeskofthetransfer

anddetailsofthepaMent.

ThetransferproceduremustbecarriedoutatTraumaTeamLeaderlevel.

FullpaMentdetailsincludingnameofreferringTraumaTeamLeadertoberecordedinthetrauma

booklet.

The Severn Major Trauma Network paMent trauma record follows the paMent to the receiving

hospital.

On arrival, the paMent must be taken to the resuscitaMon room and trauma call procedures

iniMated.

�

The SevernMajor Trauma Centre has a duty of care to the populaMon covered by The Severn

MajorTraumaNetworkandmustacceptallseverelyinjuredpaMentsinaMmelymanner.Timelyis

definedasaccordingtotheurgencyoftransferasdefinedbytheTraumaTeamLeaderonly.

TheNBTMajorTraumaconsultantoncallhas responsibility fordecisions regardingcapacityand

the ability to accept paMents from the Severn Major Trauma Network and from outside the

network.

Wherethereareproblemswithcapacity inspecificareasofNBT(suchascriMcalcare) toaccept

paMents from the Severn Major Trauma Network, it is the responsibility of the affected unit/

departmentto informtheMajorTraumaConsultant inaMmelymannerandtoworktogetherto

resolvethesituaMonexpediently.Capacityconstraintscannotbeusedoverclinicalprioritytoturn-

downordelaypaMents.

If a request forpaMent transferoriginates fromaTraumaUnitwithinThe SevernMajor Trauma

Network,itistheresponsibilityoftheNBTMajorTraumaConsultanttoensurethat,ifimmediate

major trauma centre care is not clinically required, then an alternaMve bed can be sourced in

anotherMajorTraumaCentre(inconjuncMonwiththeAmbulanceServiceCoordinaMoncentre).

The decision ofwhether a paMent requires immediatemajor trauma centre care and therefore

mustbeacceptedismadebytheTraumaTeamLeader.

IfnootherMajorTraumaCentrewithinareasonabletravelMmecanacceptthepaMentinaMmely

mannertheNorthBristolNHSTrustmustacceptthepaMent.

Automa>cAcceptanceProcessForEmergencyTransfers

Capacity&OverflowManagement

�5

�

Pre-HospitalBloodTransfusion1. SeveralprehospitalteamsrouMnelycarrypackedredbloodcellsand/orfreshfrozenplasma

orlyoplas.

2. Themajorityofpa>ents receivingprehospitalblood transfusionwillneed furtherbloodandbloodproductsonarrivalintheEmergencyDepartment.

3. All paMents who have received prehospital blood transfusion will arrive wearing specific

wrist bands for traceability. The paMent idenMfier should be used for all pathology and

imagingrequests.

4. Theprehospitalteamshouldprovideapre-transfusionbloodsample;thiswillbesentusing

the pod system to the transfusion laboratory. 2 further crossmatch samples should be

drawnandsentintheusualway.

�

Great Western, Wiltshire and Dorset & Somerset Air Ambulance teams rouMnely carry blood

productsandwillperformprehospitalbloodtransfusionswhenrequired.

EachAirAmbulancecarries2unitspackedredbloodcells. Theywillinthefuturealsocarryfresh

frozenplasmaorlyoplas.

�

• Prior toarrival, youwill receiveapre-alert (ATMIST) clearly staMng thatprehospitalblood

transfusionhasbeengiven.

• Any paMent receiving prehospital blood will have a unique paMent idenMfier (hospital

number,nameanddateofbirth)allocatedtothemintheprehospitalphase. Thiswillnot

be the paMents actual name or date of birth. The unique idenMfier allocated in the

prehospitalseNngshouldbeusedforallimagingandlaboratoryrequests.

• ThetraumateamleadershouldconfirmtheuniqueprehospitalidenMficaMonnumberatthe

MmeoftheATMISTcall:i.e beforethepaMentarrivesintheEmergencyDepartment:this

will facilitate use of the correct number for pre-requesMng laboratory and imaging

invesMgaMons.

Pre-HospitalBloodTransfusion

Background

Intheeventthatapa>entwhohasreceivedapre-hospitalbloodtransfusionistransferredtoyourhospital:

�6

PATIENT

PRE-ALERT

• Themajorityofpa>entswho receiveprehospitalbloodproduct transfusionwill requireaddi>onalbloodonarrivalintheEmergencyDepartment.

• The prehospital paMent idenMfiers and the actual paMent details will be merged by the

admissionsteamoncethepaMentarrivesatthelocaMonofdefiniMvecare. Theprehospital

teamwillprovidebloodtransfusionspecificaccompanyingdocumentaMon.

• Onarrival,apre-hospitalGroup&Savebloodsamplewillbehandedover;pleaseassistthe

prehospital team to ensure the prehospital pre-transfusion blood sample is sent to the

transfusion laboratory as quickly as possible. The South West Ambulance Service

Prehospital Blood Transfusion SOPwould normally expect this to be done using the pod

system.

�

On wristbands, paperwork and pre-transfusion blood sample you will find unique prehospital

idenMfiers.

HospitalNo:Unique7digitnumber(6139XXX)–compaMblewithNBTcomputersystemSurname:HEMS00001,HEMS00002etc.Firstname:UnknownDateofBirth:01-Jan-1900TheaboveinformaMonshouldhavebeenpassedtothetraumateamleaderwiththeiniMalATMIST

report.Allimagingandlaboratoryrequestsshouldberequestedusingthesedetails.

Even once the paMent details are known, the prehospital idenMfiers and all associated

invesMgaMonsshouldconMnuetobeusedunMlthepaMentarrivesatthelocaMonofdefiniMvecare

e.g. Intensive Care, at which point the prehospital idenMfiers will be merged with the known

paMentdetailsandalllinkedinvesMgaMonsandresultswillbetransferredtotheidenMfiedpaMent.

�

ThefollowingdocumentaMonwillarrivewiththepaMent:theprehospitalteamareresponsiblefor

ensuringitiscorrectlycompletedandcopieslodgedwiththetraumateam:

• Pre-hospitalBloodTransfusionRecord(includesprescripMon)

• BloodCompaMbilityForm

• Group&SaveRequestForm(withsample)

• SWASTPaMentCareReport(PCRorelectronicPaMentCarerecord)

Uniquepre-hospitaliden>fica>on(compa>blewithNBTcomputersystems)

Documenta>on

�7

� ATMISTHandover

1. TheATMISTapproachshouldbeusedtohandoveralltraumapaMents

2. Theprogram inappendixB (page232)mustbeused to record thepre-alert forallmajor

traumapaMents.

3. Alldetailsontheproformashouldbecompleted

�

• Themnemonic ATMIST amethod of clinical handover between pre-hospital and hospital

teams

• It offers a structured format for handover and its aim is to improve communicaMonwith

emergencydepartmentswhenpre-alerMnganduponarrivalofatraumapaMent.

• TheATMISThandoverisexpectedtotakelessthan60seconds

�

AnATMISTpre-alertisexpectedinthefollowingcircumstances:• AnypaMent triagedasmajor traumaby the ‘Major TraumaTriageTool’ – seeAppendixA

(page231)

• Any paMent where the trauma team is required outside the ‘Major Trauma Triage Tool’

criteriae.g.specificclinicalconcerns.

UponreceiptofanATMISTpre-alert,thehospitalteamshouldrecordthehandoverontheATMIST

handoverproformasMcker–seeAppendixB(page232).

Uponarrivalof thepaMent in theemergencydepartment, anATMISTapproach shouldagainbe

performedtohandoverclinicalinformaMon.

ATMISTHandover

Background

ATMIST

�8

PATIENT

PRE-ALERT

�

Pre-hospitalBloodTransfusion• If the paMent has received a prehospital blood transfusion this should have been clearly

statedduringanATMISTpre-alert.

• DuringthisATMISTpre-alert,thetraumateamleader(TTL)shouldconfirmtheuniquepre-

hospital idenMficaMon number (ie. Before arrival of the paMent in the emergency

department) – thiswill facilitate use of the correct number for pre-requesMng laboratory

andimaginginvesMgaMons.

�

�

1. SWASTCG05–ATMISTPaMentPre-alertandHandoverSystem–01/02/2013–ClinicalGuideline

hqps://www.swast.nhs.uk/Downloads/Clinical%20Guidelines%20SWASFT%20staff/CG05_ATMIST_PaMent_Pre-Alert.pdf

2. SWASTCG24–TraumaCare:AccessingTraumaServices–17/03/2017–ClinicalGuideline

hqps://www.swast.nhs.uk/Downloads/Clinical%20Guidelines%20SWASFT%20staff/CG24_Trauma_Care_Accessing_Services.pdf

SpecialCircumstances

AGE(INCLUDINGPATIENTNAMEIFKNOWN)

TIMEOFINCIDENT

MECHANISMOFINJURY

INJURIES

SIGNS–VITALSIGNS

TREATMENTSOFAR

ETA,modeoftransport(landvsair),specialistresourcesrequiredonarrival?

References

�9

https://www.swast.nhs.uk/Downloads/Clinical%20Guidelines%20SWASFT%20staff/CG05_ATMIST_Patient_Pre-Alert.pdf

�

Inter-HospitalTransferofAdultMajorTraumaPaMents

1. PaMentslikelytorequiretransfershouldbeidenMfiedearlyintheirEmergencyDepartment

admissiontofacilitateMme-efficienttransfer.

2. Incaseswhereuncertaintyexists,earlycommunicaMonwiththeTraumaTeamLeader(TTL)

atNorthBristolNHSTrust(NBT)isencouraged.

3. ResuscitaMonand stabilisaMonof thepaMent shouldoccur inparallelwithpreparaMon for

transfer

4. A dedicated team member should prepare and verify correct funcMoning of all transfer

equipment&drugs

5. ReferraltotheTTLatNBTshouldoccurinparallelwithpaMentpreparaMonwherepossible.

6. TheseniorcliniciancaringforthepaMentshouldmakethiscall,notnecessarilytheperson

undertakingthetransfer.

7. CriMcallyillpaMentsundergoinginter-andintra-hospitaltransfershouldbeaccompaniedby

twotrained,competentandexperiencedstaff.

8. EnsureallradiologyiselectronicallytransferredtoNBTsothatitisavailableasthepaMent

arrivesattheMTC.

9. The default locaMon for recepMon and handover will be Emergency Department

ResuscitaMonareaatNBT.

10. AformalhandovermustoccurbetweenthetransferteamandreceivingteamConsideraMon

shouldbegiventousingtheSBARorATMISTstructure.

11. AlltransferdocumentaMonshoulduseSWCCNdocumentaMonavailableinalltraumaunits.

Inter-HospitalTransferofAdultMajorTraumaPa>ents

�10

PATIENT

PRE-ALERT

!

AdultmajortraumapaMentspresenMngtoTraumaUnitswithintheSevernMajorTraumaNetwork

(MTN) frequently require inter-hospital transfer to facilitate specialist treatment at the Major

Trauma Centre. NaMonal guidance from the Intensive Care Society [1] and AssociaMon of

AnaestheMstsofGreatBritainand Ireland [2]hasbeenused to create regionalguidelines forall

criMcal care transfers within the South West CriMcal Care Network (SWCCN) [3], the northern

secMonofwhichcorrespondstotheSevernMTN.

TheseMTNguidelines shouldbe read in combinaMonwith theSWCCN ‘Guidelines for the inter-

andintra-hospitaltransferofcriMcallyilladultpaMents’.Standardsfortraining,equipment,clinical

governance,accompanyingpersonnelandriskassessment,monitoring,safety,documentaMonand

handoverarealldescribedandnotrepeatedinthisdocument.

�

Theseguidelines:• Apply primarily to the safe transfer of level 2 and level 3 criMcally ill adultmajor trauma

paMents

• Aim to ensure that transfer of these paMents occurs with minimal risk and in the best

interestsofthepaMent

• Provideaneasy-to-followflowcharttofacilitatesafeandMme-efficienttransfer

�

TheSevernMTNguidanceonpaMentsrequiringspecialisttreatmentintheMajorTraumaCentre

shouldbefollowed.PaMentslikelytorequiretransfershouldbeidenMfiedearlyintheirEmergency

DepartmentadmissiontofacilitateMme-efficienttransfer.PaMentswhomeetSWASTMajorTrauma

Bypass criteria will almost all require transfer. In cases where uncertainty exists, early

communicaMonwiththeTraumaTeamLeader(TTL)atNorthBristolisencouraged.

Introduc>on

PurposeofThisDocument

TransferDecision-Making

�11

�

SeeAppendixEforaddi>onalinforma>on(page251)

• IdenMfypaMentrequiringtransferonadmissionorassoonaspracMcable

• ResuscitaMonand stabilisaMonof thepaMent shouldoccur inparallelwithpreparaMon for

transfer

‣ Care should be taken to ensure paMents are safe to transfer (some paMents requiringtransfermaybeunstable)

‣ Unnecessary intervenMons thataddMmedelayshouldbeavoidedwherepossible.e.g.arterialaccessisrarelyessenMalbutfrequentlydelaystransfer.

‣ Ensureall tubes, linesdrainsetcarewell secured,protectedandaqempt tominimisetheriskofdisplacementduringtransfer.

‣ AdedicatedteammembershouldprepareandverifycorrectfuncMoningofalltransferequipment (including standard monitoring, portable venMlator, infusion pump(s),

transferbag,anddrugsandemergency/rescuemedicaMons).

‣ PrepareSWCCNtransferdocumentaMon(availableineveryEmergencyDepartment)• Contact TTL atNorthBristol; this should occur in parallelwith paMent preparaMonwhere

possible.TheseniorcliniciancaringforthepaMentshouldmakethiscall,notnecessarilythe

personundertakingthetransferitself.

• The senior clinician caring for the paMent should should then contact South Western

AmbulanceServiceNHSFoundaMonTrust(SWAST)viathe999service.

PaMentsrequiringaMmecriMcaltransferandspecialisttreatmentaspartoftheMTNwillreceive

an “Mme criMcal” 8minute response from SWAST [4]. Some paMents are not Mme criMcal but

require“immediate”ambulanceaqendancewithin30minutesofthecall. VeryfewpaMentsare

expectedtobesuitablefor“urgent”1-4hourresponse.

ThepersonmakingthecallwillrequirethefollowinginformaMon(seeAppendixF,page252)

• Typeoftransfer:MajorTraumaTransfer

• Urgencyofresponse:MmecriMcal(8minutes),immediate(30minutes),urgent(1-4hours)

• PaMentlocaMon[exactlocaMonwithinhospital]

• Receivinghospitalanddepartment

• Whetheraparamedicvehicleisrequired.Mostlevel2and3transfersareaccompaniedby2

non-ambulanceserviceescorts, sothereisnoabsoluterequirementforaparamediccrew

whichmayspeeduptheresponse.

• Detailsofescort(s)beingprovided(forinstance,doctorandnurse)

• PaMent’scurrentcondiMon(anaestheMsed,etc)

• Medicaldevicesbeingtransported(venMlator,monitor,syringepump(s),etc)

Prepara>onforTransfer

�12

PATIENT

PRE-ALERT

PackagepaMentonambulancetrolley

• ThepaMentmustbesecuredtothetrolley(askambulancecrewforhelp)

• Pay aqenMon to lines, tubes and drains to ensure their safety; these should be secured,

protectedandriskofblockage,displacementandremovalminimised.

• Ensuremonitor,venMlatorandinfusionpump(s)aresecurelyfastenedtothetrolley

• EnsurepaMent’sdignityisprotectedandpayaqenMontotemperaturemanagement

OndepartureupdateTTLwithesMmatedMmeofarrival(SWASTcrewareabletoesMmatethis)

EnsureallradiologyiselectronicallytransferredtoNorthBristolNHSTrustsothatitisavailableas

thepaMentarrivesattheMTC.

�

TheSWCCNexpectthemajorityofinter-hospitaltransferstobeundertakenbyroad. Withinthe

SevernMTN, air transportaMon of paMents will very rarely be quicker than road transportaMon

exceptinexcepMonalcircumstances.

�

CriMcally illpaMentsundergoing inter-and intra-hospital transfer shouldbeaccompaniedby two

trained,competentandexperiencedstaff.

ThemajorityofadultmajortraumapaMentsrequiringinter-hospitaltransferwillbelevel2and3

paMentswithsignificantriskofdeterioraMon,whorequireanurse(orotherregisteredhealthcare

professional) and medical escort (with the medical pracMMoner being from an anaestheMc or

intensivecaremedicinebackground).

�

ThedefaultlocaMonforrecepMonandhandoverwillbeEmergencyDepartmentresuscitaMonarea

inSouthmeadHospital. IfanalternatelocaMon(suchastheatres) isrequired,thiswillbeclearly

statedbytheTTLandarrangementsmadeforthepaMenttobemetonarrivalsothetransferring

teamdonotgetlost.

A formal handover must occur between the transfer team and receiving team led by the TTL.

Handovershouldbestructuredandconcise. ConsideraMonshouldbegiventousingtheSBARor

ATMISTapproachalongsidewriqendocumentaMon.

Selec>onofTransportMode

AccompanyingPersonnel

Recep>onandHandover

�13

�14

PATIENT

PRE-ALERT

�15

OPERATIONALGUIDELINES

�16

� TraumaTeamRolesandResponsibiliMes

1. AcMvaMonofthetraumateamisbasedonanatomicalandphysiologicalparameters

2. ThisteamshouldmanagetheiniMalassessment,resuscitaMon,imagingandco-ordinaMonof

disposalfortraumapaMentspresenMngtoNBT

3. ThedecisiontoacMvatethetraumateamismadebytheseniordoctorandBand7onduty

followingpre-alertfromtheambulanceservice.

4. ThetraumateamisacMvatedbyringing‘2222’andstaMng‘traumacall’

5. Thetraumateamleadersshouldbeavailablewithin5minutesofnoMficaMon

6. AllmembersofthetraumateamshouldinformtheirrespecMvespecialityteammembersof

incomingtraumaandaqendtheresusareaassoonaspossibleonreceiptofthetraumacall

7. All trauma team members must remain with the paMent unMl appropriate disposal is

achieved

TraumaTeamRolesandResponsibili>es

�17

Trauma Call Adult Team Contact Number

Trauma Team Leader Bleep: 9745

Anaesthetist 3rd On Call Bleep: 9034

General Surgeon Reg On Call Bleep: 9772 & 9656

Orthopaedic Reg On Call Bleep: 9750

Radiology Reg Bleep: 9746

Radiographer Bleep: 9740

Trauma Nurse Co-ordinators Bleep: 9747, 9748, 9749

ED Nurse 1 | ED Nurse 2 | ED Nurse 3

Porter Bleep: 9567

Matron ED Bleep: 9744

Senior Nurse ED Bleep: 9743

Receptionist Bleep: 9742

Other specialties may be called as clinically indicated:

Neurosurgery Reg Dial: 45726

Plastics Reg Bleep: 1311

Cardiothoracics BRI via switchboard

Haematologist Bleep: 9433

� GenericTraumaTeamRole

�

CollectSpecialityTraumableepandreceivehandover+relevantSpecialitysituaMonalreport.

�

InformrespecMveSpecialityteammembers/Consultant/Theatresof incomingTrauma–thereby

allowingforproacMveplanningofpersonnel,resourcesandtheatrespace. 
AqendResusareaoftheEmergencyDepartmentassoonaspossibleonreceiptofTraumacall.

The decision to acMvate the Trauma team is based on the expectaMon that the alerted team

memberswillbepresenttoreceivethepaMent.Thereisnorequirementforteammemberstoring

theEDtodiscussthecasepriortothepaMent’sarrival.

OnarrivaltotheEmergencyDepartment:• IdenMfyyourselftotheTraumaTeamLeader.• Givename,specialtyandgradetothescribe• FillinyouridenMficaMonsMckerandplaceinavisibleplace• Confirmexpectedrole• EnsureadequatepersonnelprotecMveequipment• On arrival of trauma team, all teammembers should be on the paMent’s le\ of the ED

trolley, except the airway nurse and anaestheMst. The paramedics will then be on the

paMent’sright.

Remainwiththepa>entun>lappropriatedisposalisachievedIfyouneedtoleavetheTraumaTeamenvironment–thismustbediscussedandbeagreedbytheTraumaTeamLeader

GenericTraumaTeamRole

StartofShil

TraumaCallAc>va>on

�18

OPERATIONAL

GUIDELINES

�

TraumaTeamAcMvaMon

AcMvaMonofthetraumateamisbasedonanatomicalandphysiologicalparameters.Mechanismof

injurydoesnotformthebasisoftheacMvaMontriagetool. 
AtraumateamcanbecalledatanystageofapaMent’sjourney.
ThereisanautomaMcacceptancepolicy.AcopyofSouthWestAmbulanceServiceNHSTrustMajor

TraumaTriageToolcanbefoundintheappendix(seeAppendixA,page231).

�

• Unsafeairway• Flailchest• PenetraMnginjurytohead,neckortorso• Severepelvicinjury• Majorcrushinjurytotorsoorupperthigh• LimbamputaMon• Twoormorelongbonefractures• Paralysisfromspinalcordinjury• Burnsover20%orpotenMalairwayburns

�

• RespiraMons30orothersignsofrespiratorycompromise• Pulse<50or>120• Systolicbloodpressure<90mmHg• Systemicsignsofshock• HeadinjurywithMotorScore≤4• Anysignsofrespiratorydistress,shockorreducedconsciouslevelinpaediatrics

�

• MulMplepaMents• HEMSrequested

TraumaTeamAc>va>on

Anatomy

AbnormalPhysiology

SpecialCircumstances

�19

�

TheethosisthatthisteammanagetheiniMalassessment,resuscitaMon,imagingandco-ordinaMon

ofdisposalbeittheatre,ITUorwardforTraumapaMentspresenMngtoNBT.

Each teammemberwill have generic roleswithin this structure, aswell as, providing individual

experMse.TheaimisthataconsistentandpredictableTraumateamresponseisprovidedtoeach

trauma,whererolesandresponsibiliMesarewelldefinedandadheredtobyeachmemberofthe

team.

Thereisaswitchboardtestcallat10:00amandat16:00

�

• Following pre-alert from ambulance service the senior doctor and Band 7 on duty will

decide whether trauma team is acMvated: decision supported by the use of trauma

acMvaMonguidelines.

• Ringx2222

• StateTraumacall

• The Trauma Team leader and Senior Nurse will carry out a situaMonal appraisal of the

departmentwiththeDutyEDleadtoallocateappropriatebaysandresources.

• On arrival of paMent the Trauma Team Leader must idenMfy themselves to the Lead

Prehospitalclinicianandreceivehandover.

• The salient points of this handover will be wriqen on the Trauma Board to prevent

repeMMonofinformaMon,usingtheATMISThandoverformula–seeseparateguideline. A

sMckerforATMISThandovershouldbeavailableandcompletedbythescribe.

• Eachmemberof the traumateamshould fulfil their rolesunless the team leaderdictates

otherwise.

• Members of the trauma team must not leave resuscitaMon without discussion with the

TraumaTeamLeader(TTL).

TraumaTeam

CallAc>va>on

�20

OPERATIONAL

GUIDELINES

�

TraumaTeamLeader

PresentinEDoravailablewithin5minutesofno>fica>on.Start of Shil: Liaise with Lead Nurse, collect Trauma bleep and TTL folder, take DepartmentalsituaMonalreportandmeetwithTraumaTeamNurse1&2.

�

Pre-Hospital:AlertCall• Takecall/reviewcallasdetailstaken• TakepaMentidenMfiersasavailable• DecidewithEDnursingshi\leadwhethertoiniMateTraumaTeamAcMvaMon• CallSwitchboardtoiniMateTraumaCall–anETAisnotrequired• IfpaMentistransferredbyAirthenSecurityandClinicalsiteteamsneedstobeinformed.

In-Hospital:AlertCall• CanbeiniMatedatanystagebytheTraumaTeamLeaderforapaMentwithintheEmergency

Department.

• ThedecisiontoacMvatetheTraumateamisbasedontheexpectaMonthatthealertedteam

memberswillbepresenttoreceivethepaMent.ThereisnorequirementforteammemberstoringtheEDtodiscussthecasepriortothepaMent’sarrival.

• All teammembers receivingaTraumacallareexpected toalert their respecMvespeciality

teamsofanincomingTrauma.

• (Thus theatre, radiology, ITU beds and blood product availability can be planned for by

respecMveteams)

Consider:• EarlynoMficaMontoNeurosurgery,PlasMcSurgery, IntervenMonalRadiology,Cardiothoracic

Surgery,UrologyandVascularSurgeryasrequired.

• MassivetransfusionprotocolacMvaMon

�

Pre-arrival• AddAlertCalldetailstoTraumaBoard–updateTraumaTeam.• LeadresuscitaMon,coordinatestaffandresources.• EnsurepersonalintroducMonsbyTeammembersandconfirmroles.• EnsureteamwearpersonalprotecMveequipment.

TraumaTeamLeader

TraumaTeamAc>va>on

TraumaLead

�21

Pa>entRecep>on• EnsureResusclockandVideorecorderstarted.• Co-ordinateATMISThandoverfromPre-HospitalTeam–adddetailstoTraumaBoard.• Co-ordinatetransfertoResusTrolley.• ManageTraumaTeamresponse.• MakedecisionsinconjuncMonwithteammembersandrelevantspecialists.• PrioriMseinvesMgaMonsandtreatments.• Ensure imminent life threateningcondiMonsare treatedanddirect rapid transfer toCTor

Theatre.

PromoteanenvironmentofopencommunicaMonwithreviewofongoingmanagementprioriMes

andplans,ensuringinvolvementofallteammembers.

AimforCTwithin15minutesunlessreasonspreventthisConsiderCTinlieuofprimarysurveyx-raysinsomecasessee“ImaginginTraumaGuidance”

Considerearlyuseof:• ONegblood

• MassiveTransfusionPolicy

• Tranexamicacid1gover10mins. 
-Themaintenancedose,1gover8hrs(givenwithin3hoursofTrauma)shouldbegivenonreturn fromCT in order tominimise infusions needed in the CT scanner, and to focus theteamonprepara>onfortheCTscanner.

• CombatApplicaMonTourniquet–useandmanagement.

• ConsidereFAST–ifthiswouldenhanceandnotdelayongoingpaMentcare.

Pa>entTransferTeammembersmayberequiredtoremainwiththepaMentduringtransfertoCTorTheatre.

Whilst sliding the paMent up or down into the head cradle, the TTL should hold the trauma

maqressfixedinposiMonwhilstthetraumateamslidethepaMent.

TraumaTeammembersmustremainwiththepaMentunMlappropriatedisposalisachieved.

IfanyTeammemberneedstoleavetheTraumaTeamenvironment–thismustbediscussedand

agreedbytheTraumaTeamLead.

AnMbioMcs, urinary catheter, arterial lines, tetanus, pregnancy test need early consideraMon but

canbedelayediftransfertotheatreforemergencysurgeryisrequired.

ResuscitaMonismanagedasadynamicprocesswhichisnotdependentongeographicallocaMon.

Handover:TheTraumaTeamleaderdeterminestheSpecialitytoleadongoinginpaMentcare.InformBloodBank:WhenpaMenttransferredandlikelyongoingbloodproductrequirements.SpeaktoRela>vesDocumenta>on:ReviewcompletecasenotedocumentaMonandcompleteHotDebriefform. Debriefteam

�22

OPERATIONAL

GUIDELINES

� OrthopaedicRegistrar

�

• CatastrophicHaemorrhagecontrol

• CervicalSpineandPelvicstabilisaMon

• Venousaccess

• PerformSecondarySurvey

�

• Direct pressure Haemorrhage control as required, in extreme condiMons for extremity

bleeds–considertourniquetuse.

• EnsureC-spinecollarinsitu,correctsizeandplacement

• EnsurePelvicsplintinsitu,correctsizeandplacement

• EnsurelegsalignedwithinternalrotaMon–bandageanklestomaintainposiMon

�

• Venousaccess–sharedrole–asdirectedbyTeamLeader

• Confirmpatencyofi.v.access

• Unless thepaMenthas twopatent i.v.access sites -Gain i.v./ i.o.accesswith20mlsblood

samplesfor:-FBC,UE’s,LFT’s,Lipase,CloNngscreen,X-match,VenousbloodgasandBlood

Glucose

• Ifpossible,freecannulatobeplacedinthebackofthele\handforthe
IVcontrast.

• If the paMent has two patent i.v. access sites then gain 20mls blood for samples from a

femoralarterialpuncture

• Ensuresamplesarelabelledcorrectlyanddispatchedtotheappropriatedepartments.

Performbaseline peripheral neurological examinaMon, if RSI planned or just prior to log roll, as

directedbyTeamLeader.

Splintanylongbonefracture

OrthopaedicRegistrar

KeyRoles

Pa>entManagement

VenousAccess

�23

Contribute to case discussion with the Team Leader, parMcularly where limb or lifesaving

intervenMonsarerequired.

Once the primary survey and immediate lifesaving intervenMons have been achieved, the

Orthopaedic Consultant must be informed of the likely case progression. This may require the

aqendanceoftheConsultanttotheResuscitaMonRoomortotheatreasappropriate.

�

Carry out secondary survey, when deemed appropriate and verbally report findings to Team

Leaderanddesignatedscribe.

• Documentallwounds,grazesanddegloving.• Evaluateeachjointandlong-bonefordislocaMon/stability/fracture.• NeurovascularexaminaMonofalllimbs.• Recordpresenceorabsenceofkeypulses&neurologicalfindings.• IdenMfyperipheralinjuriesthatneedtobeincludedintheCTscan• Splintfractures.• RepeatneurovascularexaminaMona\ersplinMng.

AnyaddiMonalimagingrequirementsinaddiMontoaCTTraumaseries(review“ImaginginTrauma

Guidance”)shouldbediscussed.RequesMngofdepartmentalfilmscanimpedetherapidprogress

ofpaMentstodefiniMveorstagingcare–andmustbeagreedamongstteammemberstoensure

co-ordinatedcare.

PaMentswhohaveanteriorpelvicinjuriesmayrequirearetrograde-urethrogrampriortoinserMon

ofurinarycatheters–thisistobeundertakenbytheOrthopaedicRegistrar.

Discuss Orthopaedic assessment / plan / needs / prioriMes with team leader. Case discussion

shouldalsoconsidertheneedforVascularorPlasMcSurgeryspecialtyaqendance,dependenton

injurypaqerns.

Liaise with theatres, anaestheMc colleagues, bed manager and consultant for paMents needing

theatreand/oradmission.

Assistwith sending/ordering tests, liaisingwith specialists or performing procedures as training

andabilityallowse.g.chestdrains,urinarycatheter.

�

DocumentallacMonsandfindingswithaclearplaninpaMentnotes.

Remainwiththepa>entun>lappropriatedisposalisachieved IfyouneedtoleavetheTraumaTeamenvironment–thismustbediscussedandbeagreedbytheTraumaTeamLeader.

SecondarySurvey

PostTraumaCall

�24

OPERATIONAL

GUIDELINES

�

SurgicalRegistrar

�

• AssessBreathingandCirculaMon.• PerformlogrollexaminaMon.• DetermineneedforimmediatesurgicalintervenMonintheatres.

�

B–Breathing:• Assessairentry,chestexpansion,percussionandtrachealposiMontoallowidenMficaMonof

significantchestpathology.

• ReportfindingstoTraumaLead,discuss,agreeandinsMtuteappropriateintervenMons.

C-Circula>on• Venousaccess–sharedrole–asdirectedbyTTL• Confirmpatencyofi.v.access• Unless thepaMenthas twopatent i.v.access sites -Gain i.v./ i.o.accesswith20mlsblood

samplesfor:-FBC,UE’s,LFT’s,Lipase,CloNngscreen,X-match,VenousbloodgasandBlood

Glucose
Ifpossible,freecannulatobeplacedinthebackofthele\handforthe
IVcontrast.

• If the paMent has two patent i.v. access sites then gain 20mls blood for samples from a

femoralarterialpuncture

• Ensuresamplesarelabelledcorrectlyanddispatchedtotheappropriatedepartments.

Performabdominalexamina>on

Performexamina>ononlogroll–ensurefullexposure.Assessforoccipitalheadtrauma,thoracic/lumbarspinalinjury,examineposteriorchestincludingauscultaMon,palpateflanks,performrectal

examinaMonandassessposterioraspectoflimbs.

ContributetocasediscussionwiththeTeamLeader.DiscussSurgicalassessment/plan/needs/prioriMesparMcularly:decisiononTransfertoCTorTheatre-CommunicaMonwiththeatresroleis

shared with ITU. Case discussion should also consider the need for Vascular or PlasMc Surgery

specialityaqendance,dependentoninjurypaqerns.

SurgicalRegistrar

KeyRoles

Pa>entManagement

�25

OncetheprimarysurveyandimmediatelifesavingintervenMonshavebeenachieved,theSurgical

Consultant must be informed of the likely case progression if paMent has iniMal SBP entun>lappropriatedisposalisachievedIfyouneedtoleavetheTraumaTeamenvironment–thismustbediscussedandbeagreedbytheTraumaTeamLeader.

PostTraumaCall

�26

OPERATIONAL

GUIDELINES

�

AnaestheMcs3rdOnCall

�

• EnsurepaMentoxygenatedandvenMlatedwithnoairwayobstrucMon.• Intubate when appropriate in discussion with the Team leader – ensuring baseline

neurologicalexaminaMonperformedbeforehand.

• ControlpaMentlogroll• EnsuresafepaMenttransfer

�

A-AirwayIntubatedpa>entsTake physical handover of ETT or LMA from pre-hospital team. Ensure end Mdal capnography

confirmsplacement.

Assess effecMveness of BMV/ Mapleson C venMlaMon in conjuncMon with surgical registrars

assessmentofBreathing

AqachtovenMlatorassoonfeasible–withconfirmaMonofeffecMvebilateralvenMlaMon.

Non-Intubatedpa>ents–requiringintuba>onIntubatewhenappropriateindiscussionwiththeTTL–ensuringbaselineneurologicalexaminaMon

performedbeforehand,orthopaedicregistrarwillassessperipherallimbresponse,anaestheMstto

assesspupilresponseandformalGCS.

Performco-ordinatedRSIwithNurse1.

EnsureendMdalcapnographyconfirmsplacement.

Assess effecMveness of BMV/ Mapleson C venMlaMon in conjuncMon with Surgical Registrars

assessmentofBreathing

AqachtovenMlatorassoonfeasible–withconfirmaMonofeffecMvebilateralvenMlaMon.

Non-Intubatedpa>entsCommunicateairwaypatencyandissuestoteamleader/scribe.

Assessrespiratoryrateandinformteamleader/scribe.

ItisusuallyappropriatefortheanaestheMsttotalktothepaMentandprovideongoingassessment

ofGCSandpupilsize.

Anaesthe>cs3rdOnCall

KeyRoles

Pa>entManagement

�27

Reassure paMent on arrival, explain what is happening, take AMPLE history and inform Team

leader/scribe

• AAllergies• MMedicaMons• PPastmedicalhistory• LLastmeal• EEverythingelserelevant

E-ExposureOnceprimarysurveycompletedandwhendirectedbytheTTLtheanaestheMstwillcontrolthelog

roll

Considerneedforendogastrictube(nasalororal).

Arterial linesmaybe indicated, to avoiddelay toCT this canusually bedonea\erCTor in the

operaMngtheatre.Itshouldnotdelayeither.

Contribute to case discussion with the TTL. Case discussion should also address ongoing fluid

management,bloodproductsand inotropicsupport.Discussmassive transfusionprotocoluse in

theEDandmanageitsimplementaMononceintheatre,informingbloodofanychangestocontact

nameandtelephonenumber.

Once the primary survey and immediate lifesaving intervenMons have been achieved, the ITU

Consultantmustbeinformedofthelikelycaseprogression.Thismayrequiretheaqendanceofthe

ConsultanttotheResuscitaMonRoomortotheatreasappropriate.

Communicate any requirements with theatres - role shared with surgical registrar. Liaise with

addiMonalanaestheMstasappropriateifcaretobehandedoverfortheatreetc.

Assistwith sending/ordering tests, liaisingwith specialists or performing procedures as training

andabilityallowse.g.chestdrains,urinarycatheter.

�

DocumentallacMonsandfindingswithaclearplaninpaMentnotes.

RemainwiththepaMentunMlappropriatedisposalisachieved 
IfyouneedtoleavetheTraumaTeamenvironment–thismustbediscussedandbeagreedbytheTraumaTeamLeader.

PostTraumaCall

�28

OPERATIONAL

GUIDELINES

�

NonAirwayNurse

LiaisewithTraumaTeamLead,SeniorEDNurseandotherTraumaTeamNurse.Reviewresusbays

andensureResuschecklistsarecompletedandsigned.Highlightandaddressanydeficiencies.

�

ResponsibleforsupporMngTraumaTeamLeader.infuser

Prepare for the traumacallwith levelone infuser run throughwhen indicated,warmed ivfluids

runthrough,chestdrainsetsout ifsuggested,scoopstretcherandpelvicbindertohand.Ensure

equipmentforgaininglargeboreIVaccessandtakingbloodsisavailable.

EnsureavailabilityofONegBlood.

MeetpaMentathelicopterifrequired–co-ordinateporters/transferequipment.

�

EnsureclockstartedwhenpaMentarrivesinResusBay

AssistintransfertotheResustrolley

PosiMonyourselftothepaMentsle\side

Havescissorsready,removeenoughclothinginiMallytoaqachmonitoring,

ClearlystatefirstobservaMonstoteamleader&scribeassoonasavailable.

ThenconMnuetoremoveallclothingincludingunderwearandstoresecurely.

Checktemperature

Coverwithforcedairwarmingblanket/blankets

HelpwithgeNngIVaccessandsendingbloodsoffifrequired,setupintraosseouskit(ez-IO)ifno/

difficultIVaccess.AqachpaMenttoleveloneinfuserifrequired.

Assistwithlogroll

Drawupdrugs/administerasprescribed

PreparefortransfertoCTASAP(within10minutesideally)and/ortheatre

HelpwithproceduresasidenMfiede.g.catheter,chestdrain,andarteriallineDressingsandsplints

ofopenfractures/significantwounds.

EnsurepaMentkeptwarm.

NonAirwayNurse

PriortoPa>entArrival

Pa>entArrival

�29

�

EnsureyouhavedocumentedallyourinteracMonsinthenotes

Ensureyouhavesignedforanydrugs

OnlyleavethepaMenta\erliaisingwiththeTraumateamleader

PostTraumaCall

�30

OPERATIONAL

GUIDELINES

� AirwayNurse

LiaisewithTraumaTeamLead,SeniorEDNurseandotherTraumaTeamNurse.ReviewResusbays

andensureResuschecklistsarecompletedandsigned.Highlightandaddressanydeficiencies.

�

• ResponsibleforassisMngwiththeiniMalassessmentandmanagementofairwaysupporMng

anaestheMst.

• AssistinpreparinganydrugsrequestedbyanaestheMst.• Checkallappropriateairwayequipmentisavailableandworking• ChecksucMonavailableandworking

�

• PosiMonyourselftopaMent’srightside• Assistintransfertoresustrolley• ReassureandestablisharapportwithpaMent• AssistanaestheMstwithairwaypatencyandvenMlaMonpassingadjunctsasnecessary• PrepareanydrugsneededbyanaestheMst(checkdrugswiththemorNurse2)Assistduring

logroll

• Preparearteriallineequipmentifrequested

�

• EnsureyouhavedocumentedanyofyourinteracMons• Ensureyouhavesignedforanydrugs• OnlyleavepaMenta\erliaisingwiththeTraumateamleader

AirwayNurse

PriortoPa>entArrival

Pa>entArrival

PostTraumaCall

�31

� RadiographerMSK

PlacecasseqesunderthetrolleytospeedupiniMalx-rays.

LiaisewithTTLornurseinchargeifteammembersarenotwearinglead.Liaisewithteamleaderif

teammembersareobstrucMngyourchancetox-raytoprioriMseacMons.

�

Radiologist

LiaisewithCTradiographertocleartheCTScannerandcommunicatewithResuswhenscanneris

likelytobeavailable.

Aqend the traumacallwheneverpossible as yourexperMsewill be valuable in reviewing x-rays,

eFAST scans and early recogniMon of intervenMonal radiology requirements and planning of

imaging(CTvsUS).

MosttraumapaMentswillneedearlyCT,naMonalguidelinesare=completetheCTandhavethe

iniMalreportwithin30minsofarrivalinED.

AstandardisedreporMngproformaisusedtoensurerapidreporMng.

RadiographerMSK

Radiologist

�32

OPERATIONAL

GUIDELINES

�

SCRIBE-emergencyNurseAssistant(eNA)

Acomplex jobbutvital.Ensureyouarebeinggiventhe informaMonyourequireand informtheteamleaderifnot.

�

EnsureRecep>onistison-handforrapidpa>entregistra>on• EnsurepaperworkisavailablefordocumentaMon• Ensurebags/documentaMonavailableforpaMentproperty• Ensureteamsignontowhiteboardonarrival• Document teammember’spresenceonTraumaBoard: includingspeciality,gradee.g.ST3

andsupervisingconsultant.

• Ensuretabards/rolelabelsavailable–encouragememberstoplacelabelsvisiblyincenterof

chest.

�

EnsureclockhasbeenstartedwhenpaMentarrivesintheResusBay.GetPaMentCareRecord(PCR)

handoverfromParamedics. 
EnsureallpaMentdetailscorrectandNOKinformaMonisdocumented. EnsurepaMentwristlabels

aresecuredonthepaMent.ListandstoresafelyanypaMentbelongings

ResponsiblefordocumentaMonofobservaMons,eventsandintervenMons

• Documentallprehospitaldrugsandfluids–Mmesandamounts.

• Document iniMal vital signs and then every 5 mins in unstable pt and every 15 mins

otherwise.ThisroleconMnuesintoCTandunMldischargedfromED.

• Maintainachronologicalrecordofalleventse.g.Mmeofvenflon,CXR,FAST,movetoCTetc.

InformtheteamleaderifkeyobservaMonshavenotbeentakene.g.TemporGCS.

Inform the team leader every 15mins that pass, the aim is to be in CT within 15mins when

appropriateaskanddocumentreasonsforanydelays.

Keepalogoftherunningtotalofbloodproductstransfused–thisrolemaybedonebyaspecified

nursememberresponsiblefortheleveloneinfuser.Inamassivetransfusiona\erevery4-5units

prompttheTTLofneedforadjuncts(suchascalciumorinsulin/dextrose).

SCRIBE-emergencyNurseAssistant(eNA)

PriortoPa>entArrival

Pa>entArrival

�33

�

• EnsurealldocumentaMoniscomplete

• Liaisewithpoliceifanypropertyhandedoverforevidence

• Ensurealldrugs/fluidssignedforbyappropriateperson

• OnlyleavethepaMenta\erliaisingwiththetraumateamleader

PostTraumaCall

�34

OPERATIONAL

GUIDELINES

� ConvenMonfortheRegistraMonofPaMentswithUncertainDetails

1. MRNandpaMentidenMfiersareissuedusingthemodeofarrival,dateandMmeinformaMon

inaspecificformatdetailedwithintheguideline.

2. DeviaMonfromthisprocesscouldleadtosignificantpaMentharm

3. Even once paMent informaMon is known, the MRN, name and DOB from the ED should

remaininuseunMlthepaMenthasreachedthelocaMonofdefiniMvecare.

�

AnypaMentwhoaqendstheEmergencyDepartmentMajorTraumaCentreatSouthmeadHospital

forwhomtheirdemographicdetailsareunknownoruncertaininanyway,shouldberegisteredas

anunknownpaMent.

ThenamingconvenMonforunknownpaMentsshouldfollowtheform:

• (Surname)MODEOFARRIVALDATEOFARRIVALTIMEOFARRIVAL• (Forename)UNKNOWN

(wheremodeofarrivalis“Air,Land”whicheverisapplicable,anddateand9mehavenocolonsorbackslashesin).

• DateofBirth:01/01/1900

Thus,apaMentarrivingon10thMarch2015at14:37hoursbyhelicoptershouldberegisteredas:

AIR100320151437,UNKNOWNDOB01/01/1900

ThiswillallowanMRNtobegeneratedwhichwillalsoensurethepaMentisfoundinICE,allowing

theorderingofpathology,bloodandx-rays/CTscans.

It is imperaMvethatthepaMentremainsregisteredasanunknownunMlsuchMmeasthepaMent

moves to an area of definiMve care, eg Intensive Care Unit, ward environment, EVEN IF THE

PATIENTDETAILSBECOMEAVAILABLE.

FullmergerofpaMentdetailsfromunknowntoknownwillbeaccompaniedbyfullmergerofthe

ICEdetails,bloodtransfusionrecord,andradiology.

FailuretoadherethispolicywillcausethepotenMalforextremepaMentjeopardy,thepossibilityof

“NEVEREVENT”occurrence,oratleasttheneedtoinappropriatelyre-bleedthepaMent.

Conven>onfortheRegistra>onofPa>entswithUncertainDetails

UnknownPa>entRegistra>onGuidelines

�35

�

EmergencyDepartment&CriMcalCareMajorTraumaDrugBags

1. ThedrugbagsshouldbekeptinthelocaMonsidenMfiedinthefollowingpages.

2. Thedrugbagsshouldbesealedwithatamperproofsealoncerestocked

3. Wherecontrolleddrugsareusedfromwithinthedrugpouches,itistheresponsibilityofthe

individual using those drugs to ensure they are appropriately prescribed, signed for in a

controlleddrugregisterandcommunicatetheneedtoreplaceorrestock.

4. It is theresponsibilityofeachclinicalservicetoensurecontentsarereplacedasusedand

drugswithindateprior toeachuse.Themechanismstoachievethismayvarybutshould

include the ability to audit restock and expiry status of contents as well as trace those

individualsresponsibleforeachrestockormaintenanceofthebags.

5. The drug bags should be available on acMvaMon of the trauma team in allmajor trauma

calls,priortoarrivalofthepaMent.

6. ThebagsshouldbeavailableduringthetransferormovementofanypaMentwithinorfrom

theEDorcriMcalcareenvironments.

�

DrugbagshouldbestoredinthelockedcontrolleddrugcupboardinResus1and/or2

EmergencyDepartment&Cri>calCareMajorTraumaDrugBags

EmergencyDepartmentMajorTraumaDrugBag

�36

OPERATIONAL

GUIDELINES

Ketamine10mg/ml1x20mlvial

Midazolam1mg/ml1x5mlampoule

Morphine10mg/ml2x1mlampoule

TheEDdrugbagcontentsmaychangeoverMme,butshouldcontainallkeydrugstosafelyperform

emergencyanaesthesiaforalltypesofmajortraumapaMents.

NotetheEDalsohaveaseparateSOPcoveringthemanagementofcontrolleddrugswithinthe

drugbagintheED-cliniciansshouldfamiliarisethemselveswiththis.

�37

Fentanyl50µg/ml1x10mlampoule

Propofol10mg/ml1x20mlampoule

Metaraminol10mg/ml1x1mlampoule

Rocuronium10mg/ml2x5mlampoule

Suxamethonium50mg/ml2x2mlampoule

Lorazepam4mg/ml1x1mlampoule

TranexamicAcid100mg/ml2x5mlampoule

�

EmergencydrugbagkeptinthePodDfridge

IntensiveCareUnitDrugBag

�38

OPERATIONAL

GUIDELINES

Adenosine3mg/ml3x2mlampoule

Adrenaline1:100002xpre-filledsyringe

Adrenaline1mg/ml2x1mlampoule

Amiodarone300mg1xpre-filledsyringe

Atropine600µg/ml2x1mlampoule

CalciumChloride10%10mg1xpre-filledsyringe

Chlorphenamine10mg/ml1x1mlampoule

Glucose50%1x50mls

�39

Ipratropiumnebuliser250µg/ml2x1ml

Magnesiumsulphate5g/10ml1x10mlampoule

Naloxone400µg/ml2x1mlampoule

Salbutamol2.5mgin2.5ml2

SodiumBicarbonate8.4%1

TranexamicAcid100mg/ml2x5mlampoule

Propofol1%2x20mlampoule

Suxamethonium50mg/ml2x2mlampoule

�40

OPERATIONAL

GUIDELINES

Rocuronium10mg/ml2x5mlampoule

Metaraminol10mg/ml1x1mlampoule

Atracurium10mg/ml2x5mlampoule

Ephedrine30mg/ml1x1mlampoule

0.9%saline10mg4x10ml

� TranexamicAcid(TXA)inMajorTrauma

1. Tranexamic Acid (TXA) is indicated in the majority of seriously injured paMents and allpaMentswithsuspicionof,orclinicalsignsofmajorhaemorrhage.

2. Itshouldbeadministeredasearlyaspossibleandwithinthefirst3hoursinallcases.

3. ComplicaMons associated with TXA administraMon are rare, but include risk of venous

thromboembolism,hypotensiononrapidbolusadministraMon,anaphylaxis(rare).

4. ContraindicaMons include: established disseminated intravascular coagulopathy, known

allergy,knownuretericobstrucMon.

�

TranexamicisasyntheMcderivaMveoflysinethatinhibitsfibrinolysisbyblockingthelysinebinding

sitesonplasminogeninthecloNngpathway.

The2010ClinicalRandomisaMonofanAnMfibrinolyMcinSignificantHaemorrhage2(CRASH-2)was

an internaMonal study of 20,207 trauma paMents with or at risk of significant haemorrhage.

PaMents were randomised to double-blind treatment with either tranexamic acid or matching

placebo, given within 8 hours of presentaMon. Tranexamic acid was associated with a 1.5%

absolutereducMoninmortalitycomparedtoplacebo,withnoincreaseintheriskofvaso-occlusive

events.

ThegreatestbenefitisseenwhenTXAisadministeredwithinthe1sthoura\erinjury,butbenefit

remainsupto3hoursa\erinjury.

ManypaMentsarrivingathospitals in theSevernTraumaNetworkwill have receivedTXA in the

prehospital seNng. Theminority thathavenot should receiveTXA,wherenocontraindicaMons

existasearlyaspossibleintheEDadmission.

�

• TXA should be given to ALL seriously trauma paMents with blood loss as evidenced by

systolicbloodpressureof<90mmHgorheartrate>110bpm.

TranexamicAcid(TXA)inMajorTrauma

Background

Indica>ons

�41

• Major trauma paMentswith normal physiology should be administered TXAwheremajor

injury is assumed to be present on mechanism, clinical examinaMon and radiological

findings.

• ThebestpaMenttariffrecommendsTXAwithin3hoursofinjury

• ForanypaMentat riskof significantblood lossaqendingNorthBristolNHSTrustwithin8

hoursofinjuryTXAshouldbeadministeredifnotalreadyreceived.

�

• IniMalloadingdose: Tranexamicacid1gisdilutedin100mls0.9%saline. Itisadministered

byintravenousinfusionover10minutes.Infusionpumprateof600ml/houroraslowbolus

over10minutes.

• Seconddose:Tranexamicacid1gdilutedin400mls0.9%salineover8hours.Infusionpump

rateof50mls/hour.

�

Cau>onshouldbetakenwhenusingTXAinpa>entswith:• Knownallergytotranexamicacid

• KnownuretericobstrucMon

• EstablishedDIC

�

1. NICEGuidance:Significanthaemorrhagefollowingtrauma:tranexamicacid

hqps://www.nice.org.uk/advice/esuom1/chapter/Key-points-from-the-evidence

2. Gruen Russell L, Reade Michael C. Administer tranexamic acid early to injured paMents at risk of substanMal bleeding

BMJ2012;345:e7133

hqp://www.bmj.com/content/345/bmj.e7133

3. TheimportanceofearlytreatmentwithtranexamicacidinbleedingtraumapaMents:anexploratoryanalysisoftheCRASH-2randomised

controlledtrial.TheLancet2011;377:9771,p1096-1101

hqp://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(11)60278-X.pdf

4. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in traumapaMentswith significant haemorrhage

(CRASH-2):arandomized,placebo-controlledtrial.TheLancet2010;376:9734p23-32

hqp://www.thelancet.com/crash-2-2010

Dose&Administra>on

Cau>ons

References

�42

OPERATIONAL

GUIDELINES

https://www.nice.org.uk/advice/esuom1/chapter/Key-points-from-the-evidencehttp://www.bmj.com/content/345/bmj.e7133http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(11)60278-X.pdfhttp://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(11)60278-X.pdfhttp://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(11)60278-X.pdf

� HEMSDirecttoCTPathway

1. HEMS teams familiarwith SevernMTCmay choose to accompanymajor traumapaMents

requiringafulltraumascanasperoftheirarrivalprocedure.

2. The pathwaymust be followed to minimise delays between paMent arrival, imaging and

handover

3. HEMS should idenMfy any paMents for the direct to CT pathway and contact the Trauma

TeamLeader/EMRedPhone

4. ThepaMentremainsundertheclinicalcareoftheHEMSteamunMlformalhandoverinthe

resuscitaMonbayfollowingimaging.

DirecttoCTappliestothefollowingemergencyaNendances:

• FASTposiMvepaMentsthroughtheStrokeThrombolysisProtocol(notcoveredfurtherinthis

document)

• IsolatedCTHeadfornon-traumapaMents(HEMSaccompanied)

• FulltraumascaninstablemajortraumapaMent(HEMSaccompanied)

The‘DirecttoCT’pathwayisaseriesofstepsthatshouldbefollowedtoensureseamlesspaMent

arrival,imagingandhandoverandtominimisedelays.

�

HEMSshouldiden>fyanypa>entswheredirectaccesstoCTisappropriate

HEMSmust contact the Trauma Team Leader (TTL) or ED Red Phone and inform of need fordirectaccesstoCT

• HEMSshouldconfirmthatthepaMentisstableforscan• PaMentnameandDOB,accurateETAandrouteoftransfermustbeprovided

ThedoctorwhoreceivestheHEMSpre-alertmust:• InformrecepMonstafftobook-inpaMentandorderrequiredimaging• InformCTradiographerandon-callRadiologyRegistrarthatthedirecttoCTpathwayisin

place

HEMSDirecttoCTPathway

BeforePa>entArrivesatEmergencyDepartment

�43

�

HEMScrew/paramedicswillproceeddirecttoCTthroughthe‘fardoor’.

HEMScrewcanacknowledgethereceivingclinician(normallytheTTL),butnohandoveristooccur

inpitstop.Wristbandswillbeapplied,butnootherintervenMonsshouldbeundertakenbytheED

traumateamatthisMme.

HEMSstaffwilltransferpaMentoffstretchertoCTscan(weightlimit200kg)

ThepaMentremainsundertheclinicalcareoftheHEMSteambefore,duringandimmediatelya\er

thescanunMltheformalhandoveroccursintheEDTraumaresusbay.Thereceivingclinician(TTL)

mayobservetheCTtoenablecontactoffurtherstaffifrequired.

ThehandoverprocessshouldnotbeginunMlpaMentinResusbay; interferencemustbeavoided.

NomembersofthetraumateamexcepttheTTLandanytraumateammembersspecificallyinvited

bytheTTLshouldaqendCT.

HEMSstaffwillloadthepaMentfromscannertoEDstretcherfollowingcompleMonofCTimaging.

AporteristobeavailabletodrivetrolleyfromCTtoResusbayandleavethroughthe‘frontdoor’

andproceedtoexpectedpaMentresuscitaMonbay.

HEMSwillformallyhandover(ATMIST)thepaMenttothereceivingclinician/TTLinEDResuscitaMon

bay.

FollowingPa>entArrivalAtEmergencyDepartment

�44

OPERATIONAL

GUIDELINES

� Death&BreakingBadNewsintheEmergencyDepartmentFollowingTraumaMcInjury

1. EffecMve&Mmely communicaMonwithpaMents and their relaMves is a crucial elementof

effecMvetraumacare.

2. A single point of contact should convey informaMon to relaMves and paMents to avoid

conflicMnginformaMonandmixedmessages.

3. UseofanamednurseandaprivatespacewithinwhichtoholdmeeMngsisbestpracMcefor

alltraumapaMents.

4. NBT supports theprincipleofwitnessed resuscitaMonand family shouldbeoffered this if

appropriate.

5. RelaMves, includingchildrenshouldbeencouragedtospendMmewiththepaMentpriorto

transfertoICUortheatre.

6. AllpaMentswithaperceiveddevastaMngbraininjurywherenoneurosurgicalintervenMonis

planned should be discussed with the ICU Consultant regarding admission to ICU for a

periodofneuro-prognosMcaMon.

7. WhereICUadmissionforneuro-prognosMcaMonisplannednodiscussionregardingorganor>ssuedona>onshouldtakeplaceinED.AspecialistnurseinorgandonaMon(SNOD)shouldbecontactedtoinformthemoftheadmissiontoICU.

8. IntheraresituaMonofadecisionbeingmadetowithdrawlifesustainingtreatment inED,

two senior cliniciansmust agree that this is appropriate. In these circumstances, prior to

discussing organ donaMonwith the paMent’s relaMves, a SNODmust be contacted by thetraumateamleader.

9. Any discussion about organ donaMon should be undertaken as a collaboraMve approach

involvingtheseniorclinician,SNODandanamedlinknurse

10. TissuedonaMonshouldbeconsideredfollowingthedeathofanypaMentintheED.

Death&BreakingBadNewsintheEmergencyDepartmentFollowingTrauma>cInjury

�45

�

Effec>veand>melycommunica>onwithrela>vesiscrucial.Keypointsinclude:ConversaMonswith familymembersshould takeplace ina roomofferingprivacyandspacewith

refreshment faciliMes available. InformaMon should be provided in a Mmely and open manner

including details of their relaMves condiMon, possible outcomes, assurances their relaMve is not

experiencing pain or distress and an indicaMon when death is imminent. Regular updates of a

paMent’scondiMonshouldbeprovided.Whereindicated,interpretersshouldbeused

CommunicaMon between staff members is essenMal to prevent conflicMng informaMon being

provided. A named link nurse to support relaMves and act as an advocate for the relaMve(s) is

essenMal

NBTsupportstheprincipleofwitnessedresuscitaMon;thisshouldbeofferedwhereappropriate.

Offer relaMves theopportunity to spendMmewith thepaMentbefore transfer to ITUor theatre,

even if this is only for a brief period. Children should not be excluded as theymay imagine a

situaMonfarworsethanthereality.

Followingdeath,relaMvesshouldbeallowedto‘saygoodbye’.Offersupportfromappropriatefaith

or religious leaders (available via switchboard). Thismayprovide support to relaMveswhilst the

paMentisintheatreorfollowingdeath

�

Wherewithdrawaloflifesustainingtreatmentisconsideredthefollowingstepsshouldbetaken:AnypaMentwherewithdrawalof life sustaining therapy isbeingconsideredshouldbediscussed

with the on call ICU Consultant so that an appropriate management plan and locaMon can be

agreed.

All paMents with a perceived devastaMng brain injury where no neurosurgical intervenMon is

planned should be discussed with the on call ICU Consultant regarding admission to ICU for a

periodofneuro-prognosMcaMon.

Where ICU admission for neuro-prognosMcaMon is planned this should be explained to relaMves

but no discussion regarding organ donaMon should take place. A SNOD should be contacted to

informthemoftheadmissiontoICU.

No discussion about organ dona>on should take place in the ED when an ICU admission isplanned.RarelyaSNODmayiniMatethisdiscussionintheEDiffeltappropriatebytheSNODandseniorclinicianresponsibleforthepaMentintheED.

Communica>onwithRela>ves

PlannedWithdrawalofLife-sustainingTreatment

�46

OPERATIONAL

GUIDELINES

In the rare situaMon of a decision beingmade towithdraw life sustaining treatment in ED, two

seniorcliniciansmustagreethatthisisappropriate.ThiswillnormallybetheTraumaTeamLeader

andICUConsultant.

Whenwithdrawal of life sustaining treatment is planned to take place in ED, a SNODmust becontacted by the Trauma Team Leader prior to discussing organ donaMon with the paMent’s

relaMves. Every reasonable effort must then be made to wait for the SNOD to aqend before

iniMaMngadiscussionaboutorgandonaMonwithapaMent’srelaMves.

A SNOD should be contactedon the followingpager - 07659591 642, in all caseswhereorgan

donaMon is being considered. TheOrgan DonaMon Register should also be checked (01179 757

580).If an approach for organ donaMon is undertaken in the ED a planned, collabora>ve approachinvolvingtheseniordoctor,SNODandnamedlinkednurseshouldbeundertaken.

AnydiscussionregardingorgandonaMonmustbeseparatedfrominformaMonregardingprognosis.This ‘de-coupling’ of ‘breaking bad news’ and an approach regarding organ donaMon allows

relaMvesMmetobegintounderstandtheposiMontheirrelaMveisin.OrgandonaMonmustnotbe

raisedunMlitisclearthatrelaMveshaveunderstoodandacceptedtheclinicalsituaMon.

Agreen foldercontaining informaMon relaMng toorganandMssuedonaMoncanbe found in the

officebehind‘seeandtreat’.InformaMonisalsoavailableontheintranetorfromtheSNOD.

TissueDonaMon (corneas, heart valves)must be considered in all paMents a\er death (24 hour

NaMonalReferralCentre–08004320559).

�

VerificaMonofdeathmustbecompletedasperNBTpolicyanddocumentedonNBTverificaMonof

deathpaperwork

All deathsmust be reported to the coroner byway of a hospital death reportwhich should be

completedbytheTTL.RecepMonstaffwillfaxthistothecoroner.

Nursing staff must complete a deceased paMent record which ensures GP’s are noMfied and

informaMoncollatedforfollow-upandaudit

In the event of a paediatric trauma/death, ‘Form A’ - noMficaMon of child death, must be

completed.Theconsultantcommunitypaediatrician(contactedviaBRIswitchboard-76100)and

AnnFry(namednurseforchildprotecMon-01173232363)mustbecontacted

RelaMves shouldbegiven the ‘WhenSomeoneDies’ leaflet.This containspracMcalguidanceanddetailsofsupportservices.Amemberofthebereavementteamwillcontactadeceased’sfamily

forfollow-upandsupport

Any further informaMon or guidance required please speak to the ED nursing team who are

experiencedandtrainedinEDbereavementcare.

FollowingDeath

�47

�

1. EndofLifeCareforAdultsintheEmergencyDepartment,RoyalCollegeofEmergencyMedicineBestPracMceGuidance,March2015

2. OrganDonaMon and the EmergencyDepartment: A Strategy for ImplementaMon of Best PracMce,OrganDonaMon and the Emergency

DepartmentStrategyGroup,NHSBloodandTransplantService,November2016


References

�48

OPERATIONAL

GUIDELINES

AIRWAY&ANAESTHESIA

�50

� EmergencyAnaesthesiaforMajorTrauma

1. Emergency anaesthesia for themajor trauma paMent is a high risk intervenMon that has

significantpotenMalbenefits.

2. TheanaestheMstaqendingamajor traumawillbeaminimumofST5 intheir trainingand

willhavereceivedappropriateorientaMontothisdocumentandtheresuscitaMonbays.

3. RSIisindicatedwhenthebenefitsoutweighthepotenMalrisks–thisisaclinicaljudgement.

The decision to RSI will be made by the Trauma Team Leader and the trauma team

anaestheMst(s).

4. ItisstronglyrecommendedthatketamineisusedastheinducMonagentofchoiceinmajor

trauma.

5. Vasopressors should be avoided in the acute phase ofmajor trauma in all but themost

excepMonal circumstances; preference is for blood product transfusion and balanced

anaesthesia.

6. Inalmostall traumapaMents, itwillnotbeappropriateorpossibletowakethepaMentor

reversemusclerelaxantsonceadministered. Intheeventofairwaydifficulty,Therelevant

DASalgorithmsshouldbeadheredto.

7. In addiMon to standard intubaMng equipment, consideraMon of videolaryngoscopy and

equipmentforPlanB&PlanDCICVmustbeconfirmedinallcases.

�

RapidsequenceinducMonofanaesthesia(RSI)inmajortraumaisperformedtopreventaspiraMon

of gastric contents in paMents who are inadequately starved; to stabilise physiology; and to

facilitate invesMgaMon and treatment. The essenMal features of RSI are safety, pre-oxygenaMon,

intravenous inducMon(usingapre-determinedinducMondose), inserMonofatrachealtubeprior

tomechanicalvenMlaMonofthelungsandtransfertoradiologyordefiniMvecare.ItisimperaMveto

avoidhypoxia,hypercarbia,hypotensionandaspiraMonduringtheprocedure.

EmergencyanaesthesiaforthemajortraumapaMentisahighriskintervenMonthathassignificant

potenMalbenefits.Ifperformedpoorly,anaesthesiainthenon-theatreenvironmentforapaMent

populaMon that o\en have unstable cardiovascular and respiratory systems can result in

unnecessarymorbidityandmortality.

EmergencyAnaesthesiaForMajorTrauma

Background

�51

The purpose of this standard operaMng procedure is to provide a consistent, standardised

approachtoemergencyanaesthesiainmajortrauma,reducingthecogniMveloadandthepotenMal

forhumanerrorandavoidingsignificantpaMentharm.

TheanaestheMstaqendingamajortraumawillbeaminimumofST5intheirtrainingandwillhave

receivedappropriateorientaMontothisdocumentandtheresuscitaMonbays.Theyarepartofthe

majortraumableep,butcanbecontactedonbleep9034iftheyhavenotaqendedoratraumacall

hasnotgoneout.

�

RSI is indicatedwhenthebenefitsoutweighthepotenMalrisks–this isaclinical judgement.The

decisiontoRSIwillbemadebytheTraumaTeamLeaderandthetraumateamanaestheMst(s).

PossibleindicaMonsforRSIinclude,butarenotlimitedto,thefollowingcategories:

A. Airway–ObstrucMonor impendingobstrucMon. Thiswould includea reduced consciouslevel with loss of airway reflexes, seizures resistant to treatment or head injuries. AGlasgow Coma Score (GCS) less than 15 is an indica>on to consider RSI to op>miseoxygena>onandven>la>on.AGCSonalofcases.

B. Breathing–OxygenaMonandvenMlaMonareinadequateorpotenMallyinadequate.C. Clinical course–e.g. thepaMentwithmulMple contaminatedopen fractures thatwill be

heading to theatre imminently; anaesthesia will facilitate further invesMgaMon and

management.

Inmassivehaemorrhage,anaesthesiawillallowconMnuedresuscitaMon,butconsideraMonshould

begiventoadministraMonofbloodproductstocounteracttheinstabilityofinducMon.

In some circumstances anaesthesia canbe administered for humane reasons, e.g. extremepain

fromsignificantburn injuries,orhighlyagitatedorcombaMvepaMents inwhomanaesthesiawill

facilitatefurthermanagement.

InmakingthedecisiontoperformanRSI,numerousrisksmustbeconsidered:

• An>cipatedDifficultAirway:anyindicaMonofadifficultairwaypre-inducMonwillhavetobecarefullyconsidered.

• Anxiety of the Intubator:anxiety for any reason can affect judgement and performance;thiswillclearlyhampertheRSIprocessandfurtherincreasethepossibilityofharm.

• Personnel-Arethemostappropriatepersonnelavailabletoperformtheprocedure?IfnothowlongunMltheyareavailable?

• Resources–AreanyaddiMonalresourcesessenMaltotheprocessthatarenotpresent?

Indica>onsforRSI

�52

AIRWAY

&

ANAESTHESIA

�

Briefing:• Whenrespondingtoamajortraumathetraumateamleaderwillprovideabriefingofthe

inboundpaMent.

• Itmaybepossiblea\ertheiniMalbrieftodetermineifanaesthesiaisrequired.AtthisMme

theRSIchecklistcanbeusedtoguidepreparaMon(AppendixG,page253).

• ItistheresponsibilityoftheanaestheMsttocheckthepresenceofequipmenttheymaywishtouse.

Environment:• The majority of major trauma paMents are received into a resuscitaMon bay in the

EmergencyDepartment. (AppendixC,page233)Ensure there is360-degreeaccess to the

paMenttoallowforfurtherintervenMonsasrequired(e.g.thoracostomy)

• Lownoiselevel–allowseffecMveteamcommunicaMon.

Iden>fyroles:• Manualin-linestabilisaMon,ifsuspectedcervicalinjury.• 1stIntubator• 2ndIntubator(EitherBleep9030anaestheMcconsultantorTTL)• AirwayNurse–airwayequipment,cricoidpressureandexternallaryngealmanipulaMon.• Drugdelivery

Monitoring:• Fullmonitoring(ECG,NIBP,SpO2,EtCO2).Ensuremonitoringisswitchedon,parMcularlythe

EndMdalCO2moduleasittakes1-2minutestowarmup.

• DonotdelayRSIforinserMonofarterialline.

�

Suc>on:• ConfirmsucMonisworkingwithappropriatesized“yankauer”sucMoncatheteraqachedand

placedontherighthandsideofthepaMents’head. Itmaybeappropriatetoarrangefora

second sucMon unit to be available if significant, hard to manage, airway soiling is

anMcipatede.g.maxillofacialtrauma.

Prepara>on

Equipment

�53

Ven>lator:• ThetraumaresuscitaMonbayshaveaDrägerOxylog3000venMlator.• ThevenMlatorshouldbetestedpriortouse.• ConfirmsuitableiniMalseNngsforthepaMent:e.g.Mdalvolumesof400mL,respiratoryrate

18breaths/minute,PEEP5cmH20,onaConMnuousMandatoryVenMlaMonseNng.Theaim

is to achieve Mdal volumes of 6mL/kg (ideal body weight) with a minute venMlaMon

appropriatetothedesiredEtCO2.

• Note the peak pressure at commencement of venMlaMon, adjusMng pressure alarms

accordingly.Change inpeakpressure isanearly indicaMonofexpandingpneumothoraces,

orspontaneousbreathaqempts.

• Ensurecorrecttubingisaqachedandthecircuittestedforanyleaks.• Ensureaself-inflaMngbagwithoxygentubingisimmediatelytohand,incaseofvenMlator

failure.

Videolaryngoscope:A CMAC videolaryngoscope is available; if it is not immediately available in the emergency

department contact the anaestheMc co-ordinator (Bleep9666) toborrow fromLevel 2 theatres.

Arrangeearlytoavoiddelay.

Airwayequipment:shouldbeplacedontopoftheairwaytrolleyreadyforuse.

Minimumlayout:• Laryngoscopex2[size3and4blade]• Bougie-rouMnelyusedinallemergencydepartmentintubaMons.• Tracheal tube with subgloNc sucMon port, endotracheal cuff tested (7.0mm ID ETT for

femaleand8.0mmIDETTformale).• CathetermountandHMEfilter• 10mlsyringe• AlternaMvesmallertrachealtube.• 2xnasopharyngealairways• 1xoropharyngealairway• Bag-maskconnectedtoO2tubing,sidestreamEtCO2aqached.• (Mapleson“C”circuitavailableifdesired)• Nasalcannula

Confirmavailabilityof:• Airway“PlanB”–SupragloNcAirwaydevice(I-gel)• AlternaMvelaryngoscope[alternaMvebladesize/type].• AnMcipateddifficultairwayequipmente.g.C-Mac.• Airway“PlanD”-Difficultairwaykit[surgicalairway]

�54

AIRWAY

&

ANAESTHESIA

�

InducMondrugsanddosewillbebasedonclinicalassessmentandpracMMonersexperienceoftheir

use.ThismustincludeconsideraMonofdrugsrecentlygivenforanalgesiaandproceduralsedaMon

inthepre-hospitalphaseofcare.

ItisstronglyrecommendedthatketamineisusedastheinducMonagentofchoiceinmajortrauma

duetoits’relaMvehaemodynamicstabilityandwidetherapeuMcmargin.A10-20%contextspecific

overdoseisunlikelytocauseharm.

Thefollowingregimesarestronglyrecommended:

• Standard“3:2:1”-Fentanyl3mcg/kg,Ketamine2mg/kgandRocuronium1mg/kgConsideraMon to slight delay (approx. 30-60 seconds) between drugs (dependent on the

paMent’s clinical condiMon) to allow the drugs to achieve maximal effect at the point of

intubaMon

• Hypovolaemic“1:1:1”-Fentanyl1mcg/kg,Ketamine1mg/kgandRocuronium1mg/kgIfseverehypovolaemiaissuspectedfentanylmaybeomiqed,insomecircumstancesitmay

be appropriate to administer a paralysing agent alone. Simultaneous administraMon of

blood products to support blood pressure is strongly recommended rather than

vasopressor/inotropeuse.

RescuedrugsVasopressorsshouldbeavoidedinfavourofappropriateinducMon/maintenancedosesandblood

products. The use of vasopressors for themanagement of hypotension due to hypovolaemia in

trauma is associated with increased mortality. In excepMonal circumstances vasopressors and

inotropesareavailableintheemergencydepartment.

Suggamadexisavailablefromlevel2theatresifanaphylaxistorocuroniumissuspected.

SpecificcircumstancesOnoccasionitmaybeappropriatetouseapropofol/opiatebasedinducMonregime.E.g.Isolated

headinjuries.

Proceduralseda>ontofacilitateinduc>onSome paMents may be agitated and uncooperaMve. They will require incremental sedaMon to

facilitatepre-oxygenaMonandinducMon.SmalldosesoftheplannedinducMondruge.g.10-20mg

Ketamine boluses Mtrated to effect. 1-2mgMidazolam can be used, parMcularly in head injured

paMents. In all cases cauMonmust be exercised and youmust be in a posiMon to immediately

maintaintheairwayandprovidevenMlaMon.

Drugs

�55

MaintenanceConMnued fentanylbolusesandPropofol infusionsareavailable formaintenanceofanaesthesia.

TheCTscannerisclosetotheresuscitaMonbays:Donotdelayatransfertoscantoawaitinfusions

to be commenced. If not immediately available maintenance can be achieved with ongoing

boluses of ketamine (10min intervals) and opiate. AlternaMvely, a fentanyl midazolam “bolus”

regimecanbeused.

Regularadministra>onofmusclerelaxantsisappropriateinmajortraumapa>ents.

�

Op>malposi>oningforpa>ent:• InthetraumapaMentwithpossibleC-spineinjurytheheadshouldbeplacedintheneutral

posiMonwithmanualinlineimmobilisaMon,andanyspinalimmobilisaMon(includingcollars)

removed.

• TheobesepaMentmayrequire“ramping”withheadandchestelevatedabovethelevelof

thepaMent’snavel.

IV/IOAccess:• Ensure two large bore intravenous access are inserted, patent, flushed and accessible.

Intraosseous devices can be used for all anaestheMc drugs in the event of inadequate IV

access.Ensurealldrugsareflushedin.EnsureIOinserMonsiteisappropriatetothepaqern

of injury. e.ghumeral inpresenceofpelvic injury. AnalternaMveopMon is inserMonofa

wideboresubclavianline.

• Simultaneous resuscitaMon with blood products may be required for haemodynamically

compromisedpaMents.

History&Examina>on:Any history and examinaMon are ideally performed before anaesthesia, but in some cases the

urgencyforairwaycontrolwilltakeprecedence.MinimuminformaMonpriortoRSIshouldinclude:

• GlasgowComaScore• Pupillarysizeandresponse• Anyevidenceofchestinjuries.(AnMcipaMngtheneedforthoracostomies).• Abdominaltendernessandguarding• NeurologicalfuncMondistaltosignificantlimbinjury• Limbmovement

Pa>entPrepara>on

�56

AIRWAY

&

ANAESTHESIA

Predic>ngadifficultairway:• History of Ankylosing spondyliMs, Rheumatoid arthriMs, previous head and neck cancer/

surgery

• Morbidobesity,prominentupperincisors,recedingmandible.• Facialtraumaorexcessivebleeding• Necktrauma(haematoma),burnstoneckorface.

Pre-oxygena>on:• For3minutes,bybagvalvemask(BVM)orWaterscircuit.• Ifagitated:facemaskwithreservoirbag+/-incrementalsedaMon(midazolamorketamine,

followedbysubsequentreducMonininducMondrugdoses).

• IninstancesofrespiratorydistressaugmentaMonofvenMlaMonwithBVMcanbeused,butis

o\endifficult.

• Pre-oxygenaMon with significant maxillofacial injuries should be done in a comfortable

posiMon for the paMent, but such that they can rapidly be re-posiMoned to facilitate

intubaMon.

• ApnoeicoxygenaMonvianasalcannulae.OninducMonofanaesthesiaflowisincreasedto15

l/min.

�

DecisiontoRSI• Appropriatepeoplealerted• Pre-oxygenaMoncommenced• Equipmentassembled• Challengeresponsechecklist(AppendixG,page253)• InducMondrugsadministered• Nasalcannulato15l/min• Cricoidpressure(ifused)• LaryngoscopyandintubaMon• Confirmtrachealtubeplacementandsecure• Cricoidpressurereleased• PaMentassessmentperformed• Preparefortransfer

Conduct-PredictedStepsinProcess

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Performarapidre-assessmentofAirway,Breathing,Circula>onandDisability.Thefollowingshouldbeac>onedandcommunicatedtotheTTLandscribe:• ConfirmaMonof tracheal tubeposiMon:Bilateral chestmovement, auscultaMon, conMnued

CO2traceonmonitoranddirectvisualisaMonattheMmeofintubaMon.

• Monitorvalues:SpO2,NIBP,ECG,EtCO2,peakvenMlaMonpressuresandminutevenMlaMon.• SetNIBPtoa1to2.5minutecycle.Thiso\enrequiresrepeaMngasthemonitorresetswhen

disconnectedfromthebaseunit.

• ANYsubsequentchangestovenMlatorseNngsormaintenancedrugs• CompleteRSIauditform.

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An>cipatedorUnan>cipatedDifficultIntuba>on:• Asperthedifficultairwaysocietyguidelines(AppendixH,page254)

• InthemajorityoftraumapaMentsreversalofthemusclerelaxantisnotanopMon.

• “Can’tintubate,CANvenMlate”:asupragloNcdevicecanbeusedtemporarily.
“Can’tintubate,CAN’Toxygenate”:ASURGICALAIRWAYisanappropriatesoluMon.

• AnyaddiMonal“difficultairway”equipment,isavailableviathetheatreco-ordinatororon-

callanaestheMcassistantlead.Delayinprocuringequipmentneedstobebalancedagainst

theurgencyoftheanaesthesiarequirement.

Desatura>on:• Confirmoxygensupplybytracingfromcylindertotrachealtube.

• ConfirmcorrecttubeplacementwithEtCO2andauscultaMonofthechest

• Confirmadequatecardiacoutput–NIBP,pulse,EtCO2

• Exclude/treatpathology:

‣ Pneumothorax +/- tension (O\en predictable, peak pressures/ minute venMlaMon onvenMlatormaysuggestaproblem)

‣ Anaphylaxis‣ Bronchospasmofothercausee.g.asthma‣ Malignanthyperpyrexia

PostIntuba>onChecks

EmergencyAc>ons

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ANAESTHESIA

Hypotension:ExcludethefollowingcausesofhypotensionpostinducMon:

• DruginducedvasodilaMon.

• TensionPneumothorax.

‣ Treatment involves finger thoracostomy anterior to themid axillary line in the fourthintercostalspaceontheaffectedside.

‣ Ifsuspectedandunilateraldecompressiondoesnotrelievetheproblemrepeatontheoppositesideofthechest.

‣ Ifperformedinasterilemannerwithskinprepthethoracostomymaybeconvertedtoaformalchestdrain.

• HypervenMlaMon

In low cardiac output states raised intrathoracic pressure impedes venous return and

hence a hypotensive state ensues. The effect can be reducedwith reducMon of PEEP,

earlybolusofbloodproducts,andpressurelimiMngthevenMlator.• Myocardialimpairment

Directinjury,hypovolaemia,pericardialeffusion.

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EmergencySurgicalAirway

1. ThisguidelineistobeusedinconjuncMonwiththeEmergencyAnaesthesiaSOPtoprovidea

consistent,standardisedapproachtoperforminganemergencysurgicalairway.

2. Emergency surgical airwaymay be needed either following failed intubaMon in the “can’t

intubate can’t oxygenate” situaMon or where iniMal intubaMon is not possible and

oxygenaMonisnotpossiblebyothermeans.

3. Surgicalairwayequipmentshouldberemovedfromthedrawerinthedifficultairwaytrolley

whenitisanMcipatedthatanairwaywillbeparMcularlydifficult.

4. TheDASunanMcipateddifficultintubaMonalgorithmshouldbefollowedincallcases.

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ThepurposeofthisstandardoperaMngprocedure,inconjuncMonwiththeemergencyanaesthesia

SOPistoprovideaconsistent,standardisedapproachtoperforminganemergencysurgicalairway.

This may need to be performed either following failed intubaMon in the “can’t intubate can’t

oxygenate”situaMonorwhereiniMalintubaMonisnotpossibleandoxygenaMonisnotpossibleby

othermeans.

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Thesurgicalairwayequipmentshouldberemovedfromthedrawer inthedifficultairwaytrolley

whenitisanMcipatedthatanairwaywillbeparMcularlydifficult.Forexample:

• Airwaytrauma

• Difficultanatomy

• Burnstofaceandneckprecludingjawmovement

• Possibleairwayburns

• Severemaxillo-facialtrauma

Thetechniquesuggestedminimisestwocommonlyencounteredproblemsnamelybleedingfrom

the incision and loss of the incision into the airway before or during tube inserMon. It differs

slightlyfromtheDASalgorithm.

EmergencySurgicalAirway

Background

SurgicalCricothyroidotomy

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AIRWAY

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ANAESTHESIA

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• Extend thepaMentsneckasmuchas feasible. In this seNngairwaymanagement should

takeprecedenceovertheriskofcervicalspineinstability.

• Insert a number 22 scalpel blade horizontally into the cricoidmembrane using a “stab /

rocking”technique

• Leave theblade inposiMonunMl theMpsof a tracheal dilator arepushed into the airway

incisiononeithersideofthebladeandopenedaswidelyaspossible.

• Remove the scalpel blade, rotate the tracheal dilators 90 degrees (handle caudally, jaws

cranially). Keep the jaws wide open throughout. This will facilitate easier passage of the

endotrachealtube.

• Inserta6.5mmcuffedtrachealtube(overalubricatedintubaMngbougieifnecessary) intotheholeheldopenbythedilators.

• Inflatethecuff,confirmtubeposiMoninthenormalwayandcommencevenMlaMon

• FixthetubeintoposiMonwithaMeorElastoplast.

• Theprocedureshouldtakearound30seconds

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Method

Cricothyroidotomy technique. Cricothyroidmembrane palpable: scalpel technique; ‘stab, twist, bougie, tube’.

(A) IdenMfy cricothyroid membrane. (B) Make transverse stab incision through cricothyroid membrane. (C)

Rotatescalpelsothatsharpedgepointscaudally.(D)Pullingscalpeltowardsyoutoopenuptheincision,slide

coudeMpofbougiedownscalpelbladeintotrachea.(E)Railroadtubeintotrachea.

Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adultsC. Frerk, V. S. Mitchell, A. F. McNarry, C. Mendonca, R. Bhagrath, A. Patel, E. P. O’Sullivan, N. M. Woodall and I. Ahmad, Difficult Airway Societyintubation guidelines working groupBritish Journal of Anaesthesia, 115 (6): 827–848 (2015) doi:10.1093/bja/aev371

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ManagementofOralandMaxillofacialInjuries

1. IniMalassessmentofmaxillofacialinjuryshouldbedonebyEmergencyDepartmentstaff

2. Theremustbeanassessmentforcervicalspineinjury.Thismustbeclearlydocumentedin

themedicalnotesanddischargesummary.

3. Specific imaging is required for maxillofacial injuries. Full imaging requirements are

describedintheguidelinesbelow.

4. The on-call maxillofacial surgical team, based at the BRI, are available 24/7 through

sw