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

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

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

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

Statistics Daily Mail!

Case Review

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

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

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

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

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

On arrival X1 posterior chest stab wound = Thoracotomy Initiated

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

Landmarks

View inside

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

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

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

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

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

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

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

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

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

Ideal Staffing

Ideal Staffing

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

Traumatic Cardiac Arrest Protocol

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