1. The treatment of Trauma patients in a trauma unit.
Shauna Pitchford.

2. May 2010, London trauma office divided London into 4 regions each with a major trauma centre and surrounding trauma units.
Major trauma centre (mtc). Las determine major trauma patients based on trauma tree.
Trauma unit (tu). Patients that don’t meet Major trauma criteria brought to nearest emergency department.
St Marys Hospital, St Georges, Kings College, The Royal London.
24 hour trauma consultant.
24 hour trauma team: general surgeons, cardiothoracics, neurosurgery, anaesthetics, orthopaedics, paediatrics, radiologists, nurses, resus room, and theatres.
24 hour CT within 30 mins.
Chelsea and Westminster, Northwick park, Central Middlesex, Hillingdon, Ealing, West Middlesex, Charing Cross.
No 24 hour consultant and reduced specialities at night time.
More risk for the trauma patient if they present.

3. Trauma presentations in a Trauma unit.
LAS assess the patient and history incorrectly and accidentally send Major Trauma to a TU.
Patient unconscious with no witnesses: missed Major trauma.
Patient walks in.
Patient is too unstable to travel to MTC and needs immediate care.

4. Suspected Trauma. Gain accurate history: SBAR.
Check the Trauma activation criteria (New edition beside blue-call phone).
Alert Nurse in charge/ Senior reg.
Patient into resus ASAP
Dial 2222 “adult trauma team to A&E Resus”
? Need for major Haemorrhage protocol. (Beside blue-call phone).
Trauma documentation packs in Resus.
Roles and responsibilities in Trauma operational policy, in your orientation booklet.
PPE’S!!

5. Primary survey: c-abc Catastrophic Haemorrhage. Airway and C-Spine.
Breathing.
Circulation.
Disability.
Expose.

6. Airway and C-spine.
Airway patent ? Patient talking/snoring/gurgling/no sounds.
Suction blood/teeth/secretions as far as soft palette.
Insert oral airway only. Not Nasopharyngeal.
If tolerated prepare for advanced airway: LMA, ET tube, or needle cricothyrotomy.
Jaw Thrust Chin Lift only. Always assume a spinal injury, especially in unconscious, confused, head injured patients. Consider distracting Injuries.
Maintain manual in line stabilisation and put adjuncts in place. Collar and Head hugger. Leave on until cleared clinically/by CT.
Examine head, face, and neck for obvious trauma, bruising, swelling. Trachea central?
Extra cautions in dealing with burns patients: potential for airway deterioration.

7. Breathing. (RIPPa)
? Present/Absent: Look listen and feel x 10 seconds.
Supported ventilations with ambubag if absent, and 15L via non-rebreather oxygen mask if spontaneous ventilation.
Assess Rate: is normal. Higher can be an indication of shock.
Inspection: look for equal chest rise and fall. ? Haemo/pneumo/tension pneumothorax. Immediate intervention.
Palpate: Feel along the chest wall for tenderness, crepitus, deformity, surgical emphysema.
Percussion: look for dullness/hyperressonance
Auscultate: Air entry equal, Absent on any one side? Wheezes/gurgling sign of aspiration.
Attach oxygen saturation probe. Low reading ? Pt cold/hypoxic/peripherally shut down/nail polish. (Obtain ABG eventually)

8. Circulation.
Pulse present? Palpate CENTRAL Pulse. Commence chest compressions 100/min. PEA caused by Hypovolaemia.
Check rate and rhythm and volume of pulse is normal in adults in pain. Tachycardia is a main indicator of shock. With bradycardia consider athletes, pacemakers, beta-blockers, or spinal shock. Attach to monitor.
Check Capillary refill time. <2 seconds, longer could indicate shock. Check skin colour and temperature.
Check BP; Low systolic is a sign of advanced hypovolaemic shock.
Control any bleeding with pressure/elevation.
Insert 2x wide bore cannulas (14-16g). Request bloods (fbc, u&e, clotting, pregnancy, venous gas.) Consider IV analgesia and anti-emetics.
Group and Crossmatch 6 units. Order units or O neg. ? Initiate major haemorrhage protocol.
IV fluids: 2 litres of warmed crystalloid. Infuse blood/fluids through level 1 rapid infusor.

9. disability
AVPU score immediately, and keep reassessing for deterioration. Use trapezius pinch, or nailbed pressure for reaction to pain. Prioritise airway maintenance in the unconscious patient.
Unresponsiveness can be caused by head injury, hypoxia, hypovolaemic shock causing hypoxia, hypothermia, drug or alcohol use, and hypoglycaemia.
Check Glasgow Coma Scale: Eye opening, verbal response, motor response. This gives a more accurate assessment.
Pupil size and reaction
Check Bm.

10. Exposure/environment.
Remove all clothes from the patient while preserving dignity.
Keep the patient warm: Active warming (bear hugger, warm fluids) and heat loss prevention. Extremely important in burn patients.
Hypothermia is classified as <36 degrees. Hypothrmia may disguise signs of hypovolaemic shock due to vasoconstriction, and makes it more difficult for haemoglobin to release oxygen to the tissues. Shivering causes an increase in lactic acid: metabolic disturbances.
Use a rectal probe as peripheries may be cool.
Prepare the patient for logroll to inspect posterior surfaces.
Get a full history from patient/relatives/ambulance crew.

11. Secondary survey. Repeat a full set of observations.
Do a thorough head-to-toe assessment of the patient to look for further injuries: Head and face, neck, chest, arms, abdomen and pelvis, perineum, legs. Log roll to inspect posterior surfaces.
Consider adjuncts: Insert catheter with hourly urine monitoring. Output should be at least 0.5ml/kg/hr. Insert orogastric tube to deflate stomach contents. Record ECG.
Was analgesia effective?
Care of the family: Updating the family or breaking bad news appropriately in a comfortable room with access to phones. Offer the services of a chaplain.
Ensure documentation and prescribing is up to date.
Prepare the patient for transfer to MTC/ICU: Call LAS, Prepare patient, staff, equipment, meds, paperwork, and update receiving hospital and family.

12. Any questions?