1. Trauma Team Training Take Home Clinical Points

2. Essential CRM skills Know your environment Anticipate and plan Effective team leadership Active team membership Effective communication Be situational aware Manage your resources Avoid and manage confli cts Be ware of potential errors

3. Trauma Apps I Phone Westmead Trauma App – https://play.google.com/store/apps/details?id=air. au.com.lpn.WestmeadApp&hl=en https://play.google.com/store/apps/details?id=air. au.com.lpn.WestmeadApp&hl=en Android Westmead Trauma App – https://itunes.apple.com/au/app/westmead- trauma/id785943004?mt=8 https://itunes.apple.com/au/app/westmead- trauma/id785943004?mt=8

4. Airway

5. Airway Pearls Plan your Airway Intervention – Equipment – Team Briefing (Plan A, B and C) – ‘Checklist’ Goal is to Oxygenate and Ventilate (not intubation) Optimise Haemodynamics and Oxygenation Prior to induction Anticipate a difficult airway (team brief as above) A Neutral position is slightly flexed at the neck so put a towel or SAM splint behind the head

6. Checklist Example

7. ITIM – Difficult Airway Management 1 Failure to Intubate Place Oral Airway and 2 person BVM with 100% O2 Attempt to Ventilate and Keep Sats>90% Call for Help Maintain Cricoid (if used) and Inline

8. ITIM – Difficult Airway Management 2 Are the SATS>90% with the BVM?? No Attempt to Ventilate using LMA Able to keep Sats>90%: If yes Proceed to Right Unable to keep Sats<90% Surgical Airway Optimise Position, Use Adjuvant(s) for Intubation Consider Waking the patient or obtaining further resources Consider Surgical Airway Yes Make 2 nd attempt at Intubation

9. Drugs for RSI - Discussion RSI is usual Technique for Trauma Intubation Dose reduce Sedative Agent = Thiopentone (if used) 0.5mg – 2mg /kg (rather than 5mg/kg) Consider Ketamine 1mg -2mg/kg or Midazolam 0.05mg – 0.1mg/kg Fluid prior to induction may be appropriate (vasopressors are not usually appropriate) May need to increase dose of Suxamethonium Need to allow all drugs more time to act Propofol is (generally) NOT recommended

10. Abdomen Protocols

14. Haemorrhage

15. Where is the Bleeding ‘PLACES’ – Pelvis – Long Bone – Abdomen – Chest – Externally and Epistaxis – Scalp

17. Chest Protocols

19. Sternal Injury

20. Penetrating Chest Injury

22. Code Crimson and Massive Transfusion

24. Massive Transfusion Prof Koutts Protocol (October 2012) – Is available on the Westmead intranet Consider 1g Tranexamic Acid Early (within 3 hours)

25. Principles of Massive Transfusion

26. Penetrating Abdominal Wounds

28. Head Injury

29. Neuroprotective Measures Head up 30 degrees IV Fluid (Relative Hypervolaemia) Avoid Hypotension and Hypoxaemia Reduce ICP and maximise Cerebral Perfusion Pressure (CPP) (Monroe Kellie Doctrine) – CO2 30-35 – No tight ties, conservative C spine precautions – Drugs – Induction, Sedation and Paralysis – ICP Monitoring (invasive) and Seizure Meds: recent evidence suggesting against

30. Hypertonic Saline

31. Continued to next slide…

33. Trauma Call Criteria

36. Cognitive Aids

39. 5 Cs OF COMMUNICATION 1.Clarity Give and receive instructions & information (be specific, be succinct, avoid jargon, CLOSE LOOPS) 2.Coordination (use people’s names, confirm you hear instructions, relay information via leader) 3.Cohesion (clarify goals, share information, invite input, summaries and updates, acknowledge effort, speak calmly, use humour) 4.Concern to be freely expressed use graded assertiveness attention /enquiry /clarify /demand) 5.Conflict to be avoided/ managed (clarity, consensus, decision)

40. GRADED ASSERTIVENESS 1. Bring to Attention: 2. Enquire (make an enquiry or offer an alternative as a suggestion): ”Are you going place an IV in that fractured arm?” 3. Clarify “ I feel uncomfortable about this, please explain what you are doing” 4. Demand a Response or Take Control of the Case: “ Sir you MUST LISTEN” KEY PHRASE “Stop – you must listen to me” Alternative Mnemonic **CUSS = ‘Concern’, ‘Unsure’, ‘Safety’, ‘STOP!’

41. CONFLICT RESOLUTION: 4 STEP NEGIOTIATION PROCESS 1.State what actually happened or what you observed (be specific) 2.State how you feel about it and find out their perspective 3. Say what you want to happen next 4. Agree on the next step Time critical situations may require an abbreviated approach. Authority : Deliver directive No authority : Graded assertiveness

42. 7 NON-TECHNICAL TEAM TASKS 1.Assemble right team - skill mix / numbers / phone consults 2.Plan & prepare - organisational / patient specific / plan A & B & C Equipment (type/location/working order/ training) Colleagues (names, skill mix, roles, brief team) Situational awareness (pt load & mix, anything else that will impact on your resources) 3.Manage resources - make decisions / allocate tasks / get help 4.Manage people - roles & goals / familiarity & trust / update 5.Communicate effectively – CCCCC 6.Monitor & evaluate - cross check / team update & confirm / documentation 7.Support each other - awareness of roles & support & feedback