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The European Trauma Course Manual
Edition 4.0
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2.
Reception and resuscitation of the seriously
injured patient
Learning outcomes
Following this part of the course you will be able to demonstrate competence in:
QThe briefing process of the trauma team
QPreparation to receive a patient with major trauma
QReceiving and giving a handover
QPerforming a primary survey
QIdentify the need for and give appropriate analgesia
QHow to plan the patient’s subsequent care
QHow to perform a secondary survey
Introduction
Modern trauma care has been reconfigured over the
past few years into a multi-professional chain of care
organised in regional networks to create a trauma
system. Within each network are a number of partners;
the pre-hospital emergency medical services (EMS),
the district general hospitals, major trauma centres
(MTC) and rehabilitation services. The main objective
of these networks is to improve patient outcome by:
Qfacilitating
communication and cooperation
between all network partners
Qproviding overarching clinical governance
Trauma networks result in a strengthening of the
‘Chain of Survival’ by improving the standards of care
at all points, from the pre-hospital phase to definitive
care. Recent figures from the UK confirm that the
introduction of a network system can decrease early
mortality of major trauma by 30%.
The level of care that patients receive at scene and
during transport depends on the configuration of the
EMS. In many European systems, pre-hospital care
for major trauma patients is delivered by teams of
paramedics and doctors with a focus on early triage,
rapid transportation and life-saving interventions
carried out at at scene, or en route. These intervention
include haemorrhage control, advanced airway
techniques, chest decompression, analgesia, sedation
and even transfusion of blood products in some
systems.
Whatever the pre-hospital system, the subsequent
in-hospital management is a complex process of
diagnostic and therapeutic procedures, carried out in
parallel, within a limited time frame. This clearly needs
thorough preparation, good organisation, an adequate
infrastructure and excellent communication between
all staff involved. It is best carried out by a well trained,
multi-specialty team. Using such a system has been
shown to result in improved outcomes after major
trauma. This is the principle upon which the European
Trauma Course is based.
Planning and preparation for
receiving a trauma patient
Hospitals that receive trauma patients usually have
a set of specific guidelines, protocols and standard
operating procedures describing the pathway for
these patients within their institution.
Equipment and facilities:
Trauma admission bays should be close to the
ambulance entrance.
QEach patient bay must provide enough space to
host a complete trauma team and all standard
resuscitation and diagnostic equipment required for
the initial management of major trauma.
QImmediate availability of additional equipment,
including; difficult airway equipment, surgical
Q
CHAPTER 2 RECEPTION AND RESUSCITATION OF THE SERIOUSLY INJURED PATIENT | 21
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instruments, massive transfusion equipment,
ultrasound machine, x-ray and adequate lighting to
carry out life-saving procedures safely.
QImmediate access to a supply of packed red blood
cells (PRBCs) and further blood products.
QIdeally the trauma reception bay should be
adjacent to an operating room to allow rapid
transfer for emergency procedures. The
continental concept of Shock-OperatingRooms represents a combination of a trauma
resuscitation bay and an operating room.
This allows for immediate life saving surgical
interventions without the need to move the
patient. Most advanced Shock-Operating-Rooms
have integrated CT facilities.
QIdeally a CT scanner should be co-located with
the Emergency Department to allow immediate
imaging.
QTransfusion services that can respond within
minutes according to the hospital’s major
haemorrhage protocol.
The trauma team
nursing, but we increasingly see paramedics and
operating department (ODP) practitioners in these
roles. TSP assist the medical staff as circulating
practitioner or will act as recording practitioner
(scribe). The TSP fulfill the classical supporting roles,
in helping to transfer the patient, removal of clothes,
application of monitoring, obtaining peripheral
vascular access, taking and processing blood
samples and assisting with invasive procedures; they
are key members of the trauma team. It is common
for the physicians allocated the A,B and C roles to
work with a dedicated TSP, forming ‘teams within a
team’.
All TSP must take part in the team brief as they
are fully integrated into the task allocation. In
addition, the TTL may allocate TSP to carry out
specific procedures, which are within their scope
of practice.
TSP are also the first line in liaising with the
patient’s relatives.
The process
Emergency Department alert
All hospitals that receive major trauma should have
a designated team that can be freed up from their
routine work to receive the patient.
QA dedicated ‘trauma alert’ system is required to
inform all team members immediately when a
trauma patient is expected.
QAll team members and team leaders must be
competent to fulfil their allocated role within the
trauma team.
Q
The composition of the trauma team can vary
considerably depending on the regional system and
the resources available.
For the purpose of the ETC the core trauma team
consists of a Trauma Team Leader (TTL) and a variable
number of Trauma Team Members (TTM).
QThe TTL coordinates the activities of the trauma
team and ensures effective communication. The
TTL remains hands off to retain overview and
situational awareness.
QThe airway practitioner (A-person), who should be
able to secure a compromised airway and provide
anaesthesisa, if required.
QA third clinician, (B-person), who is able to assess
the chest including ventilation and competent to
insert a chest drain.
QA fourth practitioner (C-person), who is capable of
assessing the circulatory system, applying a pelvic
splint and obtaining vascular access. Ideally the B- or
C-person should also be able to perform sonography
e.g. e-FAST (extended Focused Assessment with
Sonography in Trauma) as part of the primary survey.
QOn some courses there will be Trauma Support
Practitioners (TSP). Their background is usually
22 | EUROPEAN TRAUMA COURSE
Emergency Departments usually have some warning
either directly from the pre-hospital team or by central,
(ambulance) control, that a severely injured patient
is about to arrive. Ideally communication should be
directly between the pre-hospital team and the trauma
team leader (TTL) using a standardised reporting system,
e.g. ATMIST in order to minimise the loss of information
(table 2.1). The earlier the warning is given, the better
because:
Qsmaller hospitals need more time for preparation
than large centres;
Qan influx of large number of casualties requires
time to mobilise adequate additional resources;
Qspecialist equipment or support may be required.
Age, sex and relevant history (e.g. pregnancy, warfarin)
Time of incident
Mechanism of incident. This should include:
QGross mechanism of injury (e.g. road traffic accidents,
stabbing)
QO ther factors known to be associated with major injuries
(e.g. entrapment, vehicle roll-over, ejection from vehicle,
fall from height)
Injuries suspected
Signs and symptoms
QRespiratory rate, SpO2
QHeart rate, blood pressure
QGCS, focal neurological deficits
QPain
QTrends in vital signs
Treatment given and to be expected on admission (e.g. massive
transfusion)
Table 2.1 The ATMIST handover
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Key decisions that need to be considered at this stage
are the requirement for:
Qimmediate advanced airway intervention
Qmassive transfusion
Qother immediate life-saving interventions
Once this has been determined, the TTL can decide if:
Qthere is any need to deviate from the standard
cABC response (Table 2.2);
Qany specialised equipment is required;
Qimmediate operating room access is required.
equipment (e.g. for massive transfusion or difficult
airway trolley).
QEnsure all TTMs take universal precautions.
QEnsure that all TTM had the opportunity to take
part in the planning process, ask questions and
raise concerns.
O
Once all of the above have been achieved, it is the
individual TTM’s responsibility to prepare for the
trauma patient.
Preparation
TABLE 2.2
cABC
The cABC approach helps to prioritse and structure resuscitation
of trauma victims towards the most preventable causes of death,
which are
c= major haemorrhage
Airway and cervical spine control:
Qall basic and advanced airway equipment
available
Qsuction to hand and functional
Qventilator tested and ready for immediate use
Qsemi-rigid collars, blocks and tape
Qescape-plan: supraglottic airway device, surgical
airway kit, competent surgical skill availability
A= airway obstruction
B = chest injuries
C = circulatory shock
Team Brief
Once the trauma team members (TTMs) have
assembled, the TTL should:
QCarry out introductions to ensure all members
know each other.
QShare the pre-hospital information with the team
using an ATMIST format.
QConfirm the individual competencies of the TTMs
and ensure that there is senior support available
for junior TTM.
QAllocate the tasks appropriately
QEnsure that the TTMs have:
all the pre-hospital information
a complete understanding of their role within the
team
a mutual awareness of limitations (of both TTL
and TTMs)
an understanding to share concerns
confidence to ask for help when required
QAlert radiology, operating theatres and the
Intensive Care Unit (ICU) of possible needs.
QIdentify if a standard primary survey is to be
followed, and formulate ‘Plan A’ together with the
team.
QEnsure that TTMs are aware of an alternative
strategy, ‘Plan ’B’, e.g.:
need for immediate transfer to the operating
theatre
management of an unexpected peri-arrest
condition
QEnsure that TTMs are aware of the need for
additional resources:
staffing (e.g. senior colleague, obstetrician in case
of pregnancy, paediatrician)
O
O
O
O
O
O
O
O
The equipment in the trauma resuscitation bay must
be checked on a daily basis. In addition, the TTMs,
both doctors and TSP, are responsible for checking the
availability and functionality of the equipment they
require for planned and unplanned interventions:
Breathing:
Qmonitors functioning;
Qequipment for insertion of intercostal chest drain
(ICD)
Qescape-plan: actions in the event of a traumatic
cardiorespiratory arrest
Circulation:
Qmonitors functioning (including sonography if
competent)
Qdressings/ haemostatic gauze and tourniquets to
control external haemorrhage
Qpelvic binder
Qlarge bore vascular access including large central
venous catheters
Qmassive transfusion delivery system (Belmont,
Level-one)
Qescape-plan: alternative vascular access (eg.
intraosseous), plan for catastrophic haemorrhage
Finally, the TTL must:
Check with individual team members to ensure
that the equipment is complete and functioning
and that TTM know how to summon senior
support if required.
QEnsure that the room and fluids are pre-warmed.
QCommunicate
with
other
departments
appropriate to the situation:
blood bank
radiology
surgical specialties
operating room
critical care
Q
O
O
O
O
O
CHAPTER 2 RECEPTION AND RESUSCITATION OF THE SERIOUSLY INJURED PATIENT | 23
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Figure 2.1 Summary of team brief and preparations for the reception of a trauma patient
The primary survey
The Assessment Triangle
and its components
This starts immediately on the patient’s arrival, its
purpose is to identify and control any immediate lifethreatening condition.
5-Second Round and Handover
The priorities on arrival are:
QThe TTL performs a 5-second round, which is a
brief initial assessment of the patient, before the
handover commences. The aim of the 5-second
round is to rule out the following life-threatening
conditions
complete airway obstruction
massive external haemorrhage
traumatic cardiac arrest and to confirm whether
Plan A is still appropriate.
This can be achieved within seconds using the
‘Assessment Triangle’ (Fig 2.2). This is a basic visual
assessment tool that gives an immediate indication
of the severity of the patient’s condition. The
‘Assessment Triangle’ looks at three physiological
aspects.
social interaction
respiratory effort
skin perfusion
O
O
Social interaction
Social interaction
Calm, collected
Agitated
Absent
Respiratory effort
Normal
Increased
Absent
Skin
perfusion
Resp. effort
Skin perfusion
Pink
Pale, mottled
Absent
O
Figure 2.2 The assessment triangle is part of the five second round
and helps the team to assess the severity of the patients condition;
a patient that is calm, collected with normal respiratory effort and
good skin perfusion does most likely not require any immediate
intervention, whereas an agitated patient in respiratory distress,
with mottled skin, is likely to require life-saving interventions
without delay.
O
O
O
24 | EUROPEAN TRAUMA COURSE
If the TTL identifies any life-threatening conditions, he
must immediately direct the team towards resolution
of the situation rather than proceeding with the
primary survey. For example; directing the team to
apply pressure or tourniquets to stem bleeding, to
relieve airway occlusion or initiate the Traumatic
Cardiac Arrest (TCA) algorithm (See chapter 5c, TCA).
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The TTL should call out the findings of the 5-second
round clearly to make sure that all team members
understand the clinical priorities. In most cases, the
team will be able to continue with ‘plan A’.
Then the primary survey commences with all personnel
working simultaneously and supporting each other
where required (figure 2.3). During the primary survey
TTL remains ‘hands-off’. The best position for the TTL
is at the foot end of the patient’s bed, which gives
him the best overview, helps retaining situational
awareness and maximising bandwith.
The TTL should stand next to the recording TSP (scribe)
to allow for optimal communication between the two
in a sometimes noisy environment.
Prior to the Primary Survey the patient must be
exposed to allow a complete examination and access
to vital structures.
Airway
Airway personnel establish contact with the patient
and check airway patency. Following this, and
depending on the response, they will:
Qgive oxygen if the SpO is decreased;
2
Qprovide basic and advanced airway management
as necessary;
Qmonitor end-tidal CO
2
Qimmobilise the cervical spine
Qprovide analgesia
Qcarry out a focused neurological assessment (see
Disability) and obtain an AMPLE history; this is
essential if the patient is to be anaesthetized
Quse an RSI checklist if general anaesthesia is given
Qsupport other team members if no airway
intervention required
In most trauma systems this will be the role of the
anaesthesiologist, who can also insert large bore
vascular access.
Breathing
Breathing personnel:
Qassess breathing pattern
Qensure ECG and peripheral oxygen saturation
(SpO2) monitors are attached
Qexamine the chest
Qperform a lateral thoracostomy and insert ICD as
necessary
Qinspect and palpate the neck
Qsupport other team members if no chest
intervention is required.
Circulation
Circulation personnel:
Qstem any overt haemorrhage
Qestablish
peripheral vascular access, take
appropriate blood samples
Qstart monitoring of heart rate (HR), blood pressure
(BP) and capillary refill time (CRT)
Qstart fluid resuscitation or give blood products
Qexamine the abdomen, pelvis and long bones
Qapply a pelvic binder if indicated
Qif competent and indicated, perform extended
focused sonography assessment (e-FAST)
Qinsert a urinary catheter.
Disability (neurological assessment)
This is usually done by the airway personnel and
consists of:
Qassessment/reassessment of the patient’s GCS score;
Qcompare pupillary size, symmetry and light response
Figure 2.3 The Team approach to the primary survey
CHAPTER 2 RECEPTION AND RESUSCITATION OF THE SERIOUSLY INJURED PATIENT | 25
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Q
check for any gross difference in motor response in
all four extremities
Exposure
This will involve all TTMs and consists of:
QCompletion of removal of clothes.
QConsider a log roll to check the patient’s back and
remove any debris. Points to note include:
it has the highest priority in a patient with
penetrating trauma particularly in those with
stab or gunshot wounds
postpone in cardiovascular unstable blunt trauma
patients and those with actual or suspected
pelvic or spinal trauma
it can be postponed if immediate whole body CT
is planned
QActive measures must be taken to maintain
the patient’s body temperature and prevent
hypothermia. One or more of the team must
therefore ensure that the patient is covered with a
forced-air-warming blanket.
O
O
O
The key role of the TTL is to supervise and guide
the team whilst the resuscitation is ongoing. This is
achieved through good team communication:
Qall TTMs communicating their findings to the TTL as
and when appropriate
Qthe TTL processes these findings and makes
sure that all TTMs have an understanding of the
patient’s revised condition and priorities
Qformulation and alteration the treatment plan as
the resuscitation is ongoing
Qusing the ‘stop procedure’ to ensure that all team
members understand the process and the immediate
priorities. The ‘stop procedure’ is particularly helpful,
when unexpected problems arise.
Qensuring that all vital functions are continuously
reassessed and results recorded
Qreallocating tasks of the TTMs if required
Qensuring that the relevant diagnostic tests
(laboratory and radiology investigations) and
emergency interventions (e.g. major haemorrhage
protocol) are carried out
Qthe TTL is responsible for organising the patient
pathway (communication with departments or
regional specialist centres
Good documentation is mandatory and needs to be
contemporary. The use of standardised trauma charts
(see appendix) ensures that all relevant systems are
examined. The documentation includes details of all
diagnostic and therapeutic steps (both completed and
planned), recorded in such a manner that it is easy to
follow for teams that take over the care at a later stage.
Documentation is the task of the scribe. Closed loop
communication between the scribe and the other
team members ensures that important information is
not lost. An experienced scribe will also act as auditor
of the resuscitation process and prompt the TTL if
detects any deviations from standard practice.
It is the TTL’s responsibility to ensure that the
documentation is complete and to decide on
the immediate future management of the
patient.
Imaging in the major trauma patient
Sonography
Extended Focused Assessment with Sonography
in Trauma (eFAST) is a standardized ultrasound
examination aimed at identifying immediately life
threatening conditions and targeting resuscitative
efforts. In many countries it has become part of the
primary survey. It is particularly useful to identify the
source of shock in trauma.
The examination consists of three components (Fig 2.4):
1) the abdominal examination aims at identifying free
fluid in hepatorenal recess, the perisplenic and the
rectovesical space.
2) examination of the anterlateral chest wall allows to
reliably identify a pneumo- or haemothorax.
3) examination of the heart can identify a cardiac
tamponade and help assessing the intravascular
fluid status of the patient.
Figure 2.4 The standard views of eFAST (with the kind permission
Dieter von Ow, Kantonsspital St.Gallen, CH)
26 | EUROPEAN TRAUMA COURSE
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Additionally, assessment of the diameter of the inferior vena
cava (IVC) for evidence of collapse during inspiration and
an empty urinary bladder after fluid resuscitation suggest
inadequate resuscitation or more seriously ongoing blood
loss. Ultrasound guided central venous cannulation is now
regarded as the ‘gold standard’ and is particularly valuable
in trauma patients where hypovolaemia reduces the
diameter of the central veins.
Sonography has the greatest importance in trauma
patients who are haemodynamically unstable. These
patients require urgent intervention and eFAST can
be used to guide the resuscitation and to establish
the treatment priorities (eg guiding the surgeon to the
correct body cavity). However, CT remains the ‘goldstandard’ investigation for haemodynamically stable
trauma patients.
A further important role for sonography is in the
investigation of patients who have sustained moderate
trauma but do not fit the criteria for major or polytrauma.
These patients will not warrant an immediate CT, but
negative sonography and normal haemodynamics
help in planning management. Conversely, if free fluid
is identified then CT scanning should be expedited.
Finally, sonography can be used as part of the triage
system when dealing with multiple patients or in a
major incident to help identify those who need urgent
intervention.
CT scanning
Patients who have sustained major trauma require a
CT examination from head to mid-femur as soon as
possible. This is to establish a management plan based
upon the appropriateness of surgery, interventional
radiology or conservative management.
Ideally the trauma receiving area and the CT scanner
should be co-located as this enables imaging to be
performed within the first few minutes of arrival, whilst
resuscitation continues. When the scanner is remote,
well-rehearsed procedures need to be in place to ensure
CT imaging is possible within the first hour of admission.
Administrative delays should also be minimized by
having a standardised request and protocol understood
by all departments. In some advanced systems early
whole body CT scan is carried out as part of the primary
survey. This requires the CT scanner to be located in the
trauma bay or the shock room (fig 2.5).
When scanning occurs shortly after arrival there is
no need to perform plain radiographs of the spine,
(particularly cervical) or pelvis. However, if CT scanning
is not immediately available, plain x-rays of the chest
and pelvis remain part of the primary survey. Plain films
of the extremities can be taken as required but again,
should not unduly delay the transfer for scanning.
Figure 2.5 Handover from the pre-hospital to the hospital team;
Shock-Operating-Room with integrated CT-scanner at the Military
Hospital Ulm, Germany. (B.Hossfeld)
What type of CT scan?
Whole body, contrast enhanced, multi-detector CT
scanning is the default imaging of choice in the major
trauma patient. Each Radiology Department will acquire
images in slightly different formats, but as a minimum
the patient needs a CT scan of the head, cervical spine,
thorax, abdomen and pelvis with no ‘skip areas’. The
images can be acquired in a single block or as separate
acquisitions depending on type of CT scanner.
A radiologist, experienced in the interpretation of
trauma scans should provide an initial ‘primary survey
report’ within a few minutes so that any immediately
life-saving interventions (e.g. insertion of a chest
drain) can be carried out. Whilst these procedures are
on-going the radiologist then needs to review all the
images more completely allowing a ‘secondary survey
report’ to be issued.
Angiography and interventional radiology
All trauma centres should have access to angiography
and interventional radiology services 24 hours a
day within 30-60 minutes of request. Ideally, an
interventional radiologist should be immediately
available if the CT scan reveals active bleeding as the
source may be amenable to treatment.
Analgesia
From both a humane and therapeutic point of view,
all trauma patients should receive appropriate pain
relief. This can be achieved using a combination of
psychological, physical and pharmacological methods.
Psychological methods
Stress will make the perception of pain more acute and
disturbing and a combination of the following should
be used to minimise this:
Qmake eye contact with the patient;
Qmake physical contact with the patient (e.g. hold hand);
CHAPTER 2 RECEPTION AND RESUSCITATION OF THE SERIOUSLY INJURED PATIENT | 27
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talk to the patient – this is best relayed through
one person;
explain what is happening
ask about worries and needs (e.g. message
relayed to relative; wish to urinate)
warning before any painful procedure
Qmaintain dignity.
Q
O
O
O
Physical methods
Fracture stabilization: displaced fractures are
extremely painful. Early splinting is effective at
reducing the severity of pain, fracture-associated
bleeding, neurovascular damage, secondary
tissue damage (e.g. skin necrosis over the medial
malleolus in ankle dislocations) and fat emboli.
QCovering burns: a sterile dressing will reduce
pain (burns are hypersensitive) and help protect
from contamination. Clear plastic film is cheap,
sterile and non-adherent. It should be placed in
longitudinal strips to prevent limb constriction.
QEarly removal of spinal boards or scoop-stretchers:
moving patients to softer surfaces reduces pain
and the risk of pressure sores.
QPrevent and treat hypothermia: many patients
are hypothermic on arrival at hospital. Shivering
increases pain intensity and warming using a
forced-air warming blanket should be started as
soon as possible.
Q
In some patients with severe, multiple injuries
adequate analgesia is only achieved at the expense
of loss of consciousness, respiratory depression and
severe hypotension. These cases require general
anaesthesia. Endotracheal intubation and general
anaesthesia in trauma patient are high risk procedures
and require direct supervision by an experienced
anaesthesiologist. Severe cardiovascular depression
after induction is a common problem and could be
due to hypovolaemia or a tension pneumothorax
developing under controlled ventilation.
Chest decompression, massive transfusion or
vasopressors are possible treatment options.
A selection of the more commonly used analgesic
drugs and doses are shown in table 2.3. All are usually
given with an antiemetic.
In some European countries metamizole is widely
used in combination with opioids. The dose is 1g IV.
However its use is banned in other countries.
TABLE 2.3
Commonly used analgesic drugs and their doses
Drug
Route Dose (typical
given bolus)
Comments
Morphine
IV
Titrate to effect, repeat bolus every 5-10
minutes. Slow onset,
not very effective for
musculoskeletal pain.
Histamine release can
aggravate hypotension.
0.03-0.1 mg/kg
bolus
(2-8 mg)
Pharmacological methods
Parenteral opioids and ketamine are the most
commonly used drugs to provide analgesia in trauma.
Whichever drug is used, the following factors must be
taken into consideration:
Qpharmacodynamics of analgesic drugs in shocked
patients
Qroute given
Qage of patient
Qpotential side-effects
Qlocal protocols
Qavailability of drugs
Qfamiliarity with the drugs
The side-effects of potent analgesic drugs may be
profound in trauma patients. The dose of drug must
be titrated in small aliquots to control pain while
minimising the risk of adverse effects. Circulation
time is increased in patients in shock and the onset
of analgesia may be significantly delayed. Using
combinations of drugs from different analgesic classes
increases their efficacy whilst reducing total doses and
subsequent side effects.
Particular care is required in patients with:
Qa reduced level of consciousness
Qrespiratory compromise
Qshock
Qhypothermia
Qintoxication (alcohol, drugs)
Qthe elderly
28 | EUROPEAN TRAUMA COURSE
Reduce dose in elderly.
Fentanyl
Alfentanil
Ketamine
Rapid onset, shorter
duration than
morphine.
Titrate to effect;
repeat bolus every
2 minutes
IV
0.5-1 mcg/kg
bolus
(50-100 mcg)
IN
2mcg/kg
IV
5-10 mcg/kg
bolus
Titrate to effect.
0.5-1 mg
Very short duration.
IV
0.2-0.5mg/kg
(20-40 mg)
Titrate to effect.
Doses of >0.5mg/kg
may produce general
anaesthesia in compromised patients.
Risk of delirium on
recovery.
IM
2 mg/kg
100-200 mg
IN
3 mg/kg
(100 mg)
Slow onset, prolonged
duration.
If S-Ketamin is used, reduce dose by 50%
Paracetamol
IV
15 mg/kg
Every 4-6 hours.
(1000 mg)
Usually given in
conjunction with opioid.
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Planning the Patient Pathway
Planning Round
Priorities and
allocation of
outstanding
tasks
Investigations/
Diagnostics
Communicate
with other
teams
Direction of
travel
Planning of safe
transfer /
patient
movement
Secondary
Survey
Complete and
review lab results
Operating
Room
Operating
Room
Transfer
team
Blood
products
Complete and
review imaging
Radiology
CT ± interventional
radiology
Equipment
ICU
Talking
to relatives
ITU
Other specialist
teams
Tertiary referral
centre
Interhospital
transfer
Ward
Figure 2.6 The patient pathway. Before the patient leaves the Emergency Department all findings need to be summarised and the priorities
established
Quantifying the intensity of pain is an essential part of
initial and ongoing pain assessment. A number of tools are
available to assess pain. In the Emergency Department,
whichever tool is used needs to be quick, accurate and
flexible for varying situations and ages. A commonly used
system is the verbal rating scale where patients are asked
to score their pain on a scale ranging from 0 (no pain) to
10 (worst pain imaginable). This is repeated to assess the
effectiveness of the analgesia given.
Although regional anaesthesia can be used, it has
limited applicability during the primary survey. Nerve
blocks and local anaesthesia can play an important
role in preventing pain in invasive procedures, e.g.
chest tube insertion.
Summary and planning round
The primary survey concludes with a summary and
planning round which must take no longer than 5
minutes. Its purpose is to collate all findings, review all
measures taken so far and to establish an individual
patient pathway (figure 2.6). A number of factors have
a common influence on the pathway.
Patient factors:
Qactual or suspected injuries
Qphysiological condition
Hospital facilities:
Qinfrastructure
Qavailable specialties
The decision making process required to initiate an
individual patient pathway can be quite complex and
usually requires senior multispecialty input.
Ultimately, all patients will require transfer out of the
Trauma Bay regardless of the care pathway planned.
The transfer should follow the concepts described in
chapter 12.
It is the responsibility of the TTL to make contact with
staff in the immediate receiving unit (e.g. operating
room, ICU) to ensure that an appropriate handover is
given.
Time spent by the patient in the Trauma Bay should be
minimised. Those in need of time critical interventions
(e.g. damage control surgery) should be transferred at
the earliest opportunity. However this need for speed
should not be at the expense of safety. These patients
must be packaged and moved so that resuscitation
and monitoring by appropriately trained individuals
can continue. The TTL should ensure that all relevant
documentation remains with the patient at all times.
Handovers of care are crucial moments in the patient’s
pathway.
They must be carried out in line with hospital guidance
to avoid loss of critical information.
When time critical interventions are not necessary,
the patient’s resuscitation phase and secondary
survey should be completed before transfer from the
Emergency Department.
CHAPTER 2 RECEPTION AND RESUSCITATION OF THE SERIOUSLY INJURED PATIENT | 29
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The secondary survey
The Secondary Survey is a systematic and detailed
examination of all body regions that aims to identify
all subsequent injuries. It entails a physical top to toe
examination (see appendix at the end of the chapter), a
reassessment of the vital functions and a review of all
imaging and laboratory findings.
In a stable patient, the order of priority is less important
than in the Primary Survey. The examination may be
carried out systematically, head-to-toe, front-andback, by either a single clinician, which is preferable
in a conscious patient (who can only interact with one
examiner at a time) or in parallel by the full trauma
team, which is preferable in time critical, unconscious
patients (where it is generally more efficient for
appropriate team members to examine different parts).
The secondary findings should be merged together by
the team leader into a verbal summary.
As care proceeds, the evolving summary is periodically
shared with the team and then recorded.
Body regions to examine in the Secondary Survey:
QHead
QFace including eyes, mouth, nose and ears
QNeck
QChest
QAbdomen and pelvic contents including the loins,
perineum and genitalia
QSpine
QLimbs including the shoulder and pelvic girdles
and buttocks
QE xternal burns, wounds and contamination
Timing of the Secondary Survey
a) stable patient
Primary Survey
Secondary Survey
b) unstable patient
Primary Survey
Secondary
Survey
time
Figure 2.7 In stable patients the secondary survey immediately
follows the primary survey. In unstable patients the secondary
survey sometimes must be carried out staggered, as resuscitation is
ongoing; this does not always allow for the secondary survey to be
carried out in one go. Good documentation is necessary to ensure
that no information is lost and the secondary survey gets completed.
In an unstable patient, the Secondary Survey
may require a more prioritised approach. (Fig 2.7).
Following the Primary Survey, the team may have
already performed a targeted examination and
ordered emergency imaging or near-patient testing
in relation to identified or suspected threats to life. If
30 | EUROPEAN TRAUMA COURSE
there is restricted access to the patient or a brief time
window before embarking on emergency procedures,
it is wise to prioritise the subsequent examinations.
There are pitfalls in carrying out some examinations
prematurely or in omitting others. For example,
turning a patient with severe hypovolaemia can further
de-stabilise their circulation, but a stab wound to the
posterior trunk must not be missed. Similarly, logrolling a patient with a mechanically unstable pelvic
fracture may cause further damage or displace a clot,
but it is still important to identify any posterior wounds
overlying the fracture at an early stage to minimise the
risk of infection. Adjunct imaging, such as a CT scan
of the pelvis, performed first, will clarify the fracture
configuration and identify pelvic haematomas before
committing to a log roll. In compromised patients,
the team needs a flexible, dynamic approach to the
Secondary Survey.
Body orifices (ears, mouth, urethra, rectum, vagina)
are part of the examination. While some sensitive
examinations can be omitted with careful judgement,
rectal and vaginal examinations are important in some
pelvic fracture configurations: missing internal, open
fractures will increase the morbidity and occasionally
increase risk of death.
The respiratory and circulatory systems are reviewed
together with monitoring data. The GCS is repeated.
A more detailed neurological examination is
incorporated, looking for lateralised, segmental or
focal deficit. (see chapter 9, neurological examination)
Pain is assessed and treated.
Adjuncts to the Secondary Survey include completion of:
Q X-rays
Q CT scans
Q Other imaging (ultrasound, MRI)
Q Arterial
and venous blood sampling (acidbase, blood gases, lactate, glucose, electrolytes;
haemoglobin, clotting profiles including TEG and
fibrinogen, liver function tests including amylase,
drug levels; blood group)
Q Urinalysis
Reviewing radiology, laboratory and near-patient
testing reports (e.g. ultrasound, X-ray, CT, blood gases,
lactate, glucose, clotting profiles) and noting trends
in monitored parameters are also part of the the
Secondary Survey. Spinal clearance can be achieved
after the Secondary Survey and appropriate imaging,
in accordance with the local protocol.
A detailed history from the patient, witnesses, friends
and family should be combined with the Secondary
Survey, as well as clothing checks for drug or allergy
alerts. This should extend beyond the initial ATMIST
handover and basic AMPLE history. Tetanus status
should be confirmed.
In complex cases, the team leader and team members
should be aware of what elements of the Secondary
Survey have not yet been undertaken and look
to complete this at the earliest opportunity. It is
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inappropriate (a ‘cop-out’) simply to state that the
secondary survey has not been done or is incomplete.
The missing elements should be included in the
summarised diagnostic problem list.
The Tertiary Review is a re-examination of the patient’s
condition, often at the time of admission to the critical
care unit or on the day after admission when reviewed
by the team overseeing continuing acute care. It can
however occur at any stage during the patient’s pathway.
It is not time-critical, but may reveal missed injuries or
subtle physiological instability that warrant prompt
attention to avert deterioration or reduce complications.
At any stage after the Primary Survey, including up to and
beyond the Tertiary Survey, the patient may deteriorate
unexpectedly. An emergency review should then take
place, recapitulating the Primary and Secondary Surveys.
Summary
The initial resuscitation of the trauma patient is
best achieved by a well trained, multidisciplinary
team of Clinicians, and Trauma Support
Practitioners in a shock room environment.
Each member of the team must understand
their responsibilities and role within the team
and work within their competencies. Any
response of a critically injured patient to the
team’s interventions is dynamic and therefore
resuscitation during the primary survey is a
continuous cycle of assessment, intervention
and reassessment.
Having worked through this chapter you are now
ready to apply the knowledge in the scenarios
and demonstrate competence in:
Qtaking the role of the TTL;
Qtaking the role of a TTM;
Qcarry out a primary survey;
Qcarry out a secondary survey.
These cognitive abilities will be integrated with
the practical skills during the course workshops.
CHAPTER 2 RECEPTION AND RESUSCITATION OF THE SERIOUSLY INJURED PATIENT | 31
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APPENDIX:
Secondary Survey Checklist Physical
Examination
Head
QNeuro-status
GCS, pupils, eye movements,
lateralising signs
QScalp:
lacerations, bruising, depressions or
irregularities in the skull, Battles sign (bruising
behind the ear indicative of a base of skull fracture)
QMouth: lacerations, loose, missing or fractured teeth
QNose: bleeding, nasal septal haematoma, CSF leak
QEars: bleeding, blood behind tympanic membrane
QEyes: foreign body, bulbus trauma, contact lenses
QJaw: pain, malocclusion
Neck
QCervical spine: pain, tenderness, deformity, neck
movement
QSoft tissues: bruising, pain and tenderness, swelling,
surgical emphysema
QTrachea: deviation
QNeck veins: distension
Chest
QChest wall: bruising, lacerations, penetrating injury,
tenderness, flail segment
QLung fields: percussion note, lack of breath sounds,
wheezing, crepitations
QHeart: Apex beat, heart sounds
Abdomen & Pelvis
QBruising, lacerations, penetrating injury, tenderness
rebound, solid organ or bladder enlargement
QBowel sounds
QNo springing of the pelvis, take pelvic X-ray or
request CT if you suspect a pelvic fracture!
Limbs
Bruising, lacerations, muscle, nerve or tendon
damage. tenderness, deformities, open fractures,
QJoint stability/mobility
QSensory and motor function (muscle strength) of
any nerve roots or peripheral nerves that may have
been injured
Q
Back
QLog roll, inspect the entire length of the back and
buttocks and palpate the spine for tenderness, steps
between vertebrae
QBruising, lacerations
Buttocks, Genitalia, Perineum
QSoft tissues: bruising, lacerations. Inspect anus,
digital examination is rarely needed
32 | EUROPEAN TRAUMA COURSE
Record of
Drugs and Fluids:
TIME
GCS
EYES (1-4)
VERBAL (1-5)
Patient IDPatient ID
MOTOR (1-6)
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
GCS TOTAL (3-15)
Team Brief
R/L
Presumptive
Diagnosis:
PUPILS
Primary
Survey
Plan A
Plan B
Teams informed:
5 sec
Radiology/CT
Bloodbank/MHP Anaesthesia
Surgery/Theatres
catastrophic Haemorrhage:
yes
no
Airway obsdtruction:
yes
no
Breathing problems:
yes
no
Shock:
yes
no
REACTION
FiO2
D-Disability : for GCS, pupil size and reactivity and blood glucose see
vital function documentation
lateralising signs: yes no ; central neck pain: yes
no ;
!(! & no &(! & no ;
ETCO2
VENTILATION
SaO2
RESP-RATE
190
180
170
CT-head Mannitol ; CT-spine ; MRI 160
; Hypertonic saline ; Neurosurgical referral E- Exposure & Extremities: hypothermia yes
long bone fx: yes no ; distal pulses: yes
no ;
no ;
150
BLOOD
PRESSURE
AND
PULSE RATE
140
130
120
110
100
90
$SLY[9LYIHS3HPU8UYLZWVUZP]L
Change of Plan A:
80
yes
X-Ray no
Handover
;
70
60
50
CHAPTER 2 RECEPTION AND RESUSCITATION OF THE SERIOUSLY INJURED PATIENT | 33
Splinting Age
Mechanism
Injuries
Signs
Treatment
Planning
Round
40
; forced air warming ;
Injuries
30
FLUID LOSS
20
BLOOD LOSS
URINE
CHEST DRAIN
Outstanding tasks
Primary
Survey
SIZE
A-Airway: clear Oxygen TEMPRATURE
GLUCOSE
PAIN
; obstructed ; occluded ; blood : vomitus
Patient journey
Injuries identified:
________________________________________________
; Airway support ; Spine immobilisation Free Text
; RSI US ; CXR ;
;
;
C - Circulation, Abdo & Pelvis: pallor ; mottled ; cold periphery no peripheral pulse ; Tenderness ; Bruising ;
US ; Pelvic XR ;
Haemostatic dressing ; Pelvic binder ; TXA ; MHP ________________________________________________
________________________________________________
B-Chest & Neck: laboured ; > 25 min ; < 10 min ; absent Bilateral BS yes no ; Emphysema ; Bruising ;
Chest wall tenderness ; C-spine tenderness ;
other Chest drain TEMP, BM
PAIN
;
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ETC Trauma Chart
ETC Trauma Admission Chart
DATE
ATMIST
Narrative