Emergency Care
Dr Stephen Boyce
Consultant in Emergency Medicine
Sport & Exercise Medicine Specialist
Registrar
Definition of Trauma
A serious injury or shock to the body, as
from violence or an accident.
 An emotional wound or shock that
creates substantial, lasting damage to
the psychological development of a
person.
 An event or situation that causes great
distress and disruption.

“Trauma Centre”

Casualty

Accident &
Emergency (A&E)

Emergency
Medicine (ED)
Workforce Planning
Junior doctors
 ENP’s
 Registrars
 Consultants
 Moving from a “consultant led” service
to a “consultant delivered” service

What is Trauma ?



Major trauma describes serious and often
multiple injuries where there is a strong
possibility of death and disability.
In England, the most common cause is a road
accident.
The NAO estimates that there are at least
20,000 cases of major trauma each year in
England resulting in 5,400 deaths and many
others resulting in permanent disabilities
requiring long-term care.
Causes of Trauma
Road traffic accidents (RTA’s)
 Falls
 Burns
 Blunt trauma
 Penetrating trauma
 Gunshots
 Natural disasters, Terrorism

Pathway of Trauma
Trauma Scores


Injury Severity Score (ISS)
 Anatomical
 Abbreviated Injury Scale (AIS)
 0 - 75
Revised Trauma Score (RTS)
 Physiological
 RR, SBP, GCS
 0 - 12
Trauma Deaths
Immediate Deaths
First peak of deaths occurs within
seconds or minutes of injury
 Very few of these patients can be
salvaged due to severity of their injuries
 Only prevention can significantly reduce
this peak

Early Deaths
Occurs within minutes to several hours
after injury
 Intracranial, intrabdominal, multiple
fractures, multiple injuries, etc


The “Golden Hour”
Late Deaths
Several days to weeks after the initial
injury
 Sepsis or multiple organ failure
 The care provided during the “golden
hour” will have a direct effect on long
term outcome

Advance Trauma Life Support
(ATLS)






Originated in the USA
Promoted by the American College of
Surgeons (ACS)
First course was January 1980
Gradual international recognition re trauma
management
Adopted in the UK late eighties / early
nineties – RCS England
ATLS courses in over 42 countries
ATLS Concepts
Treat greatest threat to life first
 Lack of a definitive diagnosis should
never impede the application of an
indicated treatment
 A detailed history is not essential to
begin the evaluation of an acutely
injured patient

ATLS Objectives





Assess the patient’s condition rapidly and
accurately
Resuscitate and stabilise the patient
according to priority
Determine if the patient’s needs exceed a
facility's capabilities
Arrange appropriately for the patient’s
interhospital or intrahospital transfer
Assure that optimum care is provided
ATLS Course




Lectures
Practical skills
MCQ exam
Moulage
ATLS Moulage
Assessment
Primary survey
 Secondary survey
 Transfer to definitive treatment

Primary Survey
A
B
C
D
E

Airway (& C-spine control)
Breathing
Circulation
Disability (Neurological)
Exposure
Team Approach
Monitoring
 Interventions performed
 X-rays – Trauma series (C/spine lateral,
chest, pelvis)
 Catheters
 Further investigations (FAST, USS, CT)
 Blood tests

Secondary Survey
Does not begin until the primary survey
is complete, resuscitation is established
 Complete head to toe evaluation
 Reassessment of all vital signs
 Further x-rays, blood tests, etc
 Other specialty review (if not required in
primary survey)
 Transfer

Triage





Number of casualties exceeds the available
resources
A process for sorting injured people into
groups based on their need for or likely
benefit from immediate medical treatment
Essential part of major incident planning and
preparation
Mobile, dynamic process
End point of triage is the allocation of a
treatment priority
Triage Categories
Category
Description
Colour
Priority
Immediate
Immediate life saving
treatment
Treatment within 6hrs
Less serious cases
(walking wounded)
Non-survivable or
exceed resources
RED
P1
YELLOW
GREEN
P2
P3
Dead
WHITE
Urgent
Delayed
Expectant
Dead
BLUE
Dead
Triage Sieve
How Can We Improve Trauma
Care In Scotland?







New STAG audit
Consultant delivered care (balanced against
resources)
Centralisation of services (“trauma centres”)
Regular training, skill maintenance, use of
simulators, CPD
Reflection – M&M meetings
Learn from others, eg, military
Targeted interventions
Emergency Medicine Retrieval
Service (EMRS)
EMRS Recent Audit

310 emergency retrievals

1/3 trauma

24 lives saved
Flying doctors take to the air
25/10/2010
Scotland's 'flying doctor' service is to be rolled out to remote and rural parts of
the country, following a successful pilot scheme in the west of Scotland.
The service, staffed by air paramedics and consultants who are specialists in
emergency medicine, will fly across Scotland to treat critically-ill patients on
the spot. Since it began in June 2008, the team has undertaken 565 retrievals
and given advice to a further 469 patients.
The decision to expand the service was taken after an evaluation of the pilot
programme concluded that it offered good quality healthcare, value for money
in terms of benefits for patients and significant support for healthcare staff
working in remote areas.
Health Secretary Nicola Sturgeon said:
“Getting the best possible medical help to a critically-ill patient, or someone
who has been seriously injured, as rapidly as possible can significantly
improve their changes of making a full recovery.
"But critical illness or injury can strike anywhere and patients are often some
distance from the essential medical treatment they need. That's where the
EMRS comes in - experienced accident and emergency or intensive care
consultants fly to patients in remote and rural communities.
"This early intervention can make the difference between life and death and
that is why we have decided to establish Scotland's flying doctors as a national
service, delivering first class healthcare to all rural parts of the country."
Thank You