Interim Guidelines for Continuity of Trauma Care...(spica cast). o Displaced forearm fractures....
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MINISTRY OF HEALTH Interim Guidance on Continuity of Trauma Care Services During COVID 19 Pandemic July 2020
Transcript of Interim Guidelines for Continuity of Trauma Care...(spica cast). o Displaced forearm fractures....
MINISTRYOFHEALTH
InterimGuidanceonContinuityofTraumaCareServicesDuringCOVID19
Pandemic
July2020
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FOREWORD
Traumaduetoviolenceandinjuriescontinuetobeexperiencedinthecountryrequiring
theattentionof thehealth care system to reduce complicationsandmortality. This is
occurringagainstabackgroundofstretchedhospitalservicesasaresponsetothethreat
oftheCOVID19pandemic. It isthereforeprudenttoensurecontinuityofthisessential
service ismaintainedwhile observingmeasures that stop the spread of the COVID 19
infection.
Resourceusageshouldbecarefullyconsideredduringthisperiodwhenplanning
scheduled procedures, particularly with regard to materials, staff, devices,
intensive care beds and blood components. This is because these are shared
resources,whichwilllikelybescarceespeciallyifCOVID19casesareontherise.
Theintentofthisdocumentistoadvisehealthcareprovidersinvolvedintrauma
careonfactorstoconsiderasthepublichealthandhealthcaresectors learnto
adapt to managing injured patients during COVID 19 pandemic and managing
injuredpatientswhoareinfectedwithCOVID-19.
Dr.PatrickAmoth
Ag.DIRECTORGENERALFORHEALTH
MINISTRYOFHEALTH
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TableofContent
Introduction...................................................................................................................3
Generalconsiderationsfortheinjuredpatient................................................3
Principlesforoutpatientmanagement...............................................................4
InpatientManagement..............................................................................................6
ManagementoftheInjuredChild.........................................................................7
Generalprinciples........................................................................................................7
Emergencyconditions(requirerevieworsurgerywithin24hours)......8
References...................................................................................................................10
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ManagingtheinjuredpatientduringtheCOVID-19pandemic
IntroductionThe coronavirus pandemic has placed unprecedented pressure on our healthsystems and necessitated the need to change how services are organized andprovided. Measures need to be put in place to ensure that there is a balancebetweenoptimumtreatmentofapatient’s injuryorconditionagainstthesafetyofcliniciansandotherpatients.Efficientplanninganduseofavailableresourcesishighlyrecommended,asscarcitiesarelikelytobeexperiencedduringthisperiod.Different injuries present differently in terms of severity and the informationbelowistobeusedasaguidewhileassessingindividualrisksofthepatient.
Trauma care systems exist to ensure provision of quality and timely lifesavingsurgicalandcriticalcare interventions. Interventionsandbestcarepracticesarealready well entrenched in our health systems/among the trauma care team.However,theCOVID19pandemichasintroducednewchallengesandobstaclestoprovisionoftheseinterventions:limitedcriticalcareresources,healthworkersareexposedtothevirusandthusmorelikelytocontractit;about70%ofourpatientsinKenyaareasymptomatic.
Assuchtheaimoftheguidelineisto;
1. TomaintainaccesstoqualitytraumacareduringtheCOVID19pandemic.2. Prescribemeasurestoreduceexposuretimesforpatientsanddoctors
Generalconsiderationsfortheinjuredpatient
• Alltraumapatientshavearighttotimelyandhigh-qualitycarefortheirinjuries
• TraumapatientevaluationandtreatmentshouldnotbedelayedtodetermineCOVID-19statusbutappropriateprecautionsshouldbetaken.PatientsshouldhavesamplestakenthenproceedtosurgeryasCOVID19resultsareawaited.
• Duringthecoronaviruspandemic,therewillbeincreasedemphasisonreducinghospitaladmissionsandminimizinglengthofstay.
• Facilitieswithouttherequisitetraumapersonnelshouldconsidermaintainingacontactlistofspecialistswhomaybeconsultedremotelytoaidindecision-making,andpreventinadvertentmorbiditytopatientsowingtoinappropriateordelayedcare
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• Forpatientswhoareormaybeinfected,performaerosol-generatingprocedures(AGPs;e.g.,intubation/extubation,bronchoscopy,bagmasking,electrocauterization,laparoscopy/endoscopy)onlywhilewearingfullPPE,includinganN95maskorpowered,air-purifyingrespirator(PAPR).
• Ensurestrictandappropriateuseofpersonalprotectiveequipment(PPE)forALLhealthworkers
• Allpatientsshouldhaveamask• Minimizethenumberofpersonnelatthebedsidetoonlythoserequired
fordirectpatientcare.MinimumsetwouldbeTeamleader-Airway,circulation(3)withmaximumbeing4
• Spineinjuredpatientsneedemergencyorurgentsurgery• Theeffectofdelayingsurgeryshouldbecriticallyevaluated• Administrativecontrolstoincludeensuringadequateinfrastructureto
allowsocialdistancing,facilitatedaccesstoCOVID-19testing,trainingofstaffandprovisionofadequateandappropriatepersonalprotectiveequipment(PPE).
• Developamechanismtomonitorthewell-beingofhealthworkerswhohavehadpotentialCOVID-19exposureorwhoareonquarantine.
• Whenpossible,restructuretraumateamsandstaggercohortstoreducethenumberoftrauma/ICUprovidersinthehospitalsimultaneouslytodecreaseexposureriskandpreservestaff
• Developredundancyinbackupschedulesforhealthworkerswhomaybeillorexposed.
• Useofonlineplatformsforalleducativemeetingsandcontinuousmedicaleducationactivities
Principlesforoutpatientmanagement
• Providesafelyspacedwaitingareas,assessmentandtreatmentcubicles.Thesethreeareasshouldbesegregated.Planspacetostore,donandremovepersonalprotectionequipment(PPE).
• Takeappropriatehistoryincludingquestionsaboutfever,upperrespiratorysymptoms,COVID-19exposurehistory,travelhistorytohistoryandtakeappropriateisolationmeasures
• Duringapatientsfirstattendance,aconsultantshouldbeavailableto
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ensuredecisionsaredefinitivetominimizetimespentatoutpatientclinicsandtoensuresubsequentreviewsareminimizedtothegreatestextendpossible.Surgeriesshouldbescheduledafterinputfromaconsultant.
• Managementofpatientswithminorinjuriesshouldbedoneatthecasualtyareas
• Patientswhopotentiallyneedimmediatemanagementthatrequiressedationfacilities,suchasthosewithdislocations,mayneedtoremainintheoutpatientsettingbuttraumateamsshouldaimtomanagethesepatients.
• Impactonradiologyservicesshouldbeminimized.Imagingshouldberequestedafterthepatienthasbeenassessedinthecasualtyareatominimizerequestsandavoidrepeatimaging.Avoiduseofmultipleimagingmodalitiesandconsiderimmediateuseofthemodalitymostlikelytogiveadefinitivediagnosis.CTscanningshouldbeminimized,asthisistheinvestigationofchoiceforcoronaviruspneumonitis.
• Follow-upimagingshouldonlybeperformedwhenthereislikelytobeasignificantchangeinmanagement.Thereisnoroleforimagingtocheckforfractureunioninmostinjuries.
• Useofremovablecastsorsplintsshouldbemaximizedtoreducefollow-uprequirements.
• Administrativecontrolstoincludeensuringadequateinfrastructuretoallowsocialdistancing,facilitatedaccesstoCOVID-19testing,trainingofstaffandprovisionofadequateandappropriatepersonalprotectiveequipment(PPE).
• Developamechanismtomonitorthewell-beingofhealthworkerswhohavehadpotentialCOVID-19exposureorwhoareonquarantine.
• Rehabilitationservicesarelikelytobeverylimited.Alternativeresourcessuchaswrittenandweb-basedinformationcanbeused.
Specificinjuryconsideration
• Dislocationsofnativeandreplacedjointsshouldbereducedinthe
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outpatientsetupwhereverpossible.Ifthejointisstableafterreduction,thepatientshouldbedischargedwithappropriatefollow-up.
• Mostupperlimbfractures,includingclavicle,humeralandwristfractures,havehighratesofunionandmaybemanagednon-operatively,recognizingthatsomepatientsmayrequirelatereconstruction.
• Ligamentousinjuriesofthekneemaybemanagedwithbracinginpreferencetoearlyligamentreconstruction.
• Penetratinginjuries(stabwounds)totheextremitieswithoutfracturesthatarenotcontaminatedandhavenoneurologicalorvasculardeficitmaybesuturedintheoutpatientclinicsetting
• Superficialabscessesinpatientswithoutsystemicsepsiswhereamenabletolocalanesthesia,maybeincisedanddrainedintheoutpatientsetting.
• Localwoundcarewithsalineorchlorhexidinerinsestwicedailyforaweekwillbesufficientforthevastmajorityofextremitywounds.
InpatientManagement
AppropriatePersonalProtectiveequipment(PPE)shouldbeusedforSurgeriesinvolvinghigh-speeddevicesastheyareconsideredtobeanAerosolGeneratingProcedure(AGP).
Lifeandlimbthreateninginjuries
• Patientswithmultipleinjuries,pelvic&acetabularfractureswithmajorhemorrhage,openfractures,compartmentsyndromeandexsanguinatinginjuryallrequireemergentresuscitationandmanagement.
• Consideralternativetechniquesforpatientswhorequiresofttissuereconstructiontoavoidmultipleoperationsortheneedforcriticalcareinput(localflaps,intentionaldeformity,skingraftingforfasciotomywounds).
Lowerlimbfragilityfractures• Thecareofpatientswithhipandfemoralfracturesremainsurgentanda
surgicalpriority.
• Allpatientswithfracturesofthepelvis,acetabulumorlowerlimb,whether
treatednon-operativelyorwithsurgeryshouldbemobilizedexpeditiously
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towheelchair-orwalker-assistedambulationimmediatelytoallow
rehabilitation,reduceinpatientstayandreducepotentialexposureto
coronavirus
Generalorthopaedictrauma
• Patientswithcomplexfracturesshouldhavesurgeryplannedtominimizelengthofstay
• Considerday-casetreatmentofsimpleperi-articularfracturesandfoot&ankleinjuries.Wherepossible,usenon-operativetreatmentandremovablesplints,recognizingthatsomemayrequirelaterreconstruction.
• Managepatientswithupperlimbfracturesthatrequiresurgery(e.g.forearmfractures)asdaycases.
• Wristfracturesamenabletoconservativetreatmentmaybetreatedwithremovablecastsorsplintstoreduceunnecessaryfollow-up.
• Useabsorbablesuturesandwarnpatientsofthesmallriskofamildinflammatoryreactiontothesutures.
OtherOrthopaedicemergencies
• Patientswithspinalcordcompressionincludingcaudaequinasyndromerequireemergencytreatment.
• Patientswithsepticarthritis,prostheticjointinfectionorinfectedfracturesandfeaturesofsystemicsepsisrequireemergencytreatment.Thosewhoarenotsepticmaybemanagedasoutpatientsinappropriateclinics.
ManagementoftheInjuredChild
DuringtheCOVID19pandemic,thegoalofmanagementoftheinjuredchildistoprovideessentialcarewithhighqualitywhileemphasisisonmanagementthatisnon-operativestrategiesandtominimizeoutpatientvisits;
Considerthepossibilityofnon-accidentalinjuryandinformtherelevantauthority
Generalprinciples• Ifnecessary,childrenwiththefollowingsuspecteddiagnosesmaybe
managedwithoutradiologyatpresentation:
o Softtissueinjuries.
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o Wrist,forearm,clavicleandproximalhumeralfractures.
o Longbonefractureswithclinicaldeformity.
o Footfractureswithoutsignificantclinicaldeformityandswelling.
o Lowerlimbinjuryinapatientwhoisabletoweightbear
• Manychildren’sinjuriesmaybedefinitivelymanagedinacastatpresentation.
• Assessforinjuriesthatmaybetreatedwithoutacastsuchaskneeligamentandpatellarinjuriesthatmaybemanagedwithbracing.
• Mostchildrenwhorequireoperativemanagementmayhavesurgeryasaday-case
o Reducedjointdislocations.
o Fractureswithabnormalneurologyorsofttissuecompromisethatisresolvingaftertreatment.
o Peri-articularfractures.
o Extra-articularfemoralfracturesinchildrenagedundersixyears(spicacast).
o Displacedforearmfractures.
Emergencyconditions(requirerevieworsurgerywithin24hours):. Non-accidentalinjury(anychildconsideredtobeatrisk,oravictim,ofabuse
shouldbereferredimmediatelytorelevantauthorities)
. Suspectedsepticarthritis/osteomyelitis(osteoarticularinfectionshouldalwaysbeconsideredasadifferentialdiagnosisinafebrilechildandnotbeassumedthatthisisduetoCovid-19)
. Childrenwithnewneurologicaldysfunctionorlimbischaemia(includingsuspectedcompartmentsyndrome)
Urgentconditions(requirerevieworsurgeryassoonaspossibleandwithin72hours):
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• SuspectedSlippedUpperFemoralEpiphysis(unlessassociatedwithsuddenonsetlegpainanddifficultyweight-bearing,requiringemergencyadmission)
• Severepain,whichisnotrespondingtostandardanalgesia• Exposedmetalworkfromprevioussurgery
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References
1. AmericanCollegeofScience.MaintainingTraumaCenterAccessandCare
duringtheCOVID-19Pandemic:GuidanceDocumentforTraumaMedical
Directors.2. BritishOrthopeadicAssociation.Managementofpatientswithurgent
orthopaedicconditionsandtraumaduringthecoronaviruspandemic.
3. CareoftheCriticallyIllandInjuredDuringPandemicsandDisasters:CHEST
ConsensusStatement:Triagehttps://www.boa.ac.uk/resources/covid-19-
boasts-combined.html4. https://www.cdc.gov/coronavirus/2019-ncov/hcp/caring-for-patients.html
5. NHSEnglandletter(22ndMarch2020):
https://www.england.nhs.uk/coronavirus/wp-
content/uploads/sites/52/2020/03/PPE-Letter-FINAL-20-March-2020-
updated-on-22-March-2020.pdf
6. OrthopaedicDepartment.CoViD-19andorthoandtraumasurgery:TheItalianexperience.LettertotheEditor/Injuryxxx(xxxx)xxxhttps://doi.org/10.1016/j.injury.2020.04.012
7. https://apps.who.int/iris/bitstream/handle/10665/331498/WHO-2019-nCoV-IPCPPE_use-2020.2-eng.pdffile:///D:/Ortho/trauma%20in%20covid%2019%20pandemic.pdf
8. https://www.weforum.org/agenda/2020/04/africa-cannot-lose-doctors-covid-19/
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LISTOFCONTRIBUTORS
NAME ORGANISATION
Dr.WaqoEjersa MOH
Dr.EphantusMaree MOH
Dr.GladwellGathecha MOH
Dr.ElesbanKuhumbu MOH
DorcasKIptui MOH
ScolasticaMwende MOH
Dr.SorenOtieno NationalSpinalInjuryHospital
Dr.GeorgeOrerah MachakosLevel5Hospital
Dr.CarolineWaweru Getrude’sChildrenHospital
SurgicalSocietyofKenya
