Network Guideline for Emergency Adult Trauma Anaesthesia · ODN T14-1C-111 MTC Adults T14-2B-116 TU...

SYMT ODN – Emergency Adult Trauma Anaesthesia 2015 of 28 ODN Board Agreed: 12 Apr 2017 Review Date: Apr 2018 Page 1 of 28 Review Date: Apr 2018

Network Guideline for Emergency Adult Trauma Anaesthesia

This Guideline is in accordance with the National Trauma Peer Review Measures: ODN T14-1C-111 MTC Adults T14-2B-116 TU T14-2B-310

SOUTH YORKSHIRE MAJOR TRAUMA OPERATIONAL DELIVERY NETWORK


Purpose of Document

These guidelines are intended to reflect the key points for emergency adult trauma anaesthesia; i.e. that which is undertaken upon arrival in the Emergency Department. The guidelines reflect what is currently considered best practice, and as far as possible they are as generic as possible to allow for local variations in equipment and drugs.

Required Action All relevant staff should ensure they are fully aware of, and operate in line with this guideline.

Action Required by/Audience

Sheffield Teaching Hospitals NHFT Adult MTC Trauma Lead and TU Trauma Leads (Barnsley, Chesterfield, Doncaster, Rotherham) must ensure their MDTs are familiar with the policy and act in accordance.

Circulation

SY Major Trauma Operational Delivery Network Board

SY Major Trauma Pre-hospital/ED/Acute Clinical Audit and Advisory Group

Trusts Chief Executives

Trusts Medical Directors

Trusts Directors of Operations

Trusts General Managers responsible for Trauma Services

Trusts Lead Cardiothoracic Surgeon

Trusts Consultant Anaesthetist Leads for Trauma

Authors Dr Ben S. Edwards – Consultant in Anaesthesia,

Sheffield Teaching Hospitals NHSFT

Date agreed by SY MT ODN CAAG

04 Dec 2015 Version Number 2015

Date Signed off by ODNs’ Board

12 Apr 2017

Policy Review Date Apr 2018

Please note that from Jun 2017 all ODN Clinical Guidelines, Protocols and Policies

will be available on the ODN website for downloading.


Guidelines for Emergency Trauma Anaesthesia

CONTENTS:

Introduction ................................................................................................................... 2

The initial presentation: Pre-arrival preparation & receiving the patient ........................................................5

Assessing the Trauma Patient: <C>Control external exsanguinating haemorrhage .................................... 6 A Airway with C spine control .................................................................7

RSI .................................................................................................. 8 B Breathing with high flow oxygen .........................................................11 C Circulation with haemorrhage control. .................................................. 12 D Disability with secondary prevention ..................................................... 14 E Exposure with temperature control. ...................................................... 15

Whole Body CT (WBCT) & Secondary Survey ........................................................16

Subsequent care:

Damage Control Surgery (DCS). .............................................................................17 Open Fractures ............................................................................................................ 17 Early Total Care ......................................................................................................18 Pelvic Fractures ........................................................................................................... 19 Post Resuscitaion Care ............................................................................................... 20 Documentation & Audit ................................................................................................ 20 Appendices ................................................................................................................... 21 References ................................................................................................................... 25


INTRODUCTION AND AIMS

These guidelines are intended to reflect the key points for emergency trauma anaesthesia; i.e. that which is undertaken upon arrival in the ED department. The guidelines reflect what is currently considered best practice.

CONSULTANT LED TRAUMA CARE

One of the core principles of improving outcomes in trauma is involvement of respective consultants early in the management of the case. During normal working hours this should be routine and speciality doctors should be asked early if they have involved the consultant on call for their specialty.

If at any time you feel you need more senior advice or support, call the consultant immediately. These are challenging cases in a dynamic situation. If you find yourself amongst consultants from other specialties, call the consultant! Do not be offended if a consultant from ED or surgery asks you to call a consultant. Likewise, do not be afraid to suggest that trainees from other specialties call their consultant!


BEFORE PATIENT ARRIVAL

Identify yourself to the Trauma Team leader (ED consultant usually) on arrival in the resuscitation room (this includes team members who arrive later) and sign in

Put on gloves and a plastic gown with identifying sticker – also consider eye protection

You should be assigned a clear role by the trauma team leader

o You will primarily be the airway and breathing doctor but may be asked to assist with circulation and pain control if free to do so.

o An ODP from theatre is a member of the trauma team. If there is any delay or problem regarding their attendance, you should bleep 2754 immediately

o Ask for the drug cupboards to be opened and prepare any drugs you may require for RSI – including Propofol infusion for transfer

If massive blood loss is suspected ensure the following occurs (normally the role of ED staff)

o Prime the Fluido rapid fluid infuser with normal saline (not Hartmann’s) o Inform blood bank o Check that the ED O negative is available o Consider pre-ordering a massive transfusion pack

All members of the Trauma team are to remain in the ED until trauma team leader is happy they are not required at this stage but can be re-activated at any time.

o It is not your role to remain for long periods of time with the patient after initial

assessment and stabilisation unless there is a clinical need to do so (e.g. need for ongoing or impending airway intervention/ventilatory support)

o It may be appropriate however that you remain with the patient until the trauma CT has been performed (within 30 minutes of arrival) unless released by the team leader

You should communicate at appropriate intervals with on call consultant both for advice and to plan for any evolving issues (e.g. vascular angio/theatre).

RECEIVING THE PATIENT

The patient will be transferred onto the ED trolley with trauma mattress and underwarmer in place.

Unless active resuscitation is taking place, all team members should then step back from the patient to receive the ATMIST handover.


INITIAL PATIENT ASSESSMENT/PRIMARY SURVEY We have specialist training in the recognition and management of acute physiological derangement. Please communicate your findings and concerns clearly to the team leader.

Resuscitation will follow modified ATLS guidelines

Ideally this should be done within 15 minutes and use a <C> ABCDE approach3. The trauma team leader will allocate roles to allow this to occur in a horizontal rather than vertical fashion.

Observations are performed at least every 5 minutes, repeated reassessment is fundamental to a successful outcome; any deterioration should prompt a repeat of the <C> ABC assessment.

INVESTIGATIONS & ADJUNCTS TO THE PRIMARY SURVEY The priority is to perform a polytrauma CT within 30 minutes. Do not cause delay requesting other investigations The team leader will consider the below but will only do what is necessary:

You must NOT waste time requesting a lateral C spine film. Assume it is unstable, a polytrauma CT will allow diagnosis

Venous/Arterial blood gas

ECG

CXR

Pelvic XRs if not going for whole body CT

Chest ultrasound and FAST

Urinary catheter

Consider OG tube (NG only if certain of no head/facial injury)

Keep the patient warm – this is vital

<C> Control of exsanguinating haemorrhage

A Airway and cervical spine control

B Breathing with high flow oxygen

C Circulation and haemorrhage control

D Disability & prevention of secondary injury

E Exposure with temperature control

Remember the lethal triad in trauma:

Hypothermia

Acidosis

Coagulopathy


Assessing the Trauma Patient: Key Points

<C> CONTROL EXTERNAL EXSANGUINATING HAEMORRHAGE This is rare in civilian practice but does occur. Anaesthetic priorities are:

1. Call the on-call consultant for advice/assistance.

2. Ensure samples for X-match have been taken and sent to the labs and Major Transfusion Protocol is activated.

3. The patient may need to go to theatre rapidly so pre-warn the theatre team coordinator on bleep 2192.

The Trauma team leader will use the following measures to control the haemorrhage see (penetrating trauma guideline) for more details.

Direct pressure & elevation

Limb tourniquet (CAT)

Topical haemostatic agent (CELOX)

http://nww.sth.nhs.uk/STHcontDocs/STH_CGP/EmergencyDepartmentHandbook/Penetrating%20trauma%20guideline%20NGH.ppt

http://nww.sth.nhs.uk/STHcontDocs/STH_CGP/EmergencyDepartmentHandbook/Penetrating%20trauma%20guideline%20NGH.ppt


A AIRWAY WITH C-SPINE CONTROL The airway is your first priority and may be very challenging. Have a very low threshold in seeking senior assistance. As per national guidelines the airway must be rapidly secured if indicated. This is time critical. Do not be offended if intubation is requested by the team leader – they will have an overview of the whole patient.

Ensure 15 l/min oxygen via FM administered, - use nasal cannulae in addition to improve oxygenation

If the patient is intubated prior to arrival, check ETT is correctly positioned (i.e. – ETCO2, chest moving equally, appropriate length at teeth).

Maintain control of the C spine at all times. Immobilisation will usually be in situ on arrival but if not should quickly be instituted with a collar, blocks and tapes across the forehead and chin.

Whilst there is emerging evidence that c-spine immobilisation is not effective, at present we recommend it is instituted until national guidance changes.

AIRWAY ASSESSMENT

Examine for signs of airway obstruction and use suction/jaw thrust/ simple airway adjuncts. Avoid nasopharyngeal airways if facial or head injuries suspected, and avoid head tilt in any suspected cervical spine injury. You may be required to intubate and ventilate the patient at an early stage. We recommended a (modified) RSI technique.

BURNS

In the presence of burns or a blast injury consider whether or not the airway is compromised or at risk of compromise.

Warning signs are soot around the nostrils/mouth, hoarse voice, dysphagia, drooling and stridor.

Airway swelling may rapidly develop and remember the old maxim “if there is any doubt…then there is no doubt”. Don’t delay and use an uncut ETT tube.

Check the arterial carboxyhaemoglobin (HbCO) level - pulse oximetry will overestimate the true arterial oxygen saturation.

o If > 25-30% the patient should probably be ventilated. o Treatment with 100% oxygen will decrease the elimination half life of HbCO from 4 hours to

under 1 hour

Early tracheal intubation should be considered in the presence of:

hypoxaemia or hypercapnia deep facial burns full thickness neck burns oropharyngeal oedema.


ABSOLUTE INDICATIONS FOR INTUBATION

Inability to maintain and protect own airway regardless of conscious level

Inability to maintain adequate oxygenation with less invasive manoeuvres (PaO2 < 10kPa)

Inability to maintain normocapnia (spontaneous PaCO2 <4.0 kPa or >6.0 kPa)

Deteriorating conscious level (≥2 points on motor scale)

Significant facial injuries

Seizures. Also see (Appendix 1): NICE Guidelines for intubation and ventilation in the presence of brain injury.

RELATIVE INDICATIONS FOR INTUBATION

Haemorrhagic shock, particularly in the presence of an evolving metabolic acidosis. Early and repeated blood gas analysis will aid in this decision making.

Agitated patient (remember hypoxia and hypovolaemia are prime causes of agitation)

Multiple painful injuries

Transfer to another area of the hospital / Expected clinical course (e.g. vascular angio/theatres/GITU)


RAPID SEQUENCE INTUBATION Drugs

Use those drugs with which you are familiar and be careful to titrate the dose carefully in view of the potential for hypovolaemia and acidosis.

In patients with a suspected head injury the stress response to laryngoscopy must be attenuated – alfentanil 10µg kg-1 is effective.

Ketamine

o ketamine is not contraindicated in brain injury and is the agent of choice in the haemodynamically unstable patient, as it minimises hypotension in the hypovolaemic patient, and those with abnormal cerebral autoregulation.

o Initial dose for induction of anaesthesia is 1mg/kg-2mg/kg.

Etomidate

Due to the concerns over adrenal suppression Etomidate is not recommended, and is contra-indicated in head injury as it uncouples cerebral blood flow and metabolism.

Most patients will require a RSI: Suxamethonium and Rocuronium are both safe in brain injury. Suxamethonium is safe for the first 24 hours following severe burns or spinal cord injury4.

Process

Do not try to intubate the patient with a collar in place, this will make the airway more difficult and prevent rapid access to the cricothyroid membrane should a ‘can’t intubate can’t ventilate’ scenario arise.

The C-spine should be protected by manual in line immobilisation during intubation, and the collar subsequently replaced. This is best achieved by releasing the front of the collar but leaving it in place behind the neck4.

Use of a bougie to facilitate intubation and minimise neck movement.

Use an uncut tube if the patient has any facial trauma or burns to their head, face or neck, as further swelling is likely to occur over time5.

Tape rather than tie the tube if there is a suspected head injury to reduce any obstruction to cerebral venous drainage4.


RSI checklist

As the NAP 4 study has shown ED resus is a clinical area with a higher than average incidence of airway complications. In the context of major trauma this is compounded by unstable patients, unfamiliar teams and a time pressure to secure the airway within 30mins of arrival.

To address this we have developed an RSI checklist :

This will be run by the trauma team leader immediately prior to intubation – to confirm you are ready to proceed rather than act as a step by step prompt to prepare your equipment and drugs.

As with the safer surgery checklist in theatres participation is not optional.


POST INTUBATION CARE Ventilation

Consider using the transport ventilator as soon as appropriate, as patient will inevitably require transfer,

o keep it plugged into the wall oxygen supply and mains electricity until ready for transfer

Aim to keep VTe at 6-8 mls/kg and Pmax< 30

Aim for normocapnia (4.5 – 5 kPa) in all patients, including the head injured, unless specific circumstances override this. .

o This refers not the arterial blood concentration not the end-tidal concentration

A minimum of 5 cmH2O PEEP is recommended. PEEP of up to 15 cmH2O is safe in the presence of TBI.

Consider placing an arterial line – however do not delay obtaining CT scan as this may alter management

Monitor ventilation with end-tidal CO2, and regular ABG’s.

o Changing airway pressure may be an early clue to deterioration in compliance due to pneumothorax or lung injury.

MAINTENANCE OF ANAESTHESIA

Maintenance of anaesthesia should be achieved using suitable infusions (i.e. Propofol 1% at 0-20mls/hr and alfentanil 25mg/50mls at 0-5mls/hr). These should be be prepared pre-empitvely and the reasons for commencing infusions instead of volatile are below:

1. Remember that volatile anaesthesia can increase Cerebral Blood Flow (CBF), and therefore ICP, if given in excess.

2. If using volatile agents in a patient with traumatic brain injury ensure ET agent levels do not exceed 1 (age adjusted) MAC.

3. The patient will be transferred to another area of the hospital (i.e. to CT within

30minutes) and this will necessitate the use of i.v. infusions anyway – it is better to pre-empt this.


B BREATHING WITH HIGH FLOW OXYGEN

If conscious, ask for symptoms of respiratory difficulty e.g. chest tightness, subjective shortness of breath, throat swelling.

Examine the chest carefully and measure all vital signs

Life threatening chest injuries must be treated immediately:

Chest Injury Initial Treatment

Airway obstruction Secure the airway

Early intubation may be required

Tension pneumothorax

Spontaneously breathing - Needle thoracocentesis, 2nd intercostal space, mid clavicular line

Ventilated or in extremis - Thoracostomy if in extremis

Insert chest drain – Not required initially in ventilated patient with open thoracostomies

Open pneumothorax Asherman chest seal or 3 sided occlusive dressing

Look for any exit wounds if shrapnel/gunshot

Insert chest drain, not through the wound

Massive haemothorax Confirm adequate IV access

Insert chest drain and manage hypovolaemia

Flail Chest Recognise early and give good analgesia

Consider intubating as lung contusion will be significant and will aid patient comfort

Cardiac tamponade

Diagnosed on clinical grounds or ultrasound

Definitive treatment is thoracotomy, only do this in the ED if the patient arrests with a penetrating wound near the heart within 5 minutes of arrival.

Investigations CXR

This should be performed at the earliest opportunity, but both rib fracture and pneumothorax (particularly anterior) may be missed on the X-ray and only detected clinically or on CT scan (thus don’t delay CT)

Chest ultrasound

This is a useful investigation for pneumothorax and tamponade Chest drains

Chest drains should never be clamped unless expert advice requests this

If there is deterioration in clinical status, assume and check for drain malfunction

Be vigilant on patient transfer as drains are vulnerable and can easily become blocked or dislodged.

It is reasonable to transfer a ventilated patient with thoracostomies to the CT scan without drains being placed. They can be placed on return to ED – the chest is safe and decompressed


C CIRCULATION WITH HAEMORRHAGE CONTROL

THE KEY PRIORITY IN ‘C’ IS SURGICAL CONTROL OF BLEEDING

Assessment

pulse, skin colour, level of consciousness

The team leader will consider the mechanism of injury and injury patterns to determine possible causes

You can monitor trends in physiology/ABGs , serum lactate and acidosis will help determine the adequacy of resuscitation

Monitoring, access and bloods

If appropriate you should establish invasive blood pressure monitoring as early as safe to do so – but do not be a cause of delay (i.e. transfer for polytrauma CT) by performing.

2x large bore cannulae (size 16G or larger) should be sited by the ED team – you may be asked to help

Be aware of the potential for a disruption to the normal venous return system when siting IV access “downstream” of an injured limb or pelvis

Relevant blood tests: FBC, UE, Clotting, BHCG in females, and group and save or cross match

If peripheral IV access is difficult, an intraosseous device may be employed. The humeral head is the preferred placement if no contraindications to this site.

Occult blood loss? – ‘Blood on the floor and four more’

Chest

Abdomen

Pelvis

Femurs


TIME LIMITED HYPOTENSIVE RESUSCITATION In the early stages of resuscitation we recommend time limited permissive Hypotensive Resuscitation, except in the presence of head injury where a higher MAP is appropriate (see below). In resus this will be the role of the trauma team leader – but the patient may require transfer to angio/CT/theatre/another hospital and this will therefore become your role until haemorrhage is controlled.

Infusing large volumes of crystalloid is likely harmful to the patient who is actively bleeding from an uncontrolled source, it may disrupt existing clot and can contribute to hypothermia and dilution of clotting factors6.

o Initial management is targeted at maintaining a radial pulse7

o Establish the quantity of pre-Hospital fluid that has been administered o Give boluses of Hartmann’s 250mls titrated against response o Warm all fluids and blood products using an appropriate warming device.

Any patient with significant blood loss should be considered for blood product replacement, not only packed red cells but also blood products such as FFP, platelets and cryoprecipitate as per your local massive transfusion policy.

Involve the haematologist early - waiting for an abnormal clotting result before initiating treatment is too late: use your clinical judgement and give clotting factors empirically.

PENETRATING TRAUMA Penetrating trauma with uncontrolled haemorrhage and persistent hypotension needs lifesaving rapid surgical control

Most cases involve torso injuries and the decision to immediately transfer the patient to theatre will be made by the surgeons and trauma team leader.

Ensure the Consultant Anaesthetist has been contacted and the massive transfusion protocol is activated

Surgical intervention to gain temporary control may be required in the ED – an emergency thoracotomy can gain control of cardiac and lung wounds, and provide descending aortic compression for bleeding below the diaphragm. This should only be undertaken by those with appropriate training.


D DISABILITY WITH SECONDARY PREVENTION If the patient is to be intubated please ensure the following are documented beforehand:

1. Level of consciousness

2. Pupil size and reaction

3. Lateralising signs e.g. weakness, sensory loss

4. Spinal cord injury level (if relevant)

Assess pupil size and reaction regularly post sedation, any change could signify an impending intra-cerebral catastrophe.

Remember the conscious level may fluctuate and the need to secure the airway may subsequently develop – inform the team leader if this is the case.

If the GCS <9 (i.e. less than or equal to 8) the airway must be secured within 30minutes of arrival in the department– this is a national target and a time critical step.

HEAD INJURY

Aim for a higher BP (MAP >80, systolic >120mmHg) in order to ensure an adequate cerebral perfusion pressure 9, 10.

A single episode of hypotension (systolic BP <80) doubles mortality, the appropriate BP target with concurrent penetrating trauma should be decided on a case by case basis by the consultants present.

Patients may require emergency neurosurgical operations– these will usually be decompressive in nature (i.e. for acute extradural) and necessitate rapid transfer.

Any such case must be discussed with the on-call neuroanaesthetic consultant by the on-call general anaesthetic consultant – both for specialist advice and to aid planning for any subsequent transfer to neurointensive care

TRANEXAMIC ACID (TXA) (see Appendix 4)

All patients with suspected significant blood loss and within 3 hours of injury should be given Tranexamic Acid

o 1g IV over 10 mins then o Further 1 gram over 8 hours as an infusion8

This will usually have been given on the scene of the accident (confirm at ATMIST handover)


E EXPOSURE AND TEMPERATURE CONTROL

Monitor the patients’ temperature and blood glucose

The patient may be fully exposed to allow a comprehensive examination, but then KEEP WARM, acidosis and coagulopathy are all exacerbated by hypothermia

o Forced air warming devices are available

If the patient is to be log rolled you are responsible for controlling the airway, c-spine and co-ordinating the turn.

If an unstable pelvic fracture is suspected, patient movement is minimised during log roll and in general (see section on pelvic fractures for guidance).

Place a naso/orogastric tube and temperature probe as soon as possible (oral if facial trauma or skull fracture suspected).


WHOLE BODY CT (WBCT)

The key investigation in the critically injured patient is WBCT/polytrauma CT. National targets state this should be performed within 30 minutes of the patient’s arrival in the ED 1, 11.

Peripheral injuries may be scanned at the same time provided the patient is stable

As soon as possible after the scan a ‘primary survey’ written report will be available to identify life-threatening problems. A more detailed ‘secondary survey’ report will be available within one hour1,11

Anaesthetic Priorities:

Plan and swap to the transport ventilator and monitoring as soon as possible. Take with you what you need, and ensure you have adequate oxygen and battery life on all equipment.

Ensure that there is a free cannula to enable the administration of IV contrast (preferably an 18G or larger in the antecubital fossa).

The radiology department is a remote site, you must be involved in any discussions regarding suitability for transfer to CT. However, resuscitation can continue in the CT scanner – ED staff will bring the fluido rapid infusor round if required.

Is the patient stable for transfer to CT?

Patients with SBP 70 – 90 mmHg pose a difficult decision and the risks must be balanced against the potential diagnostic accuracy of a scan, however evidence shows that the most unstable benefit most from radiologically identifying the bleeding

If high volumes of IV fluid or vasoactive drugs are required to maintain this BP, a CT scan may not be safe.

The trauma team should accompany the patient to CT but ultimately if the patient is sedated and ventilated the anaesthetist is in charge of the transfer.

Patients with SBP < 70 mmHg should probably go straight to theatre

DAMAGE CONTROL SURGERY (DCS)

This involves rapid emergency surgery to save life and/or limb whilst avoiding time-consuming and potentially traumatic reconstruction.

Aim

To preserve physiology, do as little surgical trauma as possible and get the patient to ITU for continued resuscitation as quickly as possible.

Key Areas 1. Haemorrhage control 2. Decompression – cranium, thorax, pericardium, abdomen and limb compartments 3. Decontamination – wounds and ruptured viscera 4. Fracture splintage – pelvic binder, skeletal traction of femur, plaster casts and external fixators.

1 – 3 should be treated emergently.


OPEN FRACTURES

1. Check the tetanus status and ensure tetanus toxoid has been given (check resus trauma documents)

2. Give IV antibiotics as per our guidelines (also found in theatre 11anaesthetic room)

Consider adding Metronidazole if aquatic environmetal contamination

3. Timing of surgery depends on other injuries, available theatres and surgeons

4. Debridement, wound closure and definitive fracture fixation will be as per Nationally recommended BOAST guidelines

5. Severely contaminated, farm and aquatic injuries remain a surgical emergency and must be debrided as quickly as possible with respect to the overall patient picture.

FRACTURE CARE The timing of definitive orthopaedic surgery depends on a number of factors i.e. the patient’s physiological response to injury and resuscitation, in conjunction with all involved specialities (critical care, anaesthesia etc.) If the patient is stable enough then early total care (ETC) can be considered.

http://www.boa.ac.uk/LIB/LIBPUB/Documents/BOAST%204%20-%20The%20Management%20of%20Severe%20Open%20Lower%20Limb%20Fractures.pdf


EARLY TOTAL CARE (ETC) Principles:

Definitive fracture fixation within 24hs once the patient is physiologically stable. The patient must therefore be properly resuscitated before surgery

In general if a patient is not fit enough to tolerate ETC then they are unlikely to be fit enough to tolerate prolonged surgery to revascularize an ischemic limb; amputation may therefore have to be considered a life saving procedure. In each case review the lethal triad:

Hypothermia: If core temperature <35.5ºC do not attempt ETC

Coagulopathy: If platelets <120 or INR> 1.5 do not perform ETC

Acidosis: If ph <7.25 or Base Excess < -5.0 do not perform ETC Lactate Venous or arterial lactate is a useful guide, when measured serially; it reflects adequacy of resuscitation as it is one of the last parameters to return to normal. These levels can be used to guide the decision between DCS and ETC in the first 12-24hs

NB: Most polytrauma patients will have a raised lactate on admission. The important factor is the trend of the lactate level during resuscitation. During this time fractures will require adequate splinting which may be achieved with splints, casts or skeletal traction.

The Baltimore Shock Trauma guidelines recommend:

o Lactate <2.0 ETC possible o Lactate >2.5 continue resuscitation

If the lactate level remains elevated >2.5 with no evidence of a downward trend despite ongoing resuscitation during the first 12-24hs then external fixation of long bone fractures should be considered in anticipation that definitive fixation of long bone fractures may be delayed by several days.

All of the above should be continually monitored intra-operatively. If the indices deteriorate then be prepared to stop fracture surgery, perform Damage Control (Orthopaedic) Surgery and transfer the patient to GITU for further resuscitation. Surgical planning should include alternate strategies and include time points when the patients physiology is reviewed (i.e. following intra-medullary nailing).


PELVIC FRACTURES

Severe pelvic fractures cause life-threatening haemorrhage and may be associated with severe intra-peritoneal injuries. You will be involved in initial and further intervention.

Call the on-call consultant anaesthetist, these are extremely challenging patients. NB: They are not always tachycardic or hypotensive at presentation. If the mechanism of injury is significant, have a high index of suspicion.

The ED or orthopaedic team will splint the pelvis to provide tamponade and prevent movement, protecting the blood clots that have already formed.

An early x-ray helps detect the presence of a pelvic fracture, whilst CT helps differentiate between pelvic and intra-abdominal bleeding and visceral injury.

If pelvic x-ray is normal AND the patient is normotensive with no clinical signs of shock, the pelvis is provisionally cleared and the orthopaedic team may remove the binder and then repeat the x-ray.

Persistent hypotension and pelvic trauma

Clinical examination is NOT reliable and decision making is difficult. FAST scanning performed by the ED team may help.

SBP > 90 mmHg: Immediate CT

SBP 70 – 90 mmHg: CT will be useful but weigh up the risks/benefits (follow advice in Whole Body CT section above)

SBP < 70 mmHg: Take to Operating Theatre urgently if not responding to fluid resuscitation Leave Pelvic Binder ON during laparotomy

The decision whether to control pelvic or intra-abdominal bleeding first will need to be made by consultation between the Orthopaedic and General Surgery consultants. Pelvic bleeding can be stopped by angiography and embolisation.

Extraperitoneal packing of the pelvis can also be used to control pelvic haemorrhage (usually in the following scenarios)

a. Extremis patient with abdomen already open (e.g. for spleen or liver) b. Severe hypotension from pelvic bleeding and failed interventional radiology c. Continued (venous) haemorrhage with hypotension despite angiography and pelvic splint

The pelvic binder can be left in place for up to 24 hours unless the patient has a severe neurological deficit (e.g. paraplegia).

Only log-roll if absolutely necessary.


POST RESUSCITATION CARE

If it obvious that the patient will require critical care then liase with 2100 & the Consultant Intensivist on call as early as possible.

If a critical care bed is not immediately available then Consultants should decide the most appropriate area for patient care in the interim. If a prolonged wait is expected and ED care is no longer required consider movement to PACU (ext 14986 or 14224). Similarly the decision as to which doctor should remain with the patient should be made dependent upon on-going care and the situation in critical care and theatres.

Transfer to and resuscitation in ITU should be performed as a team with active input from the surgeons, anaesthetists and intensivists, all of whom have complimentary skills in the early resuscitation of the multiply-injured patient. The patient should not simply be abandoned in ITU!

DOCUMENTATION AND AUDIT

In line with national guidance, STH submits data to the Trauma Audit and Research Network (TARN). Clear documentation will facilitate this process. Please be clear regarding the patients’ injuries, interventions given and at what time.

Any anaesthetic intervention must be documented, and at what time.

Any pressing governance issues arising from a trauma case should be discussed with the on call consultant and fed back to Dr Ben Edwards or Dr Steve Rowe, Consultant Anaesthetists

The major trauma M&M and clinical governance and educational meetings allow any such issues to be discussed and raised at the appropriate forum.


APPENDIX 1: NICE guidelines for triage, assessment, investigation and management of head injury in infants, children and adults

The following indications for intubation and ventilation after head injury are recommended: Immediately:

coma – not obeying commands, not speaking, not eye opening (that is, GCS ≤ 8) loss of protective laryngeal reflexes

ventilatory insufficiency as judged by blood gases: hypoxaemia (PaO2 < 9 kPa on air or < 13

kPa on oxygen) or hypercarbia (PaCO2 > 6 kPa)

spontaneous hyperventilation causing PaCO2 < 3.5 kPa respiratory arrhythmia.

Before the start of the journey:

significantly deteriorating conscious level, even if not coma bilateral fractured mandible copious bleeding into mouth (for example, from skull base fracture) seizures

APPENDIX 2: TRANEXAMIC ACID

The CRASH-2 study demonstrated a significant reduction in all cause mortality (with few adverse events) in patients with significant haemorrhage8.

New analysis of the 2010 CRASH-2 study shows that tranexamic acid should be given as early as possible to bleeding trauma patients8.

However if treatment is not given until three hours or later after injury, it is less effective and could even be harmful6.

Tranexamic acid should therefore be administered only to trauma victims within 3 hours of time of injury with:

o Systolic BP< 110mmHg o and evidence of haemorrhage and injury

Dosing

STAT bolus of 1g IV, infused over 10 minutes

Followed by 1g infusion over 8 hours.

Tranexamic acid is available in Resus and theatres in 500mg in 5ml vials.

Please look at the STH Critical Care Guidelines for use of Tranexamic Acid Here More information can be found on the CRASH-2 website

http://www.thelancet.com/crash-2

http://nww.sth.nhs.uk/STHcontDocs/STH_CGP/CriticalCare/TranexamicAcid.pdf

http://www.crash2.lshtm.ac.uk/


APPENDIX 3: MASSIVE TRANSFUSION PROTOCOL It is assumed that polytrauma patients are coagulopathic at presentation. Aim

Restore/maintain oxygen carrying and haemostatic capacity in those patients at risk of acute coagulopathy of trauma.

Replace blood loss with blood and clotting products to prevent severe haemodilution and coagulopathy.

Consider Immediate Use

Patients presenting with SBP < 80mmHg

Patients at high risk of coagulopathy such as; - severe pelvic fractures - multiple long-bone fractures

Activation

Activated by the Trauma Team leader.

Confirm cross match specimen sent and received by blood bank.

Call the anaesthetic consultant for a second pair of hands and expertise. Protocol

Massive transfusion may be necessary and the trust protocol is available on the wall in resus and on the intranet: http://nww.sth.nhs.uk/STHcontDocs/STH_CGP/Haematology/MassiveTransfusionGuidelines.doc

If the clinical situation dictates that blood is required before the massive transfusion pack is ready (15 minutes) use emergency O negative blood available from blood bank/general theatres/cardiac theatres

The Trauma Team Leader should contact the on-call Haematologist for advice if the patient is known to take oral anticoagulants, have a clotting disorder or is a Jehovah’s Witness. They may delegate this task to another Doctor who is free.

Assign 2 members of staff to check blood and clotting products when they arrive and ensure that all paperwork is completed appropriately.

http://nww.sth.nhs.uk/STHcontDocs/STH_CGP/Haematology/MassiveTransfusionGuidelines.doc


The massive transfusion pack (MTP) will arrive in 2 parts: Part 1 – 4 hour storage box (once removed from this components should be transfused within 30minutes or returned to storage) o 4 Pack red cells o 3 FFP

Part 2 – 2 hour storage bag (once removed from this components should be transfused within 30minutes or returned to storage) o 2 Cryoprecipitate o 1 Platelets

Blood, FFP, cryoprecipitate and platelets are transfused in 4:3:2:1 dose ratios. Do not wait for abnormal coagulation tests – transfuse clotting products as soon as they are ready otherwise they will be wasted!

Ensure transfusions are warmed to decrease the possibility of hypothermia and further coagulopathy.

Patients receiving a massive blood transfusion may become hypocalcaemic. Check regular arterial blood gases and if the Calcium is < 1 give 10mls of 10% Calcium Chloride in divided doses.

Send urgent FBC, U+E, Calcium, Clotting screen after each MTP.

In the future, thrombo-elastography may be used to guide treatment. Currently this is only available in Chesterman Cardiothoracic theatres and so may only be requested by a consultant cardiothoracic anaesthetist if a cardiothoracic perfusionist is in attendance.

All components should go with the patient to theatre and the haematology technician should be informed of the patient transfer.


On-going haemorrhage and/or clinical instability Request a 2

nd MTP

Repeat blood samples as above.

Use Emergency O negative (G&S sample MUST be obtained before

transfusion) Location of Emergency O negative red cells

2 units in Blood Bank at both NGH and RHH 2 units blood fridge Jessop Wing Theatres

2 units blood fridge Cardiac Theatres 4 units blood fridge NGH General Theatres

Inform Blood Bank of pending Major Trauma or haemorrhage ASAP and request a Massive Transfusion Pack (MTP).

Send samples for cross-matching, full blood count, clotting screen

and U&Es to laboratories urgently RHH ext 12333/68602 (out of hours bleep via switchboard)

NGH ext 14246/ 69039 (out of hours bleep 793)

Adapted from Appendix 15. Blood Transfusion Policy 2009

Able to wait 15 mins from laboratory receipt of above blood samples?

No Yes

CLINICAL STABILITY.

Inform Blood Bank when they can stand down asap.

MASSIVE TRANSFUSION PACK (MTP) Indications and guidelines.

INDICATIONS: Clinical shock due to haemorrhage eg; Systolic BP <90mmHg after initial resuscitation.

Major Trauma. Ruptured Aneurysm.

(NOT FOR JESSOP WING- see separate Massive Obstetric Haemorrhage Guideline)

On-going haemorrhage and/or clinical instability seek Senior Haematology

advice before ordering further MTP’s

In Major Trauma give Tranexamic Acid 1g IV

over 10 mins.

Initiation and coordination by Senior Clinical Staff in A & E, Anaesthesia or Critical Care.

Inform Haematologist on-call if patient is on oral anticoagulants, has a known clotting disorder or is a

Jehovah’s Witness.

It is essential that all unused products and completed Blood Bank Return Slips are returned to Blood Bank Staff.

MTP ready for collection from Blood Bank. 4 Red Cells 3 FFP 2 Cryo

1 Platelets

4hr storage box

2hr storage bag


REFERENCES

1. Regional Networks for Major Trauma - NHS Clinical Advisory Groups Report September 2010. Available from URL http://www.excellence.eastmidlands.nhs.uk/welcome/improving-care/emergency-urgent-care/major-trauma/nhs-clinical-advisory-group/

2. Yorkshire and Humber Major Trauma Network Protocol - available from URL

http://nww.yorksandhumber.nhs.uk/major_trauma_network/workshop_outcomes/clinical_workshop_november_2011/ with STH additions

3. ABC to <C>ABC, redefining the military trauma paradigm. Emergency Medicine Journal 2006;

23(10): 745–746 4. Airway management after major trauma. Continuing Education in Anaesthesia, Critical Care

and Pain 2006; 6(3): 124-127

5. Anaesthesia and Intensive Care for Major Burns. Continuing Education in Anaesthesia, Critical Care and Pain 2012; 12(3): 1-5

6. Jansen J, Damage Control Resuscitation. British Medical Journal 2009; 338: b1778

7. Trauma Care Manual, 2nd edition (2009), Greaves, Porter, Garner 8. Effects of tranexamic acid on death, vascular occlusive events and blood transfusion in trauma

patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. The Lancet 2010; 376(9734): 23-32

9. Recommendations for the Safe Transfer of Patients with Brain Injury. Association of

Anaesthetists of Great Britain and Ireland 2006. http://www.aagbi.org/sites/default/files/braininjury.pdf

10. Triage, assessment, investigation and early management of head injury in infants, adults and

children. NICE Guidance CG56 2007. http://www.nice.org.uk/CG056

11. Standards of Practice and Guidance for Trauma Radiology in Severely Inured Patients. Royal College of Radiologists 2011. http://www.rcr.ac.uk/docs/radiology/pdf/BFCR(11)3_trauma.pdf

12. Recombinant Factor VIIa (NovoSeven) for Traumatic Coagulopathy.

http://www.trauma.org/archive/resus/FactorVIIa.html

http://www.excellence.eastmidlands.nhs.uk/welcome/improving-care/emergency-urgent-care/major-trauma/nhs-clinical-advisory-group/

http://www.excellence.eastmidlands.nhs.uk/welcome/improving-care/emergency-urgent-care/major-trauma/nhs-clinical-advisory-group/

http://www.aagbi.org/sites/default/files/braininjury.pdf

http://www.nice.org.uk/CG056

http://www.rcr.ac.uk/docs/radiology/pdf/BFCR(11)3_trauma.pdf

http://www.trauma.org/archive/resus/FactorVIIa.html


Authors

Dr Ben Edwards, Consultant Anaesthetist

Dr Olena Matezko, Consultant Anaesthetist

Acknowledgements Thank you to the following for their assistance in the creation of these guidelines:

Mr Richard Gibson, Consultant Orthopaedic & Trauma Surgeon Dr Tim Moll, Consultant Anaesthetist Dr Stuart Reid, Consultant in Emergency Medicine

Dr Steve Rowe, Consultant Anaesthetist Dr Neil Sambridge, Consultant Anaesthetist

Dr Matt Wiles, Consultant Neuroanaesthetist

Network Guideline for Emergency Adult Trauma Anaesthesia · ODN T14-1C-111 MTC Adults T14-2B-116 TU...

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