A A AText only | Accessibility | Privacy and cookies

Browse site A to Z

Search results

Go To Advanced Search

Feasibility of covert caesarean

Description
The Court of Protection considers whether a covert caesarean section is in the best interests of a patient.
Url
/HealthProfessionals/Clinical-law-updates/Feasibility-of-covert-caesarean.aspx

Body modification

Description
Nearly twenty years ago, a court was faced with an agonising decision: whether the proposed separation of conjoined twins was lawful.
Url
/HealthProfessionals/Clinical-law-updates/Body-modification.aspx

Restraining adult patients in hospital

Description
Auto Generated Title We are all familiar with the need to restrain adult patients who are due to their behaviour are endangering themselves or others. Whilst necessary, we all find this to be an onerous task, since compelling a patient to have treatment is not a customary clinical activity. Broadly, patients behaving dangerously are in one of three categories. By far the largest group are adult inpatients who have lost their capacity. Because they are incapacitated, such people must be treated in their best interests. Their clinical management must continue, obliging us to ensure that treatment and investigation continues. Clinical interventions are inherently unpleasant, almost always involving the patient being touched, in circumstances where the patient ’ s objections will be overruled, albeit politely. It is little wonder that such perplexed, frightened or irritated patients sometimes need to be restrained if they are to be treated in their best interests. Irrespective of their lack of capacity, (and perhaps particularly importantly because of it), clinicians strive to be invariably polite to the patient whose consent to the potentially unwanted touch is waived in this way. Nevertheless, clinicians may restrain patients to facilitate management provided that the treatment is necessary; that the restraint used is proportionate to the degree of resistance that the patient employs to avoid the administration of the treatment. In addition, the form of restraint must be the least restrictive option available to achieve the desired result. The legal authority for this approach comes from the Mental Capacity Act 2005 (MCA) . It is clear that both physical and chemical restraint can be employed in these circumstances. It is a matter of clinical judgement which to use, but both have advantages and risks attached. Physical restraint is usually easily available; but can result in harm to both staff and the patient. Physical restraint is humiliating; who is to say that an incapacitated person cannot feel humiliation? Physical restraint may be unrealistic over a prolonged period, and for that reason chemical restraint is sometimes used. This has the advantage of being relatively easily maintained; although this may encourage clinicians to use it for longer than it is necessary; restraint used for clinical convenience (rather then in the patient ’ s best interests) is unlawful. It seems likely that chemical restraint will prolong the patient ’ s incapacity, and thus becomes a more restrictive option than is needed to achieve the desired result. However, if it is clear that the patient will need restraint to achieve their clinical management objectives over a prolonged period of time; this may prove to be a better option than repeated and fraught periods of physical restraint. If prolonged restraint is contemplated, by whatever means, clinicians must consider the type of restraint, and the practical arrangements that will need to be in place to achieve the desired outcome using the least restrictive option. These considerations should be recorded in the patient ’ s care plan. Restraint in an incapacitated adult also achieves a different goal, which is to ensure that the patient remains unharmed by their own actions; and that the staff looking after them, and bystanders, are also protected from harm. These latter aims provide the sole reason for a clinician to restrain the second category of adult patients; those who have capacity. When an adult with capacity refuses treatment, or decides to leave the hospital despite not having the recommended treatment, we have no authority whatsoever to stop them doing so. By all means remind them that they are behaving contrary to advice, but accept that they are exercising their autonomy. The only circumstance when restraint of the adult competent patient can be justified is to prevent him or her harming staff or bystanders. Although staff are understandably wary of tackling badly behaved competent patients, they have a right to do so. The English common law allows all citizens to defend themselves against attack, providing they use a reasonable degree of force to do so. Equally, it is legitimate to prevent an unlawful attack on bystanders; again providing reasonable force is used. This common law right is encompassed in the Criminal Justice and Immigration Act 2008 . Finally, the Mental Health Act 1983 (MHA) provides us with authority to restrain patients who require treatment for their mental illness. But the converse is not true. The MHA gives us no authority to restrain any patient for treatment for physical conditions unrelated to their mental illness. Thus a diabetic patient detained under the MHA for the treatment of their psychosis may be restrained to facilitate the administration of antipsychotic drugs; but not to administer the insulin necessary to treat their diabetes. If this patient lacked capacity, the patient could be restrained with the authority of the MCA, in order to administer insulin. If they were competent to decide whether or not to accept the insulin, they could refuse it if they chose. Robert Wheeler Deptartment of clinical law
Url
/HealthProfessionals/Clinical-law-updates/Restrainingadultpatientsinhospital.aspx

UHS adult major trauma guidelines

Description
Adult Major Trauma Guidelines University Hospital Southampton NHS Foundation Trust Dr Mark Baxter Director of Major Trauma, Consultant in Older Persons Medicine Prof Rob Crouch Deputy Director of Major Trauma, Consultant Nurse in Emergency Medicine Emma Bowyer Major Trauma Centre and Wessex Trauma Network Manager Amendment’s log No. Amendments 1. Update Wessex Trauma Network Automatic acceptance tool 2. Hyperlinks added from contents page Page No. 22 4 3. Updated Guideline on the management of chest 107 injuries and chest decompression 4. Burns Operational Guidance added 55 5. Adult Major Trauma: Prophylactic Antibiotics guideline 81 Flowchart added to section 3 6. Adult Major Trauma; Prophylactic Antibiotic guideline 124 added to section 4 Date Sept 2021 Oct 2021 (v7.1) Apr 2022 (v7.2) Apr 2022 (v7.2) May 2022 (v7.3) May 2022 (v7.3) 2 NOTE: These guidelines are regularly updated. Check the intranet for the latest version. DO NOT PRINT HARD COPIES Please note these Major Trauma Guidelines are for UHS Adult Major Trauma Patients. The Wessex Children’s Major Trauma Guidelines may be found at http://staffnet/TrustDocsMedia/DocsForAllStaff/Clinical/WessexChildre nsMajorTraumaGuideline/WessexChildrensMajorTraumaGuidelines.pdf NOTE: If you are concerned about a patient under the age of 16 please contact SORT (02380 775502) who will give valuable clinical advice and assistance by phone to the Trauma Unit and coordinate any transfer required. http://www.sort.nhs.uk/home.aspx Please note current versions of individual University Hospital Southampton Major Trauma guidelines can be found by following the link below. http://staffnet/TrustDocuments/Departmentanddivisionspecificdocuments/Major-trauma-centre/Major-trauma-centre.aspx 3 Table of Contents (Hyperlinked) 1 SECTION 1: PREPARATION FOR MAJOR TRAUMA ADMISSIONS ................................................................................ 7 1.1 PRE-HOSPITAL TRIAGE & TRAUMA UNIT BYPASS TOOL ............................................................................................................ 7 1.2 ATMIST....................................................................................................................................................................... 10 1.3 ADULT MAJOR TRAUMA TEAM ACTIVATION ........................................................................................................................ 11 1.4 ADULT MAJOR TRAUMA TEAM COMPOSITION ..................................................................................................................... 12 1.5 RESPONSIBILITIES & ROLES OF TRAUMA TEAM MEMBERS ...................................................................................................... 13 1.6 HANDS-OFF HANDOVER................................................................................................................................................... 19 1.7 TRAUMA TEAM LEADER: EXECUTIVE ROLE ........................................................................................................................... 20 1.8 SITE MANAGER .............................................................................................................................................................. 21 1.9 SECONDARY TRAUMA TRANSFERS ...................................................................................................................................... 22 2 SECTION 2: TRAUMA RESUSCITATION ( ABCDE) ................................................................................................. 25 2.1 CATASTROPHIC HAEMORRHAGE......................................................................................................................................... 25 2.2 AIRWAY ........................................................................................................................................................................ 35 2.3 BREATHING ................................................................................................................................................................... 38 2.4 CIRCULATION ................................................................................................................................................................. 41 2.5 DISABILITY..................................................................................................................................................................... 46 2.6 EXPOSURE & ENVIRONMENT ............................................................................................................................................ 54 2.7 TRAUMA IMAGING.......................................................................................................................................................... 55 2.8 BURNS – OPERATIONAL GUIDANCE .................................................................................................................................... 56 2.9 ADMISSION DESTINATION ................................................................................................................................................ 57 3 TRAUMA RESUSCITATION SUPPORTING DOCUMENTS............................................................................................ 58 3.1 APPLICATION OF CELOXTM GAUZE .................................................................................................................................... 58 3.2 BELMONT RAPID INFUSER ................................................................................................................................................ 59 3.3 RESUSCITATIVE THORACOTOMY......................................................................................................................................... 60 3.4 MAJOR TRAUMA AIRWAY ALGORITHM ............................................................................................................................... 63 3.5 FRONT OF NECK ACCESS PROCEDURE ................................................................................................................................. 65 3.6 PRE-RSI CHECKLIST......................................................................................................................................................... 66 3.7 IMMEDIATE RSI CHECKLIST............................................................................................................................................... 67 3.8 TRAUMA BAY CHECKLIST.................................................................................................................................................. 68 3.9 RSI PACK LIST ................................................................................................................................................................ 71 3.10 RIB FRACTURE PATHWAY ................................................................................................................................................. 73 3.11 SCOOP STRETCHERS ........................................................................................................................................................ 77 3.12 MAJOR TRAUMA CT HOT REPORT ..................................................................................................................................... 79 3.13 ADULT MAJOR TRAUMA: PROPHYLACTIC ANTIBIOTICS GUIDELINE - FLOWCHART ......................................................................... 81 4 STANDARD OPERATING PROCEDURES .................................................................................................................... 83 4.1 UHS MANAGEMENT OF EXTREMITY BLEEDING & TOURNIQUET SOP........................................................................................ 83 4.2 UHS MAJOR HAEMORRHAGE PROTOCOL............................................................................................................................ 92 4.3 UHS GUIDELINE FOR THE MANAGEMENT OF CHEST INJURIES AND CHEST DECOMPRESSION IN ADULT MAJOR TRAUMA ................... 107 4.3.1 Executive Summary ........................................................................................................................................ 107 4.3.2 Introduction.................................................................................................................................................... 108 4.3.3 Scope .............................................................................................................................................................. 108 4.3.4 Aim/purpose................................................................................................................................................... 108 4.3.5 Definitions ...................................................................................................................................................... 109 4.3.6 Guideline for the management chest injuries and chest decompression in Adult Major Trauma ................. 109 4.3.7 Implementation.............................................................................................................................................. 112 4.3.8 Roles and responsibilities ............................................................................................................................... 112 4.3.9 Document review ........................................................................................................................................... 112 4.3.10 Process for monitoring compliance ........................................................................................................... 112 4.3.11 Appendices ................................................................................................................................................ 113 4.3.12 References ................................................................................................................................................. 113 4.4 UHS MAJOR TRAUMA TEAM SOP................................................................................................................................... 114 4.5 ADULT MAJOR TRAUMA: PROPHYLACTIC ANTIBIOTIC GUIDELINE............................................................................................ 124 4.5.1 Version control ............................................................................................................................................... 124 4 4.5.2 4.5.3 4.5.4 4.5.5 4.5.6 4.5.7 4.5.8 4.5.9 4.5.10 4.5.11 4.5.12 4.5.13 Index............................................................................................................................................................... 125 Introduction.................................................................................................................................................... 126 Scope .............................................................................................................................................................. 126 Aim/purpose................................................................................................................................................... 126 Definitions (if necessary) ................................................................................................................................ 126 Adult Major Trauma Antibiotic Flowchart ..................................................................................................... 127 Implementation.............................................................................................................................................. 128 Roles and responsibilities ............................................................................................................................... 128 Document review....................................................................................................................................... 128 Process for monitoring compliance ........................................................................................................... 129 Appendices ................................................................................................................................................ 129 References ................................................................................................................................................. 129 5 Introduction ‘These guidelines are the current policies and practice for the management of adult major trauma patients at University Hospital Southampton. They have been designed to provide a day to day framework for the management of patients; including the roles and responsibilities of clinical teams and their members. The guidelines were produced to try and ensure timely, consistent, high-quality care for all patients whatever day or time of day they present, recognising that these are challenging and often stressful cases. There will be situations when it is appropriate to deviate from the guidelines or where the guidelines do not cover the specific circumstances. In these cases it is essential that care of the patient is the foremost consideration, that senior staff are directly involved and that documentation is clear. If in doubt, seek senior advice and document their involvement. This second edition of the guidelines reflects the changes in practice in major trauma over the last 6 years together with changing national guidance and policy. My personal thanks to all members of the clinical and support teams who have contributed to the development of excellent practice at UHS and who have contributed to this revision. Thanks in particular to Dr Liz Shewry and Dr Simon Hughes, who begun these revisions and to Major Alan Weir who continued with this unenviable task. In addition, this second edition would not be possible without such a comprehensive first edition. Thanks for the first edition go to Dr Andy Eynon, Dr Liz Shewry and Dr Simon Hughes, who authored the first edition of these guidelines in 2012. The first edition has guided Major Trauma Care across Wessex and further afield for nearly a decade.’ Dr. Mark Baxter Director of Major Trauma, University Hospital Southampton, 6 1 Section 1: Preparation for Major Trauma Admissions 1.1 Pre-hospital Triage & Trauma Unit Bypass Tool The pre-hospital triage & trauma unit bypass tool was developed by the Wessex Trauma Network (WTN) to identify patients who have or are at high risk of having sustained major trauma. Patients who are within a 60 minute travel time of UHS may be transferred direct to UHS as the Major Trauma Centre (MTC), bypassing hospitals closer to the scene of the accident. The rationale for this is that it is time to definitive treatment rather than time to arrival in hospital that makes the biggest difference in outcomes. UHS was chosen as the MTC as it has all major trauma services on site. The pre-hospital team (Ambulance Service, BASICS, HIOWAA) will alert the ED that a patient with major trauma is en route. It is expected that a basic ATMIST (see p9) handover will be received with details of the mode and likely time of arrival of the patient. Patients who are outside a 60 minute travel time or who are deemed to be at risk of imminent airway compromise or have catastrophic haemorrhage will go initially to their nearest trauma unit (TU) for resuscitation. Once resuscitated, if the TU feel that the patient’s injuries are beyond their local facilities, the patient will be transferred on to either the MTC or another TU with specialist facilities (see Section 1.09 Secondary Trauma Transfers, p22). Certain hospitals have been designated as local receiving hospitals (LRH) by the Wessex Trauma Network. Trauma patients will only go to these hospitals if there is an imminent cardiac arrest or immediate airway problem. Patients will be expected to have only these immediate life-threatening conditions controlled before onward transfer to a TU or MTC. 7 8 Figure 1. Trauma Triage Tool (2021) 9 1.2 ATMIST Ambulance services, including the air ambulance service, are using the ATMIST handover tool. This gives basic information to enable preparations to be made to receive the patients. The sticker below is completed by the team leader and then it is stuck into the trauma booklet on arrival in ED resus. Figure 2. Pre-hospital alert ATMIST sheet 10 1.3 Adult Major Trauma Team Activation A two-tier response to trauma has been developed at UHS. A full trauma team response (Level 1 trauma call) should be instigated by the ED Consultant where a patient triggers a pre-hospital major trauma call and there is concern by the ED team that a full trauma team response is required. For less severe trauma it may be appropriate to activate the ED trauma team alone (Level 2 trauma call), which can be escalated if more significant injury is found. Criteria for activating a Level 1 trauma call (Figure 3) are based on physiology, anatomical injury, and mechanism of injury, however, this is not an exhaustive list and full trauma team activation is at the discretion of the receiving clinicians. To activate a Level 1 trauma call, contact Switchboard on 2222 and request “Adult Trauma Team, ED Resus” Physiological Respiratory rate 29 Or Pre hospital Sp02 o 110 GCS Motor Score of 4 or less Or Pre- hospital GCS of 1 fractured long bone Suspected major pelvic injury Trauma Triage Tool Activation (Trauma Unit Bypass) Other Considerations Pre-hospital intubation (Mandates Level 1 Call) Senior Clinician Concern (including mechanism) Gunshot wounds, stabbing, impaling Falls > 6 metres High impact RTC (Ejection, death of vehicle occupant, pedestrian struck by vehicle > 30mph) For the ≥ 65 age group consider • Systolic BP of ≤ 110 mmgHg • Heart Rate of ≥ 100 bpm • Fall with GCS of ≤ 12 • Taking Anticoagulants • Co-morbidities; Liver disease, renal failure, heart failure, COPD Figure 3. Criteria for Level 1 Trauma Response (December 2020) 11 1.4 Adult Major Trauma Team Composition Level 2 Trauma Team ED Consultant or ED ST4+ ED Doctor/ACP ED Nurse in charge ED Nurse x 2 HCA Level 1 Trauma Team Level 2 Trauma Team Members plus: ED Consultant Trauma Orthopaedic Consultant Major Trauma Anaesthetist Named Anaesthetist (Day) GICU SpR ODP / tech General Surgery SpR / Cons Orthopaedic Surgery SpR Site manager (if helipad arrival) Radiographer Major Trauma Clinical Coordinator (Daytime) bleep 1780 (Daytime) bleep 1783 bleep 1646 bleep 2110 bleep 1784 bleep 9990 bleep 2702 bleep 2238 bleep 1781 bleep 1963 There is agreement that the Neurosurgical SpR (bleep 2877) and Cardiothoracic SpR (bleep 9211) will not be part of unselected Level 1 calls. They may be contacted at the discretion of the Trauma Team if the pre-alert suggests their presence may be of benefit. Other specialists (eg ENT and MaxFax) may be contacted in a similar fashion. 12 1.5 Responsibilities & Roles of Trauma Team Members On receiving a major trauma alert, all members of the major trauma team should assemble in the ED Resus area to be briefed on the nature of the patient expected. This information should be written on a board or flipchart for the team to view throughout the trauma call. The Trauma Team Leader (TTL) will lead a team briefing and allocate roles in advance of the patient’s arrival. If a member of the team cannot attend within the given timeframe they should notify the ED immediately (x3807). If a specialty SpR cannot attend, the duty specialty Consultant must be informed and attend. CT CT should be informed that a potential major trauma patient will be arriving so that the scanner can be cleared and be on stand-by to perform a trauma series CT. The default emergency CT is the C level scanner adjacent to the ED (x6108 / x4999). Transfer equipment should be made ready in the expectation that the patient will be moving from resus to CT. Trauma mattresses are NOT to be used for Level 1 trauma cases. They should managed in the initial resuscitation phase on scoop, and transferred to CT/ Theatre / ITU on this scoop. If the patient remains in ED for a period of time following resuscitation then they may be transferred to a trauma mattress at this point. There is an agreed protocol for requesting a trauma series CT +/- limb angiography. The request is made electronically and then a single telephone call is made to the CT Radiographer to inform them of the request. The CT Radiographer will then inform the duty Radiology SpR who will approve request and provide the Hot Report to the trauma team. Major Haemorrhage (Code Red) If the pre-hospital information suggests that the patient has severe, life-threatening haemorrhage a ‘CODE RED’ should be called. This facilitates prompt requests for blood products from Blood Bank and allows the major trauma team to make adequate preparations for management e.g. preparation of tourniquet, preparation of rapid infuser. There is an allocated ‘Code Red Nurse’ for every shift. They should be identified when the trauma team assembles and if required prime the rapid infuser. A team of two is required for effective major haemorrhage management – a transfusion assist will be allocated to work with the ‘Code Red Nurse’ from the ED team. Consider allocation of ‘T’ (Transfusion) number for patients who have Code Red declared prehospital. A number of patient note folders and ‘T’ numbers have been pre-assigned. Blood Bank must be informed if a ‘T’ number is used, and they can issue FFP using a ‘T’ number. If a 13 ‘T’ number has already been allocated by HIOWAA then this must continue to be used on arrival at UHS. Most of the Air Ambulances carry blood for prehospital use. If HIOWAA has given blood please inform blood bank before their arrival as the Air Ambulance will need restocking. Helicopter Transfers If the patient is being transferred by helicopter, switchboard will be informed and asked to alert the helipad team (Site Manager, Portering staff). The Trauma Team is far more effective looking after major trauma patients in ED Resus rather than on the Helipad. Therefore, the priority is to transfer the patient from the Helipad to Resus before Hospital resuscitation commences. NOTE: Aside from the helipad team, no members of UHS staff are to attend the helipad even if the patient is critical 14 Trauma Team Roles Trauma Team Leader • Controls and manages the trauma team resuscitation • Makes decisions in conjunction with specialists • Priorities investigations and treatments • Is responsible for the handover and transfer • Undertakes the trauma transfer checklist, prior to departure from ED Before patient arrival • Ensures trauma team activated (consider additional specialties andseniority) • Liaises with Scribe • Ensures team members are booked in with Scribe • Introductions and roles assigned • Activates Code Red (if required). Consider plain film (CXR/PXR) if toounstable for CT • Ensures tranexamic acid is available • Briefs team. Rehearse emergency plan • Ensures Airway Assistant has started clock on patient arrival NOTE: It is imperative that the Trauma Team Leader maintains control and insists on MINIMUM noise from the Trauma Team members NOTE: The Team Leader will read aloud the Checklist for actions prior to leaving ED – the main indication for this is transfer to the CT Scanner. 15 Anaesthetist • Ensures equipment and anaesthetic drugs (Blue/Red CD pack and yellow fridge Pack) are available on patients arrival • Verbalises airway and anaesthetic plan to team leader and airway assistant • Communicates airway patency and issues to team leader and scribe on arrival • Communicates with team leader airway decision making following assessment. Ensure cervical spine immobilisation • Assess pupil size and reactivity • If indicated, RSI and ongoing sedation and ventilation • Provide ongoing assessment of GCS. Reassures patient on arrival, takes AMPLE history: A- Allergies M- Medications P- Past medical history L- Last meal E- Everything else relevant • Ensures neuro protective measures are undertaken for significant head injuries (30 degree trolley tilt, sedation, muscle relaxation, avoid tube ties and tight cspinecollar, avoid hypercapnia) • Arterial lines are rarely indicated. To avoid delay to CT this can usually be done after CT or in the operating theatre • Ensures theatres are informed as appropriate (bleep 2894 or named consultanton 1646) • Ensures CD book is signed NOTE: Insertion of invasive lines should not delay transfer to CT or theatre Airway Assistant • Completes airway check list prior to patients arrival and that difficultairway trolley is accessible if required (ask if c-mac is required) • Ensures Blue/ Red CD pack and yellow fridge pack are readily available with appropriate anaesthetic drugs drawn up in conjunctionwith Anaesthetist • Confirm airway plan • Start the clock on patient arrival • May assist with removing patients clothing, have scissors to hand • Assists anaesthetist in all airway interventions • Ensure time of intubation is recorded by scribe • Takes emergency airway equipment / drugs on any transfer(CT, Theatre, ICU) • Assists in the preparation patient for transfer to CT/theatres ASAP • Ensures CD book is signed 16 Primary Survey • Undertakes primary survey ABCDE. Clearly states findingsto Team leader and scribe • Performs procedures depending on skill levels and training. Confirmsskill level with team leader prior to patient arrival • If thoracostomies are present, re-finger to ensure patency.Is lung up or down? Delegate opposite side, if necessary • FAST scan if accredited and does not delay CT • Neurological exam needed before paralysing anaesthetic agent given • Ensure patient is kept warm • Ensures CT notified. Where indicated convey urgency of completingthe CT. Order any other radiology in discussion with the team leader,should this be appropriate Circulation • Ensures patient has two patent peripheral lines in situ (IV/IO • Ensures bloods are taken: FBC U&E LFT Crossmatch Coagulation Screen Venous Gases • Requests bloods and ensures these are sent to the lab • Performs procedures depending on skill levels and training. Confirms skill level with team leader prior to patient arrival • Administer drugs in conjunction with Drugs role • Undertakes secondary survey • Ensure patient is kept warm Monitoring/Packaging • Prepares for trauma call with warming devices • Removes all patient clothes including underwear and stored securely • Checks that all monitoring equipment is available • Connects patient monitoring on arrival • Ensures Bair Hugger / blankets are covering patient at all time • Ensures temperature is taken • Prepares patient for transfer to CT/theatres ASAP • Checks transfer stack as per the checklist • Helps with any procedures as identified e.g. catheter, chest drainand ART line 17 Drugs • Manages any external major haemorrhage if present on arrival • Assists Monitoring/Packaging with clothes removal • Liaise with Airway specialist and airway assistant to support a promptanaesthetic if required • Draws up drugs and administers them as prescribed • Helps with getting IV/IO access in conjunction with Circulation • Helps with any procedures as identified e.g. catheter, chest drainand ART line • Assists Monitoring/Packaging to prepare for transfer Scribe • Ensures correct PPE and identification worn • Use ED documentation • Records names, grades and specialities of all clinical staff attending plus time of arrival • Ensures clock is started when patient arrives • Records primary survey findings • Records all observations (including time of intubation). • Records all findings and interventions • Ensures wrist bands are applied including allergy • Observe for abnormal observation and signs indicatingpotential reactions to blood products Relative Liaison • Identify any relatives on their arrival to the department and take tothe relatives room • Ensure that relatives are kept up to date with information,where possible • To assist medical team in the delivery of patient updates and to stay with the family for further questions • If CPR is in progress discuss with team leader regarding witnessedresuscitation and if suitable offer to the relatives • Where appropriate accompany the relatives/important others to the area where the patient is to be care for next (or make sure theyare escorted) • If relatives/important others are not present whilst the patient is in theED resus room – ensure that a named individual is responsible for greeting them and passing on the necessary information 18 Code Red Prior to Arrival • Inform transfusion of code red being called and ask for MajorHaemorrhage Pack 1 • Ensure you are wearing the correct PPE and designated label • Remove x2 units of Emergency blood and scan into BloodTrak On Patient Arrival • Ensure blood products have been prescribed on the transfusion chart • Contact transfusion if major haemorrhage pack 2 is required andinform them of the requirements • Ensure the transfusion are aware of the patients destination andwhere further blood products are required to be sent Code Red Infuser Prior to Arrival • Ensure you are wearing the correct PPE and designated label • If appropriate prime the Belmont ready to infuse • Ensure Tranexamic acid 1g is available and consider second dose in massive haemorrhage On Patient Arrival • Administer blood products, under the direction of the team leaderas per the trust policy • Inform team leader when boluses have been delivered • Monitors compliance with 1:1 transfusion ratio (RBC:FFP) • Ensure the scribe has documented the number of boluses administered Code Red HCA Prior to Arrival • Ensure you are wearing the correct PPE and designated label On Patient Arrival • Takes crossmatch blood sample directly to the lab & waits for the Major haemorrhage pack 1 and bring back to ED resuscitation room • Brings blood products to ED resuscitation room and scans unitson arrival 1.6 Hands-off Handover Generally unless CPR is in progress, or there is airway compromise or concern over catastrophic haemorrhage, an ATMIST handover will be given by the ambulance staff whilst UHS staff stand-off the patient. The trauma team leader will first ask where the pre-hospital team are happy to give a 'hands off handover'. Ambulance staff assisted by UHS staff will transfer the patient from the stretcher to the trolley in resus. Patients should remain on the scoop-stretcher. 19 The ATMIST handover should be completed within 30 seconds and is designed to give ALL members of the trauma team the information necessary to proceed with the immediate care of the patient. Further information regarding the patient can be relayed to the Trauma team leader following the ATMIST handover. 1.7 Trauma Team Leader: Executive Role The ED Consultant has authority from the Chief Executive and Medical Director to request any specialty Consultant to attend. All UHS Consultants have a statutory duty to be able to respond in an emergency within 30 minutes of request. The Trauma Team Leader will: • Determine and arrange the appropriate destination for the patient i.e. theatre, ICU, ward • Ensure that medical staff of the appropriate seniority are involved in the care of the patient • Ensure that only essential imaging is performed • Ensure that necessary documentation has been completed a. Major trauma activation b. Trauma team attendance (including time of arrival and grade of doctor) c. The extent of examination performed in the ED and whether a further secondary examination is required d. The secondary survey must be signed off as complete at the earliest opportunity. The team leader is responsible for ensuring the survey is performed and documented. The default specialty to complete the secondary survey is the T&O Doctor e. Ensure spinal precautions are applied throughout where indicated f. Ensure that handover of a multi-trauma patient to a specialty service is formally documented. Until this has occurred, the patient will remain under the care of the Trauma Team Leader g. Handover between the Trauma Team Leader and the receiving team Doctor should always be done in person with a written handover of all admissions and any necessary actions NOTE: The MTC Consultant or Trauma Team Leader must always attend the CT scanner and liaise with the Anaesthetist as to the patient’s injuries and planned destination after CT. In exceptional circumstances the TTL can delegate escorting the patient to CT to an appropriately senior Doctor from outside ED – e.g. the T&O Consultant. Their principal role is not to guide resuscitation (typically this will be performed by the anaesthetist) but to ensure prompt liaison with other teams (e.g. Neurosurgery) as required. 20 1.8 Site Manager It is essential that patients can move as swiftly as possible from the ED to their place of definitive care. Patients may require immediate theatre / ICU bed / ward bed. Patients requiring immediate theatre: • Coordination of theatre will be done by the TTL with the Named Anaesthetic Consultant • Patients with isolated head / spinal cord injury requiring immediate theatre should be managed in the appropriate specialist theatre • The duty Anaesthetic Consultant will be responsible for coordinating the ongoing resuscitation NOTE: F Level Theatres recovery can be used for patients requiring ongoing resuscitation after CT whilst theatre is being prepared. Patient requiring ICU bed In principle, patients with a primary neurological diagnosis (head or spinal cord injury) should be managed on Neuro ICU with the proviso that there are very limited resuscitation facilities available in the Wessex Neurological Centre. As such, patients with ongoing resuscitation needs or with significant cardiovascular injury are best managed initially on General ICU. Patient requiring Ward bed Patients with single system injury are best managed on wards with experience of managing that injury. Patients with multi-system injury requiring a ward bed should by default go to the Major Trauma Ward (F1). Patients with isolated thoracic injuries will be admitted to the thoracic ward under the care of Thoracic surgery. NOTE: The Trauma & Orthopaedics Consultant is responsible for polytrauma patients where there is no clear single specialty. 21 1.9 Secondary Trauma Transfers The secondary transfer tool has been developed by the Wessex Trauma Network to ensure that patients with certain categories of major injury, who are managed initially in a trauma unit or local receiving hospital, are rapidly transferred to the Major Trauma Centre without delay. The categories of patient to which this applies are: a. Injuries exceed Trauma Unit capabilities b. Pre intubation GCS Motor Score 4 or Less AND evidence from CT of intracranial bleeding (any variant) c. Life threatening haemorrhage not amenable to control at Trauma Unit d. Successful resuscitative thoracotomy at Trauma Unit These patients fulfill automatic acceptance criteria for transfer to the MTC. At the Trauma Unit the senior doctor will call the Ambulance Service and state that they have a “Time Critical Trauma Transfer”. The Trauma Unit Team Leader will then inform the Major Trauma Centre via the red phone in the Emergency Department and state that there is a “Secondary Trauma Transfer”. When prompted the Trauma Team Leader will give an extended ATMIST summary of patient. • NOTE: Do not negotiate terms of admission to UHS with the Trauma Unit. The transfer tool has been specifically written to ensure automatic acceptance by the MTC. The phone call from the Trauma Unit is purely to alert the MTC rather than to seek permission for the transfer. NOTE: Any paediatric secondary transfer referrals must go via SORT (02380 775502) who will not only coordinate the transfer but also give valuable clinical advice and assistance by phone to the Trauma Unit. http://www.sort.nhs.uk/home.aspx 22 Figure 4. Major Trauma Automatic Acceptance Tool (2020) 23 After receiving a secondary trauma transfer pre-alert, the optimum response is to activate a full Level 1 Trauma Call when the patient arrives. It is expected that these patients will have a management plan in place before arrival at UHS and should move swiftly from ED to their destination. Secondary Transfer due to Pre-intubation Motor Score 4 or less • Contact Neurosurgery SpR and Site Manager • Obtain plan from Neurosurgery – Critical Care bed or direct to Theatre • Site manager to arrange Level 3 Bed - Preference NICU > GICU > CICU • Site Manager to discuss with NICU Consultant regarding patient moves if NICU is full • Site Manager to ensure relevant ICU resident medical team and Neurosurgical registrar aware of location of bed if going direct to ICU Secondary Transfer due to Life Threatening Haemorrhage • When Trauma Team arrive, brief that this is a secondary transfer, review imaging with relevant teams and plan for patient’s arrival. This may include activating Theatre or Interventional Radiology teams • Patient will go to ED Resus on arrival unless exact cause of haemorrhage known and time to prepare theatre/Interventional Radiology prior to arrival • Any decision to Bypass ED Resus is only to be made by a Consultant Team Leader Secondary Transfer due to Successful Resuscitative Thoracotomy • Inform Cardiothoracic SpR (Bleep 9211) and Site Manager • Cardiothoracic team should prepare to receive patient in Theatre. Cardiothoracic SpR to inform Consultant, activate theatres and Anaesthetist/ Perfusionist • Site manager to arrange Level 3 Bed, preference Cardiac > General > Neuro • The initial destination in UHS, ED Resus versus cardiac/thoracic theatres may need to be decided on a case by case basis by the TTL. 24 2 Section 2: Trauma Resuscitation ( ABCDE) 2.1 Catastrophic Haemorrhage Recognition and management of catastrophic haemorrhage is the first priority in trauma resuscitation. Catastrophic haemorrhage is poorly defined and simply describes bleeding that is imminently life threatening. Major haemorrhage is variously defined as: • Loss of more than one blood volume in 24 hours • Loss of 50% total blood volume in less than 3 hours • Bleeding in excess of 150ml/min A clinical based approach to defining major haemorrhage is any bleeding which results in a systolic BP 110 bpm. Pre-hospital management focuses primarily on the prevention of further blood loss and the active management of hypothermia and hypoperfusion to prevent Trauma Induced Coagulopathy (TIC). • Tranexamic Acid (TXA) should be given within three hours of injury • Minimal non-haematological fluids should be administered to maintain a central pulse • Blood is available in the pre-hospital setting via HEMS and the Air Ambulances • Tourniquets may be applied in the pre-hospital setting for the management of catastrophic limb haemorrhage 25 Non-torso Catastrophic Haemorrhage Figure 5. Management of Non-torso Catastrophic Haemorrhage 1. Direct signs of vascular injury – pulsatile haemorrhage, expanding haematoma, absence of pulse / ischaemic limb, bruit, palpable thrill, Indirect signs of vascular injury – observed pulsatile bleeding, decreased pulse, nonexpanding haematoma, injury to adjacent nerve, anatomical location of injury near vessel 2. Vascular surgery input should be obtained prior to any imaging if there are direct signs of vascular injury. This can be via the registrar bleep (1322) between 0800 and 1900 and via switch for the on-call consultant after 1900. 3. CT angiography should be undertaken in all cases of suspected vascular injury unless a. There is active haemorrhage b. There is a tourniquet in situ c. Management of other injuries have taken precedence over a controlled vascular injury Discussion with vascular surgery should follow if there is injury to a named vessel which requires surgical management i. Isolated vascular injuries at or distant to the antecubital fossa (ACF) should be referred to Plastic Surgery at Salisbury District Hospital ii. Polytrauma patients with vascular injury at or distant to the ACF should be discussed with Plastic Surgery at UHS 8am – 6pm seven days a week; 6pm – 8am seven days a week these cases should be discussed with Plastic Surgery at Salisbury 4. Pressure should be applied for at least 10 minutes but ideally 20 directly over the wound using sterile gauze. If the bleeding clearly has no prospect of being controlled in the context of a junctional injury then proceed immediately to theatre 5. CeloxTM gauze (Section 4.1) 26 6. Trauma team to transfer patient to theatre for ongoing resuscitation Tourniquets Tourniquets may be required to control life threatening limb haemorrhage. The Wessex Major Trauma Network has an agreed SOP for the use of tourniquets in the pre-hospital and hospital setting (Section 5.1). Apply direct pressure and elevate Apply haemostatic dressing and blast / Oleas bandage and keep direct No pressure on for 5 minutes Successful? Yes Successful? No Observe wound closely for Yes recurrence of bleeding and continue assessment of the patient Apply Tourniquet 5cm proximal to the bleeding wound, if pneumatic, inflate up to 180mmhg – 200mmhg Time tourniquet applied indicated on the label if available. Clearly document in the patient record the time and application of the tourniquet Refer to TUB tool and transfer appropriately Pre alert receiving hospital and advise patient with Tourniquet applied being transferred On arrival at hospital clearly inform the receiving team of the presence of the tourniquet and the time of application Figure 6. Pre-hospital Tourniquet Use 27 A TOURNIQUET INSITU IS NOT A STABLE SITUATION AND REQUIRES URGENT INTERVENTION Advised by Pre hospital team to expect a transfer with tourniquet in situ Yes Position Pneumatic tourniquet, if available (box 1), take down pre hospital dressing, reassess wound. No Can Tourniquet be released? Yes Is Bleeding No controlled? No Apply celox gauze and blast / Oleas bandage Yes Level 1Trauma call raised Are patients ABC stable on Primary Survey? No Inflate Pneumatic tourniquet if available if not reapply tourniquet Ensure a robust plan is in place to release tourniquet for 10 mins every 2hours to allow limb to re-perfuse (box 2) Contact Theatre coordinator on bleep 2894 to obtain pneumatic Tourniquet Consider early activation on Major Hameorrhage protocol Optimise patients Coagulation • 1g TXA bolus • 1g TXA infusion over 8 hours • Reverse Anticoagulation • Keep Ionised Calcium > 1mmol//l • Warm patient to normothermia • TEG to guide coagulation (if available) • Resuscitate to permissive hypotension • Activate and transfuse in accordance with the major hemorrhage protocol Plan to take patient from resus directly to theatre for surgery – Consider Vascular Surgery input Is Bleeding controlled? Yes Observe wound closely for recurrence of bleeding and continue assessment of the patient Box 1 Pneumatic Tourniquet should be placed above the CAT before removing the CAT. Remove the CAT, if bleeding recurs and cannot be controlled by direct pressure, inflate the pneumatic tourniquet. If no longer bleeding, leave pneumatic tourniquet in place, but deflated until definitive decision made about destination of patient Figure 7. In-hospital Tourniquet Use Box 2 –Release of Tourniquet Limb is acutely ischaemic as soon as the tourniquet is applied and ATP stores deplete. Tourniquet should be released for a minimum of 10 mins every 2 hours to allow period of reperfusion. This is in order to reduce the risk of irreversible microvascular injury. Risks with release of tourniquet. • Potentially fatal arrhythmia • Increased PaCO2 and lactate • Increased intracranial pressure • Severe pain • Compartment syndrome • Rhabdomyolysis 28 Cavity Catastrophic Haemorrhage Evidence of cavity catastrophic haemorrhage (persistent hypotension and/or tachycardia presumed secondary to cavity blood loss) that cannot be stabilized in ED Resus requires urgent definitive control via Surgical or Interventional Radiology means. This requires a timely discussion between the TTL, Interventional Radiologist, and relevant Surgical Consultants. Further detail can be found in Section 2.4 Circulation. Massive haemorrhage in the presence of haemodynamic instability should prompt consideration of calling in the oncall Consultant for the cavity of concern. This should be done as soon as possible, and may be considered based on the pre-hospital information received. The decision to go straight to Theatre, either bypassing Resus on arrival or bypassing CT, carries great risk, particularly as the Theatre Suite is not located in close proximity to the ED. This decision must only be taken after consultation between the Team Leader and the relevant Surgical and Anaesthetic Teams. CODE RED Patients with life threatening haemorrhage require urgent replacement of lost circulating volume with blood products. Code Red refers to the activation of the UHS massive transfusion policy (Figure 8 & Section 4.2). Rapid transfusion of blood products is achieved via the Belmont Rapid Infuser (Section 3.2). This is an extremely powerful rapid transfuser which, left unchecked, can deliver huge volumes of blood/fluids within an extremely short period of time e.g. 750ml/minute. The default is to administer repeated boluses (e.g. 250 ml) with regular reassessment of the patient. The CODE RED nurse will be in charge of the Belmont and is also responsible for ensuring an accurate running total of the volume and type of fluids / blood products administered. They should regularly liaise with the Anaesthetist and Team Leader as to ongoing requirements. The benefits of the Belmont include the ability to transfuse when disconnected from a power source but the Belmont will not heat fluids whilst running on battery power and the rate will be reduced to 50ml/minute. 29 Suspected Major Haemorrhage (MH) Action Send G+S to transfusion lab Activate CODE RED (pick up the MH red phone OR call 2222 and state ‘Major Haemorrhage’) Request Pack 1 Allocate staff member/ Code Red practitioner to coordinate transfusion activity Make plan to stop bleeding: Consider splinting, tourniquets, contacting on-call Surgeons (general surgeon bleep 9990) Endoscopist or Interventional Radiologist via switchboard Give Tranexamic acid 1g IV stat bolus dose, followed by 1g over 8 hours infusion. Ensure reversal of anti-coagulants: Warfarin: Octaplex 30iu/kg + give Vit K 10mg IV Heparin: Protamine 6U Blood: Major Haemorrhage Pack 1 Group O from nearest fridge (O-ve for women, O+ve for men) or type specific/cross matched blood from lab (dictated by urgency) Pre-thawed (type A until group specific available) available in ED for ED patients or from the Blood Transfusion Laboratory Request Major Haemorrhage Pack 2 Aims of Transfusion Haemodynamic Stabilisation Hb > 80g/l Platelet count > 75x109/l (> 150x109/l in CNS trauma) INR and APTT ratio 2 Keep iCa2+ above 1.1mmol/l with calcium chloride (starting adult dose 10ml of 10%) Temp > 36oC pH > 7.2 Lactate 13kPa Aim PaCO2 4.5-5kPa Aim MAP > 90mmHg (CPP > 60mmHg if ICP monitored) Maintain normothermia Loading with 1g IV Phenytoin should be considered In addition, the patient’s neck should be in a neutral position and the cervical collar checked to ensure venous outflow is not obstructed. Loosen cervical collar in intubated patients while keeping the head immobilised (e.g sand bags and tape). NOTE: In the absence of hypotension the whole bed should be placed on a 300 head up tilt for patients with severe head injury. This simple manoeuvre47 can significantly help in reducing raised intracranial pressure. Scoop stretchers are for extrication of patients and are used to facilitate transfers. They are uncomfortable and present a significant risk of pressure damage for all patients but particularly those with spinal cord injuries. NOTE: It is the responsibility of the team leader to ensure that the scoop stretcher or spinal boards are removed as soon as possible. Mannitol & Hypertonic Saline The European Brain Injury Consortium and the Brain Trauma Foundation recommend the use of mannitol as the osmotic drug of choice in brain injured patients. Mannitol reduces intracranial pressure within a few minutes. Patients with 1 or 2 fixed & dilated pupils, which is felt to be due to raised intracranial pressure, should receive an IV bolus of either • 10% Mannitol 1g/kg (10ml/kg 10% Mannitol), or • 2.7% saline 6ml/kg Traumatic Brain Injury: Ventilated Patients www.neuroicu.org.uk for up to date guidance. Rapid assessment including pupils and monitoring parameters. Airway Breathing Circulation Disability Environment ET tube type & length at lips; EtCO2 monitoring FiO2; RR; Tidal Volume; Bilateral air entry & SpO2 > 97% HR; BP (MAP > 90mmHg); Presence and positioning of arterial line Pupils (remove contact lenses); Sedation; ?Muscle relaxation Temperature; Glucose Ensure adequate sedation and determine level of pre-existing neuromuscular blockade using a Nerve stimulator/ TOF device. All patients should be assumed to have an unstable spinal injury unless the spinal algorithm (Figure 16) has been completed and Consultant Radiologist report confirms the absence of any acute spinal injury. Transfer patient onto Neuro ICU bed maintaining spinal alignment. • Patient should be placed in a hard cervical collar • Transfer of patient will require spinal turns or the use of a scoop stretcher • 30o head up tilt of whole bed Follow Intracranial Injury Pre-transfer Checklist (Figure 15). 48 Figure 15. Intracranial Injury Pre-transfer Checklist 49 Traumatic Brain Injury: Self-ventilating Patients www.neuroicu.org.uk for up to date guidance. Rapid assessment including pupils and monitoring parameters. Airway Breathing Circulation Disability Maintained and clear; No signs of upper airway obstruction Adequate rate and depth of respiration with Sp
Url
/Media/SUHTExtranet/WessexTraumaNetwork/UHS-adult-major-trauma-guidelines.pdf
1 to 4 of 4