NCEPOD: Trauma - Who Cares? - London Health Programmes

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CHAPTER 4 - Prehospital carecaused respiratory depression which was not adequatelymanaged by suitable respiratory support. In three cases withsignifi cant thoracic injuries Entonox was the analgesic usedand this was considered by the advisors to be inappropriatebecause of the risk of tension pneumothorax.One must question why the provision of analgesia in a groupof severely injured patients was so low (110/504 – 21.8%)?Patients with severe injuries are likely to experience pain and theprovision of analgesia to reduce this is a basic humanitarian aim.It is rare that contraindications exist to the provision of pain relief.Key findingsIn a third of cases (245/749), the ambulance patient reportform was not available.652/783 patients (83.3%) were transported to hospital byroad ambulance and 92/783 patients (11.7%) by helicopter.23/56 (41.1%) patients treated by a helicopter-basedsystem were intubated on scene compared to 32/440(7.3%) patients treated by a road ambulance system.None of the patients treated by a helicopter based systemwere taken to an inappropriate hospital compared to31/440 (7%) patients treated by a road ambulance systemwho were initially taken to an inappropriate hospital.Blood pressure was recorded in 398/504 (80%) casesdespite recommendations that this should not bemeasured in the prehospital phase.Only 46/170 (27.1%) patients who suffered a severe headinjury (GCS less than 9) were intubated prehospital.Only 110/504 (21.8%) patients were given analgesia in theprehospital phase.RecommendationsAll agencies involved in trauma management, includingemergency medical services, should be integrated intothe clinical governance programmes of a regional traumaservice. (All healthcare providers)Ambulance trusts should work together to standardisethe content and layout of the Patient Report Form(PRF), and ensure that it is fi t for purpose and facilitatescomparative audit. Clinicians must ensure that a PRFis received for every patient and secured in the medicalrecord. (Emergency medicine physicians and ambulancecrews)It is important that where guidelines exist, they are widelydisseminated to appropriate groups, and there is arobust system in place to monitor compliance with thoseguidelines. (Ambulance and hospital trusts)It is vital that all patients who have sustained serioustrauma should have a primary survey conducted atthe earliest opportunity, and that critical resuscitationinvolving airway, breathing and circulation (with cervicalspine control) should be undertaken and reviewedthroughout the prehospital phase of care. This must bedocumented. (Emergency medicine physicians)Airway management in trauma patients is oftenchallenging. The prehospital response for these patientsshould include someone with the skill to secure theairway, (including the use of rapid sequence intubation),and maintain adequate ventilation. (Ambulance andhospital trusts)Severely injured patients are likely to be in pain and theprovision of adequate analgesia is required. If analgesiais not given there should be a clear record in the PatientReport Form of the reasons for this. (Ambulance trusts)48
4Prehospital careReferences1. Nathens AB, Brunet FP, Maier RV. Development oftrauma systems and effect on outcomes after injury.Lancet 2004; 363(9423):1794-8012. The form sent to lead A&E Clinicians contained thefollowing defi nition of a major incident protocol:“Pre-planned and exercised procedures which areactivated once a major incident has been declared.A major incident is any emergency that requires theimplementation of special arrangements by one or moreemergency services, the NHS or the local authority”.3. The Royal College of Surgeons of England and the BritishOrthopaedic Society. Better Care for the Severely Injured.20004. Thomas SH, Biddinger PD, Helicopter trauma transport:an overview of recent outcomes and triage literature.Current Opinion in Anaesthesiology 2003; 16(2):153-85. Carr BG, Caplan JM, Pryor JP, Branas CC. A metaanalysisof prehospital care times for trauma.Prehospital Emergency Care 2006; 10(2):198-2066. Lockey D, Davies G, Coats T. Survival of trauma patientswho have prehospital tracheal intubation withoutanaesthesia or muscle relaxants: observational study.BMJ 2001; 323:1417. Christensen EF, Hoyer CC. Prehospital tracheal intubationin severely injured patients: a Danish observational study.BMJ 2003; 327:533-48. Winchell RJ, Hoyt DB: Endotracheal intubation in thefi eld improves survival in patients with severe head injury.Trauma Research and Education Foundation of SanDiego. Arch Surg 1997; 132:592-79. Garner A, Rashford S, Lee A, Bartolacci R. Addition ofphysicians to paramedic helicopter services decreasesblunt trauma mortality. Aust N Z J Surg 1999; 69:697-70110. Adnet F, Jouriles NJ, Le Toumelin P, Hennequin B,Taillandier C, Rayeh F, Couvreur J, Nougiere B, Nadiras P,Ladka A, Fleury M: Survey of out-of-hospital emergencyintubations in the French prehospital medical system: amulticenter study. Ann Emerg Med 1998; 32:454-6011. Bochicchio GV, Ilahi O, Joshi M, Bochicchio K, ScaleaTM. Endotracheal intubation in the fi eld does not improveoutcome in trauma patients who present without anacutely lethal traumatic brain injury. J Trauma 2003;54:307-1112. Davis DP, Fakhry SM, Wang HE, Bulger EM, DomeierRM, Trask AL, Bochiocchio GV, Hauda WE, RobinsionL. Paramedic rapid sequence intubation for severetraumatic brain injury: perspectives from an expert panel.Prehosp Emerg Care 2007; 11:1-813. Gerich TG, Schmidt U, Hubrich V, Lobenhoffer HP,Tscherne H: Prehospital airway management in theacutely injured patient: the role of surgical cricothyrotomyrevisited. J Trauma 1998; 45:312-414. Schmidt U, Frame SB, Nerlich ML, Rowe DW,Enderson BL, Maull KI, Tscherne H: On-scene helicoptertransport of patients with multiple injuries: comparisonof a German and an American system. J Trauma 1992;33:548-5315. UK Ambulance Service Clinical Practice Guidelines 2006.Joint Royal Colleges Ambulance Liaison Committee(JRCALC)16. NICE Technology Appraisal. Prehospital initiation of fl uidreplacement therapy in trauma. 200449
Page 1: Trauma: Who cares?A report of the N
Page 4 and 5: ContentsAcknowledgements 4Foreword
Page 6 and 7: AcknowledgementsThis is the twenty
Page 8 and 9: AcknowledgementsThe organisations t
Page 10 and 11: ForewordSevere injury - a car crash
Page 12 and 13: Summary of fi ndingsThis study show
Page 14 and 15: Principal recommendationsOrganisati
Page 16 and 17: IntroductionTrauma remains the four
Page 18 and 19: IntroductionReferences1. Chaira 0,
Page 20 and 21: MethodQuestionnaires and casenotesT
Page 22 and 23: MethodQuality and confidentialityA
Page 24 and 25: CHAPTER 1 - Data overviewFigure 2.
Page 26 and 27: CHAPTER 1 - Data overviewMode of ar
Page 28 and 29: CHAPTER 2 - Organisational dataTabl
Page 36 and 37: CHAPTER 3 - Overall assessmentAll c
Page 38 and 39: CHAPTER 3 - Overall assessmentKey f
Page 40 and 41: CHAPTER 4 - Prehospital careRespons
Page 42 and 43: CHAPTER 4 - Prehospital careFigure
Page 44 and 45: CHAPTER 4 - Prehospital careTranspo
Page 46 and 47: CHAPTER 4 - Prehospital careAdequac
Page 48 and 49: CHAPTER 4 - Prehospital careIn 40/5
Page 52 and 53: CHAPTER 5 - Hospital receptionIntro
Page 54 and 55: CHAPTER 5 - Hospital receptionTable
Page 56 and 57: CHAPTER 5 - Hospital receptionTraum
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CHAPTER 8 - Head injury management1
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CHAPTER 9 - Paediatric careOrganisa
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CHAPTER 9 - Paediatric careClinical
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CHAPTER 9 - Paediatric careKey find
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CHAPTER 10 - TransfersIntroductionM
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CHAPTER 10 - TransfersArrangement o
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CHAPTER 10 - TransfersFigure 52. De
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CHAPTER 10 - TransfersKey findingsR
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CHAPTER 11 -Incidence of trauma and
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CHAPTER 11 - Incidence of trauma an
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APPENDIX B - Injury severity scoreA
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APPENDIX C - Adult and paediatric G
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APPENDIX D - An example of an excel
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APPENDIX E - Level 1 trauma careAs
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APPENDIX F - ParticipationTrustCase
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APPENDIX G - Corporate structureThe
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Published November 2007 by the Nati
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