NCEPOD: Trauma - Who Cares? - London Health Programmes

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CHAPTER 7 - Management of circulationRecommendationsRapid identifi cation of patients who require immediatesurgery for control of haemorrhage is essential. Ongoingfl uid requirements and instability identify a group ofpatients who require immediate intervention ratherthan further investigation. Local protocols shouldclearly identify the patient population for whom it isinappropriate to delay the surgery/intervention forreasons of ‘stabilisation’ or further investigation. (Hospitaltrusts, clinical directors and emergency physicians)Trauma laparotomy is potentially extremely challengingand requires consultant presence within the operatingtheatre. (Clinical directors)CT scanning will have an increasing role in theinvestigation and management of trauma patients. Inmajor centres, CT facilities should be co-located withthe emergency department to provide a combinedinvestigation/resuscitation area. (Hospital trusts)If CT scanning is to be performed, all necessary imagesshould be obtained at the same time. Routine use of‘top to toe’ scanning is recommended in the adulttrauma patient if no indication for immediate interventionexists. (Royal College of Radiology and radiologydepartment heads)Timely access to CT scanning is essential. CTradiographers should be available within 30 minutes ofthe patient arriving in hospital. In larger trauma centres,with a higher workload, CT radiographers should beimmediately available at all times.In the setting of remote radiology facilities and/or lack oftimely access to CT scanning, unstable patients shouldnot be taken to the CT scanner. These unstable patientsshould have immediate surgery. (Trauma team leader)References1. Shackford SR, Mackersie RC, Holbrook TL, et al. Theepidemiology of traumatic death: A population-basedanalysis. Arch Surg 1993;128:5712. Sauaia A, Moore FA, Moore EE, et al. Epidemiology oftrauma deaths: A reassessment. J Trauma 1995;38:185-1933. Champion HR, Copes WS, Sacco WJ, Lawnick MM,Keast SL, Bain LW, Flanagan ME, Frey CF. The MajorTrauma Outcome Study: Establishing National Norms forTrauma Care. J Trauma 1990; 30: 1356-13654. Marmarou A, Anderson RL, Ward JD, et al. Impacton ICP instability and hypotension on outcome inpatients with severe head trauma. J Neurosurg1991;75(suppl):S59-S665. Chestnut RM, Marshall LF, Klauber MR, et al. The roleof secondary brain injury in determining outcome fromsevere head injury. J Trauma 1993;34:216-2226. Goins WA, Reynolds HN, Nyanjom D, et al. Outcomefollowing prolonged intensive care unit stay in multipletrauma patients. Crit Care Med 1991;19:3397. Moore FA, Moore EE. Evolving concepts in thepathogenesis of postinjury multiple organ failure. SurgClin North Am 1995;75:2578. Jurkovich GJ, Greiser WB, Lyterman A, et al.Hypothermia in trauma victims: an ominous predictorof survival. J Trauma 1987;27:1019-10249. Luna GK, Maier RV, Pavlin EG, et al. Incidence and effectof hypothermia in seriously injured patients. J Trauma1987;27:1014-101782
7Management of circulation10. Reed RL, Bracey AW, Hudson JD, et al. Hypothermiaand blood coagulation: dissociation betweenenzyme activity and clotting factor levels. Circ Shock1990;32:141-15211. Schreiber MA. Damage control surgery. Crit Care Clin2004;20:101-11812. MacLeod JB, Lynn M, McKenny MG, et al. Earlycoagulopathy predicts mortality in trauma. J Trauma2003;55:39-4413. Cosgriff N, Moore EE, Sauaia A, et al. Predicting lifethreateningcoagulopathy in the massively transfusedpatient: hypothermia and acidosis revisited. J Trauma1997;42:857-6214. Hill DA, West RH, Roncal S. Outcome of patients withhaemorrhagic shock: an indicator of performance in atrauma centre. J R Coll Surg Edinb 1995;40:221-415. Spahn DR, Cerny V, Coats TJ, et al. Management ofbleeding patients following major trauma: A Europeanguideline. Criti Care 2007;11:R1716. Demetriades D, Chan L, Cornwell E, et al. Paramedicvs. private transportation of trauma patients. Effect onoutcome. Arch Surg. 1996;131:133-817. Gervin AS, Fischer RP. The importance of prompttransport of salvage patients with penetrating heartwounds. J Trauma 1982;22:443-818. Gold CR. Prehospital advanced life support vs. ‘scoopand run’ in trauma management. Ann Emerg Med.1987;16:797-80119. Feero S, Hedges JR, Simmons E, Irwin L. Does out-ofhospitalEMS time affect survival? Am J Emerg Med.1995;13:133-520. Regel G, Stalp M, Lehmann U, Seekamp A. Prehospitalcare, importance of early intervention on outcome. ActaAnaesthesiol Scand. 1997;110(Suppl.):71-621. Ruteledge R, Fakhry SM, Meyer A, Sheldon GF, BakerCC. An analysis of the association of trauma centres withper capita hospitalisations and death rates from injury.Ann Surg 1993;218:512-2422. Eastman AB, Schwab CW, Annest JL, et al. Positionpaper on trauma care systems. J Trauma 1992;32:127-923. Shackford SR, Mackersie RC, Hoyt DB, et al. Impact ofa trauma system on outcome of severely injured patients.Arch Surg 1987; 122:523-724. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al.A national evaluation of the effect of trauma-center careon mortality. N Engl J Med. 2006;354:366-7825. West JG, Trunkey DD, Lim RC. Systems of trauma care:A study of two counties. Arch Surg 1979;114:45526. Lowe DK, Gately HL, Goss JR, et al. Patterns of death,complication and error in the management of motoraccident victims: Implications for a regional systemof trauma care. J Trauma 1983;23:50327. Van Wagoner FH. A three year study of deaths followingtrauma. J Trauma 1961;1:40128. Tien HC, Spencer F, Tremblay LN, Rizoli SB, BrennemanFD. Preventable deaths from hemorrhage at a level 1Canadian trauma center. J Trauma. 2007; 62: 142-629. Porter JM, Ivatury RR. In search of the optimal endpoints of resuscitation in trauma: a review. J Trauma1998;44:908-1430. Revell M, Greaves I, Porter K. Endpoints for fl uidresuscitation in hemorrhagic shock. J Trauma2003;54:S63-S6783
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Trauma: Who cares?A report of the N
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ContentsAcknowledgements 4Foreword
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AcknowledgementsThis is the twenty
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AcknowledgementsThe organisations t
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ForewordSevere injury - a car crash
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Summary of fi ndingsThis study show
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Principal recommendationsOrganisati
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IntroductionTrauma remains the four
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IntroductionReferences1. Chaira 0,
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MethodQuestionnaires and casenotesT
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MethodQuality and confidentialityA
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CHAPTER 1 - Data overviewFigure 2.
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CHAPTER 1 - Data overviewMode of ar
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CHAPTER 2 - Organisational dataTabl
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Page 36 and 37: CHAPTER 3 - Overall assessmentAll c
Page 38 and 39: CHAPTER 3 - Overall assessmentKey f
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Page 56 and 57: CHAPTER 5 - Hospital receptionTraum
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Page 114 and 115: CHAPTER 9 - Paediatric careOrganisa
Page 116 and 117: CHAPTER 9 - Paediatric careClinical
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Page 120 and 121: CHAPTER 10 - TransfersIntroductionM
Page 122 and 123: CHAPTER 10 - TransfersArrangement o
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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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