1
Q
What are the aims and objectives of the TBI SOP? (8)
A
- To ensure all TBI patients receive optimal pre-hospital care
To describe:
2. Rationale of clinical care for TBI
3. Triage for TBI
4. Appropriate analgesia/sedation in TBI
5. Indications/precautions for PHEA in TBI
6. Principles for prevention of secondary TBI
7. Indications + administration of hypertonic and TXA
8. Process for activation of RLH code black
2
Q
What are the management principles for TBI patients (3)
A
- Prevent secondary TBI
- Treat other significant injuries
- Rapid transfer
3
Q
What are the triage considerations for TBI?
A
Better outcomes shown at neurosurgical centre even if no surgical intervention - if in doubt call on call consultant
4
Q
What should be used to sedate patients with TBI and a high GCS + low suspicion of raised ICP?
A
Midazolam
5
Q
What should be used to sedate severely agitated patients needing a PHEA with TBI?
Why? (2)
A
Ketamine
- Some evidence it reduces ICP in patients whose ventilation is being controlled
- Causes less respiratory depression
6
Q
What 3 things should we ensure when performing PHEA in TBI?
A
- Adequate induction agent and paralysis
- Gentle laryngoscopy
- Minimal tube movement
7
Q
What 3 neurological signs must we remember to document in TBI pre-PHEA as a minimum?
A
- GCS
- Pupils
- Limb movements
8
Q
With regards to ventilation and TBI what should we aim for to prevent secondary brain injury?(3)
A
- Avoid hypoxia + hyperoxia
- Avoid PEEP if able
- Aim ETC02 of 4.5
9
Q
Why must we pay particular attention to BP in TBI?
A
Patient can lose their ability to auto-regulate cerebral blood flow. Hypotension can therefore lead to reduced cerebral oxygenation even if normal ICP
10
Q
What BP should we aim for in isolated TBI?
A
SBP >120 and MAP >90
11
Q
How should we control BP in polytrauma patient and TBI? (2)
A
- Control haemorrhage ‘meticulously’
- Aim SBP 100mmHg
12
Q
If TBI what should be the upper limit SBP before we attend to control it?
A
Aim for SBP <150mmHg
13
Q
What 4 things does the TBI SOP state we should do differently to package patients?
A
- Blocks/tape over collar, if collar then loose
- ETT tie loose to taped
- Head up 20-30 degrees
- Keep temp 35-38 degrees C using pharyngeal temperature monitor
14
Q
When should we use hyptertonic saline? (2)
A
HI and either:
1. Unilateral/bilateral pupil dilatation / GCS < 8 (normally 3)
2. Progressive HTN (SBP >160mmHg) and HR <60bpm / GCS < 8 (usually 3)
15
Q
What dose of hypertonic should we give?
A
6mk/kg 5% hypertonic (max 350ml)
16
Q
How should hypertonic be given?
A
Via minimum 18G cannula over 10 mins
17
Q
What additional advantage might hypertonic give to the polytrauma patient aside from reducing ICP? (2)
A
- Increase circulating volume
- Decreased inflammation
18
Q
What 3 criteria should be met to give TXA in TBI according to the SOP?
A
- TBI
- < 2 hours from injury
- GCS 12 or less
19
Q
What 3 criteria need to be met to activate a ‘Code Black’?
A
- Suspicion of significant TBI
- Pupillary signs suggestive of impending herniation OR Cushings response (SBP >160 and HR < 60)
- GCS 8 or less pre-PHEA
20
Q
What percentage of 1) TBI and 2) severe TBIs lead to seizure?
A
- 2%
- 12-50%
21
Q
What dose of keppra should be given to our 1) adults and 2) children in seizures post TBI?
A
40ml/kg for both
Max 4.5g in adults
Max 3.0g in children < 18
22
Q
What are the aims and objective of the spinal injury SOP? (4)
A
- Outline the assessment, treatment and triage of patients with suspected/confirmed spinal injuries
- Describe dynamic risk assessment for immediate extrication
- Describe types of immobilistion
- Describe treatment and triage of spinal cord injury
23
Q
What does the background of the SCI SOP say?
A
Have a low threshold for spinal precautions but not at the expense of addressing a A, B or C problem
24
Q
How are ‘spinal precautions’ defined?
A
A group of devices and a system for patient handling that aims to decreased spinal cord damage
25
What are the mentioned indications for spinal precautions in the SOP? (6)
1. Mechanism consistent with SCI
2. Signs/symptoms of SCI
3. Neck/back pain
4. Reduced GCS
5. Intoxicated
6. Distracting injury
26
Under what circumstances does the SCI SOP say we can 'clear' a c-spine pre-hospital? (4)
Non-severely injury + :
- no neck pain
- full ROM
- no neurology
27
Under what circumstance does the SCI SOP state we can elect not to immobilise the c-spine that has not been 'cleared'?
Neck pain only but full ROM and no neurology
Must handed over that not 'cleared'
28
In terms of SCI what should prompt a lower threshold for RSI?
High spinal injury
29
What does the SCI SOP say about hypotension? (2)
1. Exclude other causes of hypotension
2. 25-50mg aliquots adrenaline
30
What does the SCI SOP state about spinal boards?
Only to be used for extrication not transfer
31
What 3 extrication devices does the SCI SOP mention?
1. SARA
2. MIBS
3. Scoop
32
What does the SCI SOP say about triaging suspected SCI?
1. If positive signs SCI then MTC
2. If not, use clinical judgement
33
What is the minimum neurological examination required pre-RSI in SCI?
1. Limb movement
2. Sensory level
3. CV findings
4. Priapism
34
What spinal cord syndrome is the most common?
Central cord syndrome
35
What tract does central cord syndrome affect?
Corticospinal
36
Which demographic and mechanism usually leads to central cord syndrome?
Elderly and hyperflexion
37
What are the features of central cord syndrome? (2)
1. Motor deficit upper > lower limbs
2. 'Burning sensation in upper limb extremities
38
What is the usual cause of anterior cord syndrome?
Direct injury to anterior spinal causing injury to anterior spinal artery
39
What is the usual mechanism that leads to anterior cord syndrome?
Flexion/compression of spine
40
What are the classic neurological findings of anterior cord syndrome?
1. Motor loss lower>upper
2. Dissociated sensory loss - loss of pain/temperature below level
41
Which of the spinal cord syndromes has the best prognosis in terms of function?
Brown-Sequard
42
What is the mechanism leading to Brown-Sequard syndrome?
Hemi-transection of the cord (usually penetrating trauma)
43
What are the neurological findings in Brown-Sequard Syndrome?
1. Ipsilateral paralysis and loss of proprioception/vibration and touch
2. Contralateral loss of pain/temp
44
What is the evidence from the Cochrane review re: abx in open fractures?
Decrease wound infection but not osteomyelitis/amputation/death
45
What is the BOAST consensus statement around abx in open fractures?
< 1 hour of injury
46
What should we consider additionally in open fractures to reduce need for removing dressings?
Photo
47
Should we irrigate open fractures?
No
48
What abx should we give in open fractures?
Augmentin
49
What abx should we give in open fractures if penicillin allergic and what important effect might this have?
1. Clindamycin 600mg
2. Enhances sux and roc effect
50
What are the aims + objectives of the penetrating trauma SOP? (3)
1. To ensure all patients with penetrating trauma receive timely and effective interventions and transfer
2. Describe the broad philosophy of clinical care for penetrating disease
3. Describe the triage policy for penetrating trauma
51
What are the 2 main points in the Background section of the penetrating trauma SOP?
1. A proportion of these need urgent surgery, therefore minimise scene time
2. Patients may have relative/true bradycardia therefore any change in physiology is concerning
52
What, in penetrating trauma, should prompt rapid transfer to MTC and delaying complete examination till then?
Wound in the 'danger zone'
53
What should we attempt to avoid in penetrating trauma to aid with forensics?
Cut through the clothes around the stab/gunshot site
54
How should bleeding penetrating trauma to the chest be managed?
Pack with haemostatic dressing then sleak
55
How should penetrating trauma to the neck be managed? (3)
1. Consider RSI
2. Direct pressure and haemostatic gauze
3. Consider foley/epistats but may lead to vagal response, stop if this happens
56
What analgesia is recommended for penetrating trauma?
Opiates
57
When should we transfuse patients with penetrating trauma? (2)
1. Stop talking
2. SBP <80mmHg
58
Describe the neck zones in trauma
Zone 1 - clavicle/sternum to cricoid
Zone 2 - cricoid to mandible
Zone 3 - angle of mandible
59
If loss of output with zone 1 neck or trunk injury what should be done?
Thoracotomy - pull over or consider landing aircraft to do this
60
How should eviscerated bowel by managed?
Cover with wet dressing - blast bandage with plastic sheet best of our kit
61
What penetrating trauma should go to MTC? (3)
1. Chest
2. Neck
3. Suspected vascular injury
62
What is the only trauma service that Norwich lacks?
Neurosurgery
63
What are the 3 principles or haemorrhage?
1, Limit blood loss
2. Increase clot formation
3. Decrease clot disruption
64
How should an femoral # and unstable pelvis be managed?
1. Pull femur to length
2. Apply pelvic binder
3. KTD
65
How can we manage a midshift humeral #? (2)
1. KTD
2. Benecase
NB: can be difficult to split, consider risk:benefit of scene time
66
If removing a tourniquet what should we ensure?
Monitoring on - complications associated with long term use
67
How should bleeding scalp wounds be managed?
Suture
68
What can be used to stop arterial bleeding distally?
Proximal indirect pressure
69
What does the haemorrhage SOP say about permissible hypotension? (2)
1. Non-compressible haemorrhage
2. In first 60mins
70
When should be ensure before we commence resusitation with blood products/adjuncts?
Haemmorrhage control has been optimised
71
After 60 mins what does the haemorrhage SOP say about permissive hypotension?
After 60 mins weigh up consequence of multi-organ failure/coagulopathy
'Novel hybrid' approach maybe more appropriate
72
How should we volume resusitate hypotensive patients with blunt injury and HI? (3)
1. Talking - don't transfuse
2. Not talking - transfuse to talking
3. I+V = SBP 100mmHg
73
How should we volume resusitate hypotensive patients with blunt injury and no HI? (3)
1. Talking - don't transfuse
2. Not talking - transfuse to talking
3. I+V/unconscious - aim for what you think would maintain CPP (around SBP 60-80mmHg)
74
What is needed to trigger a MHP (EoE) or Code Red (London)? (3)
1. SBP <90 at any time
2. Non-responder to fluid
3. Suspected/confirmed haemorrhage
75
What is the aim of the TCA SOP?
To provide clear guidelines to aid team in management of TCA
76
What are the objectives of the TCA SOP?
1. Define TCA
2. Provide understanding of background causes of TCA
3. Provide algorithim to help guide treatment priorities
77
What does the TCA SOP say about ALS? (2)
1. Continue until hx/MOI confirmed
2. ALS without attention to reversible pathology is unlikely to lead to ROSC
78
In TCA what may PEA suggest?
Low flow
79
What does HOT stand for?
H - ypovolaemia
O - oxygenation
T - ension PTX
80
If we get ROSC post thoracotomy what should we do? (2)
1. Transfer - ideally MTC if stable enough
2. Consider bicarbonate and calcium
81
If we do not get ROSC post thoracotomy what should we do in:
1. Children
2. Adults
1. Take to local ED with resus ongoing
2. Consider PLE
82
What are the aims + objectives of the pelvic splintage SOP? (3)
1. Ensure all patients with unstable pelvic injuries receive timely and effective splintage
2. Define indications for use of pelvic splint
3. Describe application of pelvic splint
83
How does the pelvic splintage state we should examine a pelvis?
If not obviously deformed lightly grasp ASIS + assess symmetry + attempt small (<1cm) medial/lateral movement of ASIS
Only do this once
84
What are the two suggested ways to apply a pelvic splint?
1. At the same time as the scoop
2. If very unstable then 2 person small lift+ shuffle binder up and secure before scoop
85
What should we aim for when splinting a pelvis?
Anatomical alignment only
86
What must we remember to check when placing on a binder?
Perineal region
87
If a patient is very unstable what else can be done to help stabilise the pelvis apart from the splint?
Internally rotate the legs and stablise knees/ankles with bandage
88
How do we inflate epistats?
- 4 x 20ml syringe with normal saline
- posterior (white port) 1st with around 10ml
- middle balloon (green port) second with 20-30ml
- inflate alternately little at a time
89
What are the aims and objectives of the burns SOP? (3)
Aim: Ensure burns patients receive appropriate and timely treatment/triage and transportation
Objectives
1. Describe the clinical management of burns
2. To understand the appropriate triage of burns
90
When arriving to a fire who should we check re: safety?
Fire incident commander
91
What 3 things should be removed in a burn?
1. Loose clothes, leave adherent clothes
2. Jewelry (can retain heat)
3. Hydrogel burns dressings (don't cool enough)
92
How should patients with burns be cooled initially/
10 mins with water 12-18 degrees C
93
Why is cling film good for covering burns? (3)
1. Reduce heat loss
2. Non-adherent
3. Effectively sterile
94
What should we not cover with cling film in a burn? (2)
1. Circumferentially
2. Face
95
Which 2 groups are at most risk of hypothermia following a burn?
Children and the elderly
96
How should we attempt to get burns patients warm? (5)
1. Oesophageal probe if I+V
2. Fluid warmer
3. Remove wet clothes
4. Temp up if in DSA
5. Usual EHAAT warming stuff once burns addressed
97
What is the big difference betweem superficial and superficial partial burns?
Presence of blistering
slightly paler (pink as opposed to red)
98
How are deep dermal burns described? (4)
- dark pink/red or white
- mottled/ stained / cherry red
- delayed or absent CRT
- Dull/variable sensation
99
How are full thickness burns described? (5)
- white/black/brown/yellow
- dry and leathery
- no CRT
- no sensation
Eschar may be present
100
What TBSA % burns mandate the Parkland formula in:
1. Paeds
2. Adults
1. 10%
2. 15%
101
What is the Parkland formula?
2-4ml/kg/%TBSA over 24 hours
102
Over how long should the fluid in the Parkland formula be given?
24 hours
50% in first 8 hours
50% in second 16 hours
103
What should be done with regards to infection control in burns?
Get allergy and tetanus status to hand over in hospital
No need to give pre-hospital abx
104
What should we consider in burns in confined spaces? (2)
1. CO
2. Cyanide
105
What should be done in suspected CO poisoning and why?
High flow 02 because this will decrease the half life of CO from 320 mins to 80mins
106
What should we do in suspected cyanide poisoning?
Manage physiology
Hand over in hospital (no antidote with EHAAT)
107
How should we position suspected airway burns pre-RSI and why?
Sit up if awake to decrease swelling to airway
108
What are the indications for RSI in burns? (8)
1. Enclosed space
2. Burns to face/torso/necl
3. Singed nasal hairs
4. Carbonaceous sputum / soot particles in airway
5. Change in voice - hoarseness/harsh couhg
6. Dyspnoea
7. Stridor
8. Erythema/swelling in oropharync on direct visualisation
109
What are the indications for prompt/mandated RSI in burns? (4)
1. Change in voice - hoarseness/harsh couhg
2. Dyspnoea
3. Stridor
4. Erythema/swelling in oropharync on direct visualisation
110
What is the recommended lung protective strategy in burns?
1. TV 6-8ml/kg
2. plateau pressure < 30cmH20
111
In burns what must we be aware of with tube tie?
Swelling over time can lead it to cut into skin - keep checking
112
What is the most common reason to need surgical airway in burns
Burns to neck limited mouth opening
113
What does the haemorrhage/vascular access SOP 'policy' section say? (4)
1. Exclude a ventilator or obstructive cause for shock
2. Maximise natural tamponade / clot production.
3. Blood products should be considered for volume replacement where indicated.
4. Inotropes are rarely indicated (unless neurogenic shock)
114
What is first line for IV access at EHAAT?
14G/16G in antecubital fossa (preferably uninjured arm / ipsilateral chest wall injury)
115
What does the haemorrhage/vascular access SOP state about 'mission critical cannula' should be secured? (3)
1. Loop the giving set through 1st web space and back along forearm.
2. Tape x 2.
3. Cling bandage where possible.
116
What is second line at EHAAT if IV access difficult?
Subclavian vein access with Multi-Lumen Access Catheter (MAC kit).
117
What does the pelvic splintage SOP say about placing splints due to MOI?
No need if:
- GCS 15
- No CV instability
- No clinical findings to suggest significant pelvic injury
118
What can a badly sited pelvic binder lead to? (2)
1. May open the posterior elements of a disrupted pelvis.
2. An over tightened splint can cause bony fragments to damage pelvic viscera.
119
What are the aims (1) and objectives (2) of the maxfax SOP
To ensure that patients with facial injuries have appropriate assessment and
management on scene, especially where airway compromise or haemorrhage
present a threat to life.
1. Describe the particular considerations for pre-hospital anaesthesia in maxillofacial
injury.
2. Describe the methods used to attempt to control excessive haemorrhage from
maxillofacial injury.
120
What is the background of the maxfax SOP?
1. Due to the rich
blood supply to the head and neck, it is possible to exsanguinate from facial injuries
2. Aim to recreate a stable column for the facial skeleton, which will allow some restoration of anatomical alignment and
hence minimise ongoing haemorrhage.
3. Usually associated with an obstructed airway
(actual or impending)
4. For the epistat balloons to provide tamponade rest of the 'column' most first be in place
121
What can causes epistats to be ineffective/worsen maxfax bleeding?
For the epistat balloons to provide tamponade
in the nasal space it is important the hard palate is braced against the lower jaw
[which is supported by a cervical collar] with dental blocks / McKesson props.
Failure to utilise all of these adjuncts will result in a mobile maxilla being pushed off the base
of the skull and increasing the space for bleeding.
122
What does the maxfax SOP say about intubation?
1. Position where most comfortable
2. Additional suction
3. Optimise 1st attempt
4. Surgical airway kit out, landmarks identified and plan vocalised
5. If ongoing haemorrhage post I+V contintue with bite blocks/collar/epistats
123
What factors impact the severity of blunt chest trauma? (7)
1. age >65 years
2. high velocity trauma
3. penetrating trauma
4. History of COPD
5. more than two rib fractures
6. Respiratory Rate > 25
7. hypoxemia
124
What is the treatment priority in blunt chest trauma?
To maximise oxygen delivery as early as possible and avoid any ventilatory component to cellular hypoxia and shock.
125
What are the 2 principles mentioned when performing interventions on patients with blunt chest trauma?
1. All procedures should be performed using sterile technique.
2. Formal assessment and confirmation of landmarks must take place prior to any surgical incision being made.
126
Which does the blunt chest injury SOP state about bariatric patients?
- They may have no/limited external signs.
-Can become hypoxic quickly due to potential splinting/reduced alveolar recruitment, especially when supine
127
What does the blunt chest injury SOP state about paediatric patients?
Given chest wall pliability can show no/limited external signs injury but have significant internal injuries
128
What 3 'warning signs' does the blunt trauma SOP state should trigger urgent reasssessment?
1. Undetectable SATs
2. Unexplained hypotension
3. High airway pressures
129
How does the blunt trauma SOP say we should examine for flail? (3)
1. Stand at foot end and look for anterior flail
2. Position yourself so you can look vertically down and then look for lateral flail
3. Remember posterior flail (difficult if on scoop)
130
What is the mortality of sternal injuries according to the blunt trauma SOP?
0.7-3.5%
131
What percentage of blunt sternal trauma have cardiac complications (inc. aortic dissection)
1%
132
What signs/symptoms should prompt clinicians to assess for Systemic Air Embolus (SAE) (3)
1. Unexplained shock
2. Cerebral symptoms
3. Haemoptysis
(exclude tension PTX)
133
Which burns mandate a burns centre? (5)
i. >15% TBSA in an adult
ii. >10% TBSA in a child
iii. Airway burns / Inhalational lung injury
iv. Burns to special areas – Face, hand, perineum or genitals, feet, flexures (particularly neck or axilla), over a joint which may affect mobility or function
v. Electrical / chemical burns
134
What should we remember with electrical burns? (4)
1. Small entry/exit wounds may hide larger damage internally through path of current
2. May need lots of fluid
3. High risk compartment syndrome - continually examine extremities to pulses/CRT
4. Can have arterial/venous thrombi leading to distal schaemia
135
How can electrocution lead to death? (3)
1. VF/asystole
2. Tetany of chest
3. Trauma from being thrown
136
137
How much TXA should be given in TBI to 1)adults and 2) children?
1. 2g
2. 15-30mg per kg
138
For RLH what should be done in the event of a suspected TBI meeting code black criteria that is haemodynamically unstable?
Request code red and code black
EHAAT sign off
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