BRIAN BURNS: TRAUMA BEFORE + BEYOND THE HOSPITAL
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Brian Burns on managing trauma patients in extremis and extreme conditions. This talk was given at SMACC 2013. Go to http://intensivecarenetwork.com/index.php/icn-activities/smacc-2013/podcasts/643 for the audio.
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BRIAN BURNS: TRAUMA BEFORE + BEYOND THE HOSPITAL
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Editor's Notes
- thank you, i’m going to talk to you about trauma management from a prehospital perspective. Before I do that I thought I’d first reflect on the concept of the hospital.
- What is a hospital? Is it a place? Is it defined by the people who provide care at that location? This is the Asclepion at Kos, the origin of Western medicine. Sick would come and pray to Asclepios and his two daughters, Panacea and Hygeia . A visit by these three was expected to cure all ailments.
- hospitaller knights, 11th century. provided both care for poor, sick or injured pilgrims to the Holy Lan d , foreru nners in modern prehospital care, started to branch out..
- Grand master of the knights- a keen researcher performing a randomized decompressive craniectomy trial at the siege of Acre in 1291 The Hospitaller grand master Guillaume de Clermont defending the walls at the Siege of Acre in 1291 , by Dominiqu e-Louis Papéty (1815–1849) at Versailles .
- Whilst as prehospital providers we don’t fight wars, some symbols from the hospitaller knights still remain.
- in your mind’s eye how do you envisage your ideal hospital today?
- is it characterised by the technology? This is the RAPTOR suite at Liverpool Hospital in Sydney. A hybrid suite capable of complicated trauma care.
- Or is it characterised by the professionals housed within?
- what is the role of a hospital? treat disease, cure disease, above all to save life and limb. TRAUMA is a disease. I would argue that advanced HEMS services are flying EDs.
- so let’s look at this from a trauma patient’s perspective.
- Driver, hits tree at 120kph, Trapped by confinement.. head injury, trismus, chest injury. open femur #, blood pooling in the footwell 200km from MTC the disease process has NO regard for location, time or place.
- so what are we going to do for this guy? dogma-champions would say ‘scoop and run’. that’s as intuitive as giving this patient paracetamol and ibuprofen, closing your eyes and patting him on the back.
- this guy needs some help
- let’s look at meaningful interventions that this kind of patient NEEDS
- A-. Prepare for RSI :
- insert an LMA whilst trapped, BVM assistance, titrated small doses for ketamine/midazolam to tolerate/control and get set up for RSI
- HEMS RSI operating procedure with a challenge/response checklist such as ours is now increasingly being used in the ED.
- MAXIMIZE first-look success rate and avoidance of AEs is achieved by : team simulation training, pre-intubation briefing, RSI checklist use, optimisation of position including using a sam splint occipital pad to maintain head neutral , ADO, ketamine/roc induction, bougie use, bimanual laryngoscopy, and confirmation with waveform capnography.
- B- if trapped and suspect tension reasonable to perform needle decompression as a temporizing measure.
- FOR all others OPEN FINGER THORACOSTOMY AFTER I+V. 360 ACCESS NB AS THIS OFTEN SOON FOLLOWS RSI. THE PPV AND RE-FINGERING KEEPS IT OPEN. WE RARELY INSERT A CHEST DRAIN IN PREHOSPITAL environment. I’ll talk more about this and other procedures on wednesday
- this is why, tube kinks, blocks, may not work or not in the chest as you see here.
- C- follow haemostatic resuscitation principles, IO access, blood products, TXA, haemorrhage control-tourniquets, pelvic binder, CT-6 femoral traction splint. haemostatic gauze
- D- RSI neuroprotection operating procedure, RSI avoiding hypotension and hypercarbia. ETCO2 KPI(30-40). SBP>90 with fluid, SpO2>90. ICP-PEEP not >5, ETT not too tight for VR, head up where possible, adequate sedation, analgesia. Signs raised ICP- give hypertonic saline 7.5% 5ml/kg-max 250ml. relative hyperV
- moving on to logistics. Accessing trauma patients in austere conditions and environment is common in our HEMS service. the patient you see above required a 2 hour walk out of blue mountains intubated, involved more than 50 rescue personnel
- team briefing in accessing the patient in flight is similar to the team brief on the ground when treating the patient-same principles. aim to establishing a collaborative definitive plan
- We are among a handful of services globally that performs doctor winching to get access to these patients.
- and you can see why winching is required in the area we serve
- trauma affects patients in all types of environments. Interestingly the austere high-stakes environment lends itself to clinical governance and operating procedures which decrease error
- Australia suffers from the “tyranny of distance” as the founder of the RFDS put it.
- patients are transported long distances from the scene to the trauma centre.
- it reinforces the need for life-saving meaningful interventions to be integral to what a HEMS service offers. To paraphrase my colleague Cliff Reid “bringing upstairs care downstairs and 700km out the door”.
- so what about when the patient arrives at the trauma centre.?
- often there are multiple players, multiple opinions which can slow down meaningful interventions and mitigate against critical decision making
- lets look at the timelines TIMELINES INCIDENT 000 CALL DESPATCH ROAD LEG TO ACCESS PT ON SCENE MANAGEMENT TRANSPORT LEG HOSPITAL AND THEN A RANGE OF EMERGENCY DEPARTMENT INTERVENTIONS AND OCCASIONALLY OT (<3 % OF MAJOR TRAUMA)
- Helicopter gives us the ability to reach the scene rapidly. Emergency Department care forward in the timeline to the scene. We can perform those meaningful interventions earlier and make a difference to the patient. Time spent doing these procedures also means less time spent on arrival in the hospital and if they need to go to CT or OT this can be done directly - bypasing the ED or shortening this time.
- cognition is mental processing involved in learning and problem solving. That processing is comprised of attention and memory.
- Our unique working environment has helped our HEMS teams develop cognitive resilience-or the ability to think under pressure. attention not diverted by all the auditory and visual stimuli, keeping eyes on the prize. memory aided by checklists and drills, reinforced with simulation training Controlling environment and team critical to success in prehospital environment. All of this is translatable to the ED resus room
- inherent in HEMS where a core medical team of 2 focus on meaningful interventions in order of life-threatening injuries.This also focuses the team on avoidance of non-meaningful interventions
- task priorities- i wouldn’t perform ocular US in a TBI on scene. This scan was performed en route to the MTC in the helicopter.
- Task performance under stress inherent-environmental factors, other services/ bystanders/media can all distract you from the job at hand and cause stage fright. In fact we include human factors/CRM training in our registrar induction courses.
- training in specific critical interventions is covered in a 2 week induction period including a porcine skills lab. this is reinforced with ‘currencies’ such as RSI currency where all clinicians run through regular competency-based assessment. This is in the form of an on-line MCQ followed by sim based-practical session. Clinicians must maintain currency with this and other critical interventions in order to remain on-line
- we practice the RSI with checklist on the ground
- and at the cliff edge (vertical awareness day)
- these principles and training make the real-life event less stressful and more efficient and safer for the patient. do they looked stressed?
- critical decision making- such as bringing the right patient to the right hospital at the right time. or expediting patient to OT in prehopsital FAST + scan. activating MTP from the helicopter or activating IR are crucial interventions a HEMS can offer
- so what lies ahead in the future of prehospital trauma care in the civilian setting? Whilst we haven’t got a tricorder yet we should always strive to improve trauma care resuscitative emergency balloon occlusion of aorta for severe abdominal/pelvic trauma blood products to combat ATC such as freeze dried plasma. Lastly, the evolution of prehospital ECMO to suspend animation in a dying trauma patient may NOT be that far beyond our grasp
- Above all the most important thing is to enjoy your work and not take yourself too seriously
- Oh but what about the Golden Hour. Patients who were pronounced dead at the scene were considered “immediate” deaths, while those who were transported to the hospital were classified as “early” deaths (≤4 hours from injury) or “late” deaths (>4 hours from injury). Those who were transported to the hospital and were pronounced dead on arrival were classified as early deaths.50%< 1 hour, 20% 1-6 hours
- getting the patient to the right place, FAST+ in shock patient