Preparation for Casualty

This is a link to a critical care page

You may only receive a triage category and a mechanism of injury.

For T1 casualties activate the Trauma Team

Mechanism/History

Penetrating trauma

• Gunshot or shrapnel wound
• Blast injury (mine/IED/grenade)
• Stab wound

Blunt trauma

• Motor vehicle crash with ejection
• Motorcyclist or pedestrian hit by vehicle >30km/h
• Fall >5 metres
• Fatality in the same vehicle
• Entrapment and/or crush injury
• Inter-hospital trauma transfer meeting activation criteria and

Anatomy

• Injury to two or more body regions
• Fracture tot two or more long bones
• Spinal cord injury
• Amputation of a limb
• Penetrating injury to head, nexk, torso or proximal burns
• Airway obstruction

OR

Physiology

• Systolic blood pressure <90mmHg or pulse > 120 bpm (adults)
• Respiratory rate <10 or >30 per minute (adults); SpO₂ <90%
• Depressed level of consciousness or fitting
• Deterioration in the Emergency Department
• Age >70 years
• Pregnancy > 24weeks with torso injury

Team Leader (emergency physician)

• Controls and manages the resuscitation
• Makes decisions; prioritises investigations and treatment
• Ensures trauma chart is fully completed
• Documents resuscitation in notes, which must include a summary of injuries and descisions

Airway Specialist (anaesthetist)

• Responsible for assessment and management of the airway & ventilation
• Counts the initial respiratory rate
• Administers oxygen; performs suction; inserts airway adjuncts; endotracheal intubation (RSI)
• Maintains cervical spine immobilisation and controls the log roll
• Takes an initial history (AMPLE)

Airway Assistant (ODP or ED nurse)

• Applies monitoring
• Assists in preparing equipment for advanced airway intervention
• Assists with advanced airway intervention, e.g. applies cricoid pressure
• This role may be undertaken by Nurse 1
• Examines the patients back/buttocks/perineum during the log roll
• Undertakes the primary survey: +B to E
• Clinical findings are clearly spoken to Team Leader and recorded by Scribe
• Performs procedures depending on skill level and training
• Undertakes secondary survey with support from specialists

All team members are responsible for ensuring their findings and decisions are correctly recorded This team represents a best practice model

Where there are limited resources individuals in the team will assume more than one role and specialist resources (e.g. surgeon) may move serially from one patient to another dependent on the need for specialist assessment and intervention skills

Nurse 1

• Cut/remove clothing
• Applying monitoring

Nurse 2

• Cut/remove clothing

Scribe (ED nurse or medic or HCA)

• Collates all information and records decisions on Trauma Chart

Radiographer

• X-rays as directed by the Team Leader

Background

“Right turn” refers simply to the layout of the field hospital in Camp Bastion:

The term indicates a casualty who moves directly into the operating theatre on arrival. It emerged as an useful process in the resuscitation of combat casualties who are at the very edge of their physiological envelope.

This protocol does not by-pass Emergency Department care as the whole trauma team moves into the operating theatre for the multi-disciplinary resuscitation.

Which patients?

Decision points

A decision to “right turn” can occur at two points:

• Receipt of the advance pre-hospital information
• Ambulance bay triage

Note: an earlier decision is better as the team can pre-position itself.

Actions

1. ED Team to OR
   
   • Team Leader
   • Nurse Massive Transfusion Team
2. Team leadership starts with the Consultant Emergency Medicine (positioned at the foot end) and is passed on to the Consultant Anaesthetist (at the head end) once rapid infusion lines are secured, fluid resuscitation with blood products has started, the patient is anaesthetised, and the initial imaging is complete (e.g. FAST scan and/or critical plain films.
3. Anaesthetists
   
   • Manage: “A” and central access
   • Massive Transfusion Protocol
4. Surgeons
   
   • Surgical intervention will start immediately in cardiac arrest or peri-arrest, if thoracotomy and aortic cross-clamping is indicated.

Using these cuts will enable complete removal of Tier 3 protection and provide adequate exposure for examination and treatment.

Preparation

Team Leader (MO, Senior Medic or RNO)

• Assess casualty
• Prioritise & direct stretcher decontamination process
• Prioritise & direct Emergency
• Medical Treatment
• Manage airway
• Gain sternal IO access
• Administer sternal IO medication
• Decompress tension pneumothorax, if required

Medic

• Gain IV access in arm, if required & administer medication
• Gain sternal IO access, if required & administer medication
• Gain tibial IO access, if required & administer medication
• Assists TL by passing & receiving medical equipment & preventing secondary contamination of medical equipment
• Carry out wound decontamination as required & directed by TL
• Applied dressing & tourniquet (clean) as required

Decon 1 (closest to Medic & Medical Equipment)

• May be medical or non-medical
• Apply dressing & tourniquet (dirty) as required
• Decontaminate arm or leg for IV or IO access ‘expose to treat’ as directed by TL
• Support Medic gaining IV access in arm by acting as manual venous tourniquet
• Carry out stretcher casualty decontamination

Decon 2 (furthest from Medic & Medical Equipment)

• May be medical or non-medical
• Apply dressing & tourniquet (dirty) as required
• Decontaminate & remove respirator ‘expose to treat’ as directed by TL
• Carry out stretcher casualty decontamination

Scribe

May be medical or non-medical

Record exposure, injuries, decontamination & medical interventions including drugs

Handover information at Clean Dirty Line

Team Leader (MO, Senior Medic or RNO)

• Assess casualty
• Prioritise & direct stretcher decontamination process
• Prioritise & direct Emergency Medical Treatment
• Manage airway
• Gain sternal IO access
• Administer sternal IO medication
• Decompress tension pneumothorax, if required

Medic

• Gain IV access in arm, if required & administer medication
• Gain sternal IO access, if required & administer medication
• Gain tibial IO access, if required & administer medication
• Assists TL by passing & receiving medical equipment & preventing secondary contamination of medical equipment
• Carry out wound decontamination as required & directed by TL
• Applied dressing & tourniquet (clean) as required

Decon 1 (closest to Medic & Medical Equipment)

• May be medical or non-medical
• Apply dressing & tourniquet (dirty) as required
• Decontaminate arm or leg for IV or IO access ‘expose to treat’ as directed by TL
• Support Medic gaining IV access in arm by acting as manual venous tourniquet
• Carry out stretcher casualty decontamination

Decon 2 (furthest from Medic & Medical Equipment)

• May be medical or non-medical
• Apply dressing & tourniquet (dirty) as required
• Decontaminate & remove respirator ‘expose to treat’ as directed by TL
• Carry out stretcher casualty decontamination

Scribe

• May be medical or non-medical
• Record exposure, injuries, decontamination & medical interventions including drugs
• Handover information at Clean Dirty Line