NTACC

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 97 Thermal burns are the result of direct contact with fames or thermal energy (heat) on the skin or tissue. In all types of thermal burns, treatment should aim to limit the damage caused by the thermal energy, which may still be present when you reach the casualty, who may even still be on fre. MANAGING THE BURN This involves actively cooling the injured area to dissipate the thermal energy which, can remain and cause further damage, even after the direct heat source has been removed. • Place the injured area under clean, cold running water as soon as possible for at least 20 minutes • Only dress the burn once it has cooled completely (see fgure 48). Immersion in cold water is not as efective as running water, which continues to remove heat energy from the burn. However, if the only water available is in a static container or vessel, then it is better than no cooling. Water does not have to be sterile, but ideally it should be clean. However, if all that you have is tap water, a garden hose or water from the fre engine tank, use it, as the active cooling is the priority and any infection risk is very much a secondary issue, as most burns get infected at some point. DRESSING THE BURN • Cover the burns with ‘burn-flm’ (or ordinary cling-frm if nothing else is available) laid on in sheets • Face shield can be used for facial burns • Hands and feet – burn bags or freezer bags • Gel dressings are not ideal as they have a limited heat absorption and are not as efective as running water. Burn flm keeps the area clean, reduces fuid loss, and signifcantly reduces pain by covering the exposed nerve endings. Never wrap or wind flm around a limb. Always lay strips or sheets on lengthways, as when the limb starts to swell, the dressing will not be tight, constricting the limb. Hands and feet are best managed with clear plastic bags or freezer bags and if possible, with a few millilitres of sterile eyewash/saline added to the bag and then loosely taped around the wrist or ankle. This creates a humidifed environment and allows ongoing inspection of the burn, through the bag in hospital. Figure 48: Burns are covered with burn-flm and plastic bags containing a few millilitres of saline eyewash for the hands and feet. Thermal burns Chapter 5.5 / H: Head Trauma and Other Serious Injuries

98 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Chemical burns result from contact with a caustic or corrosive substance or a substance that reacts with moisture on the skin to generate heat. Every efort should be made to identify the chemicals involved to determine the most appropriate form of treatment, as certain chemicals, such as sodium phosphorous may react negatively with water producing more heat. All chemical powders should be brushed of the patient’s clothing or skin, carefully avoiding coming into contact with this substance yourself. Dry decontamination (ideally by the individual themselves) is now the favoured approach. Removing clothing and brushing the agent of with paper towel is recommended, but if it’s burning, irrigate as soon as possible. After you have removed as much of the dry chemical as possible, irrigate the burned area with clean, cold running water. The water washes of remaining chemical residue and residual thermal energy. Flush the afected area for at least 30 minutes. Once it has been decontaminated efectively, cover the area with a burn-flm dressing (if there is obvious residual chemical on the skin, avoid dressings). Diphoterine – This is an emergency agent used on many chemical sites/labs for the immediate management of chemical burns. Some studies have indicated that it may reduce the injury from burns. However, hospital burns units would still recommend the use of cold running water, for at least 20 minutes, especially for more major burns. Diphoterine can be used, but for smaller burns or for immediate management. It is rarely in sufcient volume, especially for larger burns and we should switch to running water when it runs out. Phosphorus burns – water was traditionally avoided as its action can generate signifcant heat. When a sufcient volume of water is used this efect is minimised and it is therefore a safe and efective option. Electrical burns Electrical burns result from direct contact with a live electric energy source. Even small electrical burns, if sufcient to burn the skin (often looking like cigarette burns) can cause a large amount of tissue damage and a great deal of pain. With electrical burns, there is an added risk of cardiac arrest, which requires immediate basic life support and defbrillation. Before treating an electrical burn, always ensure that the scene is safe and that you are adequately protected from the electrical source. Before you touch or treat a person who has sufered an electrical burn, be certain that the casualty is not still in contact with the electrical power source which caused the burn. If the casualty is still in contact with the power source, anyone who touches him or her may also be electrocuted. If the patient is touching a live power source, your frst act must be to unplug, disconnect, or turn of the power. If you are unable to do this alone, call for assistance and stand clear until help arrives. After the power has been disconnected, examine the patient carefully, assessing airway, respiration, and circulation before treating visible, external burns. If there is obvious thermal injury (e.g. fames or blistering), the area may be cooled with water only when there is no risk of contact with electricity. Even small electrical wounds can hide major tissue injury, or result in cardiac injury. All electrical burn patients should be referred to specialists. Chemical burns Chapter 5.5 / H: Head Trauma and Other Serious Injuries

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 99 • The fnal step in the M.A.R.C.H algorithm addresses head trauma and other serious injuries, including spinal injuries, bone fractures, abdominal injuries, and burns • Treatment of head injuries in the feld focuses on preventing further damage • The AVPU scale is used to assess patient responsiveness • Head trauma patients must be rapidly transported to hospital • All patients with signs or symptoms of spinal injury should be considered time critical • While there are certain situations in which the spine should not be immobilised, providers should fully immobilise the spine if there is any doubt • Fractures should be immobilised by splinting which limits movement, reduces pain, helps control bleeding, and decreases the risk of damage to the nearby nerves and vessels • Many diferent materials can be used as splints. Splints can be improvised from rigid materials, but commercially available products ofer more robust immobilisation • Splints should be applied when there is a doubt about their necessity • For rib fractures, responders should be careful to handle the casualty gently and continually reassess for developing respiratory concerns • Pelvic fractures require immobilisation, since these injuries often involve severe blood loss • Examine casualties carefully for signs of abdominal injury and provide rapid transport to hospital if abdominal injury is suspected • Burns are categorised by depth (superfcial, partial-thickness, and full- thickness) and by source (thermal, chemical, electrical) • Thermal burns are the result of direct contact of fames or thermal energy (heat). They should be cooled under running water, dressed in burn-flm wrap • Chemical burns result from contact with a caustic or corrosive substance or a substance that reacts with moisture on the skin to generate heat. Chemical burns should be identifed, cleaned, washed, and dressed • Electrical burns result from direct contact with a live electric source. Safe approach is essential when treating electrical burns. Wounds should be dressed with burn-flm. All electrical burn patients should receive supplemental oxygen • When appropriate, pain management drugs such as Entonox and Fentanyl may be used to help stabilise patients. Summary: Chapter 5.5 / H: Head Trauma and Other Serious Injuries AVPU scale: A scale to measure a casualty’s level of consciousness. The letters stand for alert, verbal, pain, and unresponsive. Cervical collar: A neck support that partially stabilises the neck following injury. Full-thickness burns: Burns that extend through the skin and into or beyond the underlying tissues; the most series class of burn. Logrolling: A technique used to move a patient onto a longboard. Partial-thickness burns: Burns in which the outer layers of skin are burned; these burns are characterised by blister formation. Splinting: A means of immobilising an injured part by using a rigid or soft support. Superfcial burns: Burns in which only the superfcial part of the skin has been injured; for example, a sunburn. Vital vocabulary

100 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com In this chapter we are going to examine paediatric trauma and resuscitation. A large proportion of childhood deaths in the U.K. are related to trauma. The TARNet data has identifed the most common mechanism of injury and cause of severe trauma is Road Trafc Collisions (RTCs) and falls. The median Injury Severity Score (ISS) reported in the TARNlet data for the U.K. was IIS = 9. Head injuries are reported as the main cause of death in children despite most children presenting with a GCS of 15 on arrival. In relation, to paediatric resuscitation cardiopulmonary arrests in this cohort are more commonly secondary to either a respiratory or circulatory failure. Primary arrests with a cardiac cause such as arrhythmias are less common and asphyxial or respiratory arrests (e.g. trauma, drowning or poisoning) are more common in the young adult. Chapter 6. Paediatric Trauma

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 101 Paediatric Trauma Paediatric trauma cases are always more stressful, even for the most experienced staf. Emotions run high and we need to use whatever tools we can to try and reduce the cognitive load and the stress on the team. If you work in a general TU or MTC the key to improving your team skills and performance with such cases is good leadership with a shared mental model and preparation. Organising paediatric trauma scenarios on a regular basis will help you and your team in preparing for the real-life eventuality. Additionally, it is important to invest in your paediatric resources for example having an allocated paediatric resus bay. This space would be stocked with all require paediatric kit and paediatric aide memoirs (WETFLAG) these could also include handy electronic apps such as Paeds ED or Mersey Burns. In doing this you best prepare your team, and this will help them in identifying the similarities and establish a familiarity with the diferences which as a result the paediatric patient will become less daunting. Emergency medicine is about keeping it simple and doing the basics well, this approach is what saves lives therefore when it comes to the most complicated eventualities such as trauma and resuscitation, simple is your friend. NTACC in relation to paediatric patients prefer the terminology “little humans”. There are diferences between the adult and paediatric patient however, as experienced practitioners you should use your existing knowledge and experience from adult practice and channel it into the management of paediatric trauma and resuscitation. In order to move passed the panic and reduce the cognitive overload apply the following approach going forward. “ Look for the similarities and be mindful of the diferences! ” So, there are a number of key diferences between the child and the adult trauma patient but will address these diferences in more detail in the following section on assessment. Below is a brief overview of the key diferences in the child and bear in mind with each childhood stage these elements will change: • Weight • Anatomically – size and shape • Physiologically – cardiovascular, respiratory and immune function • Psychological – intellectually and emotionally Assessment of the Paediatric Trauma Patient When assessing the trauma patient most of you will be used to the CABCDE approach however, in NTACC we have adopted the ATACC approach to assessment of the trauma patient which is M.A.R.C.H. As you will see once we go through the MARCH algorithm they still encompass all the same elements and in a similar order. Chapter 7. Paediatric Trauma

102 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com M.A.R.C.H ALGORITHM – FOR CHILDREN B.L.S. PROTOCOL NO SIGNS OF LIFE Re-assess again! SAFE APPROACH TIME CRITICAL HAEMORRHAGE CONTROL D.D.T Not more than 60 secs if single rescuer AIRWAY MANEOUVRES • Jaw Thrust • Oxygen 15L/min • Chin Lift - Sats > 95% • NP/OP • Cx spine caution RESPIRATORY SUPPORT • RR <8/min - BVM - Pocket mask • Oxygen 15L/min • Chest seal (wounds) CIRCULATORY SUPPORT • Re-assess D.D.T CONSIDER: • ‘Scoop and Run’ • Pelvic Strap • Gentle handling • Traction Splints • Elevate Legs INJURY SUPPORT HEAD INJURY • Keep child talking / engaged SPINAL INJURY AND FRACTURES • Immobilise BURN INJURY • Cooling • Cling-flm/bags ENVIRONMENT • Keep warm • Package for Transport MASSIVE HAEMORRHAGE AIRWAY PROBLEM? • Unconscious • Airway at Risk • Obstructed • Cx spine: if 2 persons • Sats <95% HEAD & OTHER INJURIES • Unconscious • GCS <12/15 • AVPU • Pain or numbness • Drowsy / Listless • Burns • Crying • Fever • Others AGE 0-6MTHS 7-12MTHS 1-3 YRS 4-6 YRS 7 YRS RESP/MIN >30-60 >25-45 >20-30 >16-24 >14-20 AGE 0-12MTHS 1-2 YRS 2-5 YRS 5-12 YRS >12 YRS BPM 110-160 100-150 95-140 80-120 60-100 RESPIRATORY PROBLEM? • RR >20/min • Difculty in breathing • RR <8/min • Sats <91% air / <94% 02 CIRCULATION PROBLEM? • Unconscious • Radial Pulse absent • CRT > 3secs • Radial Pulse >110/min NOT BREATHING Chapter 7. Paediatric Trauma

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 103 Paediatric Trauma M = MASSIVE HAEMORRHAGE The rationale for starting your assessment with massive haemorrhage is that frst and foremost as a practitioner you are trying to preserve circulation. And in any patient child or adult if they have an uncontrolled massive haemorrhage, irrespective of what life-saving treatments you put in place, this will kill them before anything else will. The management of massive haemorrhage uses the same principles as the adult. The steps for controlling haemorrhaging can be remembered by the phrase I-DiD-iT, which stands for: I – Indirect pressure Di – Direct Pressure Di – More direct pressure (2nd time) T – Tourniquet application Administration of tranexamic acid (TXA) in the paediatric patient should be within the frst 3 hrs of trauma. Table 7 – Tranexamic Acid MAX DOSE DILUENT INFUSION DELIVERY Loading Dose 15mg/kg Max 1g sodium chloride 0.9%/glucose 5% 10 minutes Maintenance Dose 2mg/kg/hr 500mg in 500ml sodium chloride 0.9%/glucose 5% 2mls/kg/hr Rocuronium Induction 1.5mg/kg 60 secs 15-25 mins Remember, in children their circulating blood volume/kilogram of body weight is higher than that of an adult (70-80 ml/kg), but the actual volume is smaller. Table 8 – Circulating Blood Volumes AGE BLOOD VOLUME (ML/KG) Neonate (Birth - 4wks) 85-90 Infants (4wks – 1yr) 75-80 Children 70-75 Adults 65-70 Chapter 7. Paediatric Trauma

104 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Paediatric Trauma A = AIRWAY The main goal here is to oxygenate and there are a number of diferent things that can afect oxygenation such as obstruction, loss of consciousness, physiological exhaustion. The paediatric airway is diferent in a few obvious ways for example children have relatively large heads in proportion to their bodies, they have short necks, small mandibles and large tongues. It is also important to remember that the anatomy of the paediatric airway changes with age. In particular in infants <6mths, this cohort are predominately nasal breathers and have quite narrow nasal passages which are easily obstructed. However, it is important to remember the airway ladder approach to resolving an airway issue is the same in children and adults there are just some minor adjustments to be made. Positioning for opening the airway is dependent on the age of the child for infants we use the snifng position due to their large occiput and in the older child it is head tilt, chin lift (as per the adult). Suctioning in infants is usually focused on the nasal passages and may not be tolerated well in the alert child potentially increasing the demand on oxygenation. When using a bag value mask (BVM) ensure you are using the correct size paediatric BVM. Airway adjuncts such as OP and NP airways are available in paediatric sizes and are sized the same way as the adult. Additionally, i-Gels are also available for children as small as 2kgs and are particularly helpful in airway obstruction. The fnal step on the ladder is intubation and can be tricky if you are not familiar with paediatric patients. Important thing to bear in mind is all young children has a horseshoe shaped epiglottis which project posteriorly and anteriorly at a 45-degree angle and tube size and insertion depth vary with age. Table 9 – Rough Guide to ETT in Paediatrics AGE CUFFED UNCUFFED Premature Neonate Not used Gestational age in wks/10 Full-Term Neonate Not usually used 3.5 Infants 3.0 – 3.5 3.5 – 4.0 Children (1-2yrs) 3.5 – 4.0 4.0 – 4.5 Children (>2yrs) Age/4+3.5 Age/4+4 Finally, when managing a very young intubated child, be aware that due to their airway anatomy (short trachea and the angles of the epiglottis) tube displacement is more likely. Chapter 7. Paediatric Trauma

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 105 Paediatric Trauma R = RESPIRATORY The respiratory assessment for children is similar to that of the adult however, children (under a certain age) have a compliant chest wall, an increased O2 consumption and a higher basal metabolic rate (BMR) than that of the adult. Therefore, if a child presents with an airway obstruction or a respiratory problem it will commonly manifest as prominent recession and an increased respiratory rate (RR). The degree of recession is an indication of severity of respiratory difculty this increased work of breathing will manifest as suprasternal/tracheal tug (found at the junction of the clavicle and the base of the neck), subcostal (indrawing at the base of the ribs) or intercostal (indrawing of the musculature in between at the rib spaces) recessions. These indicators are more commonly found in younger infants due to the compliant chest wall, the presence of recession in older children (> 6yrs) indicates a severe respiratory problem. The child who has become exhausted and no longer has the ability to compensate will have decreased recession and may potentially start to pant and drool. It is also important to remember the efect increased respiratory demand can have on the other body systems some more specifc than others. Bearing in mind, mechanical adjuncts such as pulse oximetry can be key tools when assessing a child in the early stages of respiratory illness nothing can compare to your own clinical observation when examining your patient. Changes in skin colour caused by hypoxic vasoconstriction is a late pre-terminal sign. By the time central cyanosis is apparent the patient is close to respiratory arrest. Tachycardia in the older infant and child is also a sign of hypoxia however, is deemed non-specifc as anxiety and pyrexia will also contribute to tachycardia. However, prolonged hypoxia will lead to bradycardia which is also a pre-terminal sign in the paediatric patient. Hypoxia in a child (like the adult) can produce initial agitation and as things progress exhaustion takes hold causing drowsiness and fnally loss of consciousness. It is important to monitor ETCO2 if patient is showing signs of worsening respiratory illness, consider ventilation. C = CIRCULATION The heart rate in shocked paediatric patients will initially be increased due to catecholamine release and as a compensatory mechanism due to the small stroke volume in child (particularly in infants < 2yrs). A circulatory assessment in the paediatric patient can be achieved by assessing three key elements: capillary refll time (CRT), pulses and blood pressure. CRT can be done both centrally and peripherally (Sternum/nailbeds) using your fnger depress the skin for 5 seconds and wait for the colour to return, which should be < 2 seconds. Delayed refll time is indicative of poor skin perfusion, shock or hypothermia. Table 10 – Normal respiratory rates AGE BREATHS/MIN 0-6 mths 30-60 7-12 mths 25-45 1-3 yrs 20-30 4-6 yrs 16-24 >7 yrs 14-20 Table 11 – Normal heart rates AGE BEATS PER MIN (BPM) 0-12 mths 110-160 1-2 yrs 100-150 2-5 yrs 95-140 5-12 yrs 80-120 >12 yrs 60-100 Chapter 7. Paediatric Trauma

106 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Paediatric Trauma Pulse volume is also a gauge of perfusion and is assessed by comparing peripheral and central pulses (radial/brachial). The absence of peripheral and weak central pulses are a serious sign of advanced shock and an indication that hypotension is already present. Although, hypotension is a late pre-terminal sign it is a key element of the circulatory assessment. Once a child’s blood pressure has fallen cardiac arrest is imminent. Blood pressure (BP) in the child varies within each age group by height however, there are formula which can help to estimate the expected systolic BP (85 + (Age in yrs x 2) = 50th Centile; 65 + (Age in yrs x 2) = 5th Centile). Cannulation and venepuncture in the paediatric trauma patient can be difcult therefore after one failed intravenous attempt, access should be gained by the intraosseous route. Of note, myocardial function and response to fuid is similar to that of an adult by 2 yrs of age. Damage control resuscitation using 5mls/kg boluses of fuid (preferably blood) should be used to maintain a peripheral pulse. Traumatic injuries acquired from high risk mechanisms such as high speed RTC or pedestrian vs. car or bike vs car can be potentially fatal therefore it is our responsibility as practitioners to do as much as we can in the initial stages. Traumatic injuries in the paediatric trauma patient resulting from the aforementioned mechanisms such as long bone fractures, pelvic injuries and pneumothoracies/ haemothoracies are managed similarly to the adult. Long bone fractures (e.g. femoral) in all ages can be managed with the application of traction using standard Kendrick Traction Devices. Pelvic fractures where haemorrhage is suspected can be splinted using the T-Pod or Prometheus pelvic binder. The pelvic binder will reduce blood loss and be potentially life saving. Marks on the abdomen left by seat belts in an RTC, are high risk markers for intra-abdominal haemorrhage and potential rupture of solid or gas flled organs. Pneumothoracies/haemothoracies can be managed in patients of all ages with fnger thoracostomies, in ventilated patients, although needle drainage may be necessary if your fngers will not ft between the ribs. If spontaneously breathing they will require a non-return valve or underwater seal on a drain. H = HEAD & OTHER INJURIES In trauma rapid assessment is key to management in the initial stages, in this section we will discuss the assessment of neurological function. A rapid assessment of conscious level can be determined by using the AVPU scale similar to the adult. Each patient is assigned to a category: • Alert • Responding to Voice • Responding to Pain • Unresponsive Posture can also be a key indicator of illness in the child, children who are seriously unwell commonly present in a hypotonic state (‘foppy child’). Other postures that may present are stif postures such as decorticate (fexed arms & extended legs) and decerebrate (extended arms & extended legs) are suggestive of serious brain dysfunction. Identifcation of depressed neurological function or in the case of head injury a more detailed assessment would be carried out using a paediatric specifc Glasgow Coma Scale (GCS), this assessment would also encompass pupillary size and reaction. When assessing for any other injuries it is important to consider the environment/scene of the accident, the mechanism of injury and in all cases, we need to consider nonaccidental injury (NAI) if the story does not ft the clinical picture. All of the above will help the practitioner in determining the potential injuries and direct our assessment accordingly. The previous sections have considered the obvious anatomical and physiological diferences between the child and the adult patient. In this next section we will examine what could be considered the most signifcant diference between the two, the psychological diferences. Children as they grow develop not only physically but intellectually and emotionally too. Trauma, irrespective of age, is frightening and disorientating. However, as adults we can rationalise a situation a lot faster than a child, as we have developed both intellectually and emotionally to facilitate this process. When managing children, it is important to remember that some of the standard practices, such as immobilisation, may be intentionally ignored in an efort to reduce the risk to the patient. In addition, adult practitioners can fnd pain assessment and analgesia in the paediatric patient a real challenge. Chapter 7. Paediatric Trauma

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 107 Pain assessment and analgesia A ‘Pain-Free ED’ and especially children is a key goal for everyone on the trauma team and is also a key quality indicator for ED staf. Paediatric pain management in emergency departments across the globe, is an area of clinical care in which emergency practitioners continually struggle. There are a number of contributing factors including; lack of familiarity with paediatrics, failure to appreciate the impact of pain, lack of education in paediatric pain assessment and the fear of overdosing a child. Pain is a key vital sign that should be recorded for every patient attending the ED and it is important to remember inadequate pain management can be detrimental to the critically ill child. Table 12 – Efect of Pain on the Body Systems SYSTEM OUTPUT Cardiovascular Increased Heart Rate Increased Blood Pressure Increase CO2 Increased O2 consumption Respiratory Increased Respiratory Rate Decreased Flow/Volume Decreased SPO2 Endocrine Increased Cortisol Levels Increased Adrenaline Increased Glucagon Increased BM Gastrointestinal Reduced Gastric & Gut Motility Musculoskeletal Tension Spasm Fatigue Chapter 7. Paediatric Trauma

108 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Pain assessment and analgesia However, before you can manage the pain you must frstly assess it. Paediatric pain assessment uses self-report scales which measure the patients pain intensity along a continuum of ‘no pain’ to ‘worst pain’. However, the developmental stages make this process more challenging. The self-report scales can be efectively used in paediatric patients from 3yrs onwards, with the exception of children whose cognitive function does not align with their chronological age. The most commonly used self-report tools are the Face Pain Scale – Revised (FPS-R) appropriate for use in children from 4–12yrs, it is quick to administer and requires minimal instruction for both practitioner and patient. THE WONG-BAKER™ PAIN SCORE 10 DEATH IMMINENT WORST PAIN POSSIBLE 8 UNBEARABLE SEVERE PAIN 6 INTERFERES WITH CONCENTRATION SERIOUS PAIN 4 INTERFERES WITH TASKS MODERATE PAIN 2 CAN BE IGNORED MILD PAIN 0 NO PAIN NO PAIN 0 1 2 3 4 5 6 7 8 9 10 Chapter 7. Paediatric Trauma

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 109 Pain assessment and analgesia The real challenge for the Trauma team is the under 3yrs (infant/toddler). This cohort of children are for the most part non-verbal and therefore cannot directly communicate how they feel and the pain they are experiencing. However, worry not, there is alternative pain measurement tool which can assist the practitioner in formulating a pain management plan for a child under 3yrs. Behavioural scales, although not considered as robust as self-report scales, are the best alternative for infants or non-verbal children. The most commonly used behavioural scale in the emergency setting is known as “FLACC". This scale ofers the practitioner with a numerical fgure of pain intensity almost solely based on interpretation of the child’s behaviour. Table 13 – FLACC Pain Scale CATEGORIES SCORE ZERO SCORE ONE SCORE TWO FACE No particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant quivering chin, clenched jaw LEGS Normal Position or relaxed Uneasy, restless, tense Kicking or legs drawn up ACTIVITY Lying quietly, normal position moves easily Squirming, shifting back and fourth, tense Arched, rigid or jerking CRY No crying (awake or asleep) Moans or whimpers, occasional compliant Crying steadily, screams or sobs, frequent complaints CONSOLABILITY Content, relaxed Reassured by occasional touching, hugging or being talked to, disctractable Difcult to console or comfort If a child is displaying these behaviours, it doesn't necessarily mean that they are in pain, as some of these behaviours measured by the FLACC scale can happen for other reasons. However parents are advised to follow up high scores with a professional. 0 Relaxed and comfortable 1-3 Mild discomfort 4-6 Moderate pain 7-10 Severe discomfort of pain or both INTERPRETING THE BEHAVIOUR SCORE Each cataegory is scored on the 0 - 2 scale, which results in a total of 0 - 10 Chapter 7. Paediatric Trauma

110 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Paediatric trauma transfer Once patient has been stabilised the decision is then made as to admit of transfer to a paediatric major trauma centre. There are number of structured procedures to undertake when making these decisions. Primarily, we will examine the 5 R’s: 1. - Right time 2. - Right people 3. - Right place 4. - Right form of transport 5. - Receive the right care through-out Once the decision to transfer has been made a systematic approach to the transfer of a child should be initiated such as: A – ASSESSMENT Key element of any patient is the reassessment, especially by the transport team if they have not been involved in the patient management up until the point of transfer. This assessment will be undertaken by the ED clinician and the transport team on handover. Once the patient care has been taken over by the transport team a continuous assessment will be undertaken and monitoring for any changes in the child’s condition will be managed accordingly. C – CONTROL Once the joint assessment is complete the transport organiser will take over management and similar to the assigning of roles prior to the patients’ arrival the transport leader will undertake the same process with their team. C – COMMUNICATION The transfer of a critically ill patient from one place to another, whether it is a to a ward/ICU or another hospital it requires level cooperation and coordination by multiple clinician and organisations. Clear and concise communication is key to this process being successful. E – EVALUATION This is to confrm that the transport is appropriate, is the patient stable, what is the clinical urgency or the suitability of the patient for the receiving ward/hospital. P – PREPARATION AND PACKAGING Patient = Ensure the airway is clear and secure and the appropriate ventilatory support is established. Confrm that venous access is established and functioning preferably, 2 large bore cannulas or a central line, if these cannot be achieved IO is the alternative option. Confrm that the patient has adequate fuid resuscitation is in progress or completed. If required make sure the patient is appropriately immobilised. Equipment = Confrm all batteries are suitably charged and back-up power sources are available. Supplies of all drugs, oxygen and fuids are calculated and that you have enough for the whole journey and any potential delays. Personnel = Ensure all staf are trained and appropriately prepared for transport T – TRANSPORT Mode of transport – this is a decision which will be made by the team leader, the receiving clinician and the transport team. Factors that would afect the mode of transport are nature of the illness, urgency of transfer, mobilisation time, geographical factors, weather, trafc conditions and cost. Chapter 7. Paediatric Trauma

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 111 The research would suggest that elderly trauma patients have worse outcomes than their younger counterparts. There are a number of reasons identifed in the literature which impact on the elderly trauma patient. Studies would suggest that older patients are often under triaged in the Emergency Department (ED). A contributing factor related to this phenomenon is elderly patients have a lower tolerance related to mechanism of injury (MOI) and therefore can sustain serious or lifethreatening injuries from incidents which could, on the face of it, seem quite benign. Additionally, older people are also known for their stoicism and therefore under-report their true pain. In fact, data from the Trauma Audit and Research Network (TARN) and work by the HECTOR team at Heartlands Hospital found that the most common mechanism of injury (MOI) for patients over 65 years of age was a simple fall from standing height. Chapter 7. Silver Trauma

112 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Silver Trauma Additionally, older patients often have signifcant underlying medical conditions, which can cause complications in trauma such as, the patients’ physiological observations may deviate signifcantly from the recognised norms. For example, we usually regard a patient to be in shock if their blood pressure falls below a systolic of 90mmHg as we assume ‘text book normal’ to be around 120/80. However, an elderly patient may function perfectly well with a baseline blood pressure of 180 systolic. This means that for them a systolic blood pressure of 120 would constitute a massive drop in pressure but may be overlooked when we are looking for signs of shock. Where possible previous notes and a primary care record of their regular medications should be located to appreciate patients’ baseline observations and potential drug interactions. Elderly patients are often on anticoagulant medication which means that haemorrhage control can be challenging. NICE guidelines state that patients with a head injury who are taking anti-coagulants should have a CT scan within 8 hours of arrival to the ED. Where active bleeding is present it may be necessary to reverse the anticoagulant. The treatment protocols used to reverse anticoagulant therapies will vary depending on what medication the patient is taking and what reversal agents are present in your trust. Therefore, it is advisable that you familiarise yourself with your local protocols. For example, warfarin is a vitamin K agonist and is reversed using vitamin K IV, however, this treatment can take between 6 to 8 hours to have an efect. If an immediate reversal is needed due to on going bleeding then it may be more appropriate to give fresh frozen plasma or more commonly, a pro-thrombin complex such as Octaplex. Octaplex contains the human vitamin K dependent blood coagulation factors II, VII, IX and X. More recently, patients may have been started on a non-vitamin K antagonist oral anticoagulant (NOAC) which is slightly more complex. At present reversal agents exist for some, but not all of these medications, and the correct treatment will require a discussion with your haematology department. Finally, we need to consider the anatomy of the older person as many have underlying skeletal abnormalities such as scoliosis or osteoarthritis. This is important as when managing particular traumatic injuries such as neck or spinal injury. In trauma management, we as practitioners often put patients in a cervical collar and blocks. However, for the older person with aforementioned skeletal abnormalities, laying them fat and/or manipulating their neck into a rigid collar will most certainly cause distress to the patient and possibly exacerbate their condition. The same is also true with other joints, as they may be more rigid and similar to reduced tolerance for MOI the forces needed to cause disruption will be lower. With this in mind consideration of the standard treatment processes we use in trauma patients should be adapted for the elderly patient as long periods of immobilisation may lengthen the period of hospitalisation for this patient cohort. Whilst we do our best to avoid these instances, trauma patients may often be laid prone for long periods of time. Despite practice change in relation to spinal boards, we still keep people laid fat for long periods whilst we await results of imaging. In the elderly this can be life threatening. We have all seen a patient who presents as a ‘long-lie’ having had a fall then being unable to get up and then develops complications such as rhabdomyolysis. These instances can also occur if an elderly patient lies for long periods on a hospital trolley, therefore it is imperative that as clinicians we promote early mobilisation as soon as is safely possible. The same is also true for respiratory problems, leaving patients laid prone they are more likely to develop infections such as pneumonia, especially if they already sufer from underlying lung pathologies such as COPD. The increased rigidity of the chest wall, along with reduced alveolar surface area, means that again a lower mechanism of injury to the chest is required to cause potentially life-threatening injury. Whilst there may be many possible complications when treating the elderly trauma patient, gentle handling and an individualised approach can help to overcome the majority of variables which can cause undue harm to this particular cohort. Chapter 8. Silver Trauma

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 113 The world’s population is changing as you can see from this diagram. Not only is it signifcantly growing, but it is also growing older. (see fgure 49) The numbers under 15yrs (Green) is now fairly constant, but all other ages are steadily increasing, especially from 60 years onwards, including the over 80 years age group. This is refected in our own Prehospital Fire & Rescue casualty data which shows that: • 67% are over 50 years • 40% are over 80 years • 10 % are over 90 years. In the 90s the average age of trauma victims was 36yrs and the largest single age group was the 0-24yrs (40%) involved in road trafc collisions. Some 20 years later in the 21st century, the average age group is 59yrs with the largest group being the >65yrs with only 30% of them involved in RTCs, but 40% have had a ‘low fall’ and 86% get CT scanned for major trauma. Elderly Chapter 8. Silver Trauma World Population Source: UN 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 8 8 8 9 9 10 11 13 16 19 21 34 37 38 35 33 30 27 25 24 22 21 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000 6,000,000 7,000,000 8,000,000 9,000,000 10,000,000 Above 60 Percentage Below 15 80 + 75 –79 70 –74 65 –69 60 –64 15 –59 0 –14 Age Figure 49: WORLD POPULATION Source:UN

114 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com FALLS This simple infographic from the USA, demonstrates the scale of the problem for the elderly. As you can see, those of 80+ years on average fall once every year. Up to 50% of these falls go unreported as the majority are in the home. Elderly Chapter 8. Silver Trauma TRIPS T TABLETS OR MEDICATION R RESTRICTED OR REDUCED VISION I IMMOBILITY, WEAKNESS OR POOR BALANCE P PAST MEDICAL HISTORY S SAFETY HAZARDS Figure 50: TRIPS ACRONYM They have an increased rate of falls for several reasons: T – Tablets and medication that may reduce awareness, create dizziness on standing or balance problems, as well as increasing the risks after a fall such a Warfarin and bleeding. R – Restricted or reduce vision. I – Immobility, weakness or poor balance. P – Past medical History e.g. Parkinson’s, previous stroke, cardiac disease. S – Safety hazards e.g. rugs, carpets, steps and stairs. Falls Age 65+ 1 out of 3 people fall each year Age 72+ Fall every two years Age 80+ Fall every year

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 115 The elderly are often very stoic and many will sufer in silence or they are used to pain and discomfort from managing their day to day problems such as arthritis. So we need to look out for non verbal cues and take care not dismiss things that they say. Many will try to dismiss their injury, or their trauma as minor or trivial, as it would have been years ago. PAIN Pain is under treated in the elderly and not just from trauma but also ‘elder abuse’ & maltreatment is under reported, so always consider welfare and safeguarding issues. ASSAULTS Assaults are sadly not uncommon in the elderly and leave them injured & vulnerable these victims have a 5 times higher mortality from the injuries than a younger population with similar injuries. The elderly account for 20-30% of pedestrians hit by motor vehicles as they are more at risk with their reduced senses and slower reaction. They are also far more at risk from injury from the most minor trauma. OSTEOPOROSIS A gradual weakening of the bones (see fgure 51) from 50yrs on wards, primarily in females, which greatly increases the risk of all fractures, especially hips after a fall and necks after RTCs. Patients >65years with rheumatoid arthritis are also at much higher risk from neck injuries in RTCs and we should have a low threshold to immobilize them for extrication. Elderly Chapter 8. Silver Trauma Figure 51: Bone deterioration over time

116 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 10 COMMON CHRONIC CONDITIONS FOR ADULTS 65+ Figure 52 illustrates that in over 65 years up to 80% have 1 chronic condition and 68% have 2 or more. High blood pressure, cholesterol and arthritis are the commonest but there are a number of others. Many of them also like a tipple and this can increase their risks of falls, bleeding and getting cold very quickly. Elderly Chapter 8. Silver Trauma 80% have at least 1 chronic condition 68% have 2 or more chronic conditions 11% Chronic Obsturctive Pulmonary Disease 14% Heart Failure 14% Depression 11% Alzheimer’s Disease and Dementia 29% Ischemic 27% Diabetes Heart Disease (Coronary Heart Disease) 47% High 31% Arthritis Cholesterol Quick Facts 58% Hypertension (High Blood Pressure) 18% Chronic Kidney Disease The elderly are very mobile with over 1 million drivers over the age of 80 years on UK roads and 121 over 100 years. They are not necessarily more dangerous as drivers, but they are far more vulnerable than younger age groups The under 30’s represent the age group in the most RTCs, but this may refect the fact that >70years do far fewer miles. They are however far more susceptible to injuries, even at low speeds, especially as they are often poorly placed for the safe use of SRS protection in the car. Mobility scooters are very popular with many elderly people, but remember that they can result in some falls and injuries at 15-20 mph or more, which can be very serious in this age group. Being able to travel some distance can often put the injured in some remote isolate locations where there is little help and they will get cold and features of hypothermia very quickly. However, even lying on the foor at home for half an hour or more can result in pressure sores, muscle damage and hypothermia, depending upon the surface, the clothing and the temperature of the environment. Always assume the worst until they clearly demonstrate that they are uninjured and their normal self. Figure 52: Common Chronic Conditions.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 117 WHAT’S THEIR NORMAL? Clearly not all elderly people are the same. Important to get some history about their health. Look around for clues if they cannot tell you, such as medication, med-alert bracelets, inhalers, breathing machines such as this CPAP machine or home oxygen. Encourage them to use any medication that they feel will help them, until the ambulance arrives. Many will be on lots of tablets and there are many sorters and simple devices to help identify what medicines are due throughout the day. Have a look if they have missed tablets today or may be taken too many. WARFARIN Warfarin is one of a number of diferent types of blood thinning medication, taken by an increasing number of elderly patients, which will signifcantly increase the risk of major life threatening bleeding in trauma and any patient that mentions that they are taking such anti-coagulants should raise serious concern, even after minor injury, especially if there is evidence of traumatic injury, wounds, head or chest injuries. Other medications such as some blood pressure tablets can mask the normal signs of shock, so we must always have a high index of suspicion and a low threshold for hospital referral. CONFUSION Confusion is not always due to dementia, it could also indicate other problems such as: • Sepsis • Medication problems • Low blood sugar • Hypothermia • Stroke. As some simple questions, including: • ‘Have you eaten today?’ – if they are fully conscious but confused then ofer them a sweet drink (2 sugars) in case they have a low blood sugar • If they feel very hot then consider sepsis and inform ambulance control • If they are very cold then gently warm them up with warm blankets and/or body heat if not in a heated environment. Elderly Chapter 8. Silver Trauma

118 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com FRACTURES Suspect fractures when there is: • Pain • Swelling • Deformity • Unable to use limb. In falls in the elderly the classic injury is a fractured neck of femur which will give severe hip pain and they will be unable to stand on the leg in the majority of circumstances. The afected leg is usually shorter and rotated outwards or inwards compared to the normal leg. Rib, shoulder, collar bone and wrist fractures are also common even after minor falls. STROKE FAST is an acronym for the easy to recognise features of a developing stroke: F – FACE: look for facial weakness, suggested by one side of the face drooping, or an unequal smile, or dropped eyelid or inability to puf out the cheeks equally. A – ARMS: ask the patient to raise both arms at the same time and look for any diferences, can they keep them up there normally for them. S – SPEECH: is the speech slurred or abnormal? This will often be noticed by the family and can be quite subtle or very obvious and can include an inability to speak or express what they want to say. T – TIME: this stresses the fact that time is of the essence in terms of identifying the problem and getting the patient to hospital immediately. A key part of making the diagnosis is to compare both sides of the body. If any are abnormal then this is a stroke until proved otherwise. HEART ATTACK Heart attack and cardiac problems are not always as obvious in the elderly. They may simply feel dreadful, short of breath or dizzy and light headed. These symptoms always warrant further investigation as well as chest pain and sudden onset of back pain. AWARENESS Look at the patient, the scene and be suspicious as the signs of a problem may be very subtle. If necessary arrange to call back and do a welfare check wherever possible. Be gentle with everything that you do, as skin, muscles and bones are all easily damaged and pain can result from even small movements in arthritis and other conditions. At all times, respect their privacy and dignity as they are still entitled to make choices in their life with any necessary support. Some may have advanced directives in place which defne what treatment that we can ofer. If in doubt, listen to the patient (if they have capacity it is their choice), the family or the carers, but if still unsure in an emergency then do what feels right, appropriate and in the patients best interest. Elderly Chapter 8. Silver Trauma

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 119 Unfortunately, despite our best eforts, patients may die following a traumatic injury. The manner in which we deal with this eventuality will vary between departments and will align with local guidelines and protocols. Chapter 8. Death of the Trauma Patient

120 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Breaking bad news This is never an easy job however it is part of our working life. These discussions should be carried out by the clinician who knows the patient and preferably with another member of staf present, who will be responsible for supporting the family. It is important to be sensitive to the religious or cultural needs of the deceased and their family. The news should be given in a sensitive yet timely manner, making sure to avoid jargon or euphemisms such as ‘they have gone on’. It will be dependent on the services available in your trust however, where possible a referral to the bereavement team should be made to ensure a follow-up plan can be made with the family. Ideally a designated relative’s room should be available where family members can sit whilst life support attempts are ongoing and in the moments after the patient has been confrmed dead. This room should have access to beverages and should be located near the resus room. Wherever possible a private viewing room should be available for relatives to view their loved ones’ body away from the chaos of the resus room. Written information regarding the process following the death of a family member should be given to the family prior to leaving the department as due to the traumatic and emotional nature of the situation they may struggle to retain important information provided by the ED staf. Procedures following death At the earliest opportunity patients should be referred to the Specialist Nurse in Organ Donation (SNOD) who can support the family and provide guidance. The SNOD can assess the patient for suitability for organ donation and, where appropriate approach the patient’s next of kin for consent. For tissue donation, referrals should be made via the National Referral Centre on: 0800 4320559. This service co-ordinates consent from family and tissue retrieval. Staf welfare As mentioned in previous chapters, major trauma is often unpleasant and staf should be given the opportunity to debrief after a distressing incident. This hot debrief can be followed with a more formal debrief at a later stage, but at the very least staf should be followed up and supported if necessary for a period after the more serious events. It is also important for Trusts to ensure appropriate counselling services are available if required, but in the frst day sand weeks after and event fashbacks and upsetting feelings are not uncommon of abnormal. Chapter 9. Death of a Trauma Patient

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 121 This section contains a brief overview of the procedures and skills you may be expected to undertake or assist for during the management of a major trauma patient, in the emergency department. In particular we will focus on the specifc nursing aspects such as the setting up and assisting rather than the specifc competence related to performing the procedure itself. The following is designed as template and not a defnitive reference document however, this will provide a general baseline document for all NTACC providers. Chapter 9. NTACC Trauma Skills

122 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Trauma skills Below is an overview and short description of each skill including their specifc indications and contraindications in relation to the major trauma patient. Additionally, we have included a suggested equipment list for each procedure/skill. However, as previously mentioned this is not a universal document and it is vital you familiarise yourself with the policies, procedures and kit of your parent department and trust. A) SURGICAL AIRWAY B) FINGER THORACOSTOMY AND INTERCOSTAL DRAIN C) THORACOTOMY D) EMERGENCY HYSTEROTOMY E) SPLINTS a) Emergency surgical airway Approximately 3% of all intubation attempts are considered difcult airways therefore when attempting RSI an airway plan must be considered from the very outset with multiple options including the potential for an emergency surgical airway (ESA) or Front of neck access (FONA). Thankfully the instances of ‘can’t intubate, can’t ventilate’ are rare however it is essential that anyone preforming or involved with an RSI are aware of the indications, complications, kit and procedure to perform this emergency bail out procuedure. The indications for emergency surgical airway (ESA) are: • 'Can’t intubate, can’t ventilate’ where other methods have failed and with decreasing SPO2 • If ETT intubation, Supraglottic airway or BVM is not feasible (massive facial trauma or burns) The contraindications for emergency surgical airway (ESA) are: • There is a simpler and quicker alternative eg a SGA • A relative indication is airway trauma that renders access via the cricothyroid membrane difcult, impossible or futile – e.g. laryngeal fracture, tracheal transection – open tracheal injury ANATOMY Positioning of the patient will be essential to achieve a successful surgical airway. Ideally sit the patient up to maintain the best position for breathing in a comprpomised airway and to reduce venous bleeding. If unconscious will not be possible. Extend the patients neck in supine position to make anatomy more accessible. A sand bag or litre of fuid under the shoulders may help to improve the nexk extension. NB: that airway has priority over suspected c-spine injury. With the non-dominant hand, identify the laryngeal landmarks (thyroid cartilage, cricoid cartilage and the cricothyroid membrane). The incision is made vertically at the level of the crico-thyroid membrane, just below the cricoid cartilage. EQUIPMENT • Skin prep • Scalpel (e.g. size 10) • Forceps (ideally tracheostomy dilators however 7-inch curved mosquito or spencer wells forceps are adequate) • Intubating bougie • Size 6.0 uncut cufed ETT (or tracheostomy tube) • 10ml syringe (to infate balloon) • Tube ties Chapter 10. NTACC Trauma Skills

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 123 a) Emergency Surgical Airway PROCEDURE • Once the laryngeal landmarks have been identifed, stabilise the structures with middle fnger and thumb of the non-dominant (ND) hand, ensuring the index fnger is on the cricothyroid membrane. • The scalpel is held in the dominant hand and rests on the patients sternum for stability and support • Lift the ND index fnger and with scalpel, make 4 cm vertical/ horizontal incision (practitioner dependent) through skin over cricothyroid membrane • Once skin incised, palpate cricothyroid membrane position and blunt dissect with a gloved fnger or forceps through subcutaneous tissue until and palpate tracheal lumen, ideally identifying the cartilage of the posterior wall of the trachea/ cricoid ring • Ignore bleeding until airway is secure (ETT placement usually has a tamponade efect) • Pass bougie alongside fnger/forceps into trachea • Bougie usually sticks at carina <10cm from the skin (may feel tracheal rings as the bougie advances), do not force if it sticks here as may perforate carina • Pass ETT over bougie and intubate trachea. Ensure the ETT balloon is fully defated and twist ETT as it passes the skin. Only advance the ETT until the balloon is within the airway and no longer visible (if advanced further then endobronchial intubation is likely). • Ensure ETT is held secure while bougie is removed and ETT is connected to BVM • Confrm ETT placement with ETCO2 (also adjunctive measures: auscultation, bilateral rise and fall of chest, fogging of tube and subsequent CXR) b) Finger Thoracostomy and Intercostal drain insertion Simple fnger thoracostomy is efective in decompressing a chest in a ventilated patient with a tension pneumothorax. This procedure is not typically used in the spontaneously breathing patient, as it will result in a sucking chest wound, further compromising ventilation. The procedure for fnger thoracostomy also forms the initial stage in the insertion of a chest drain. Once the immediately life-threatening situation has been dealt with thoracostomies at some point it must be converted to a formal intercostal chest drain. Surgical chest drains are to be used in trauma patients for the management of traumatic haemothorax or pneumothorax. Generally, Seldinger type chest drains while useful in treatment of spontaneous pneumothoraces, have no place in the management of traumatic chest injuries. ANATOMY The approach should be via the 4th or 5th intercostal space as when placing a drain. However, the presence of surgical emphysema and fail segments can make placement of the incision over the 4th or 5th intercostal space difcult. • landmarks = “triangle of safety”: anterior to mid axillary line, posterior to pectoral groove, above 5th intercostal space • layers that must be breached (superfcial to deep) = skin, subcutaneous tissue, intercostal muscles, parietal pleura ensuring that the blunt dissection method is used • be aware of the neurovascular bundle sitting on the inferior aspect of the ribs Chapter 10. NTACC Trauma Skills

124 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com b) Finger Thoracostomy and Intercostal drain insertion EQUIPMENT • Sterile clothing (gloves, gown, mask, facial shield) • Chlorhexidine in 80% alcohol • Sterile drapes • lignocaine 1% • 22G long needle • Scalpel • Forceps (7 inch and 9-inch spencer wells or mosquito) • Chest drain (>24 French for blood) • Suture material • Underwater seal drain • Dressing (various types) PROCEDURE • Position patient as appropriate so as to gain access to the chest wall • Usually the arm is place behind the head • Find the appropriate landmark as described above • Clean and drape entry site • Infltrate local anaesthetic • Make initial incision with scalpel (through skin only) – 3-4 cm • Continue with blunt dissection using forceps until chest wall is breached • Insert fnger and sweep to feel for the lung – is it infated? • Listen for air being released or blood coming out To proceed to full chest drain, use the following points: • Insert drain using spencer wells forceps • Suture drain to skin (local policy) • Attach drain • If conscious ask patient to cough • Apply dressing to site c) Thoracotomy A Resuscitative thoracotomy is one of the most invasive procedures carried out within the emergency department. As it is such an invasive procedure there are physical and psychological risks to consider with regard to healthcare staf, the trauma team, the patient and their family. The NTACC provider is well placed to support the trauma team leader in their decision-making process. Before commencing a thoracotomy, the airway must be secured with an endotracheal tube or a surgical airway. This is a traumatic cardiac arrest so chest compressions will simply delay or impair the procedure. This is NOT ALS and we should not enter the typical ALS loops of drugs and compressions etc Pre-hospital Considerations: • Major Trauma Centre more than 10 minutes away following loss of output • Appropriately trained personnel Indications for Resuscitative thoracotomy include: • Cardiac arrest within 10-15 minutes in penetrating trauma of chest or torso • Witnessed loss of output following blunt chest/epigastric trauma associated with cardiac arrest • >1500mls from a chest drain or thoracostomy • Major lung or tracheobronchial injury and airleak • Persistent BP <70mmHg despite resuscitation ? aortic X-clamping Chapter 10. NTACC Trauma Skills

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 125 c) Thoracotomy Contraindications to Resuscitative thoracotomy include: • Defnite loss of cardiac output for greater than 15 minutes • Any patient who has a cardiac output including hypotensive patients MANAGEMENT OF TRAUMATIC CARDIAC ARREST – HOT • Exclude hypovolaemia – push blood volume • Ensure oxygenation • Exclude tension pneumothorax: throacostomies • Exclude Tamponade – thoracotomy The order of the procedure would include: • Push volume • Ensure delivery of oxygen – ETT or i-Gel and ventilation • Make bilateral thoracostomies • STOP - Re-assess • Proceed to thoracotomy (joining up thoracostomies) Clamshell thoracotomy is the approach of choice in major trauma: Taking this approach of ‘joining up the incision that you have already made’ has been established and promoted by HEMS London, as it signifcantly reduces the operator stress in performing this procedure. As stated above your bilateral thoracostomies are the basis of the thoracotomy and the landmarks are as follows: • 5th intercostal space • Mid-axillary line Table 14 – Equipment for Resuscitative thoracotomy Finochietto Rib spreader (not essential) Chapter 10. NTACC Trauma Skills

126 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Table 14 – Equipment for Resuscitative thoracotomy Metzenbaum scissors Gigli saw (not essential) size 22 blade scalpel Trauma shears Chapter 10. NTACC Trauma Skills

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 127 c) Thoracotomy Procedure – Nurses will not be expected to perform a thoracotomy alone, but you may have to assist • Connect the thoracostomies with a deep skin incision following the 5th intercostal space • Insert two fngers into the right/left thoracostomy to hold the lung out of the way while cutting through all layers of intercostal muscles and pleura towards the sternum (repeat on other side) • Tuf-cut shears are the safest tool to cut through the sternum, although a Gigli saw can be used if staf are familiar with it but be careful as they are sharp • Open ‘Clam Shell’ using one or two large self-retaining retractors/rib spreaders • Lift (tent) the pericardium with clamp forceps and make a large midline incision • Evacuate all blood and clot and inspect the heart for site of bleeding • When massage is required it must be done with care from apex to base and a two-handed technique is preferred • One fat hand applied to the posterior of the heart and one on the anterior. Blood is ‘milked’ from the apex upwards at a rate of 80 beats/min Chapter 10. NTACC Trauma Skills

128 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com d) Resuscitative Hysterotomy Resuscitative hysterotomies are rare however, there are clear indications and time will be critical so it is best to be prepared. The evidence available indicates that resuscitative hysterotomy can improve maternal survival and potentially that of the baby too. A pregnant traumatic cardiac arrest victim will not be resuscitatable without emergency delivery of the foetus. A rapid decision to proceed is essential and it should be considered upto 20 minutes after the apparent loss of output. These three key factors improve the maternal chances of survival and establish rationale for resuscitative hysterotomy which are as follows: • It relieves aorto-caval compression facilitating better venous return • With the uterus empty the diaphragm returns to normal anatomical placement increasing space for lung expansion therefore improving pulmonary mechanics • When the baby and the placenta is delivered the oxygen demand on the mother is reduced These three key factors improve the maternal chances of survival. Indications for Resuscitative hysterotomy: • Confrmed or impending traumatic cardiac arrest ANATOMY The landmarks for resuscitative hysterotomy are the xiphisternum to the pubic symphysis. EQUIPMENT If your department has a thoracotomy kit it will have all the required instruments for a resuscitative hysterotomy. If not, you will require the following: • Size 10 scalpel • Scissors/trauma shears • Clamp x 2 (umbilical if available) • Packing material PROCEDURE The following is purely for information purposes, nurses will not be performing this procedure. • This is a traumatic cardiac arrest so chest compressions will simply delay or impair the procedure. This is NOT ACLS and the most likely cause will be hypovolaemia and foetal compromise of the circulation. • Begin with a vertical midline incision from the xiphisternum to the pubic symphysis (deviating around the belly button) • Incision will penetrate the skin, subcutaneous tissue, linea alba (avascular fbrous structure which runs down the midline of the abdomen) and the peritoneum • Dependent of the gestation of the foetus it would be best to ‘tent’ the peritoneum make an incision and with the scissors cut vertically on both sides. This will help to avoid ‘nicking’ the bowel • This will reveal the uterus and gestation dependent, the bladder. Remember the uterus is above the bladder • Similar to the peritoneum make an incision in the uterus and extend the incision with the scissor using your fngers to protect the baby • Deliver the baby, apply both clamps to the umbilical cord and cut between the two clamps • Pass the baby to a suitably qualifed clinician who can provide neonatal resuscitation • Deliver the placenta • Pack the uterus with large gauze swabs and maintain direct pressure. Chapter 10. NTACC Trauma Skills

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 129 e) Splints The goals of splinting are simple and are basically used to immobilise potentially broken bones, reduce the chances of further soft tissue injury that bone movement may cause and decrease the pain experienced by the patient. The other indications for splinting of fractures are: • Haemorrhage control • Protection of neurovascular supply Below is a table of some splints you may use when managing the trauma patient. As part of the course there will be opportunity to practice applying some of these splints and time to discuss their merits and difculties as no one piece of kit is perfect. Table 15 – Splints SPLINT INDICATION IMAGE Box splint Relatively cheap, reusable but the patient needs to ft the splint which can be difcult if not impossible. Absolutely fne for a simple lower limb injury but not quite so for a displaced fracture. Vacuum splint Basically a plastic bag full of polystyrene beads. If a patient has an displaced limb injury it can be moulded to ft almost any shape. Once applied the air is vacuumed out to give the equivalent of an instant plaster cast. They are lightweight, reusable and thanks to the negative pressure of a vacuum they cause less issues with pressure sores. They can be x-rayed, CT scanned and MRI scanned safely. Chapter 10. NTACC Trauma Skills

130 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com e) Splints Table 15 – Splints SPLINT INDICATION IMAGE Pelvic Binder Forms part of the circulation management of trauma patients. Several diferent designs available. Again should be ready on the ED trolley if not applied pre-hospital. If mechanism suspicious of pelvic fracture then apply. Femoral traction splints The Kendrick Traction Device is designed for traction to reduce mid shaft femoral fractures. It is simple and quick to apply helping to reduce haemorrhage and pain from the injury. Getting hold of a Thomas splint can be quite difcult in most ED’s so this type of device gives an excellent alternative that if not applied prehospital can be done quickly in the ED and with very little movement of the injured limb. Chapter 10. NTACC Trauma Skills