Major Trauma

“The early deaths that occur within minutes or hours after injury are largely due to bleeding. These deaths can be prevented and this group of patients are the focus of the ATLS protocol and those that good emergency department care can probably make the most difference to.”

CMP 3 – Major Trauma

EM Curriculum: (click to view)

Background

In the UK major trauma is the leading cause of death in those under 40 years old [1]. In children, mortality from injury is greater than childhood mortality from all other causes combined [2].

Major trauma is, however, a minor element of emergency department work equating to less than 0.2 per cent of total activity [3].

As a result those involved in the management of severely injured patients may not have regular or significant previous experience with such cases. Therefore it is important to have a good understanding of the principles behind the initial assessment and management of trauma patients.

The pattern of  trauma deaths are classically described as having a Trimodal distribution comprising of immediate, early and late deaths. Immediate deaths are those due to massive injury that occur within seconds to minutes of the traumatic insult and are not preventable.

The early deaths that occur within minutes or hours after injury are largely due to bleeding. These deaths can be prevented and this group of patients are the focus of the ATLS protocol and those that good emergency department care can probably make the most difference to.

References:

  1. National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Trauma: who cares? A report of the National Confidential Enquiry into Patient Outcome and Death (2007), November 2007.

  2. Mace SE, Gerardi MJ, Dietrich AM, et al. Injury prevention and control in children. Ann Emerg Med 2001;38:405–14.

  3. National Audit Office (NAO). National Audit Office (NAO). Major trauma care in England. Report by the Comptroller and Auditor General. HC 213 Session 2009-2010, 5 February 2010.

Learning outcomes from completing the tasks

  • Perform and interpret a primary and secondary survey.

  • Recall how to perform an emergency cricothyroidotomy.

  • Describe how to establish intra-osseous access and apply a pelvic binder.

  • Identify life-threatening thoracic injuries including those mentioned specifically in the CEM ACCS curriculum.

  • Undertake needle thoracocentesis and intercostal drain insertion.

Learning outcomes from face-to-face teaching

  • Identify life threatening injuries related to abdominal trauma.

  • Recognise and manage hypovolaemic shock.

  • Use the EZ-IO kit to establish intraosseous access and apply a pelvic binder.

  • Provide c-spine immobilisation and co-ordinate the performing of a logroll on a patient.

Tasks

Complete the following before the face to face session:

TASK 1: Initial Assessment & Management of Major Trauma

Duration: 40 mins (total for all parts)

Read the two blog entries from Life in the Fast Lane regarding preparation for and initial assessment of major trauma patients then complete the Doctors.net module on immediate management of major trauma to test and consolidate what you have learned.

Part I: Trauma! Are you Prepared?

Part II: Trauma! Initial Assessment & Management

Task 2: Major Trauma is Mutating

Duration: 2 mins

This short video of Prof Coates is taken from #GemCON16 and discusses how major trauma in the 21st century has become a disease of the low mechanism injuries in older patients. (If you want more on the TARN data it is available in this paper from the EMJ).

Task 3: Thoracic Injuries

Duration: 120 mins (total for all parts) 

This task covers thoracic injuries in depth as this topic is given particular emphasis in the Major Trauma section of your curriculum. After completion of the two eLearning modules on Thoracic Injuries and the module on Chest drain insertion you have have a good understanding of how to identify and manage such injuries.

Parts I & II provide a thorough overview of serious chest injuries seen in major trauma patients. Part III covers the indications and technique for chest drain insertion as well as post-procedure management.

Part I: RCEM Learning – Thoracic Injuries I

Part II: RCEM Learning – Thoracic Injuries II

Part III: RCEM Learning – Chest Drain Insertion in Adult Trauma

Task 4: Equipment & Procedures

Duration: 30 mins (total for all parts)

Trauma, who doesn't love a good trauma? The problem is we don't always get exposed to enough especially when it comes to practical skills. It is important to be familiar with and prepared to use a range of equipment. ATLS allows some familiarisation with equipment, and further local simulation can help consolidate this. To start with watch the following videos and then take the time to locate the following pieces of equipment in our department.

Part I: EZ-IO

Watch this video that demonstrates the use of the EZ-IO device.

Part II: T-POD Pelvic Binder

Watch this video that demonstrates how to apply the T-POD pelvic binder.

Part III: Cricothyroidotomy

This page explains how to perform an open cricothyroidotomy.

TASK 5: FAST SCANNING

Duration: 30 mins

The use of US in the ED is increasing and whilst it is mostly a HST skill it is important to be aware of its uses. The FAST scan is a powerful tool in trained hands. Read the following and then take time to watch scans performed in your department and consider a Level 1 US course.

#EM3 Content

Lighting Learning:

SIMBLOG:

Case Discussion

We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.

Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.

Part of the face-to-face teaching will be spent discussing the case(s) below:

“An unknown male has been brought into the ED having been struck by a car whilst crossing the road.”
“You are just starting in Resus and take a handover for what sounds like a rather interesting trauma case in Bay 3. You are asked to do the secondary survey.”

Additional Resources

Have a look at the following additional resources relevant to this topic:

Anatomy for Emergency Medicine:

Need a refresher on your anatomy? These video podcasts (also available on iTunes) by an Irish consultant are aimed at anatomy relevant to the CEM curriculum. It is well worth watching as many of these as you are able, and they can be useful for MCEM A revision. Specific trauma ones are below:

DNuk:

A quiz on trauma radiographs, aimed to identify some of the pitfalls of imaging in trauma. This can be found in the eCME quizzes section of the Education pages.

Sketchy Medicine:

Surface anatomy of the chest and sites for decompression or chest drains.

Trauma.org:

A useful website with a number of resources covering range of topics related to trauma

Anaesthesia-UK:

Another anaesthetic resource, this particular page attempts to summarise the whole of trauma and makes a reasonable effort of it. Key sections include:

  • Preparation both pre-hospital and in hospital.

  • Triage with adult and paediatric trauma scores.

  • Summary of primary/secondary surveys, what you are looking for and outlining adjuncts.

  • Airway and ventilation management.

  • Shock: including classification and management.

  • Summaries of Chest, Abdo, Spine and Head trauma.

  • MSK injuries and thermal injuries.

  • Trauma in women and in pregnancy.

Course Feedback

Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form:

Updated: 28th July 2016