trauma care in new zealand. trauma in new zealand zno overarching national database but yrtc death...
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TRAUMA CARE IN NEW ZEALAND
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TRAUMA IN NEW ZEALAND
No overarching national database BUT RTC death rate about 9/100,000/year Major trauma incidence about
40/100,000,year Overall death rate about
25/100,000/year
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PREHOSPITAL CARE
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PREHOSPITAL CARE
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Initial Assessmentof the Trauma Patient
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International ATLSInternational ATLS®® Program Program
> 30 Countries> 30 Countries > 1,000,000 doctors > 1,000,000 doctors
trained worldwidetrained worldwide 30 year history30 year history
> 16,000 doctors > 16,000 doctors trained in Australasiatrained in Australasia
1000th EMST course 1000th EMST course in 2011in 2011
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Initial Assessment of the Trauma Initial Assessment of the Trauma PatientPatient
Primary SurveyPrimary Survey
ResuscitationResuscitation
Secondary SurveySecondary Survey
Definitive careDefinitive care
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Primary Survey
Airway with c-spine control
Breathing
Circulation (stop external haemorrhage)
Disability (AVPU or GCS + pupils)
Exposure and Environmental control
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Airway Airway (CAUTION C-SPINE)(CAUTION C-SPINE)
Talk to the patientTalk to the patientLook with suctionLook with suctionChin lift/ jaw thrustChin lift/ jaw thrustOral/nasopharyngeal airwayOral/nasopharyngeal airwayCuffed tube (oral/nasal/surgical)Cuffed tube (oral/nasal/surgical)OXYGENOXYGEN
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BreathingBreathing
Ensure airway is adequateEnsure airway is adequateLook (chest wall/RR/cyanosis)Look (chest wall/RR/cyanosis)Feel (chest Feel (chest
wall/trachea/percuss)wall/trachea/percuss)Listen (auscultate)Listen (auscultate)Adjuncts (SaO2)Adjuncts (SaO2)
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Tension PneumothoraxTension Pneumothorax
Respiratory distress Respiratory distress (RR>30 or <10)(RR>30 or <10)
Elevated neck veinsElevated neck veins Cyanosis (late)Cyanosis (late) Deviated tracheaDeviated trachea (Hyper)resonant chest (Hyper)resonant chest
on one (both) sideson one (both) sides Unilateral absence of Unilateral absence of
breath soundsbreath sounds
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Insertion of chest tubesInsertion of chest tubes
5th ICS in MAL5th ICS in MAL Local anaestheticLocal anaesthetic 3cm incision3cm incision Blunt dissectionBlunt dissection Finger explorationFinger exploration Remove trocarRemove trocar Blunt forceps to Blunt forceps to
insert chest tubeinsert chest tube
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Immediately Life-threatening Chest Immediately Life-threatening Chest TraumaTrauma
Airway obstructionAirway obstruction Tension pneumothoraxTension pneumothorax Massive haemothoraxMassive haemothorax Open (sucking) pneumothoraxOpen (sucking) pneumothorax Flail chestFlail chest Cardiac tamponadeCardiac tamponade
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CirculationCirculation
Look (stop external Look (stop external bleeding)bleeding)
-- CHECK PERFUSIONCHECK PERFUSION --Feel (pulse/BP)Feel (pulse/BP)Listen (BP)Listen (BP)2 large bore (16Fg) IVs2 large bore (16Fg) IVs2 l balanced salt solution 2 l balanced salt solution
(20ml/kg) in children(20ml/kg) in children
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DisabilityDisability
AVPU AVPU AlertAlert responding to Verbal responding to Verbal
stimulistimuli responding to Painful responding to Painful
stimulistimuli UnresponsiveUnresponsive
GCSGCSPupilsPupils
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Exposure/Environmental Exposure/Environmental ControlControl
UNDRESS THE PATIENT UNDRESS THE PATIENT COMPLETELY BUT COMPLETELY BUT PROTECT FROM PROTECT FROM HYPOTHERMIAHYPOTHERMIA
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ResuscitationResuscitation
Provide airwayProvide airwayOxygenateOxygenateTreat shockTreat shockMonitor vital signsMonitor vital signsECG/ SaO2ECG/ SaO2Urinary catheterUrinary catheter
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RadiologyRadiology
Chest XRChest XR
AP pelvic XRAP pelvic XR
Lateral cervical spine XRLateral cervical spine XR
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Secondary SurveySecondary Survey
Head (remember neurological exam)Head (remember neurological exam) Face (NG tube if not contraindicated)Face (NG tube if not contraindicated) Neck (remember X-rays)Neck (remember X-rays) ChestChest Abdomen (including rectal exam)Abdomen (including rectal exam) Pelvis (urethral catheter if not contraindicated)Pelvis (urethral catheter if not contraindicated) Extremities (splint as necessary)Extremities (splint as necessary) ExternalExternal
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HistoryHistory
AllergiesAllergiesMedicationMedicationPast illnesses/injuriesPast illnesses/injuriesLast MealLast MealEvents/Environment Events/Environment
DETAILS OF MECHANISM OF INJURY DETAILS OF MECHANISM OF INJURY ARE VITALARE VITAL
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Neurological ExaminationNeurological Examination
GCS (best GCS (best response)response)
PupilsPupils Worst Worst
neurological neurological responseresponse
Localising Localising signssigns
ReflexesReflexes
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DocumentationDocumentation
LegibleLegibleChronologicalChronologicalConciseConciseDetail consentDetail consent
MUST BEMUST BE
REMEMBER, YOUR NOTES MAY BEREMEMBER, YOUR NOTES MAY BEREQUIRED FOR EVIDENCE IN COURTREQUIRED FOR EVIDENCE IN COURT
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Initial Assessment of the Trauma Initial Assessment of the Trauma PatientPatient
Primary SurveyPrimary Survey
ResuscitationResuscitation
Secondary SurveySecondary Survey
Definitive careDefinitive care
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Problems in organising a trauma Problems in organising a trauma centrecentre
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ACSCOT Criteria for Trauma ACSCOT Criteria for Trauma System DevelopmentSystem Development
AdministrationAdministration AccessAccess Trauma centresTrauma centres RehabilitationRehabilitation AuditAudit ResearchResearch PreventionPrevention
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Key concepts in a trauma Key concepts in a trauma systemsystem
Trauma system co-Trauma system co-ordinationordination
Data collectionData collection Retrieval services/pre-Retrieval services/pre-
hospital carehospital care Emergency DepartmentsEmergency Departments Specialised hospital Specialised hospital
servicesservices RehabilitationRehabilitation
A functioning trauma system gets the right patientA functioning trauma system gets the right patient to the right place at the right timeto the right place at the right time
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In some nations, specialisedIn some nations, specialisedhospitals or trauma receptionhospitals or trauma receptionfacilities concentrating on thefacilities concentrating on thetreatment of injuries have treatment of injuries have developed. These are known asdeveloped. These are known astrauma centres. The emphasis intrauma centres. The emphasis inAustralia is now, and is likely toAustralia is now, and is likely toremain, on trauma remain, on trauma systems systems rather than trauma centresrather than trauma centres
Each health care area, district orEach health care area, district orregion should establish an region should establish an organised approach to manage-organised approach to manage-ment of injury victims fromment of injury victims frominjury scene to definitive care.injury scene to definitive care.This approach should beThis approach should beintegrated with the area, districtintegrated with the area, districtor region’s disaster response.or region’s disaster response.
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Trauma centre vs Trauma Trauma centre vs Trauma serviceservice
VSVS
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What is a trauma centre?What is a trauma centre?
An hospital which, regardless of size,An hospital which, regardless of size,is organised for, and committed to,is organised for, and committed to,the delivery of quality care for the the delivery of quality care for the trauma patienttrauma patient
BUTBUT
There are different levels at whichThere are different levels at whichhospitals can provide quality carehospitals can provide quality carefor the injuresfor the injures
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A critical element in matching healthcare resources to severityA critical element in matching healthcare resources to severityof injury is the ability to categorise hospitals and otherof injury is the ability to categorise hospitals and otherlocation-based providers of injury care according to theirlocation-based providers of injury care according to theircapabilities. This process has been undertaken in othercapabilities. This process has been undertaken in othercountries and resulted in a description of “levels of care”.countries and resulted in a description of “levels of care”.A principle underlying such categorisation is that any givenA principle underlying such categorisation is that any givenfacility should receive enough trauma patients to be able tofacility should receive enough trauma patients to be able tomaintain the skills, experience and expertise of both the staffmaintain the skills, experience and expertise of both the staffand systemand system
Levels of careLevels of care
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Advanced Trauma ServiceAdvanced Trauma Service
An An advanced trauma serviceadvanced trauma service is the hub of the trauma system. The care is is the hub of the trauma system. The care isbased around a comprehensive ICU committed to providing treatment tobased around a comprehensive ICU committed to providing treatment tothe injured. The hospital also has many 24hr/7day resources and is completethe injured. The hospital also has many 24hr/7day resources and is completewith regard to contemporary diagnostic services.with regard to contemporary diagnostic services.
These facilities carry the major responsibility to coordinate trauma servicesThese facilities carry the major responsibility to coordinate trauma servicesin urban and rural areas for given regions. Patients are uncommonly in urban and rural areas for given regions. Patients are uncommonly referred on but may be transferred to a tertiary referral service for thereferred on but may be transferred to a tertiary referral service for themanagement of specific injuries. management of specific injuries. Advanced trauma servicesAdvanced trauma services should provide should providea rapid retrieval and primary response service within their geographic area.a rapid retrieval and primary response service within their geographic area.Access for both road ambulance and helicopter should be readily availableAccess for both road ambulance and helicopter should be readily availablewith direct access to the Emergency Departmentwith direct access to the Emergency Department
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What are the problems in What are the problems in organising a trauma centre?organising a trauma centre?
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Trauma Service OrganisationTrauma Service Organisation
Problems:Problems: Availability of qualified medical directorsAvailability of qualified medical directors Lack of enthusiasm for committee/guidelinesLack of enthusiasm for committee/guidelines Lack of finance for data system/registryLack of finance for data system/registry
ATS DTS BTS
Medical director of the trauma service E D -A trauma committee E D -Organisation chart E D -Written procedural guidelines E E -Written patient management guidelines E E -Surveillance data systems E D -Injury management data systems E D -
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Data collectionData collection
Problems:Problems: Different data setsDifferent data sets Every hospital/region Every hospital/region
wants its own softwarewants its own software No overall directionNo overall direction No national registryNo national registry
END RESULT:END RESULT: The trauma system is The trauma system is
flying blind.flying blind.
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StaffingStaffing
Problems:Problems: Ensuring ATLS/EMST training available Ensuring ATLS/EMST training available
programme available and all appropriate programme available and all appropriate staff are given access to attend itstaff are given access to attend it
ATS DTS BTS
Doctors present in the hospital 24 hours E E -Doctors on call 24 hours E E EDoctors with EMST training9 E D DNursing staff with trauma training E E D
(e.g. the Trauma Nursing Core Course, TNCC)
Specialists available for resuscitation and early managementemergency medicine E D -surgery E E -anaesthetics E E -intensive care E D -
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StaffingStaffing
Problems:Problems: Ensuring nurses Ensuring nurses
have access to have access to trauma training trauma training
Having all relevant Having all relevant specialties either specialties either available ($) or on available ($) or on callcall
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Emergency DepartmentEmergency Department
Problems:Problems: No communications with ambulanceNo communications with ambulance Lack of proximate ambulance accessLack of proximate ambulance access
ATS DTS BTS
ED open 24 hours E E -Radio communication with ambulance E E DAmbulance access (same level) E E EOn site aircraft access E D DTriage on arrival E E EDocumented policies and protocols E E -Research and education programs E D -Designated medical director E E -Specialist doctor (FACEM)
in house or on call 24 hours E D -Trained trauma nurse in charge of nursing
resources for trauma E D -Trained nurses and aides E E DRadiology in proximity E E D
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Emergency DepartmentsEmergency Departments
Problems:Problems: No designated medical directorNo designated medical director Lack of specialist staffLack of specialist staff Limited availability of trained nursesLimited availability of trained nurses Poor design of departmentPoor design of department Radiology access not proximateRadiology access not proximate
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Intensive Care UnitIntensive Care Unit
Problems:Problems: Lack of commitment to trauma careLack of commitment to trauma care Inadequate bed numbers to meet Inadequate bed numbers to meet
demanddemand Lack of quality (open vs closed unit)Lack of quality (open vs closed unit)
Staffed and equipped in accordance withANZCA P10, (Appendix 4)Minimum Standards for Intensive Care Unit L III L II/I -(L III = Level III)
ATS DTS BTS
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Radiology and medical Radiology and medical imagingimaging
Problems:Problems: Lack of priority access to Lack of priority access to
imagingimaging Insufficient funds for up-to-date Insufficient funds for up-to-date
equipmentequipment
Equipment including but not limited toangiography E D -sonography E E -nuclear scanning E D -CT scanning E D -
ATS DTS BTS
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Operating theatres and Operating theatres and recovery roomrecovery room
Problems:Problems: Lack of 24 hour capabilityLack of 24 hour capability No priority access to OR 24/7No priority access to OR 24/7 Unavailability of specialised servicesUnavailability of specialised services Lack of specialised equipmentLack of specialised equipment
Staff immediately available 24 hours E E -Specialised equipment
cardiopulmonary bypass capability D - -neurosurgical capability E D -operating microscope D - -on-site X-ray E E -
ATS DTS BTS
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Laboratory serviceLaboratory service
Problems:Problems: Lack of commitment to provide emergency serviceLack of commitment to provide emergency service Inadequate supplies of bloodInadequate supplies of blood
Available 24 hours a day E E -Services including but not limited to
standard analyses of blood etc E E Dblood typing and cross matching E E -coagulation studies E E -blood bank E E -blood gas and pH E E -serum and urine osmolality E E -microbiology E E -drug and alcohol screening E E -
ATS DTS BTS
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Quality assurance, training Quality assurance, training and researchand research
Problems:Problems: No $s for researchNo $s for research No time/planning for No time/planning for
training programmestraining programmes No enthusiasm for No enthusiasm for
clinical indicatorsclinical indicators
QA organisation structure E D -Use of clinical indicators E D -Trauma outcome studies E D -Trauma research programs E D -Trauma training programs
doctors E D Dnurses E D Dallied health personnel E D D
ATS DTS BTS
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RehabilitationRehabilitation
Problems:Problems: Number of spinal units Number of spinal units
does no match demanddoes no match demand True rehab facilities for True rehab facilities for
younger patients hard to younger patients hard to accessaccess
Funding streams for Funding streams for rehabilitation byzantinerehabilitation byzantine
Few rehabilitation Few rehabilitation specialistsspecialists
Excessive delays in Excessive delays in beginning rehab process beginning rehab process reinforcing “sick” reinforcing “sick” behaviourbehaviour
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Some general trauma centre Some general trauma centre problemsproblems
Difficulties in retaining and attracting Difficulties in retaining and attracting staffstaff
Determining the best training system Determining the best training system for surgeons who manage traumafor surgeons who manage trauma
Most trauma related services Most trauma related services experience significant in-hospital experience significant in-hospital delays in scheduling surgery for all delays in scheduling surgery for all but the most urgent patientsbut the most urgent patients
Intensive care resources often less Intensive care resources often less than demandthan demand
Transfer to rehab. locations almost Transfer to rehab. locations almost always delayedalways delayed
Funding stream uncertainFunding stream uncertain
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SummarySummary
A trauma system is effective at reducing A trauma system is effective at reducing preventable death by 15%-50% (Level III)preventable death by 15%-50% (Level III)
Trauma “centres” are a loose definition which Trauma “centres” are a loose definition which applies to hospitals working within a trauma applies to hospitals working within a trauma system.system.
Trauma “centres” should provide an effective Trauma “centres” should provide an effective trauma service, the key to optimal outcome.trauma service, the key to optimal outcome.
Trauma “centres” and services are problematic Trauma “centres” and services are problematic to run and must be matched to level of to run and must be matched to level of demand and mechanism of injury.demand and mechanism of injury.
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