Version 2: Published September 2020

Clinical Guidelines for

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Introduction/1  Updated: 08/01/2020  v2.0 Introduction/1  Updated: 08/01/2020  v2.0 How to use this guide: Editor’s introduction:        may They mean: applied. strictly have but throughout are guidelines to these used not emphasize been the text, following symbols The Key: you. from to hearing forward Ilook [email protected]. directly: me email Please received. gratefully be will contributors future and current from suggestions, and feedback All www.eprronline.gov.uk/ourwork web the on or guidelines the or front at the page index latest the on number version the by checking any of guideline to up date version most the using You are you that independently. (and be) check be will updated can can guidelines regularly. Individual I Response and Resilience Preparedness, Emergency Group Reference Clinical Birmingham Hospital, Trauma, Elizabeth Major in Queen Doctor Specialty Ed Lee Justine care. casualty quality good in standards global to set and training, and learning ongoing to support used constantly and updated perpetually be will guidelines these that Ihope events, terrorist of victims and servicemen wounded by managing gained expertise and knowledge of covet always as However, acustodian this. Iwill response, acting casualty to amajor regard with and someplace, ashelf on dust gathers and used is never work to Editor their that an wish is for It unusual incident. amajor during memoire asaide an serve and preparedness emergency clinical of basis the form should guidelines centre, these emergency local or unit atrauma in teamresponder, trauma occasional the For these. to replace intended not are guidelines these and casualties injured severely centres trauma Major may have multiple managing own protocols in place guidance for their and already practice. clinical NHS to UK relevant made and incidents, recent from points learning and injury, NGO/global doctrine trauma ballistic and blast managing of over many years gained experience military knowledge, clinical expert with blended have been practices trauma advanced and care pre-hospital from guidance and Current protocols response. incident amajor during unit, conveyed trauma to the been has who patient aP1 or P2 patient, to adeteriorating treat need who unit atrauma in surgeons for example, for mind, in team trauma occasional the with created have been Incident aMajor in use for Guidelines Clinical The t is important that these guidelines are practical, self explanatory, relevant to the users and updated updated and users to the relevant explanatory, self practical, are guidelines these that t is important from this point. If there is time, the mechanism of injury section should be reviewed be should as section injury of mechanism the is time, there If point. this from itor and follow the guidance and follow guidance the DECLARED to MI turn declared, aMajor has been Incident If must do’s, mandatory, immediate action do’s, immediate mandatory, must avoid, not do warning alerts, consider, note of points check this has been done link to external reference/onlinelink to external resource choices, for, look decision made to be communicates the types of injury mechanism(s) injury of communicates types the involved. report METHANE the

haemorrhage C atastrophic C B A E D Exposure/everything else Exposure/everything Disability Circulation Breathing Airway Catastrophic haemorrhage

Contents 1 planning Pre-event key including note Editorial Forewords Introduction 1 (MOI) of injury Mechanism 2 3 4 1 Major Incident STANDBY 5 2 1 Major Incident DECLARED 1 Emergency Department (ED) 2 2 1 and Resuscitation Reception ED 3 3 2 4 major incident or mass casualty event casualty mass or major incident trauma a in use for guidelines Clinical v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 (CBRN) v1 v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 Major Incident v2 v2 v2 Incident pathway aMajor in v2 v2 v2 Ballistic injury injury Ballistic Chemical, biological, radiation and nuclear events nuclear and radiation biological, Chemical, Major Incident awareness Blast injury Blast Crush injury Crush Penetrating knife injury knife Penetrating Major Incident STANDBY METHANE report METHANE Major Incident DECLARED Incident Major ED triage (adults)ED triage C NHS ED triage (paediatric <12 (paediatric ED triage years) Trauma Incident aMajor in teamroles in advice up follow and discharges ED outcomes, MI Senior clinical decision making making decision clinical Senior MI Catastrophic haemorrhage and massive transfusion MI Imaging (incl. CT whole body) whole CT (incl. Imaging MI - Patient Summary sheet Summary - Patient linical impact assessment call call assessment impact linical 1 in ED management Injury 2 3 4 5 6 7 8 9 1 overviews Specialty 2 3 4 7 6 5 8 9 12 11 10 Acknowledgements Links Glossary Appendices 15 14 13 v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 a Major after Incident v2 v2 v2 v2 v2 v2 v1 Incident aMajor in Eye injuries v2 v2 v2 v2 v2 v2 Incident v1 Incident v2 Bereavement care in a Major Incident Incident aMajor in care injury spinal Safe a Major Incident v1 MI anaesthesia for P1/Resus for anaesthesia MI casualties MI neuro trauma (brain injuries) (brain trauma neuro MI MI surgical/proximal haemorrhage control surgical/proximalMI haemorrhage MI vascular trauma vascular MI MI thoracic trauma thoracic MI MI abdominal trauma abdominal MI MI pelvic and long bone injuries injuries bone long and pelvic MI MI immediate wound management Forensic awareness in a Major Incident MI universal fasciotomies universal MI Acute acoustic trauma (AAT) and hearing loss loss (AAT) hearing and trauma Acute acoustic Antimicrobial prophylaxis in a Major Incident aMajor in prophylaxis Antimicrobial Psychosocial support for anyone affected by a Major by a affected anyone for support Psychosocial Blast lung in a Major Incident aMajor in lung Blast Rehabilitation co-ordination and medical in support Burn injury in a Major Incident aMajor in injury Burn Head, face and neck injuries in a Major Incident aMajor in injuries neck and face Head, Paediatric casualties in a Major Incident aMajor in casualties Paediatric Pain management in a Major Incident Psychosocial support for staff after a Major Incident Major a after staff for support Psychosocial aMajor in casualty apregnant of Management

Introduction/2  Updated: 08/01/2020  v2.0 Trauma Centre Major Adult MTC limited availability of resource for incident response. incident for resource of availability limited to the due lower be will arrangements casualty mass their of activation for trigger the as burns, such services specialist For casualties. simultaneous of number large to the due enacted to be response casualty amass as to require so located, geographically be or may combine, incidents smaller Several to manage. ability services’ healthcare and emergency the of resources normal the beyond is that ascale on casualties causing incidents) of (or is series incident an resources health UK for incident casualty A mass awareness incident Major Î Î Î

pandemic influenza. as such diseases infectious of as aresult casualties bang), exclude and (big events onset by sudden caused usually (P3). injuries minor or wounded walking (P2) delayed being 50% be and can that intervention requiring (P1), intervention saving life immediate 25% 25% with requiring categories of amixture to be likely are casualties numbers. casualty the with deal to appropriately measures further require and to cope procedures incident major normal of capacity the beyond be will to which response the injuries, of arange with casualties of thousands or may involve hundreds Survivor Reception Centre Patients unlikely tosurvive unlikely Patients Move to appropriate area toappropriate Move P1 and make comfortable Non injured survivors survivors injured Non their injuries. injuries. their P1 Hold P1 12 years or old over Consider air transport to to transport air Consider Units A TU

out of area MTCs/TUs area of out dult Traumadult

Adult

P2 If regional capacity exceeded capacity regional If scene, GP scene, on Treatment Centres, W hospitals, emergency Local facility healthcare Any Major incident scene incident Major alk in in alk

(and produces METHANE report) METHANE (and produces Am Primary triage atPrimary scene P3 number of live casualties live of number bulance Service estimates estimates bulance Service as per NARU guidelines) NARU per as (Triage sieve (Triage children) smallest to the given (priority Centre Major Trauma Paediatric MTC (Paeds)

P1

Request mutual aid from NHS England England NHS from aid mutual Request or within paediatric triage tape triage paediatric within or

to disperse casualties outside of the the of outside casualties to disperse local region to further afield to further region local Under 12 years old Paediatric (<12yrs) capability paediatric with Trauma Units (designated) TU P2 to treat the casualty, as no as casualty, no to the treat ambulance transfers will transfers ambulance medical facility. Expect Expect facility. medical may present to any may present of any age group anyof age Self presenters be available be that day W hospitals, emergency Local facility healthcare Any scene, GP scene, on Treatment Centres, alk in in alk

P3

PEP/1  Updated: 08/01/2020  v2.0 Pre-event planning  Major incident awareness

MI Awareness PEP/1  Updated: 08/01/2020  v2.0 Pre-event planning  Major incident awareness Your hospital’s planning, preparedness, emergency response and resilience to amajor incident manager (see local MI protocol) and decide whether to self declare and start escalation of the hospital major incident plan. plan. incident major hospital the of escalation start and declare to self whether decide and protocol) MI local (see manager site clinical or director medical the contact will duty on nurse call/senior on ED consultant the then incident, emerging an is a surge of in there casualties warning without ED arriving If incident. major actual or potential this is if a and is required incident the of escalation if decide will They call. on director management incident their notify will and rooms control their in activity notice unusual to first the (ambulance/police/fire) are usually services emergency local The hour. first to the accept in pre-agreed has hospital each many how casualties and service ambulance to by the dispersed be will casualties where showing used, be should event, to casualty amass To response aregional assist hours. first 24 the for sites between patients to transfer (if any) ability little for, be will as there planned be (P2) to recieve predominantly toreceive expect (MTC) should centre trauma A major (c) war or terrorism, which threatens serious damage to the security of the United Kingdom. United the of security to the damage serious threatens (c) which terrorism, or war Kingdom; United the in aplace of environment to the damage serious threatens (b) which situation event an or Kingdom; United the in aplace in welfare to human damage (a) serious threatens which situation event an or means “emergency” an CCA the 2004 1of Section Under Response Framework. and Resilience Preparedness, Emergency NHS England of 6.4 section in as an as any“emergency” event defined include this will NHS the For implemented. to be arrangements special as to require casualties, of types or numbers such causes or community the of health to threat the serious presents that is any occurrence incident A major awareness incident Major patients and other medical facilities will be assigned (P3) assigned be will facilities medical other and patients (casualty regulation) plan dispersal patient a pre-determined , or if there is news (via social media or word of mouth) of mouth) of of word or media (via is social news there if , or (P1)

patients. patients, a Trauma Unit (TU) should expect expect aTrauma should (TU) Unit patients, However, a mix of casualties should However, should casualties of amix of casualty presentation Clinical lying down) (crouched and position defensive Casualty in in Casualty three shots fired – of gunfire Origin wound tracts Note: setting aclinical in look tracts wound person, and how same shows Figure average path. the in not are that fragments produce and fragment tumble, will bullets that appreciated be must it However Diagrams below demonstrate the average path of bullets. Ballistic injury Ballistic t 2. 1. mechanisms: main by two injury cause Bullets Introduction Î Î

four

anatomical) regions. anatomical) body (or different across tracts wound to multiple may lead fragment that Bullets temporary cavitation better than others others than better cavitation temporary Some tissues tolerate from deformity skeletal muscle versus bone. versus muscle skeletal catastrophic internal damage catastrophic may mask wounds exit and entry Small cavity. temporary by the displaced and stretched being Tissue path. bullet the along lacerated and crushed being Tissue

KEY POINTSKEY

z x x y x ie z y

Investigations  c Î Î Î omponents andbeaffectedand movedbytheMRImagnetic field.

I CT is used to screen for bullet fragments prior to MRI (if needed). (ifneeded). to MRI prior fragments bullet for to screen is used CT tracts. wound multiple producing casualty the within (‘ up fragment’) break bullets Some casualty. the within bullet the of travel of direction may the show debris bullet and fragments bone of pattern The Retained bulletsandfragme ` t `  Immediatewoundmanagemen  Gunshotinvolvingface/nec a a C m Î Î Î Î Î Î

atastrophic haemorrhage atastrophic

a Standard care. Standard management. airway =standard face/neck involving not Gunshot immediate energy transfer. energy immediate greater tip) the produce (rather with and on than face side hit unstable, clothes) may become (bags, targets intermediate pass through or surface intermediate an off ricochet that Bullets clinicians. by in responding is examined casualty the position the not is often –which running) crouching, sitting, (standing, struck when orientated were they how on depend will casualty the within bullet by the taken path actual The care). initial during important rarely to itdistinguish is (and difficult very be can practically, but characteristics have do different wounds exit and Entry get’ you what be may not see you –‘what condition clinical by the guided Be internal injury. significant with associated may be wounds exit and entry Small injury multicavity/multi organ for look so boundaries anatomical respect not will path bullet The care. Standard tourniquets. See immediate See wound management IMEDtourniquets. Compressible?  Non-compressible? ging iscoveredin EDResus C B A E D Î Î

condition. clinical casualty’s by the is dictated and approach CABC standard the follows management casualty Immediate bullet. by the hit organs underlying and area body on the depend will effects clinical The Apply direct pressure/junctional techniques/ pressure/junctional direct Apply 

Does patient need to go direct to theatre? direct to go need patient Does n t s k arelikelytohavesteel 4 – seeSpecialityOverv t asperIMED .

8 iew  8 7

MOI/1  Updated: 08/01/2020  v2.0 Mechanism of Injury  Ballistic injury

Mechanism of injury MOI/1  Updated: 08/01/2020  v2.0 Mechanism of Injury  Ballistic injury ( ( inch an of fractions –usually width bullet the for measurements using imperial described also be can Ammunition length: and by width described often is Ammunition scene. incident at the present may be and (a ‘brass’) gun or the ‘spent case’ from is ejected cartridge The of consists ammunition of A round Ammunition Graphics used with kind permission from Defence Academy of the United Kingdom, Shrivenham, Nov 2017 Nov Shrivenham, Kingdom, United the of Academy Defence from permission kind with used Graphics eg Î Î Î Î

fired. fired. when energy kinetic more bullet the gives This case. the into packed to be propellant more for allows ammunition, 9×19mm to the compared case, longer The 39mm long. A ‘7.62×39mm’ 7.62mm abullet has acase and wide a handgun/pistol. from fired often ammunition 19mm describes case This long. abrass and A ‘9×19mm’ width in 9mm head abullet has case Cartridge Bullet Ballistic injury Ballistic .223in/5.56mm). eg .223) or using both imperial and metric measurements measurements metric and imperial both using .223) or (the part that leaves the gun and strikes the target). the strikes and gun leaves that the (the part that contains primer and propellant. and primer contains that two main parts: and the cavity will be larger. be will cavity the and tissue, and bullet the between area surface contact to agreater due is transferred, energy this tip. In way more its than rather material to the face side its present will it to tumble, begins and muscle or gelatine the within unstable becomes bullet the If bullet. by the created tract permanent smaller amuch around down collapses This a second. of fractions for lasting muscle or gelatine within cavity’ a‘temporary creates impact bullet the from energy The effects. wounding possible to illustrate torso ahuman of outline the on superimposed shown is also cavity temporary The tissue. way to asimilar muscle in 10% behaves shot, gelatine When impacts). actual of photography digital speed high from (derived 10% blocks gelatine into 500×250×250mm impacts bullet depicting below figures the using is illustrated This 2. 1. on: depend effects The target. to the is transferred energy atarget, impacts abullet When Bullet effects

the bullet design bullet the target the of properties material the stretching and tearing. and stretching tissue with associated cavity temporary creating a large unstable, becomes then initially straight flies bullet The 7.62×39mm ammunition AK47 ammunition. rifle with associated that than is smaller cavity temporary The 9×19mm ammunition Pistol through and hit someone else. someone hit and through go not and shot person first the of body the in to stay likely is more bullet The flight. bullet’s the in early is large cavity temporary the and rapidly transferred is energy that so atarget, on impacting after soon out (‘expand’) to flatten designed abullet of is example an This tip exposed Remington .223 Police rifle 5 5 Blast injury Blast a a ` ` ` ` Does patient have a traumatic amputation or is this an isolated injury? Look for other associated injuries: associated other for injury? is Look this or isolated an amputation have atraumatic patient Does C

atastrophic haemorrhage atastrophic Plan for damage control surgery initially surgery control damage Plan for limbs Fasciotomy blast for injury fragment if (BBV) screen virus ablood-borne Do early (TXA) acid tranexamic Give Use rapid transfuser (Level I/Belmont) to ankles) (head body whole CT Early 6 Î Î Î Î

IEDs and floor-based devices). floor-based and IEDs Blast Pelvis breached. not wall is abdominal if even perforation, bowel late and bleeding intra-abdominal Blast significant of Abdomen –risk to care. ICU through and outset ventilation from protective lung intubation, – early Lung Blast opinion. cardiothoracic early –seek disruption aortic and vessel great catastrophic of risk Blast –High Thorax h KEY POINTSKEY

resuscitation. CT imaging is desirable as soon as possible, if the patient is stable enough. is stable patient the if as possible, as soon is desirable imaging CT resuscitation. at to any assist time required may be Surgery resuscitate. and control binder, proximal gain pelvic Apply – High mortality rate from exsanguination, especially if SI joints are open (of relevance for landmines, landmines, (of for relevance open are SI joints if especially exsanguination, from rate mortality –High 3 1 2 4 Introduction Î Î

Look for a occult injuries and monitor for evolving injuries. evolving for monitor and injuries aoccult for Look survivors. range close in is required resuscitation Aggressive H w a a t h ` Traumatic amputation h Pelvis a a breached is not wall abdominal the even if perforation, bowel late and bleeding significant cause can mechanisms blast tertiary and by secondary caused injury abdominal Blunt Abdomen a a a Chest fatal often and common are injuries neck Penetrating Neck Î Î Î Î Î Î Î a

h

ve Flash burns indicate a high risk of blast lung blast of risk ahigh indicate Flash burns (bus/underground/metro) space aconfined in were casualty and compromise airway for suspicion of Have index ahigh outset and through to care ICU through and outset ventilation from protective lung and intubation early Consider drain decompression/chest chest for Have threshold alow ablast with associated Rib fractures, pneumothorax and lung contusions are commonly O Low initial survivors initial among injury fatal common most is Lung the Blast e Avoid crystalloids during resuscitation (worsens coagulopathy) (worsens resuscitation during Avoid crystalloids tourniquet(s) pneumatic for to exchange Prepare applied tourniquet(s) haveCheck been required may be surgery and resuscitation Further control proximal rapid and binder pelvic with initially Manage requirement transfusion the greater the symphysis, pubic the wider The joints SI open with occur can bleeding Significant ischaemia to mesenteric leading embolism Air Liver/splenic rupture contusions arrhythmias to - may cardiac Myocardial lead tamponade Pericardial injury vessel/aortic Great n ahighindexofsuspicio casualtyinanencloseds

B A D E C 2 Sats may indicate primary blast lung injury lung blast primary may indicate Sats 2 n

p for blastlung(incidenceincreases a c e) s ee SpecialityOverview 6 1 4 3 if blast blast if 3 

MOI/2  Updated: 08/01/2020  v2.0 Mechanism of Injury  Blast injury MOI/2  Updated: 08/01/2020  v2.0 Mechanism of Injury  Blast injury h device. the from distance increasing with rapidly reduce effects as overpressure survivors in rare but fatalities, in common injuries blast Primary Distance from blast ofinjury blast Classifications bearings etc. ball nuts, screws, with example, for fragments, with packed or weapon, blast predominately may be device Explosive Explosive devices Blast injury environment Î Î Î Î Î Î Î Î Î

Aggressive resuscitation in survivors is required damaged. structures vital unless serious less and numerous, less are fragments distance increasing predominate and much survival more likely, with injuries blast tertiary and away –secondary Further contents. exposed with injuries abdominal chest, head, open amputations, traumatic Close range injuries outside. outside,explosion victim – field open the in distance over longer especially Fragmentation weapons collapse. building and lung as blast such Blast weapons Quinary Quaternary Tertiary Secondary Primary Chest a a a Spine a a a a Head injury Blast

and haemorrhage Haemothorax, pneumothorax, contusions pulmonary injury lung Blast cordSpinal injury disruption ear inner TM rupture, foreign body subconjunctival perforation, Globe haemorrhage, Penetrating injury with brain exposed contusions, stroke cerebral (DAI),fracture, injury axonal skull Diffuse D – injury from displacement of the body (thrown against a wall/up in the air). awall/up the in (thrown against body the of displacement from –injury – sequelae and late complications, for example fungal infection if major tissue damage. major if infection fungal example for late complications, and –sequelae – injury resulting in direct tissue damage from the shock wave hitting the body. the wave hitting shock the from tissue damage direct in resulting – injury – injury from fragments (‘shrapnel’) from a device or the environment. the or adevice from (‘shrapnel’) fragments from –injury – other types of injury (for example: burns, inhalation injuries etc). injuries inhalation burns, (for example: injury of types – other increase the risk of primary blast injuries injuries blast primary of risk the increase

– mutilating injuries common, common, injuries –mutilating

increase the risk of fatality fatality of risk the increase 5 Blast location Suicide bombers Î Î Î Î Î

implantation. biological viruses) from borne (e.g. blood infection of Risk fragments. bone –especially occur can victim other or bomber from fragments Secondary environment. and device explosive of type to related and above as effects Main Î Î Î Î or inside building vehicle. – victim outside Explosion Î Î pub etc.) bombings bombs, (bus inside victim inside, explosion space: Enclosed

Î Î Î

Safest environment, unless building collapse occurs. building unless environment, Safest fractures. pattern civilian with predominate, injuries blast Tertiary fragments. from protected also Victim injury. blast primary Low of risk furniture. or walls by offered protection if localised be may Effects survivors. or fatalities both in common lung blast especially injuries blast Primary amplification. and to reflection due overpressure of effects increased with environment blast Complex tissue damage soft is major there if infection late fungal for Observe sight or hearing of loss claudication, injury, cord limb spinal abdomen, acute MI, stroke, as present can and is common embolism Air gateway number: 2017077gateway number: May 2017) Produced: HIV Cand B, (hepatitis victims blast (BBVs) virus bloodborne of risk bomb in Management ( advised may be screen virus borne Blood E ) – PHE publications ) –PHE publications

Overview: 

Summary injury Crush Consider injuries other multiple Î Î Î Î Î Î Î Î Î

fragment injury should also considered. be and as blast such types injury additional explosions, In syndrome. crush at of risk are and organs and tissues different affecting injuries may havePatients multiple sensorineural hearing loss hearing sensorineural may salvage –steroids rupture membrane tympanic eye injuries haematoma subdural fractures multi-fragmentary lung blast fragmentation injuries burns 7 6 KEY POINTSKEY 4 5 1 : 3 asudh kid ojnfiawfa dkmg asudh kid jsjsdvdisudviawfa dvdv dkmg dgfdf sahfg gm wyda dkfdfkvm vdisudvdvdv ojnf dgfdf sahfg asudhkid gm wyda dkfdfkvm jsjsd ojnfiawfa dkmg asudhkid dfkvm jsjsdvdisudvojnf iawfa dvdv dkmg dgfdf sahfg gm wyda dkf jsjsd vdisudvdvdv dgfdf sahfg asudhkid gm wyda dkfdfkvm NaCl 2 Multiple fractures are common fractures Multiple Penetrating eye injuries a Cranial trauma Risk of : of Risk a a fractures Rib ` t h t h scene mayat fluids have IV patient had extrication, prolonged If a Î Î Î

risk of death due to crush syndrome syndrome to crush due death of risk at increased are co-morbidities with person older child/frail small damage nerve/tendon occult for Look ophthalmology)  missed easily Are  outcome poor with Associated involved involved ribs four than more if segment flail of stabilisation Surgical analgesia multimodal Early onwards ED from patients Ventilation ventilated all for Protective Lung hyperkalaemia/death of –risk RSI for Suxamethonium use not Do care Standard catastrophic haemorrhage catastrophic is there unless extremity toacrushed tourniquet apply not Do a a resuscitation fluid adequate Continue a Î Î Î Treat hypothermia if present Treat present if hypothermia

crystalloid solutions to ensure adequate urine output output urine to adequate ensure solutions crystalloid give then is present, shock haemorrhagic if Use blood isPatient rhabdomyolysis at of risk binder pelvic for need Consider haemorrhage associated with fracture pelvic of risk High contusions organ from bleeding internal of Risk entrapment from release on collapse CV D C B A E Î Î

may lead to worsened renal failure or cardiac arrest. cardiac or failure renal to worsened may lead collapse; cardiovascular of risk ahigh with associated is entrapment of period along after Extrication Prolonged entrapment may occur. h h a t Î

1

rhabdomyoylsis suspected or confirmed or suspected rhabdomyoylsis if output urinary good to establish crystalloid Give myoglobin urine Check creatine kinase Check Rhabdomyolysis: syndrome crush for suspicion of index Have a high 4 5

inspect the globes (if unable to do so, refer to to so, refer to do (ifunable globes the inspect

7 6

seek early neurosurgical advice neurosurgical early seek 3 2

MOI/3  Updated: 08/01/2020  v2.0 Mechanism of Injury  Crush injury MOI/3  Updated: 08/01/2020  v2.0 Mechanism of Injury  Crush injury Patients are at risk of: Observe for: normal kidney function. kidney normal to regain likely are patients any of infection, absence however, treatment; dialysis of the in months to two to up one may require failure renal acute with Patients a ITU a ED Resus phosphorous, and creatine kinase into the circulation into the kinase creatine and phosphorous, potassium, myoglobin, releases Rhabdomyolysis FailureRenal h ED Resus a a Observe for: Hypotension a a Injury Reperfusion syndrome crush and injury Crush Î Î Î Î Î Î

Patient haemodialysis may require failure 30mls/hr, to renal prevent at least of diuresis mannitol maintain to and fluids Patient IV may require abnormalities metabolic causes muscles ischaemic from electrolytes of Release untreated may result if necrosis Myoglobinuria in tubular renal suddenly released is casualty or limb atrapped when May occur failure renal may cause circulation into tissues the necrotic toxins of from Release abnormalities metabolic with Acute hypovolaemia Initiate (or continue) IV hydration—up to 1.5 (orInitiate L/hour continue) hydration—up IV failure renal of Signs (consider prophylactic fasciotomies) Compartment syndrome losses) space (third hours first 24 the in replacement fluid considerable mayCasualties require myoglobinuria (may lethal) arrhythmias be cardiac

t management: may following have the patient had the Pre-hospital, Î Î

Observe all crush casualties, even those who look well look who even those casualties, crush all Observe injury. reperfusion limb to distal prevent is required tourniquet – of release slow limb affected the on used may have been A tourniquet entrapment. as 1hour as little (>4 hours), after however may occur crush prolonged of cases in important is especially This injury. reperfusion to systemic prevent body crushed the releasing to prior given may have fluids been Intravenous ITU a ED Resus abnormalities Metabolic Co O  temperature ofaffectedlimb  Manageopenwoundswith  Compartment syndrome Î Î Î Î

p

F Applyicetoinjuredareasandmonitorforpain, Consider correcting Hyperkalemia/Hypocalcemia this situation exacerbate may acidosis metabolic arrest; cardiac including arrhythmias, cardiac may life-threatening cause acidosis: Metabolic Hyperkalemia: membranes leaky through Hypocalcaemia: (lactated Ringer’s) or N. Saline Ringer’s) N. or (lactated Use Hartmann’s required. is diuresis not Alkaline Î Î Î Î paresis, painonpassivem   T  en wounds mplications

a s or PR or PO 100mL 20% sorbitol with 25–50g Kayexalate bolus Regular 1mg/kg bicarbonate Sodium IV minutes 10% over two IV 5mls chloride calcium give required, If D Antibiotics SpecialityOverview c etanus toxoid i ebridement EDinjuryman otomies EDinjurymanagement insulin 5–10insulin D5O 1–2 Uand IV ampoules Potassium from ischaemic muscle ischaemic Potassium from Calcium flows into muscle cells into cells muscle flows Calcium calcium gluconate 10% gluconate 10mls or calcium Lactic acid from ischaemic muscle ischaemic from acid Lactic

ovement, andreduced a gemen 2 slow push push slow 9 t 8

Penetrating knife injury Terror related stab wounds differ from inter personal and non-terror related penetrating blade injuries. There are usually a greater number of wounds with more body regions injured, particularly of the upper body and neck. Terror related stab injuries (TRS) Î Usually inflicted by a powerful overhand grip, with the intention to kill. Interpersonal stab injuries Penetrating knife injury Î Most likely to be caused by an underhand grip, with the intention to threaten the victim. The management of penetrating trauma is likely to involve: Î endotracheal intubation Î chest drain insertion Î IR (if available) and/or surgery Mechanism of Injury of  Mechanism

Catastrophic haemorrhage  Non-compressible?  Does patient need to go direct to theatre?  Compressible?  Apply direct pressure/junctional techniques/tourniquets. See immediate wound management IMED 8

A TRS injuries more likely to be a Airway injury - bubbling wound, stridor, change of inflicted to the voice. 1 head and upper Î Consider early intubation or access to airway via body wound 1 Î Oesophageal/nerve injuries can usually wait

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If patient is stable: h a whole body CT If patient is unstable: a potential cardiac and abdominal injury h manage/exclude the cardiac injury first

Be mindful of transient responders. 3 a an occult ongoing bleed in the abdomen may suddenly decompensate. Only 40% of patients with peritoneal penetration have an injury requiring laparotomy. Even if haemodynamically stable, keep patients with abdominal stab injuries NBM for 12-24 hours, regularly examine abdomen and monitor lactate levels (every 2-4 hours).

D v2.0

t Don’t forget to examine the back KEY POINTS

 Tertiary survey (don’t forget the back)  Whole body CT imaging with contrast, as soon as patient is stable enough  Timely clinical reviews and re-review of imaging, to look for occult injuries. GI/GU injuries are challenging to diagnose  Blood Borne Virus PEP Speciality Overview 2

 Counselling signposting Speciality Overview 11  Updated: 08/01/2020  MOI/4 MOI/4  Updated: 08/01/2020  v2.0 Mechanism of Injury  Penetrating knife injury In general, casualties injured in TRS events: TRS in injured casualties general, In injury knife Penetrating Spine face and Head wounds TRS of Anatomy abdominal and lower limb injuries. injuries. limb lower and abdominal to have likely more are casualties stabbings, non-TRS In severe. more to be tend wounds likely, less the are injuries TRS however in Abdominal Abdomen Chest Î Î Î Î Î Î Î Î Î Î Î

Six times more likely to die in hospital after TRS after hospital in to die likely more times Six injury of mechanisms other with stay compared hospital longer Have asignificantly (ICU) care critical require will third One surgery emergency to require likely are Half patients these to manage resources hospital more require Will transfusion blood to require likely More scores) trauma revised lower and GCS lower with (hypotensive condition ED worse in in to arrive likely More neck wounds, of greater severity greater of wounds, neck and face head, of number increased an with Associated Chest injuries are more severe more are injuries Chest MSK injuries and to have likely thorax More extremities upper and spine to the injuries More NHS Guidance.indd1 type ofexposureandpresenceanycontaminationorcontagiouscasualtyhazards. Version: 0.1(June2017)(DRAFT) Author: SurgeonCommanderSteven Bland, DefenceSpecialist Advisor inCBRNMedicine as The management ofCBRNcasualtiesincluding HAZMAT follows general principles NHS Guidance.indd 1 NHS Guidance.indd1 type ofexposureandpresenceanycontaminationorcontagiouscasualtyhazards. Version: 0.1 (June 2017) (DRAFT) Author: Surgeon Commander StevenBland, Defence Specialist Advisor inCBRN Medicine as The management ofCBRNcasualtiesincluding HAZMAT follows general principles type ofexposureandpresenceanycontaminationorcontagiouscasualtyhazards. Version: 0.1(June2017) (DRAFT) Author: SurgeonCommander StevenBland, DefenceSpecialist Advisor inCBRNMedicine as The management ofCBRNcasualtiesincluding HAZMAT follows general principles well as specific treatment specific as well Comprehensive PHE guidance is available PHE Publication Gateway No. 2018080 No. Gateway PHE Publication is available PHE guidance Comprehensive bysupported NPIS (National Poisons Information Service). patients individual of management clinical the and system) Advice Scientific nationalECOSA the through Co-Ordinated (Emergency quickly obtained be should incidents such managing on Assistance hazards. casualty contagious or any of contamination presence and exposure of type the on depend Priorities care. trauma including priorities treatment as specific as well principles general HAZMAT including follows casualties CBRN of management The publications/chemical-biological-radiological-and-nuclear-incidents-recognise-and-respond Nuclear events (CBRN) and Radiological Biological, Chemical, (HAZMAT) Materials and Hazardous well as specific treatment specific as well well as specific treatment specific as well CBRN Guidelines:Principles PRINCIPLES OFCBRNCASUALTY CARE PRIORITIES FORCASUALTY CARE CBRN Guidelines:Principles CBRN Guidelines:Principles PRINCIPLES OFCBRNCASUALTY CARE PRINCIPLES OFCBRNCASUALTY CARE including trauma care. trauma including priorities PRIORITIES FORCASUALTY CARE PRIORITIES FORCASUALTY CARE priorities including trauma care. trauma including priorities including trauma care. Priorities depend on the on depend Priorities care. trauma including Priorities depend on the on depend Priorities ™ ™ CBRN assistance: Emergency

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26/06/2017 10:48:26 26/06/2017 10:48:26

MOI/5  Updated: 08/01/2020  v1.0 Mechanism of Injury  Hazardous Materials (HAZMAT) and Chemical, Biological, Radiological and Nuclear events (CBRN) SO/4  Updated: 11/01/2018  v1.0 Specialty Overview  CBRN (Chemical, Biological, Radiation and Nuclear Injury) MOI/5  Updated: 08/01/2020  v1.0 Mechanism of Injury  Hazardous Materials (HAZMAT) and Chemical, Biological, Radiological and Nuclear events (CBRN) NHS Guidance.indd 2 and Nuclear Injury) Nuclear and Radiation (Chemical, Biological, CBRN Further advice:TOXBASE https://www.toxbase.org Reference:References: Further advice: TOXBASE https://www.toxbase.org NHS InitialOperationalResponse (IOR)toaHAZMAT/CBRN Incident Further advice: Further References: Radiological and Nuclear events (CBRN) (HAZMAT) Materials Biological, Hazardous Chemical, and STEP 1-2-3PLUS-SAFETY TRIGGERSFOREMERGENCY PERSONNEL Unusual investigationresult(s)includinglaboratoryanddiagnosticimaging Any unusualorunexplainedsymptoms,signs,illnessdeaths Unexplained symptomsincluding: Unexplained deadanimals Unusual taste,smellormist Multiple casualtieswithsimilarnon-traumaticsymptomsandsigns(STEP 1-2-3PLUS) Any symptomsinvolvingemergencyservicesandhospitalstaff PLUS: thesesafetyinterventionsmayinclude: Step 3:Threeormorepeopleincloseproximity, incapacitatedwithnoobviousreason Step 2:Two peopleincapacitatedwithnoobviousreason Step 1:Onepersonincapacitatedwithnoobviousreason Chemical exposuresaremorelikelytobeassociatedwithimmediateoracute(minuteshours) ------Manage withcautionusingstandardprotocols(considerpersonalprotectiveequipment). Manage usingstandardprotocols(considerprecautions). onset symptomsalthoughnotinallcases.Biologicalandradiologicalexposuresmaybe Manage inasafeareawellventilatedarea(s)(consider disrobingbeforehandover). Evacuate however wherepracticablelife-savinginterventions shouldbep Disrobe Decontamination Communicate Non-thermal burns(erythema,blisteringandnecrosis) Chest tightness Headache Altered vision If anyambulanceorhospitalstaffhavesymptoms-GostraighttoStep3

(adapted fromJointEmergencyServicesInteroperabilityProgrammeforhospitaluse) NATO MedicalManagementofCBRN Casualites

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Excessive secretions Difficulty inbreathing Eye pain (AMedP-7.1Chapter19:NerveAgents) (AMedP-7.1Chapters4and5 erformed first.   ssential staff; ), 26/06/2017 10:48:26

NHS Guidance.indd 3 and Nuclear Injury) Nuclear and Radiation (Chemical, Biological, CBRN Nuclear events (CBRN) and Radiological Biological, Chemical, (HAZMAT) Materials and Hazardous profound bradycardia(<40),cyanosis. distress, respiratoryparalysis/arrest, Unconscious, convulsions,respiratory Antidotes andsupportivetherapyarethemaintreatmentoptions. liquid. non-volatile to through hazard vapour and liquid volatile from ranging propeties highly are agents Nerve Version: 0.1(June 2017)(DRAFT) Author: SurgeonCommander StevenBland, Defence Specialist Advisor inCBRN Medicine osiu Respiration Conscious Unconscious Convulsions P1 (Severe) CBRN Guidelines:Nerve Agents Increased, then reduced or apnoea EMERGENCY MEDICAL TREATMENT CASUALTY (CRESS) ASSESSMENT raohshru cmons ih ayn physical varying with compounds organophosphorous lethal incontinence. not obeyingcommands,wheezing, Excessive secretions,confusion, Not walking. Pinpoint pupils (delayed following skin exposure) Eyes P2 (Moderate) TRIAGE ertosSi Other Skin Secretions Increased Vomiting pain. Pinpoint pupils,dimmedvision,eye Walking. waigBradycardia Sweating P3 (Mild) 26/06/2017 10:48:27

EDSM/5SO/5 MOI/5 Updated: Updated:  Updated: 11/01/2018 11/01/2018 08/01/2020  v0.1 v1.0  v1.0 Mechanism of Injury  HazardousSpecialty Materials Overview (HAZMAT)  andCBRN Chemical, (Chemical, Biological, Biological, Radiological Radiation and Nuclear eventsInjury) (CBRN) MOI/5  SO/6 Updated:  Updated: 08/01/2020 11/01/2018  v1.0  v1.0 Mechanism of Injury  Hazardous Materials (HAZMAT)Specialty and Overview Chemical,  Biological, CBRN (Chemical, Radiological Biological, and NuclearRadiation events and Nuclear (CBRN) Injury) NHS Guidance.indd 4 Radiological and Nuclear events (CBRN) (HAZMAT) Materials Biological, Hazardous Chemical, and and Nuclear Injury) Nuclear and Radiation (Chemical, Biological, CBRN Further advice:TOXBASE https://www.toxbase.org Reference: atropinisation canbemonitoredbyreversalofbronchospasm andcapnographynormalisation. strategy: Ventilation Benzodiazepines: Benzodiazepinesareusedasanti-convulsantsandalso neuroprotective. requirement forhighatropinedosesorfailuretoreverse nicotinic effects. An alternative VX. and sarin for efficacy oxime is obidoxime and may be used if tabun or delayed enzyme reactivation is suspected especially with a good has and pralidoxime is UK the in oxime of choice first The are Oximes therapy: Oxime atropine includehyoscine. therapy. oxime effective of absence the in to especially Alternatives past the in used been have 1000mg) to to effect based on the reversal of bradycardia (endpoint > 90), bronchospasm and secretions. High doses (up Atropine: Atropine is an antimuscarinic and reverses nerve agent parasympathtic effects. The dose is titrated Neuromuscularjunction: Sympatheticganglia: Centralnervoussystem: Parasympathetic: acetylcholine. This resultsinover-stimulationofthefollowingpartsnervoussystem: Nerve agents cause the inhibitionof that breaksdown the the enzyme acetylcholinesterase neurotransmitter advice: Further References:

NATO MedicalManagementofCBRNCasualites

Miosis,secretions(tears,bronchorrhoea,salivation),vomiting,incontinence,bradycardia. biological-radiological-and-nuclear-incidents-recognise-and-respond PHE Recognise and respond to CBRN https://www.gov.uk/government/publications/chemical- to CBRN respond and PHE Recognise N T N N OXBASE https://www.toxbase.org CBRN Guidelines:Nerve Agents ATO Medical Management of CBRN Casualites (AMedP-7.1 Casualites CBRN of ATO Management Medical 5) 4and Chapters HS England EPRR IOR https://www.england.nhs.uk/ourwork/eprr/hm/#ior HS https://www.england.nhs.uk/ourwork/eprr/hm/#ior England EPRR IOR to aHAZMAT/CBRN (IOR) Response Incident Operational HS Initial Tachycardia, hypertension.Sweatglands:Sweating. This is similar to the asthma ventilation strategy due to high airway pressures, and pressures, airway high to due strategy ventilation asthma the to similar is This Fasciculation(systemicandlocal),depolarisingparalysis,respiratoryfailure. Confusion,coma,seizuresandcentralrespiratoryfailure. MECHANISM OF ACTION AND EFFECTS OF ACTION AND MECHANISM REFERENCE AND SPECIALIST ADVICE REFERENCE AND enzyme reactivators MEDICAL THERAPIES

and should be given as soon as possible to P1patients. andshouldbegivenassoonpossible (AMedP-7.1Chapter19:NerveAgents)   26/06/2017 10:48:27

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MI STANDBY MIS/1  Updated: 08/01/2020  v2.0 Major incident standby  Major incident STANDBY INTENTIONALLY LEFT BLANK THIS PAGE HAS BEEN

METHANE report

METHANE is the recognised common model for passing incident information between services and their control rooms. All services have use a common model which will mean information can be shared in a consistent way, quickly and easily, whoever the information is passing between.

MAJOR INCIDENT STANDBY MAJOR INCIDENT DECLARED

Standby message received: Declared message received: Has a major incident been declared? Date: Date: M Major incident (Yes/No) Time: Time:

Please use the following spaces to write details and any changes/updates:

What is the exact location or geographical E Exact location area of the incident?

Blast/Explosion/Gunshots/Fire/Building T Type of incident Collapse/Flood/Chemical/Nuclear/ Biological/Radiation

What hazards or potential hazards can be H Hazards identified?

What are the best routes for access and A Access exit?

How many casualties are there, and what N Number of casualties condition are they in?

Which, and how many, emergency assets E Emergency services and personnel are required or are already on-scene?

MIS/2  Updated: 08/01/2020  v2.0 Major incident standby  METHANE report MIS/2  Updated: 08/01/2020  v2.0 Major incident standby  METHANE report INTENTIONALLY LEFT BLANK THIS PAGE HAS BEEN

E N A H T E M others to information METHANE give or out report METHANE the update to prepared Be incident Major ED TriageED checklist ED (H)MIMMS checklist general is cancelled. call standby the and activated is not plan the is received, –Cancelled’ Incident ,‘Major message the If Major –Cancelled Incident Î Î Î Î Î Î Î Î Î Î

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MID/1  Updated: 08/01/2020  v2.0 Major incident declared  Major incident DECLARED

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NHS Clinical impact assessment call -Patient Summary Sheet (Patients 1 to 10)

Î This sheet gives early indication to NHS England, extent of resources required and plan support Î Recommended method: use one grid for patients with single injury and one for multiple Î Precise details of injuries should not be recorded on this summary sheet system trauma Î Please only include admitted patients Official SensitiveOfficial upon completion Official SensitiveOfficial upon completion Injury Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Patient 9 Patient 10 Hospital number Patient identifiers

On scene triage SIEVE (P1/P2/P3) Hospital/ED triage (P1/P2/P3) Age Mechanism Arrival time Destination Outcome (critical care/ward/RIP) Traumatic brain injury Spinal injury – cord or fracture Chest trauma Abdominal trauma Vascular trauma Pelvic trauma Single open fracture Multiple open fracture Single closed fracture Multiple closed fractures Soft tissue injuries Burns Maxillofacial trauma Ocular trauma Others

MID/2  Updated: 08/01/2020  v2.0 Major incident declared  Clinical impact assessment call patient summary sheet Injury Others Patient 11Patient Patient 12Patient Patient 13Patient Patient 14Patient Patient 15Patient

MID/2  Updated: 08/01/2020  v2.0 Major incident declared  Clinical impact assessment call patient summary sheet Patient 16Patient

Patient 17Patient NHS Clinical impact assessment call

- Patient Summary Sheet (Patients 11 to 20)

Î This sheet gives early indication to NHS England, extent of resources required and plan support Î Recommended method: use one grid for patients with single injury and one for multiple Patient 18Patient Î Precise details of injuries should not be recorded on this summary sheet system trauma Î Please only include admitted patients

Injury Patient 11 Patient 12 Patient 13 Patient 14 Patient 15 Patient 16 Patient 17 Patient 18 Patient 19 Patient 20 Hospital number Official SensitiveOfficial upon completion Official SensitiveOfficial upon completion Patient 19Patient Patient identifiers

On scene triage SIEVE (P1/P2/P3) Hospital/ED triage (P1/P2/P3) Age Patient 20 Patient Mechanism Arrival time Destination Outcome (critical care/ward/RIP) Traumatic brain injury Spinal injury – cord or fracture Chest trauma Abdominal trauma Vascular trauma Pelvic trauma Single open fracture Multiple open fracture Single closed fracture Multiple closed fractures Soft tissue injuries Burns Maxillofacial trauma Ocular trauma Others Emergency department triage (adults) Priority for intervention Introduction This is an in-hospital clinical guideline for use in a major incident. It is designed to be used in times of SURGE in order to identify patients in need of a life-saving intervention and suggests the intervention(s) required. Î Early secondary assessment from senior clinicians is recommended to mitigate for initial over-prioritization.

t Note: This guideline is not designed for pre-hospital triage.

High Priority (adults) Emergency Department triage Catastrophic YES haemorrhage? for intervention (big C) Tourniquet NO Pelvic binder Haemostatic agents Emergency DepartmentEmergency  YES Low Priority Once applied, restart algorithm Walking? walking NO wounded patient may deteriorate reassess regularly High Priority NO Dead Breathing? declare when for intervention resources allow (ABCDE) Î Definitive airway

Î YES Thoracostomy (needle/finger/tube) Î Chest seal ED Triage Î Positive pressure ventilation

Î ≥4units blood products OR Responds NO un-crossmatched blood to voice? Î TXA place patient Î Laparotomy/Thoracotomy/Pericardial in the recovery window for trauma position Î Surgery/IR for proximal vascular control YES Î ALS/ACLS for periarrest/arrest High Priority situations (ABCDE) Î Neurosurgery for management of Respiratory NO intra-cranial haemorrhage rate 12–23? Î Spinal nursing for C1-C3 fracture Î Seizure-terminating medication

Î Correction of hypothermia Î Correction of low blood glucose YES NO Î If CBRN suspected, consider chemical antidotes v2.0 Heart rate YES Medium KEY POINTS <100? Priority ED ‘triage for intervention’ principles reassess regularly Î Reassess patients regularly and repeat assessment after an intervention If patient deteriorates, restart algorithm Î Is the patient now stable enough for CT whole body? Rationale for the MPTT-24 Î Is the patient still a high priority for ‘direct to

Î Can be completed by inexperienced personnel in 30 seconds theatre’?  Updated: 08/01/2020

Î The MPTT-24 is designed to minimise under-triage  Adapted from Modified Physiological Triage Tool 24 (MPTT-24). Vassallo 2017 CC BY 4.0 EDT/1 Emergency department triage (adults)

List of life-saving interventions to be considered in a major incident or mass casualty event. These were defined through an international Delphi consensus of experts involved in major incident management.1

1 Intubation for actual or impending airway obstruction

Emergency Department triage (adults) Emergency Department triage 2 Surgical airway for actual or impending airway obstruction  3 Thoracostomy (needle/finger/tube) 4 Application of a chest seal (commercial/improvised) 5 Positive pressure ventilation for ventilatory inadequecy 6 Application of a tourniquet for haemorrhage control 7 Use of haemostatic agents for haemorrhage control 8 Insertion of an intra-osseous device for resuscitation purposes Emergency DepartmentEmergency 9 Receiving un-crossmatched blood 10 Receiving ≥4 units of blood/blood products 11 Administration of tranexamic acid 12 Laparotomy for trauma 13 Thoracotomy or pericardial window 14 Surgery to gain proximal vascular control 15 Interventional radiology for haemorrhage control 16 Application of a pelvic binder 17 ALS/ACLS for a patient in a peri-arrest/cardiac arrest situation 18 Neurosurgery for the evacuation of an intra-cranial haematoma 19 Craniotomy/Burr hole insertion 20 Spinal nursing for a C1–3 fracture 21 Administration of a seizure-terminating medication 22 Active/passive rewarming for initial core temp <32ºC 23 Correction of low blood glucose 24 Administration of chemical antidotes

This process is designed to be used in circumstances when the receiving hospital is over-whelmed with casualties from a major incident i.e. in times of SURGE and when individual patients cannot be met by individual treatment teams. Casualties arriving at the hospital may not have undergone a pre-hospital triage process.

Under normal circumstances, casualties from a major incident will have undergone a pre-hospital triage process to determine their priority for treatment. On arrival at hospital, they will be met by individual and designated treatment teams.

The aim of this process is to rapidly identify those casualties in need of life-saving interventions. It can be completed by providers with all levels of experience in under 30 seconds.

The physiological assessments within the process are evidence-based (adapted from the MPTT-24) 2 and have the greatest sensitivity for identifying those in need of life-saving interventions within both the civilian and military environments.

As a consequence of this, a greater proportion of casualties will be categorised as “High Priority” including a number of those who do not require life-saving interventions. At the earliest opportunity, and within a permissive setting, early secondary assessment by a senior

v2.0 decision-maker is required to review those categorised as “High Priority”.

References:

1. Vassallo J, Smith JE, Bruijns SR, Wallis LA. Major incident triage: A consensus based definition of the essential life-saving interventions during the definitive care phase of a major incident. Injury. 2016 Sep;47(9):1898–902. 2. Vassallo J, Smith J, Bouamra O, Lecky F, Wallis LA. The civilian validation of the Modified Physiological Triage Tool (MPTT): an evidence- based approach to primary major incident triage. Emergency Medicine Journal. 2017 Dec;34(12):810–5.  Updated: 08/01/2020  EDT/1 Emergency department triage (paediatric <12 years) Introduction In conventional triage, the objective is to sort and prioritise patients; to do the best for each individual. However the objective of triage in a mass casualty situation is to do the greatest good for the greatest number.

JumpSTART© is a system designed specifically for triaging children in disaster settings. Infants are seen first, followed by anyone who is or appears to be a child aged 12 or less. Î Allows paediatric casualties to be assessed based on physiology and should not prioritise paediatric casualties above sicker adult casualties Î Provides an objective framework when decision making may be stressful and emotive

Able YES years) <12 (paediatric Emergency Department triage to Minor Secondary triage* walk? * In the JumpSTART ©system, infants are evaluated first, using the entire NO JumpSTART© algorithm. Other children who cannot walk on their own (but are carried to the treatment area) are evaluated next.

NO BREATHING Emergency DepartmentEmergency  Breathing? Position upper airway Priority 1

APNOEIC YES NO Palpable pulse? Dead YES APNOEIC Five rescue breaths Dead

BREATHING Priority 1

<15 OR >45 Respiratory Priority 1 rate

15–45

Palpable NO pulse? Priority 1

YES

‘P’ (INAPPROPRIATE), POSTURING OR ‘U’ AVPU Priority 1 v2.0

‘A’, ‘V’ OR ‘P’ (APPROPRIATE) Priority 2 KEY POINTS

Î If a casualty appears to be a child, use this algorithm Speciality information

Î If a casualty appears to be an adult, use the Î Reflects unique aspects of paediatric physiology  Updated: 08/01/2020

Adult Triage tool ED Triage 1 Î Can be completed within 30 seconds  EDT/2 Emergency department triage (paediatric <12 years)

Primary triage Secondary triage Î Typically performed at the scene of the incident Î Performed to re-evaluate a patient after primary triage has Î Helps to prioritise patients for evacuation/transport been completed Î Can occur at a hospital Î Typically done once the patient arrives in hospital Î Can also be done at an alternative care site, casualty clearing station or if time on scene is prolonged

Priority 1 Immediate Severely ill/injured but treatable. Able to be saved with relatively quick treatment and Emergency Department triage (paediatric <12 years) <12 (paediatric Emergency Department triage transport eg severe bleeding, sepsis, open chest or abdominal wounds, severe respiratory  distress, emotionally uncontrollable.

Priority 2 Delayed Injured/ill and unable to walk on their own; potentially serious injuries/illnesses but stable enough to wait a short while for medical treatment eg burns with no respiratory distress, spinal injuries, moderate blood loss, conscious with a head injury.

Emergency DepartmentEmergency Priority 3 Minor Minor injuries/illnesses that can wait for a longer period of time for treatment eg minor fractures, minor bleeding or minor lacerations.

Priority 4 Expectant Dead or obviously dying. May have signs of life but injuries are incompatible with survival eg cardiac arrest, respiratory arrest with a pulse*, massive head injury. It can be emotionally challenging to tag a child as expectant/deceased. Resist the tendency to assign a higher triage category to paediatric patients just because they are children. Using an objective triage tool during a major incident can provide emotional support for staff forced to make these decisions for children.

* In children, typically respiratory failure precedes circulatory failure. If a child is apnoeic but has a pulse, a brief trial of ventilations, may ‘jumpstart’ their respirations (trial: five rescue breaths)

Main differences between adult and paediatric triage

1. In children, if positioning the airway does not restart The JumpSTART© paediatric triage MCI triage tool (usually ventilation, then give a trial of ventilation, as this may shortened to JumpSTART©) is a variation of the simple triage and restart spontaneous ventilation. In adults, there is no trial rapid treatment (START) triage system. Both systems are used to of ventilation and the adult casualty is tagged expectant or sort patients into categories at mass casualty incidents (MCIs). dead. 2. In children, only peripheral pulses should be used However, JumpSTART© was designed specifically for triaging to assess circulation. children in disaster settings. Though JumpSTART© was 3. In children, AVPU is used to assess mental status, developed for use in children from infancy to age 8, where age not ability to follow commands. is not immediately obvious, it is used in any patient who appears to be a child (patients who appear to be young adults are triaged Non-ambulatory children include: using START or other adult triage systems). Î infants (who can’t walk yet) Î children with developmental delays Î children with acute injuries or chronic conditions prior to the incident that prevented them from walking v2.0  Updated: 08/01/2020  EDT/2 their wounds and physiological status allows this, to protect theatre and bed capacity for other more urgent cases. urgent more other for capacity bed and theatre to this, protect allows status physiological and wounds their if place, in plans up follow or management further ED with from discharged and managed may be patients injured severely Less delay. without and time first destination treatment their reach patients decisively, these that and so quickly to made need patients sickest the regarding decisions incident, amajor In incident discharges and follow up advice in amajor outcomes, department Emergency Î

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EDT/3  Updated: 08/01/2020  v2.0 Emergency Department  Emergency department outcomes, discharges and follow up advice in a major incident EDT/3  Updated: 08/01/2020  v2.0 Emergency Department  Emergency department outcomes, discharges and follow up advice in a major incident INTENTIONALLY LEFT BLANK THIS PAGE HAS BEEN

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 5 

ED Resus /2A  Updated: 08/01/2020  v2.0 ED Resus  Catastrophic haemorrhage and massive transfusion pathway in a major incident ED Resus/2A  Updated: 08/01/2020  v2.0 ED Resus  Catastrophic haemorrhage and massive transfusion pathway in a major incident transfusion pathway major incident transfusion a in massive and haemorrhage Catastrophic MASSIVE TRANSFUSION PATHWAY TRANSFUSION MASSIVE Goal directed therapy directed Goal if available) blood specific group use (And ` a patient Reassess h a a a a available now are results lab If Î Î Î

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ED Resus/2B  Updated: 17/01/2020  v2.0 ED Resus  Catastrophic haemorrhage and massive transfusion pathway in a major incident ED Resus/2B  Updated: 08/01/2020  v2.0 ED Resus  Catastrophic haemorrhage and massive transfusion pathway in a major incident INTENTIONALLY LEFT BLANK THIS PAGE HAS BEEN

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ED Resus/3  Updated: 08/01/2020  v2.0 ED Resus  MI senior clinical decision making ED Resus/3  Updated: 08/01/2020  v2.0 ED Resus  MI senior clinical decision making INTENTIONALLY LEFT BLANK THIS PAGE HAS BEEN

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exceptions are there but non-ferrous to be tend rounds Pistol otherwise until proven ferromagnetic are bodies foreign frag/metallic all Assume is available online  online is available RCR, caveats with weeks six after safe to be likely MRI PHE and Welsh guidance WelshPHE and guidance 4 (including CT whole body) whole (including CT Department planning Department a body whole CT Î Î Î Î Î Î Î 2

Î scanner Two CT per consultants Use USS to CT ED in to triage flow imaging ED in to consultant coordinate senior Consider injury organ solid if considered at 5–7 be imaging days should delayed Repeat, is gained control haemorrhage after done be can CT Intraoperative protocol) (Bastion trochanters to lesser head means traumagram CT to ankles head means body whole CT injuries, blast In large) be can radius (blast blast in and events mass in to image Low threshold

The first issues an acute report, the second completes a full report full a completes second the report, acute an issues first The 4 CT whole body radiation exposure is approx 12mS approx is exposure radiation body whole CT training will reduce this. team Regular preparation. and transfer patient on spent is time the of rest the minutes, two takes body whole CT theatre. to direct have gone should probably patient the case which in unwell, critically unless scan aCT during resuscitated ‘doughnut death’. of the longer is be no can Patients CT 1 3 Head Thorax Head Bones a a a a a a a a a a

Fractures Î Middle ear effusion Î Î Î Haemorrhage Î Î injury ring Pelvic Î fractures bone Long alignment mal- and fractures Spinal Î Î Î Î Lung parenchyma Pneumothorax/haemothorax integrity Tracheobronchial integrity great vessel and Pericardial

+/- ossicular disruption ridges at bone foci petechial small extra-axial or intra- sacral fractures sacral integrity SIJ embolus fat hrs 24-72 over next mayARDS develop (may transient) emboli be infiltrates contusions 1 3 . 2

ED Resus/4  Updated: 08/01/2020  v2.0 ED Resus  MI imaging (including CT whole body) ED Resus/4  Updated: 08/01/2020  v2.0 ED Resus  MI imaging (including CT whole body) INTENTIONALLY LEFT BLANK THIS PAGE HAS BEEN

In ‘non-star’ patient positions (eg lateral), is the patient position impeding: position (eg lateral), patient is the positions patient ‘non-star’ In anaesthesia MI Unexplained drop in blood pressure NOT due to hypovolaemia. Consider: to hypovolaemia. due NOT pressure blood in drop Unexplained a a a Patient in ‘star’/cruciform in Patient position Anaesthesia Induction Anaesthesia Î Î Î Î

Circulation a a a saturation Falling oxygen Î Î Circulation movement? chest movement?diaphragm Patient in ‘star’/cruciform in Patient position responsibilities/tasks designate and –decide checklist RSI

Could there be emboli? be there Could lung’? ‘blast or contusion lung developing Is there pneumothorax? into atension to develop pneumothorax unrecognised an IPPV caused Has cardiac tamponade? cardiac tension pneumothorax? KEY POINTSKEY

4 (for P1/Resus casualties) 1 5 2 Communication Î

WHO is doing WHAT is doing WHO WHAT in and SEQUENCE? briefing: WHO Chest drains  h a h a Arterial line for: line for: Arterial Î  Î Î Î Î Î Î Î Î Î Î

C-spine control in blast injury mechanism C-spine injury blast in control Developing Blast lung theatre temperature theatre fluids, warm mattress, blanket Warm patient: pressure blood blood samples output urine Monitor Consider using Ketamine agents induction of doses Reduce Hypovolaemia line peripheral large and/or transfusion rapid access for central 8.5F Major loss? blood are visible Ensure bags/bottles kinked not are tubes Check Heat and moisture exchange filter filter (HME) exchange moisture and Heat difficulty airway anticipated in tube ET size Use asmaller (ET) tube endotracheal Uncut ‹C› ‹C› B E C A

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IMED/1  Updated: 08/01/2020  v2.0 Injury management in ED  MI Anaesthesia (for P1/Resus casualties)

ED Injury Management IMED/1  Updated: 08/01/2020  v2.0 Injury management in ED  MI Anaesthesia (for P1/Resus casualties) INTENTIONALLY LEFT BLANK THIS PAGE HAS BEEN

specialist centre. centre. specialist at another for cared be should apatient that may dictate injuries other or possible, this be may not incident major centre, a however in to aneurosurgical transferred be would injury abrain with apatient injury. Ideally brain secondary reduce is aim to or prevent principal The MI neurotrauma (brain injuries) neurotrauma MI including: ICP, to reduce techniques simple some are there raised, ICP If h h a Limb weakness Signs of injury of Signs Pupil response Conscious level injury brain for Assessing Î Î Î Î Î Î Î Î Î Î Î

Hypertonic saline: 6mL/kg of 5%, up to 350mls max dose to up 5%, 350mls of max 6mL/kg saline: Hypertonic required) if repeated (diuretic 0.5–1g/kg action): (canMannitol is given be dose IV PEEP keep <12 and normocapnia for Aim ventilation. Control H BP. reduce will sedation of forms Most analgesia. give and Sedate (at 30º) head-up Nurse relief) (except pressure for patient the Avoid moving patient) the strangling (it may collar be cervical Remove to) not reason medical (unless is overriding an there reversed be should Anticoagulants Î Î >100mmHg pressure blood systolic Maintain Control haemorrhage and hypovolaemia correct injury brain hypoxic of risk reduce and ventilation to optimise injuries chest Manage Scan to CT transfer safe allow and airway the to protect Intubate GCS alow has or combative or is aggressive patient if early Intubate airway? the to secure intubation require patient the Does

patients with GCS<8 with patients TBI in especially may outcome, improve saline Hypertonic out. is ruled hypovolaemia of cause as a bleeding until blood with be should Volume replacement B A D C ` ` applicable if to intubation prior GCS patients’ ecord neurosurgeons with discussing E4, the when use V5,lease breakdown M6 14-15, GCS ild 9-13, GCS Moderate <8 GCS Severe

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signs of injury of signs any external without (mTBI) occur injury However, often contusions brain simple traumatic and mild brain. extruding fractures, skull open/closed/depressed bruising, any lacerations, Document important is very scene on starting assessment, at each movements apatient’s of documentation Simple injury the of side the indicate can and sign is alateralising response Pupillary GCS AVPU referred for monitoring patient and detecting subtle signs of deterioration deterioration of signs subtle detecting and patient monitoring for referred ood for basic assessment assessment basic for ood G P R P M ie patient able to move all four limbs to move four all able patient (DAI), cerebral contusions and subdural haemorrhage. (DAI), subdural and contusions cerebral injury axonal diffuse are injuries brain blast common Most transfer. to that prior care their to how optimise and possible) are (once transfers surgery for transferred to be need patients which recognising to in are assist guidelines These 2 0 Other medical management medical Other _ _ _ _ t a a

Î Antibiotics Î Magnesium Î Nimodipine Î Steroids AVOID: Î vaccine Pneumococcal Î Keppra (Levetiracetam)

leak CSF without or with fractures, based skull in infection prevent that antibiotics evidence No trauma cranial in use its to support evidence No trauma cranial in use its to support evidence No (GCS<14) avoided be should and injury head in use steroid with associated weeks at two mortality Increased gas cranial intra of evidence is any there if and fractures cranial open with to patients given be Should haemorrhage intracranial with patient any in to fitting prevent used be should 7/7 for BD 1g dose 500mgs Loading then

IMED/2  Updated: 08/01/2020  v2.0 Injury management in ED  MI neurotrauma (brain injuries) IMED/2  Updated: 08/01/2020  v2.0 Injury management in ED  MI neurotrauma (brain injuries) brain injury Secondary (Battle’s Sign) mastoid(s) over the Bruising CSF otorrhea haemorrhage Subconjunctival eyes) (Raccoon/Panda haematomas Bilateral peri-orbital haemorrhage Subarachnoid CSF rhinorrhea Signs of basal skull fractures (EDH) haematomas (epidural) Extradural injuries brain of significance and Classification brain injury Primary Types of brain injury (brain injuries) neurotrauma MI Diffuse injuries Diffuse haematomas intracerebral Contusions and haematomas (SDH) Subdural

Others glucose Abnormal blood Coagulopathy Acidosis pressure intracranial Raised Ischaemia Hypoxia Î

However, prevention of secondary injury is essential. injury However, secondary of prevention management. surgical replace will intervention any that is medical it unlikely surgery, requires patient If

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severe brain injury centres injury brain severe intervention surgical for scope Little (DAI).injury axonal diffuse to severe through concussion mild from injuries of Full spectrum treat to difficult and threatening life injuries cerebral minor may ICP in make these rise associated and Oedema monitored to be may need pressure injury. Intracranial post evolve. Tends and may coalesce 48–72 haematomas hours and contusions to peak Discrete cause aneurysmal to exclude Angio CT to have anon-urgent need Will care. supportive good with managed be can and treatment surgical to require Unlikely to need neurosurgical intervention neurosurgical to need likely are and shift effect/midline mass may as cause they recognised, be must Acute bleeds bleed chronic or to acute an due May be EDHs than worse is outcome usually therefore injury, and brain primary significant with Usually associated evacuation however most will require neurosurgical conservatively, managed be can EDHs Small

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May take 24-48 hours to develop hours 24-48 May take or blood from an external ear laceration ear external an from blood or leak) (?CSF membrane tympanic to ruptured due May be cavity orbital the from tracking blood May indicate 1-3May take days to develop cases) of 50-60% in (present fossa cranial anterior the of fractures with Associated unvaccinated if Pneumovax Give mucus) in not but CSF in (present Glucose for to test dipsticks stix/urine Use BM h Î Î Î Î Î Î Î

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and these patients are usually managed in regional regional in managed usually are patients these and

Abdomen 19. 17. 6. 5. 1 Access) (Rapid Incisions: Primary Thorax Neck . control haemorrhage surgical/proximal MI a a proximal to the immediate zone of injury. To control retrograde filling, vessels distal to the injury should also be exposed. be also should injury to the distal injury.vessels To of filling, zone immediate to the retrograde proximal control vessels by exposing achieved rapidly most is normally This access. by surgical control to obtain ishaemorrhage”, it essential “uncompressible called so atourniquet, or pressure by direct stemmed be cannot haemorrhage catastrophic If a a a a Longitudinal incision along anterior border of the sternocleidomastoid muscle (ABSCM) muscle sternocleidomastoid the of border anterior along incision Longitudinal Supraclavicular for proximal control of arm vessels arm of control proximal for Supraclavicular Î Î Î Î Î Î Î Clam shell thoracotomy shell Clam

Longitudinal groin incisions for proximal control of leg vessels leg of control proximal for incisions groin Longitudinal Lower midline laparotomy for pelvic packing (can be extended to 15) (can extended be packing pelvic for laparotomy Lower midline

EY POINTSEY

packing by is achieved control rapid injury, organ is solid there If laparotomy. amidline via be should (andaorta common iliacs) to the approaches other All Î thoracotomy anterolateral 4th space of injury of zone or any of haematoma outside control distal to proximal/ Aim achieve extension incision and wound the document not, If surgery. before wound photograph is time, there If required. if line wound incorporate can Incision incisions extensile Use Interventional radiology is not recommended for genuine catastrophic haemorrhage in an unstable patient. patient. unstable an in haemorrhage catastrophic genuine for recommended is not radiology Interventional atrial. of as part used and as experimental viewed be should currently REBOA may but have arole knowledge of anatomical landmarks. on relies vessels the finding so present be always may not pulse apalpable patient hypovolaemic profoundly the In Î Î Î thoracotomy anterolateral space 4th intercostal Î incision clamshell space 4th intercostal 1injuries Zone of control proximal for required be may sternotomy Median Î ABSCM the along incision longitudinal Oblique

peri-arrest situations peri-arrest high injuries abdominal and in control proximal Rapid thoracic aorta thoracic descending the of control internal massage cardiac tamponade cardiac for 3 2and Zones and internal jugular vein tree access carotid tofor the K all large thoracic vessels thoracic all large 5 3 in in 1 R 3 17 1 19 5 Upper limb Upper Lower limb Pelvis a a a Î Î Î Î

running parallel to the clavicle to the parallel running supraclavicular incision Medial external iliac vessels by external of Control packing pelvic For rapid haemorrhage control by Î Î achieved with atourniquet. with achieved the of part upper to the distal Control a a a a a tourniquet. with is achieved artery brachial the of part upper to the distal Control Î grove bicipital medial the in arm the down longitudinally extending and incision Axillary Î incision infraclavicular horizontal Lateral

vessels subclavian the of control laparotomy. a via packing by direct incision mid-line lower a via approach extraperitoneal axillary artery axillary the of part proximal most longitudinal groin incision longitudinal a extending by laterally approach extraperitoneal laparotomy a via dissection direct brachial artery artery axillary the of part distal most the for artery axillary the of access majority to the superficial femoral artery femoral superficial as they cross the first rib first cross as the they upper upper and 17 19 is is

IMED/3A  Updated: 08/01/2020  v2.0 Injury management in ED  MI surgical/proximal heamorrhage control IMED/3A  Updated: 08/01/2020  v2.0 Injury management in ED  MI surgical/proximal heamorrhage control Thorax: Neck: in the following regions: toSurgical control approaches haemorrhage catastrophic Abdomen: Î Î Î Î Î Î Î Î Î Î Î

median sternotomy.median incision. this of extension adistal via skull the of base the reach to is it possible retraction good With nerve. hypoglossal the Preserve vein. facial the and omohyoid as can divided sternocleidomastoid muscle the of edge anterior the along incision longitudinal 3by oblique an 2and Zones in accessed be depending on the level of the injury. the of level the on depending – mesentery the of root at the compression infra-renal or diaphragm the below immediately compression coeliac The The vessels. thoracic aorta control and of the massage descending cardiac internal tamponade of cardiac relief diagnosis, for used be can alone thoracotomy anterolateral space A 4th intercostal incision clamshell space intercostal a4th via accessed be can thorax the in vessels large All The (innominate) to vein access. improve brachiocephalic left sternotomy amedian via vessels Zone 1 injuries right. or left the from rotation visceral by medial or mesentery the of root at the directly either retroperitoneum the into by entry Access is achieved vessels main to the involved. organ or injury vascular the of location exact by the is dictated dissection Further packing. For For laparotomy. amidline via be should iliacs common and aorta tothe approaches other All thoracotomy.anterolateral thoracic aorta descending the of by control quickly more addressed may be situations peri-arrest and injuries abdominal high Probable control haemorrhage surgical/proximal MI approaches for planned vascular surgery. vascular planned for approaches best the necessarily not are They control. vascular saving access to life achieve rapid for are approaches following The rapid control is achieved by by is achieved control rapid injury organ solid large vessel injury left subclavian artery left tree carotid

. It does not give easy access to other access to other easy give not does . It may require proximal control of the great great the controlof proximal may require and internal and jugular vein

rapid control is achieved by supra- is achieved control rapid is more easily accessed via a a via accessed easily is more . The sternal head can be be can head sternal . The . If necessary, divide the the divide necessary, . If via a 4th space a4th space via . can can

, Upper limb:Upper Lower limb: Pelvis: Î Î Î Î Î Î Î Î Î Î

point. a the the the of trunks The nerve. phrenic the of preservation with muscle head of sternocleidomastoid and then the anterior scalene clavicular the of division requires This clavicle. to the parallel supraclavicular incision amedial via achieved be can artery axillary the of part proximal most the and rib can be divided with a saw in its mid portion. mid its in asaw with divided be can it is it required beneath artery axillary the of portion exact access if to the but clavicle the to violate to need isIt rare proximity. close in are plexus brachial the of cords The afat-pad. in vessels axillary reveals the then This tendon. its through divided muscle minor pectoralis deeper the then and horizontally split be should major pectoralis of fibres The incision. infraclavicular horizontal a lateral artery axillary the of majority The the of Control of femur). of third (distal to proximal atourniquet with is achieved artery femoral superficial the of part upper to the distal Control The ring. lateral to ligament inguinal the deep the groin incision dividing and a longitudinal laterally extending by approach by extraperitoneal an or alaparotomy via iliac vessels External a laparotomy. via dissection by direct Common and internal iliac vessels a laparotomy. via packing direct incision midline alower via approach extraperitoneal by an achieved be can packing by pelvic control Rapid (mid-humerus). atourniquet with achieved is artery brachial the of part upper the below Control insertion. humeral at its tendon major pectoralis the by dividing exposed vessels the with joined be can grove incisions bicipital and infraclavicular grove. necessary, If bicipital medial the in arm the down longitudinally extending and brachial artery upper and artery axillary the of part distal most The longitudinal groin incision longitudinal are accessed via via are accessed vessels iliac external the of part lower brachial plexus common femoral artery subclavian vessels are best approached via an axillary incision incision axillary an via approached best are are in close proximity. close in are can be controlled by direct dissection dissection by direct controlled be can centred over the mid-inguinal centred over mid-inguinal the to beyond its bifurcation and as they cross the first first cross as the they is accessed through is through accessed are most rapidly control control rapidly are most

running running or by by or MI surgical/proximal haemorrhage control (Additional options for vascular exposure) Î Use extensile incisions Î Incision can incorporate wound line as required Î Aim to achieve proximal/ distal control outside of any haematoma or zone of injury

Pelvis Abdomen Lower limb

Incision: lower midline Incision: midline laparotomy from Incision: thigh - parallel to the laparotomy into extra peritoneal xiphisternum to pubic symphysis 15 anterio-lateral border of the plane to level of SI joints 17 Proximal control: supra coeliac sartorius muscle 20 Î allows pelvic packing with an aortic supra coeliac and intra Proximal control: femoral and extensile incision abdominal IVC. Visceral vessels. profunda femoris vessels Example wound for use: Distal control: distal external iliac Distal control: proximal 1/3rd Î pelvic injury without vessels and proximal internal iliac popliteal vessel segments requirement for laparotomy vessels Example wound for use: Example wound for use: Î proximal control for popliteal Incision: supra inguinal 18 Î penetrating or blunt artery injury 2 cm above and parallel to the abdominal/ pelvic injury Improve exposure: Connect groin inguinal ligament, extending from and thigh incisions 21 the lateral rectus sheath to a point Î allows full exposure of common 2 cm cephalad to the anterior femoral and femoral vessels superior iliac spine

Î allows extra peritoneal control Incision: 1 cm behind the exposure) vascular for options (Additional heamorrhage surgical/proximal MI 15 posterior border upper half of of proximal external iliac vessels  tibia 22 Î Incision: longitudinal groin 19 17 incorporate into leg fasciotomy Over the femoral pulse with 1/3rd 18 wounds where used of the incision above the inguinal Proximal control: distal 1/3rd

ligament and 2/3rds below inguinal 19 popliteal vessel segments ligament Distal control: Origin of anterior Î if no palpable pulse then 21 tibial artery, tibial peroneal vessels incision should extend and proximal posterior tibial and longitudinal through mid point peroneal vessels Injury ED in management between pubic symphysis and 20 Improve exposure: Connect thigh ASIS and leg incision 23 Proximal control: distal external Î allows exposure of middle iliac vessels 23 1/3rd popliteal vessel segments Distal control: common femoral through division of dividing the vessel bifurcation tendons of the semitendinosus, Example wound for use: gracilis, and sartorius muscles Î exposure of injured femoral segment in conjunction with Incision: Anterolateral leg 24 22 more proximal and distal 24 Î incorporate into leg fasciotomy control wounds where used Î proximal control for thigh If no fasciotomy wound exists, injury then a longitudinal incision is made in the anterolateral leg, halfway between the tibia and fibula over 10-15cm Î allows exposure of mid anterior tibial artery Y KE

Primary (Rapid Access) incisions: 17. Lower midline laparotomy for pelvic packing (can be extended to 15) v2.0 19. Longitudinal groin incisions for proximal control of leg vessels Alternative incisions for Vascular Access: 15. Midline laparotomy incision 18. Supra inguinal incision 20. Anterior-lateral thigh 22. 1 cm behind the posterior border upper half of tibia 24. Anterior-lateral leg  Updated: 08/01/2020 Extensions: 21. to extend/connect 19 and 20 to allows full exposure of common femoral and femoral vessels  23. to connect 20 and 22 to improve exposure of popliteal vessels IMED/3B IMED/3B  Updated: 08/01/2020  v2.0 Injury management in ED  MI surgical/proximal heamorrhage (Additional options for vascular exposure) Neck Shoulder and limb proximalShoulder upper division of clavicle of division incisions supraclavicular infraclavicular and with Connect exposure Improve wound junctional limb use: for wound shoulder/ upper Example vessels 1/3rd middle control: axillary Distal vessels 1/3rd proximal control: axillary Proximal 8cm) approximately for 1/3rd extending clavicle, the of middle the below 2cm is made incision skin A horizontal Incision: infraclavicular Incision: injury penetrating through athrough- in example for exposure tract aerodigestive vascular good for flap asub platysema lift and distally ABSCM incisions bilateral Connect exposure Improve injury use: for wound Example skull of to base artery carotid : Internal Control Distal neck of to root artery carotid Common control: Proximal head to the retromandibular region (ABSCM)muscle anterior of border the sternocleidomastoid Incision: sternotomy and 5th space left anteriolateral (trap door) anteriolateral 5th and left space sternotomy (+/- supraclavicular clavicle), of Connect division median exposure Improve wound use: for junctional wound shoulder/upper limb Example vessels subclavian thoracic extra control: Distal vertebral artery Proximal control laterally 8cm approximately extending and head clavicular at the beginning clavicle, to the parallel and above 1cm is made incision An control control haemorrhage surgical/proximal MI Î Î Î

vessels 1/3rd proximal of axillary exposure improved allows apex intrathoracic left and neck of to root exposure improved allows inferior to the lobe of the ear at its distal end. distal at its ear the of lobe to the inferior just extended and slightly curved be should supraclavicular longitudinal incision along the 14 , extending from the, clavicular extending : extra thoracic subclavian vessels, vessels, subclavian thoracic : extra 7 9 2 Zone 2 carotid vessel vessel 2carotid Zone (Additional options for vascular exposure) vascular for (Additional options

8 6 1 7 2 3 1 4 Upper limb -forearm vessels ulnar distal vessels, radial forearm mid control: Distal bifurcation Proximal control kaplan’s to finger ring cardinal line) of boarder radial of to line crease at wrist transverse ulna, to distal forearm mid to radial (M-LLSACF possible where Incision: volar adaptforearm use/ fasciotomy incision incision to M-LLSACF incision groove triceps biceps/ Connect exposure Improve wound forearm mid use: and for wound proximal Example control: Distal bifurcation Proximal control: crease elbow 2-3cm below and above forearm, (M-LLSACF) Fossa anti-cubital Sacross lazy tolateral medial Incision: incision to infraclavicular Connect exposure Improve distal use: for brachium wound wound mid- Example bifurcation brachial vessels/ brachial control: Distal Proximal control: biceps andIncision: triceps alonggroove between Î Î Î 6

volar fasciotomy incision fasciotomy volar additional without vessels forearm of exposure allows vessels brachial of exposure full allows delto pectoral approach pectoral delto through vessels axillary of exposure junctional allows 8 9 Thorax 11 distal descending control: thoracic aorta Distal aorta Proximal control: Incision: Incision: incision Connect exposure Improve use: for wound Zone 1carotid vessel injury Example vessels branch aortic thoracic intra of extent distal control: Distal Proximal control: process xiphoid to notch 2cm2cm below sternal above Î Î 5

thoracic (supra hepatic) IVC control (supra hepatic) thoracic and chest the through occlusion aortic allows achieved been has control distal proximal/ once wound of exposure junctional allows 10 Distal brachial vessels/ brachial bifurcation brachial vessels/ brachial Distal

4 median sternotomy incision to ABSCM to ABSCM incision sternotomy median : Distal brachial vessels/ brachial brachial vessels/ brachial : Distal Clam shell thoracotomy Median Sternotomy Distal brachial vessels/ brachial brachial vessels/ brachial Distal vessels brachial - from biceps/triceps groove to mid to groove mid biceps/triceps -from 13 13 11 proximal descending thoracic origin of aortic branch vessels branch aortic of origin 12

3 5 10 12 14 Initial management Initial Remember: order that in limb, and life preserve to surgery MINIMUM the Do trauma vascular MI h C Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î

atastrophic haemorrhage atastrophic

EY POINTSEY provide the most effective targeted interventions in theatre, such as thoracic aortic stenting or IVC filter placement IVCor filter stenting aortic as thoracic such in theatre, interventions targeted effective most the provide to diagnostics for utilised be could IR situations,however casualty mass in role alimited has radiology Interventional consultantssurgical by two made be should to amputate decision reconstruction; limb in futility Recognise high. may rate be Amputation reconstruction not and aMI, in injury vascular for treatment of mainstay the be will ligation vessel and shunts vascular Temporary numbers to casualty due interventions vascular to undertake may need specialists Non-vascular possible as Transfer as soon to theatre vessels to any visible haemostats of Avoid application manipulation wound any with concurrent analgesia opiate IV with pain Manage Kurlix (e.g. packing gauze internal with managed be can cavities Larger pressure digital and swab gauze asingle with managed be can wounds Small underlying axial skeleton the against wound compress to force applied Orientate Antibiotics & Tranexamic acid as per standard/ local guidelines local standard/ &Tranexamic as per acid Antibiotics shunts for needed is not Anticoagulation default) be (should fasciotomy of use Liberal repair to definitive shunt as abridge vascular Use temporary supply blood to restore (ifpossible) repair simple Consider loss blood further to ligate stop Shunt or Proximal/distal control STOP THE BLEEDING bleeding is controlled bleeding the once Traumagram/imaging have can aCT and theatre the direct go should patient haemorrhage, uncontrollable In STOP and control THE proximal BLEEDINGGain K TM ) and palmar pressure palmar ) and Clinical features of vascular injury vascular of features Clinical Active bleeding Active Palpable thrill or audible bruit haematoma Expanding limb pale cold Pulseless signsHard Temporary vascular shunts Indications How touse How Document What touse What Î Î Î Î Î Î Î Î Î Î Î Î Î

external fixator: fixator: external an of to application prior ashunt, As lost continuity all if vessels, axial Distal knee/elbow above vessels axial All loops to pull) loops vessel to (where press/which theatre away out from shunt falls if Actions 30 mins) (e.g. every required checks limb distal post-op of Frequency placed ashunt been has That hrs to up 48 for place in remain Shunt can shunt and vessel around tie with Secure injury of zone below and above vessel Place uninjured shunt in clamp saline) and ml 500 in (5000U saline Heparinised Fill shunt with required) may be (embolectomy bleed back and inflow Confirm available and appropriate) – whatever tubes is Nasopharyngeal / tubing/Nasogastric (IV vessels for sized appropriate of tube plastic Sterile Vascular shunt (e.g. available if Pruitt), Î Î

shunt the is placing surgeon orthopaedic the when table at the be should surgeon vascular the possible, if shunt. of length choose you when created by surgeon orthopaedic ensure you account for movement

major vessel major to close injury Penetrating deficit Neurological haematoma Non-expanding bleeding active of History signs Soft

IMED/4  Updated: 08/01/2020  v2.0 Injury management in ED  MI vascular trauma IMED/4  Updated: 08/01/2020  v2.0 Injury management in ED  MI vascular trauma Postoperative phase Plan planning Surgical Intraoperative phase Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î

MI vascular trauma trauma vascular MI who can arrange for a specialist surgeon to come to to you) come surgeon aspecialist for arrange can who coordinators Network regional your (liaise with available specialist vascular when hours) and 24-48 (typically stable when reconstruction for to theatre patient the Plan to return Î Î Î Î of; details clearly Document hospital another even in teamor by another performed may be surgery carefully details operative Document surgeons by two amputation or to revascularisation prior assessed be should viability Limb dissection) (vascular manoeuvres appropriate despite restored not flow is if indicated may be angiography table On flow is key assessing in Doppler Use of minutes) 15 every other each update and (set alarm plan operative evolving situation and transfusion requirements, inotrope status, physiological You of: aware be surgeon. all and must anaesthetist between communication Plan regular “SITREP” injury. 1neck Zone for sternotomy median approach; Morrison Rutherford with unfamiliar if artery iliac the of control (e.g. junctional with for laparotomy comfortable access the you are through control most Gain control distal and proximal to gain have able Must access to be cavities to enter multiple prepared Be Place “star”/cruciform in position required may clinician be senior from arbitration coordinators; through – communicate early elsewhere invested best may be resources futility; intraoperative –recognise threshold) use product (blood surgeon to alert team/anaesthetist theatre for parameters Set cavity additional an to open maye.g. need notice at short may plan change that to staff Communicate opened to be cavities or Cavity required Equipment priorities) of (with order plan control damage the Deliver team theatre to the identified injuries Communicate checklist WHO Use a(truncated)

Actions for major post-op bleeding to theatre return for parameters Physiological Anticoagulation antibiotics List

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indicated for: indicated is surgery thoracic Delayed resection). lobar attempting before injury lung penetrating for tractotomy pulmonary consider and staplers, gastrointestinal use resection (for non-anatomic anatomical not physiological be should Surgery a F 1hour. within complete be should surgery context, casualty amass In possible. as short as time on-table keep save life: to surgery necessary MINIMUM the Do MI thoracic trauma t thoracotomy: Indications for damage control drains, as a rule of thumb: of arule as drains, appropriately-sizedSelect chest C Î Î Î Î Î Î Î ragments from blast and other ballistic projectiles do not respect anatomical boundaries: anatomical respect not do projectiles ballistic other and blast from ragments Î Î

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injury ballistic following fragments be done ‘routinely’ to retrieve have not to does Thoracotomy Î Î Î Î priority may have casualties higher other aMCI, of context the in and poor very to is be likely arrest cardiac pre-hospital after Outcome compromising ventilation For massive air-leak Î ED) in output arrest aperi- in resuscitation For injury abdominal of co-existing is evidence there if laparotomy e.g. cavities body adjacent enter and (eg. neck) area junctional on to operate prepared Be choice. of incision is the thoracotomy Clam-shell -32F Adult: Child: 12-16FInfant: On-going blood loss of approximately 200 ml/hr 200 approximately of loss blood On-going patient 1.5 unstable an in litres approx. of tube chest from return Immediate

team surgical thoracic your regional with closely liaise concern: or complications Other Thoracic empyema leak air Persistent Persistent bleeding time resuscitation to extend is extra-thoracic loss blood of source the if REBOA, Consider KEY POINTSKEY

patient 24 16-24F

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see Speciality Overview  Overview Speciality operationprimary see the of duration the or insertion drain chest beyond required often not are essential; however, is antibiotics Early prophylaxis antibiotic surgical physiotherapy chest and relief pain effective ensure injury: chest with patient every For 1 1

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also consider ‘permissive hypoxia’ Consider ‘permissive hypercapnoea’ but intubated if ventilation protective lung Consider placement tube chest require only injury chest with patients of Majority Î Î Î and resuscitation status of patient of status resuscitation and perfusion organ end of measure a sensitive is as UO is catheter advised, urinary Early Avoid fluid over-resuscitation to normovolaemia Resuscitate theatres to prior roll have mayPatient log not had chest posterior and back the Examine IPPV) (from embolisation air and Potential fragment for experience if possible thoracic with anaesthetist an - choose necessary always is not tube lumen A dual

reduce and use lowest FiO lowest use and reduce High FiO Peak pressures minimised volume tidal Reduced B C E D A 8 - 24 hours then then 8-24 hours first 2 for 2

 2 2

IMED/5  Updated: 08/01/2020  v2.0 Injury management in ED  MI Thoraci c trauma IMED/5  Updated: 08/01/2020  v2.0 Injury management in ED  MI Thoraci c trauma ` _ is stable) patient the when re-look (with planned operation control adamage Plan for thoracotomy Prepare damage a for control Î Î Î Î Î Î Î Î Î Î Î

come to you. come to surgeon aspecialist for arrange can who coordinators with a thoracic surgeon; hours 24-48 at to theatre back patient the totake Plan Î Î Î You team. aware of: anaesthetic be must your with dialogue intra-operative Maintain “SITREP” setting. ICU an in managed and thoracotomy trauma after ventilated and intubated be should Patients at 120mmHg. suction to wall dressing the attaching closure, thoracic temporary for technique vacuum-pack Use the injury.abdominal of think and diaphragms the tocheck Remember resection. major attempting than rather injury pulmonary penetrating from and/or leak air bleeding to control possible when done be should tractotomy Pulmonary staplers. gastrointestinal with done be can lung damaged of resection Non-anatomic incision. your below and above sternum; the of underside the on vessels mammary internal the to control Remember haemopericardium. treat or to exclude pericardium the open Always access. insufficient Make a incision: clamshell temperature. covered and to maintain appropriately draped be can once patient prepped, to knees; chest patients’ Prep necessary often not are tubes Double-lumen disaster. acrisis into a turn and lung un-injured (dependent) the contaminate can lung injured an from bleeding bronchial as endo- side their on patient the turn formally NOT DO but help side injured the on chest patient’s the behind bag) (e.g. infusor bag pressure injury, abolster unilateral For position) (“star”/cruciform abducted arms with supine patient Place MI thoracic trauma

how long you have operating been situation transfusion requirements inotrope including status physiological

: liaise with your regional Network Network regional your with liaise limited left thoracotomy gives gives thoracotomy left limited

Pre- laparotomy Pre- Selection for laparotomy for Selection C Remember: DAMAGE CONTROL. think save life: to surgery necessary MINIMUM the Do trauma abdominal MI Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î

atastrophic haemorrhage atastrophic

EY POINTSEY Traumagram with 4 quadrant abdominal packing in situ, once the bleeding is controlled bleeding the once situ, in packing abdominal Traumagram 4quadrant with have can Patient aCT control. proximal for to theatre direct go should patient haemorrhage, uncontrollable In STOP and control THE proximal BLEEDINGGain Î making decision Senior Checklist WHO injury. adiaphragmatic through coming may be blood chest, the is from bleeding on-going of source laparotomy. the If exploratory after athoractomy to do may you e.g. need cavities body to adjacent enter prepared Be organs hollow in injuries ‘paired’ for Look boundaries. anatomical respect not do projectiles ballistic other and blast from Fragments guide selection for surgery for selection guide to help sparingly Use CT back the inspect and patient and carefully patient the examine judgement: clinical Use your don’t get ‘task fixated’ on complex reconstructive surgery and anaesthesia and surgery between a dialogue Maintain finishing or finished be should you hour at 1 possible: as soon as table the off patient the Get hours 24-48 at re-look for plan and closure abdominal atemporary Make formation stoma or repairs intestinal definitive do not Do Î Î are: priorities The incision midline afull Make possible where operating consultant” Have “two

transfer to palliation) transfer (such as decisions surgical difficult for as arbiter to act incident commanders and for contact of as point act activity,departmental to of oversight to maintain is ideal) anaesthetist plus team(surgeon A senior Then: controlcontamination Then: bleeding the stop First: K don’t forget to roll the the toroll forget don’t

1 2 1 3 ` h h Î Î Î Î Î Î Î Î Î

cause significant hepatic or splenic injuries or splenic hepatic significant cause may trauma blunt from fractures Lower rib Care Standard earliest, appropriate opportunity at the roll log survey. needs Patient secondary primary/ have mayPatient acomplete not had chest posterior and back the Examine is mandatory survey atop-to-toe and imaging of MDT review A full injuries missed for look Actively gases Regular blood trauma abdominal in suspected examinations abdominal Serial the patient is stabilised surveysecondary must be completed once and Primary patient. injured seriously the survey, in primary the of part may form laparotomy +/-Resuscitative thoracotomy collapse cardiovascular early at of risk are and reserve physiological have little patients Old loss before deteriorating blood significant Young may tolerate patients patient of status resuscitation and perfusion organ end of measure sensitive catheter urinary Early B A E D C to monitor condition is advised, as UO is a is a as UO is advised, 3 are required are required 2

IMED/6  Updated: 08/01/2020  v2.0 Injury management in ED  MI Abdominal trauma IMED/6  Updated: 08/01/2020  v2.0 Injury management in ED  MI Abdominal trauma The operation Patient positioning Pre-laparotomy of: aware be must you team: anaesthetic your with dialogue intra-operative Maintain Laparotomy Control Damage Î Î Î Î Î Î Î Î Î Î Î Î Î

laparotomy incision. /pericardium chest cavities: adjacent about think abdomen, the in control apparent despite instability continuing with apatient In diagnosis. make the possible)you mayhelp if (flexi sigmoidoscopy table on injury; rectal extraperitoneal about Think Î Î Î Î Î areas: following the Beware contamination and bleeding have you once of control exploration athorough Do sutures. over-sewn with simply be can injuries Minor abdomen. the in discontinuity’ in ‘stapled ends bowel leave the and bowel damaged to resect devices stapling injury, use destructive or segment, one in injuries bowel stoma). of are multiple there formation If or anastomosis & repair, with (i.e. resection surgery intestinal definitive contamination of is control goal Next it. and loss controls blood of source the finds then and clot and blood evacuates surgeon the hiatus while the at aorta the occlude digitally should assistant -your patient Firstly, aim for haemorrhage control to pubis. xiphisternum incision: midline afull Make temperature. maintain covered and to appropriately draped be can patient prepped, once to knees; &abdomen chest patient’s: Prep position). (crucifix abducted arms with supine Place patient to palliation). (such as transfer decisions surgical difficult for as arbiter to act and commanders incident for contact of as point to act activity, departmental of oversight to maintain rooms operating between moving department the in surgeon have asenior possible; If available. are staff if helpful, is very operating “Two consultant” used. be should Checklist WHO The laparotomy. primary the of duration the beyond prophylaxis antibiotic to surgical continue need not do you however, to incision; your prior essential are Antibiotics Î Î Î Î MI abdominal trauma abdominal MI

major incident (are new patients still arriving?) arriving?) still (are patients incident new major evolving the and theatres on demands of context wider awareness) improve will situational anaesthesia (regular is from updates taking your time surgery the situation transfusion requirements inotrope including status physiological Retroperitoneal colon Mesenteric border of intestine sac Lesser OGJ around stomach on High right and left Diaphragm, . A pericardiotomy can be done via your your via done be can . Apericardiotomy . . In a very unstable unstable avery . In : do not attempt attempt not : do

Planned re-look Temporary closure abdominal t Imaging Î Î Î Î Î Î Î Î Î Î Î Î

going inotrope requirement etc. etc. requirement inotrope going on- transfusion, massive with injured, severely most the in appropriate may be acolostomy of Formation many cases. in injury bowel large and small both in avoidance stoma of with option is areal by anastomosis continuity bowel of restoration stable, relatively is patient the (atre-look) if first fragment) destructive or GSW for extensive more fragment, energy low or (minimal knife for mechanism injurious the of energy to the according vary will debridement the of extent re-repaired then and bowel to healthy, vascularized debrided be should bowel the so and injury penetrating with injury’ of a‘zone always is There re-done. and down taken be should injuries intestinal Over-sewn injury. missed to exclude &pelvis abdomen entire of the exploration do a thorough laparotomy: re-look first At hours. at 24-48 to theatre back patient Plan tothe take ICU setting. an in intubated to apatient compared awake an in patient evisceration of risk is increased an as there applied, properly is dressing the ensure but closure abdominal temporary of this form with extubated and woken be can Patients at 120mmHg. suction to wall dressing the attaching closure, abdominal temporary for technique vacuum-pack Use the injury. missed of amarker are bowel the in holes Un-paired injury. diaphragmatic though coming and chest the is from bleeding on-going of source the if laparotomy after thoractomy e.g. cavities body adjacent enter and area junctional on to operate prepared be retroperitoneum, the about think organs; hollow in injuries ‘paired’ for Look organ injury on CT-such as free fluid) before operating. before fluid) as free CT-such on injury organ of evidence associated or (clinical status corroboration for ;look injury visceral without may have pneumo-peritoneum patients blast-injured :remember CT had has apatient If injury. blast after Evisceration of bowel and or omentum is relatively common physical sign. is ahelpful tract urinary the in ,blood early Catheterise injury. penetrating for carefully Look aPR. do roll, log the during thoroughly back the examine aspect, aposterior has abdomen the remember required; is judgement surgical and examination clinical Thoughtful necessary). if course clinical their in later scanned be always can (patients them need who patients for resources scan CT scarce ; reserving laparotomy for indications clinical your on rely mandatory; is not CT inside. leave ends and device stapling with colon –divide colostomy the mature don’t but is as above, injury rectal for technique ‘damage control’ The washout. and rectum from faeces remove manually and it injury rectal penetrating with patients for colostomy adefunctioning Form

; repair the injury if you can access access can you if injury the ; repair . The . The Specialty checklistSpecialty starter ‘shock pack’ for red blood cells and plasma cells and blood red for ‘shock pack’ starter as unit your in available products blood 1–or *MTP ` ` a a a Key considerations injuries bone long and pelvic MI a ` h C Î Î Î

atastrophic haemorrhage atastrophic

Carry out the coagulation studies available in your unit unit your in available studies coagulation the out Carry limb lower destroyed per MTP* one for –plan proactively blood Give Keep patient warm Peri-op antibiotics antibiotics Peri-op as appropriate) infusion or (bolus TXA Give survey primary Repeat Is there uncontrolled haemorrhage? closed? or open wound is the injuries, limb In injury? have apelvic casualty the Could Actively resuscitate with red cells and plasma. Avoid crystalloids, give platelets early. early. platelets give Avoid crystalloids, plasma. cells and red with resuscitate Actively 1* MTP 4UFFP) and Get (4U blood 3 see Speciality Overview  Overview Speciality see

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hours <6 time binder tokeep Aim x-ray and reassess binder,pelvic Apply and splint it splint and limb Realign time tourniquet start inflate it and note – possible as tourniquet as soon a pneumatic to tourniquet prehospital change and dressing Apply pressure indicated clinically if ex-fix Only suitable if splints fabricated traction/pre- skin splints/ Use Thomas backslab POP Apply limb Realign splinted? be simply patient the Can Patient may have higher priority for theatre. for mayPatient priority have higher caseRe-discuss with Resus Surgeon Commander. Apply pelvic binder injury? Limb Lower Blast

Have you excluded compartment syndrome? syndrome? compartment Have excluded you 2 a a

antibiotics lung protective ventilation

3 1 2 a a Î Î Î Î Î

Pack against binder not ex-fix not binder Pack against so: If theatre? to togo need patient Does ready and available Transfer Suite to if IR transfer? for stable Is patient bymanaged IR? be bleed pelvic the Could continuity tourethral confirm urology to refer unsuccessful, If catheterisation. urinary at pass one Attempt required if MHP activate and Anticipate coagulopathy t a a a a h Î Î Î Î

than minutes 60 Do not operate longer event MI in unlikely time, if vessel Repair needed) (shunt if only Fasciotomise distally Ligate control proximal Get the bleeding? tostop totheatre to go need now patient Does now? Can it wait? totheatre togo need really patient the Does required? blockade Peripheral nerve fasciotomiesPerform checks neurovsacular distal Regular

IMED/7  Updated: 08/01/2020  v2.0 Injury management in ED  MI pelvic and long bone injuries SMED/7  Updated: 08/01/2020  v2.0 Injury management in ED  MI pelvic and long bone injuries INTENTIONALLY LEFT BLANK THIS PAGE HAS BEEN

Specialty checklistSpecialty be correctly informed. be correctly can specialties specific for need and surgery for priority that degree toasufficient wound each for adiagnosis tomake Aim: MI immediate wound management medications medications impacting comorbidities and patientsOlder have physiology normal but loss blood Young –may have significant A TXA, ABx. TXA, drugs? eg. Any pre-hospital time. tourniquet the Know dressings? dressings/haemostatic Any tourniquets/pressure T observations. pre-hospital the Note patient. to the Listen S were handed over. than wounds more for Look I it. by distracted be not do but mechanism the of aware Be weapon. the treat not –do wound the then patient, the treat Initially M LOC. unknown or entrapment if prolonged tourniquet use, syndrome or pressure effects compartment of arisk May be T anticoagulants. a a a ` h h t C njuries Î Î Î Î Î reatment given reatment igns and symptoms and igns ime ge

echanism

atastrophic haemorrhage atastrophic

concurrent activity). activity). concurrent access, mitigation, (hypothermia go asingle in body whole the than rather areas sequential examining Consider vascularity. concerns regarding for and wounds complex in especially re-looks, to avoid unnecessary present, asurgeon with review or Photograph, back. the forget Don’t off.methodical. come Be must dressings all so examined be must wounds All In all types of blast and ballistic wounding, a CT ‘whole body’ scan should be performed. be should scan body’ ‘whole a CT wounding, ballistic and blast of types all In Any viscera/brain? exposed to prevent deterioration? attention any immediate Are there that require wounds Uncontrollable haemorrhage is probably the only indication. assessment? further without to theatre immediately to go patient the require that wounds any obvious there Are guidelines). MI or (local/Trust guidelines microbiology as per antibiotics systemic Administer Use tourniquets if pressure dressing with elevation fails (ifpracticable) fails elevation with dressing pressure if Use tourniquets tourniquets for rush not do then is calm situation the If as possible as soon TXA Give Junctional and ongoing is intra-cavity bleeding an indication (or for surgery IR). eg

β-blockers or or β-blockers 

Place a saline soaked gauze on these, do not use antiseptic solutions. antiseptic use not do these, on gauze soaked Place asaline 4 2 1 4 3 100 90- a ` a at scene. loss’ blood ‘large of reports of because resuscitation over of Beware controlled. may have been wounds significant even from Bleeding, Î Î Î Î

patient up. patient If practicable and appropriate, sit the swelling?emerging or bleeding have might that on-going wounds neck any or face risk; Airway Keep the patient warm. patient the Keep of wounds pattern the with fit doesn’t that consciousness of level Reduced profile. coagulation and response their physiology, patients on based and products by blood be should Fluid replacement management of catastrophic haemorrhage to refer bleeding, significant Continued for: good are dressings seal chest Adhesive Î Î Î Î Î

chemical/biological weapon? chemical/biological injury, hypovolaemia, missed injury, hypoxia head alcohol/drugs, wounds. abdominal and chest management any wound initial B A E D C 3 1 2

IMED/8  Updated: 08/01/2020  v2.0 Injury management in ED  MI Immediate wound management IMED/8  Updated: 08/01/2020  v2.0 Injury management in ED  MI Immediate wound management Non-surgical control of haemorrhage of control Non-surgical ` and planning Documentation t a a ` identified. correctly be can specialties specific for need the and surgery for priority and decision the that such degree to asufficient wound each Aim: to diagnose wounds of Examination Î Î Î Î Î Î Î Î Î Î Î Î Î

surgeons and operating theatres are available, the approach approach the are available, theatres operating and surgeons where ahospital, within Once areas. junctional as in such dressings prove pressure and inadequate, tourniquets where capability surgical of alack for to mitigate use pre-hospital for designed are primarily These available. agents topical haemostatic of types several are There dressing pressure a with controlled be can wound the from oozing General explored. This should be done in an operating theatre. operating an in done be should This explored. formally to be wound the for is requirement there function normal in alteration or fractures open or bone exposed fascia, deep or cavity abody of is any penetration there If turn. is it until their held be will patient the where dictate and to theatre timings for list a priority generate will This steps. next of planning for coordinator clinical relevant to the presented be must findings The findings. CT the supplementing theatres team in surgical by the done best Probably at some-point. done be must it because involved) structures and size exact location, anatomical (precise documenting the forensic description of the wounds for responsibility has who plan!) (in the Have pre-agreed is it at possible. all if Take photographs quality must documented. be findings the assessed fully have wounds been the Once harmful. potentially is and information useful further no Probing the wound with instruments orprovides fingers deficits. tendon and vascular, for nerve examine formally Then, Î Î Î to ascertain: possible is it normally observation simple By wound. the exploring without as possible information as much toAim get wounding? to the any patterns there Are wounds. dirty of risk ahigher has dirt in covered patient A assessment. overall the with helps but specific (dust?(torn? burnt?) dirt soil? soot?). and shredded? Non- clothing of terms in patient the of state general the Note dressing, consider doing under tourniquet control. a removing when haemorrhage significant is of arisk there If go. asingle in body whole than the areas rather sequential doing Consider wounds and for vascularity issues. in complex relevant Particularly re-looks. unnecessary to avoid present asurgeon with it doing Consider back. the forget Don’t manner. thoughtful and this amethodical in Do removed. be must dressings all so examined be must wounds All MI immediate wound wound management immediate MI

Is bone exposed? breached? been has fascia deep the that obvious Is it bodies? foreign with contamination obvious Is there and/or elevation.

t 12 next hours: the within totheatre togo likely patients For Timing of wound management t Î Î Î Î Î Î Î Î

inflated tourniquet makes a patient a priority for theatre. theatre. for priority a patient makes a tourniquet inflated An is addressed. wound the before evaluated be should this survey primary the during arrival on applied or hospital debridement in theatre is not considered necessary) is formal that such contamination of degree the and structures important or to deeper damage of evidence as apriority. obtained be should control vascular surgical formal and tourniquet pneumatic the inflate then bleeding, is significant there tourniquet windlass the releasing on If Î Î Î a has patient the If ensure appropriate delayed closure occurs. closure delayed ensure appropriate to patient the of up follow for made be must Provision ballistic closed. No wounds primarily be should Î with those For suffice. will swab soaked asaline of Application time. buy does so and bacteria contaminating of proliferation the to reduce shown been has possible as as early antibiotics systemic of Administration prioritised patients these and assessment, triage surgical the of part grossly of contaminated presence The wounds should be debridement. to formal adelay such even with ward the ED in or irrigation to support evidence clear no is still there thisIn case first the in to theatre get mayhours. not tissue wounds 12 soft with patients situations, casualty mass significant In solutions. antiseptic of use the to support evidence is no There wound. the to irrigate tempted be not Do dressing. outer an with secure and wound the on swab soaked Place asaline tourniquet is released. before had, be should fasciotomies for need potential patient’s and condition, overall general viability distal discussions managing the about hours, thanmore two significantly for on been has tourniquet initial the If should be limited to extreme situations only. situations to extreme limited be should hospital within dressings haemostatic of use The control. surgical formal be should wounds bleeding to continuously

assessment of distal vascularity can be made. made. be can vascularity distal of assessment At an this point debridement. during use for or as aprecaution place in remain should but immediately inflated to be need not does tourniquet pneumatic the then haemorrhage significant is no there If observed. wound the and released be then can windlass The outflow. venous restricts it that such tightly too applied nor initially inflated not but windlass to the proximal placed be can This as is practicable. as soon pneumatic tourniquet, by a replaced be this use, should pre-hospital for as is common type, windlass is asimple tourniquet the If practices under appropriate analgesia. to usual according cleaned be can wounds These

for theatre 12 before hours where possible.

superficial superficial wounds tourniquet in place either from pre- from either place in (where there is no is no there (where

the the

Fasciotomy Incisions reconstruction decompression of lower leg compartments and artery tibial anterior mid of exposure allows wound, fasciotomy leg Lateral fasciotomy leg Medial Volar fasciotomy Forearm adequate allow vascularand access to decompress compartments designed have been fasciotomies universal These fasciotomies universal MI 4. 2. 1. compartments: lateral and anterior the of Release 5. 4. 2. 1. compartments: posterior deep and superficial of Release tibia. the of borders anterior and medial the of markings surface to the draw marker Use askin the lower leg for fasciotomy compartment Two four incision, 3. 3. Î Î Î

A I U S D M A E I D M injury incision to fully release the lateral compartment the release to fully incision I intramuscularthe septum. have will This revealed felt. is fibular the until laterally fascia the of aspect deep the follow malleolus. lateral the above and of front in to just down flare tibial the from tibia the anterolateral to the marked anterior border of tibia. the off muscle soleus the dissecting compartment posterior deep the release to fully incision into the posterior deep compartment. entry have will gained This over it. fascia thinner the distally, incise and done easily most bundle, malleolus. medial the behind to down flare tibial the from tibia the of border medial to marked the posteromedial released the anterior compartment have will fully This incision. skin the of length whole the along fascia the incise then and skin released theposterior superficial compartment have will fully This incision. skin the of length whole the along fascia the incise then and skin ncision can incorporate wound line as required line wound incorporate can ncision ncise this along the whole length of the skin skin the of length whole the this along ncise dentify the posterior tibial neurovascular neurovascular tibial posterior the dentify weep the exposed muscle bellies medially and medially bellies muscle exposed the weep xtend this along the whole length of the skin the of length whole the this along xtend ccess to the more proximal part will require will part proximal ccess more to the im to achieve proximal/ distal control outside of any haematoma or zone of of zone or any of haematoma outside control distal toim proximal/ achieve se extensile incisions extensile se eepen theeepen incision without undermining the theeepen incision without undermining the ake an incision through skin 2 cm 2cm skin through ake incision an 2cm skin through ake incision an . . 22 14 (that can be used for vascular access) future soft tissue , without tissue compromising soft future . 24 . . 24

14 14 24 22 22 24 22 14

IMED/9  Updated: 13/01/2020  v2.0 Injury management in ED  MI universal fasciotomies IMED/9  Updated: 08/01/2020  v2.0 Injury management in ED  MI universal fasciotomies INTENTIONALLY LEFT BLANK THIS PAGE HAS BEEN

Acute acoustic trauma (AAT) and hearing loss after a major incident Symptoms common to acute acoustic trauma include Î Patients with abnormal audiograms should be referred hearing loss, tinnitus, earache or vertigo. The ear is highly and reviewed urgently and if appropriate, steroids given. susceptible to injury after blast, and this is often missed Î If hearing tests are normal, no immediate action is as the trauma teams manage life threatening injuries first. required. Patients may self present days later, to the ED or GPs. Î If tinnitus persists, then other therapies may be useful at a later stage.

“I was near the blast and my hearing has been affected. I think I need a hearing test”

Do not wait! Your regional coordinating Use phone app or urgently arrange non-hospital audiogram to confirm hearing loss ENT resource

 Hearing loss diagnosed.  Acute acoustic trauma and (AAT) hearing loss after a major incident Phone GP urgently for hospital audiology referral for further assessment t Please include Î Patients contact details Î Clinical examination GPs/Other non-hospital audiology providers. Î Contraindications to high dose h Request formal audiogram with Regional Co-ordinating Audiology Department (RCAD) (Other providers may be commissioned/authorised depending on surge demand) steroids Î This is a clinical priority treatment options are severely time limited NHS number if known Specialty overview  Î MI audit - Report all cases of hearing loss/abnormality to RCAD PRE HOSPITAL IN HOSPITAL RCAD audiogram confirms hearing loss. URGENT referral to Regional Co-ordinating ENT Department (RCENTD)

Regional Co-ordinating ENT Department (RCENTD). Consultant Otologist - ‘Paper’ review of audiogram, endoscopic images if available and other clinical information. (Documentation to include NHS number and advice given)

h Triage patients to Outpatient appointments h If necessary repeat Pure Tone Audiogram and Tympanometry Case not appropriate for steroids. (plus TM Endoscopic photography if resource available) Monitor patient as per local policy and provide Hearing Aids if appropriate

Pure conductive loss Sensorineural or mixed loss

Adult and Paediatric follow ADULTS (Priority 1) PAEDIATRIC <16 (Priority 1) up Î Check contraindications for steroids If hearing loss is suitable for management with by ENT at local hospital Î Discuss intratympanic and/or oral steriods steroids (or Regional co-ordinating Î Recommendation for oral regime: Î All cases must be managed with paediatric ENT Department) Prednisolone 1mg/kg to a max of 60mg OD consultant input (Priority 2) for 7 days, after appropriate consent Î Discussion with parents re: contraindications of

Î Gastric cover with PPI and Gaviscon steroid use in a young patient v2.0 Advance Î Consider oral steroids and ITSI (particuarly if patient *AAT and steroid use Î Ensure patient has ENT follow up after has GA/Sedated for any other reason) See overleaf before 7 days. If oral steroids only selected, Î Titrate dose by weight (Prednisolone 1mg/kg PO intratympanic steroid injection (ITSI) should OD 7 days to a maximum dose as per local policy)

prescribing Specialty overviews be reconsidered Î Discuss use of gastric cover if appropriate

Î If persistent sensorineural loss after 7 days of oral steroids, consider intratympanic steroids (ITSI) Î If persistent mixed loss, where conductive element is related to a perforated ear drum, consider aural toilet and topical steroids  Updated: 08/01/2020  SO/1 SO/1  Updated: 08/01/2020  v2.0 Specialty overview  Acute acoustic trauma (AAT) and hearing loss after a major incident If the loss is purely conductive which may be due to; due may be which conductive is purely loss the If assessment. for (RCENTD) URGENTLY guidance ENT local per as indicated, may be therapies other then persists, tinnitus If is required. are no immediate normal, tests hearing action If compromised: may (ITSI) be injections membrane tympanic intra deliver to available resources where scenario, casualty mass the In beneficial. be may steroids sensorineural purely or is mixed loss hearing If ` ` ` I (RCAD). Department Audiology Coordinating Regional by the performed be should tests hearing loss, hearing proven or symptoms with children, and adults For limited. time Treatment severely are options evolves. exposure blast and noise with (SNHL) loss associated hearing sensorineural of rescue to the related as evidence taken been has approach apragmatic and maturing is rapidly based, are protocols these which on evidence The situation. casualty mass the in fracture associated without bone temporal injury hearing of management the tostreamline designed is overleaf flowchart The trauma. following hearing their of quality the in areduction to perceive patients for many are reasons There Injury Acute Hearing f abnormalities are detected, results should be passed on on passed be should results detected, are f abnormalities Î Î Î Î Î Î Î

when compared to oral steroids for hearing salvage. salvage. hearing for steroids to oral compared when should considered be as there is evidence of superiority steroids intratympanic loss the of component sensorineural the in improvement is no there if week one After consent. appropriateafter consideration of contraindications and PPI OD, 7days with for cover 14 for 60mgs of to amax days, 1mg Kg Prednisolone, per oral prescribed be can Patients interval appropriate to their pathology. at an outpatients in routinely up followed be can Patients dry. ear the Keep is needed. action immediate No ossicular discontinuity perforation membrane tympanic canal auditory external the in blood together. children and parents is to awish keep there and dictates location the or services audiology paediatric on pressure place injured numbers the if considered be This should five. of age the above children with performed be often can Pure Tone ‘adult’ Audiometry standard however, appropriate, age to be need tests children, For earlier. to test appropriate is it perfectly and is imperative treatment and assessment however, loss hearing asevere early of presence the In hearing loss after a major incident major a after loss hearing Acute acoustic trauma (AAT) and to the Regional Coordinating ENT Department Department Coordinating ENT to Regional the

.

, OTHER CONSIDERATIONSOTHER - remember to CHILDREN YOUNG AND PEOPLE FOR Updated Advice (2017) given. usually and considered be should protection gastric children and adults both For effects). side (to possible of consultation aware are all ensure paediatric/ENT ajoint after and contraindications of absence F also concurrently be administered. be can steroids intratympanic the which during procedures operative is having patient the if particularly considered be may steroids however, contraindicated, intratympanic may be steroids oral/IV polytrauma, associated of presence the In Î Î Î Î Î or children, oral Prednisolone should be considered in the the in considered be should Prednisolone oral children, or

*AAT use steroid and Î Î Î Î must be documented for all patients. patients. all for documented be must options, treatment other and this, on given information The effects. side possible the to explain meticulous Be to weight. DOSES STEROID TITRATE Î Î as; such ideas mayYour have some audiologist isolation. of sense patients’ injured the to reduce simply or consent, informed to complete order in e.g. aid conduction abone with period immediate the in helped be can loss hearing have who aconductive Patients any reason. for aGA has or is sedated achild, especially apatient, if considered be should This use. steroid systemic with associated complications of risk relative the reducing effect, may good give steroid of injection tympanic Intra ideal. is the present consultant apaeds with ENT possible, if Have consultation ajoint

consideration should be given a high priority. ahigh given be should consideration this is lost, vision If considered. be should ITSI present, are steroids suspicion exists but relative contraindications to systemic In severe trauma, where objective evidence of SNHL or high burns. unable to subjectively test e.g. intubated patient with severe scalp but loss sensorineural has patient suspicion is astrong there if present) perforation if drops topical or (ITSI use steroid Consider appropriate. be may ITSI an than rather presence of a perforated ear drum topical steroids given regularly the in part sensorineural the to treat persists loss amixed If oral steroids. of week one after salvage or as presentation first at steroids oral to alternative as an considered be should steroids Intratympanic Bone conduction aids that stick to the mastoid. to the stick that aids conduction Bone (used BAHA). aids pre “Alice secured band”

are relatively clean gunshot wounds whereas (GSW) recolonised); become remain so even extensive after debridement, or will rapidly (and will contaminated and extensive are wounds Blast Introduction prophylaxis Antimicrobial a report. microbiology the treat just don’t but wounds other as injury, same is the ballistic or blast in infection Bacterial t Î Î Î Î Î

response and it may not be due to infection. an due be may it not and response have inflammatory will ahuge patient your Recognise antibiotics and measures tosimple Keep Î Î Î possible. as information as much microbiologist your Give unusual clinical picture. clinical unusual an for alert on commonly, be occur things but Common team is essential. multidisciplinary the within amicrobiologist with liaison Close infection? or this is if colonisation Consider discuss with your microbiologist organisms, resistant ESBL+ve other CPE, or MRSA, with colonised tobe known is patient If

Any organic contamination or water exposure? water or contamination Any organic obtained? was it which in environment the was What sustained? injury the was How KEY POINTSKEY . 5 2 1 6 3 4 7

a Penetrating chest trauma chest Penetrating eyePenetrating injury injury CNS Penetrating fracture skull post leak CSF Penetrating soft tissue injury injury tissue soft Penetrating fractureOpen limb/hands trauma abdominal Penetrating Î # t # # t t # t # t # a t

Î Î Î Î Î Î Î Î (unexpected) necrosis. (unexpected) evolving with wounds of suspicious or aware Be common pathogens and may overlook others. for to up look set are labs as diagnostic picture, clinical unusual or findings Tell unexpected the about lab the

GI contents GI Penicillin allergy: Clindamycin 450mg qds iv tds iv) 500mg 750mg Metronidazole and tds iv (if unavailable, 1.2g iv give tds Cefuroxime Co-amoxiclav iv tds 450mg iv +Clindamycin bd 400mg Ciprofloxacin iv tds +Metronidazole iv 2g bd Ceftriaxone Give required antibiotics No Penicillin allergy: Clindamycin 450mg qds iv tds iv) 500mg Metronidazole or 750mg tds iv Cefuroxime give (if unavailable, 1.2g iv tds Co-amoxiclav Penicillin allergy: Clindamycin 450mg qds iv tds iv) 500mg Metronidazole and tds iv Cefuroxime (if unavailable, 1.2g iv give tds Co-amoxiclav Add tissuedamage significant soft tds 500mg iv. VancomycinMetronidazole Add 1gm if bd and iv bd 400mg Ciprofloxacin allergy: Penicillin tds iv) 500mg 750mg Metronidazole and tds iv (if unavailable, 1.2g iv give tds Cefuroxime Co-amoxiclav presence of intercostal drainspresence or progress on depending weeks, to two One body foreign of removal after weeks ≥two for Give duration weeks two courses All tds500mg iv +Vancomycin iv bd 1g400mg +Metronidazole iv bd Severe Penicillin Allergy (Anaphylaxis): Ciprofloxacin 2g tds iv Meropenem allergy: Penicillin Non-severe Until first surgical debridement/washout (BOAST4soonest guidelines) is whichever tissue cover 72 hours, or Until soft days if perforation. 5 for Continue exploration. surgical until Continue Fluconazole Pneumovax if GI perforation and risk of spillage of of spillage of risk and perforation GI if (if sinus/auditory canal breached) canal (ifsinus/auditory

3 2 4 6 1 7 5

SO/2  Updated: 08/01/2020  v2.0 Specialty overview  Antimicrobial prophylaxis Antimicrobial prophylaxis

a Post event transfers: Infection Prevention and Control (IPC) teams need advance notice of patient movements and suspect organisms if possible, to ensure the receiving

Antimicrobial prophylaxis Antimicrobial unit is prepared and can mitigate risk (ie is there a side room available?).

Prevention of Blood Borne

Specialty overview  Virus Transmission (Hepatitis B, C and HIV)

Follow principles of Inoculation Accident Injury.

Obtain blood sample from patient ` As soon as possible, a blood sample from the patient should be stored for baseline. Î Refer to Bloodborne viruses: managing risk in bomb blast victims PHE Guideline on BBV 

Hepatitis B Vaccination ` Start vaccination course within 48 hours of injury. ` Give accelerated vaccine schedule. ` Store blood and check for seroconversion at three and six months. Î Will have some opioid sparing effect.

Hepatitis C Vaccination Î No vaccine/antiviral strategy possible. ` Store blood and check for seroconversion at three and six months.

HIV Î Post exposure prophylaxis not routinely recommended. Î Risk assessment will be directed by Public Health England. ` Store blood and check for seroconversion at three and six months. v2.0  Updated: 08/01/2020  SO/2 Blast lung in a major incident Introduction Casualties with a primary blast lung injury (PBLI) will probably be symptomatic by the time they reach hospital. Casualties with PBLI will develop varying degrees of respiratory distress with impaired gas exchange. They may require supportive care in a high dependency or intensive care environment and up to 80% will require mechanical ventilation.

t The combination of blast injury and haemorrhagic shock is particularly life threatening and requires rapid and

aggressive treatment. Blast lung in a major incident

Catastrophic haemorrhage

Î Catastrophic haemorrhage may result from a massive

haemothorax Specialty overview  h Needs prompt recognition, haemostatic resuscitation and damage control surgery

A

Î May have haemoptysis

B

Patient may present with: Î mild to moderate respiratory distress Figure 1 Î Pneumothorax/pneumatoceles Î Broncho-pleural fistula in severe cases a CT chest to exclude pneumohaemothorax

No specific therapy for PBLI currently exists and patients should be ventilated as per current best practice for acute lung injury. Intensive Care Management Î Ventilate in accordance with current best practice Î Early CPAP at 5cm H2O, once pneumothoraces are drained Î Moderate PEEP levels on case by case basis if broncho-pleural fistula Î Use pAPRV and/or ECCO2R (local experience and resources permitting) Î Euvolaemic volume status Î Expect a good recovery

C

Figure 2 Î Hypotension may be due to myocardial impairment and decreased SVR a Consider vasopressor use to avoid excess administration of IV fluids

KEY POINTS

Casualty identification Has patient been exposed to: v2.0 Î If asymptomatic at two hours, patient will not need Î Toxic industrial chemical exposure (eg Chlorine/ mechanical ventilation. Phosgene / Cyanide). Î If asymptomatic at six hours, significant PBLI is unlikely Î Other toxic or smoke exposure. to occur. t Tympanic membrane rupture is not a sensitive or Risk factors specific risk factor for PBLI. Î Explosion in confined space Î Close proximity to explosion  Updated: 08/01/2020  SO/3 SO/3  Updated: 08/01/2020  v2.0 Specialty overview  Blast lung in a major incident require mechanical ventilation. mechanical require or criticaldependency care environment and the will majority ahigh- in management PBLI require with Casualties PBLI. of signs Respiratory compromise and possibly haemoptysis, are early respectively. bombings, train London and Madrid in the suffered casualties P diagnosis and Presentation greater. much injury of risk the and important less result a event is as explosive in a confined-space distance stand-off manner. achaotic in The itself augments and self-propagates readily, so dissipate not but wave does shock the within energy the trains, or buildings as such space aconfined in occurs However, explosion all. at an when injury no virtually suffering and injury blast fatal a suffering between difference make the can metres afew of amatter just explosion, air open an in that means wave energy shock in decline exponential The result of venous air embolism. laceration, and pneumothoraces. Immediate fatalities are the lung rupture, haemorrhage, parenchymal and as alveolar manifests damage significant lung, the however in shockwave, by the injured may be also bones long the and organs Solid supersonic explosive shockwave toa exposure from results and injury”, tertiary or secondary to due not and 12 exposure within of hours occurring “radiological and clinical evidence of acute lung injury as defined is injury. PBLI predominant the is normally (PBLI) injury lung blast primary which of disease, system multi- threatening, is alife syndrome injury blast Primary Background Î Î Î Î BLI was seen in 63% and 54% of the critically injured injured 63% in critically 54% the of and seen was BLI

Figure 3a shows the modelled effect on arterial oxygenation of the early application of ambient-air CPAP. Figure 3b compares the effect on oxygenation oxygenation of standard on conventionaleffect ventilation, the airway pressureCPAP. releasecompares ventilation3b ambient-air andFigure of ultra-protective tidal volume ventilation.application early the of oxygenation arterial on effect modelled the shows 3a Figure suggested by these studies. oxygenation in improvements potential the demonstrating studies modelling computerised of results The 3. Figure contusion from blunt injury should be considered. be should injury blunt from contusion or phosgene for example), gastric aspiration and pulmonary (with cyanide injury lung toxic co-existing of possibility The identified. and for sought be should less the non but PBLI with correlated is poorly rupture Tympanic membrane disease. important clinically to develop unlikely are exposure after 6hours asymptomatic are who Patients is unlikely.alone to PBLI due ventilation mechanical need the that suggests injury after 2hours compromise respiratory of absence The Blast lung in amajor incident Fig.3a iwypesr rele pressure airway Figure al application ambient early of PaO (kPa) 2

Figure iwypesr rele pressure airway al application ambient early of PaO (kPa) 2 10 11 2 . 6 7 8 9

h eut fcomputerised of 4amodelling results Figure studies. The 0 2 10 11 . 6 7 8 9 h eut fcomputerised of 4amodelling results Figure studies. The 0 s etlto and ventilation ultra ase Time (Hours) 10 a s etlto and ventilation ultra ase Time (Hours) 10 - a i PP iue4 oprsteefc on oxygenation standard effect ventilation, conventional of the 4b compares Figure CPAP. air (Figure 1). - i PP iue4 oprsteefc on oxygenation standard effect ventilation, conventional of the 4b compares Figure CPAP. air 20 20

- rtcietdlvlm ventilation. volume tidal protective 10 cmH 5 cm H 0 cmH -

rtcietdlvlm ventilation. volume tidal protective 10 cmH H cm 5 cmH 0 2

2 O 2 O O

2 2 O 2 O O Plain film radiography may demonstrate: radiography Plain film injury after shortly PBLI, severe Figure 2 overleaf such patients should be triaged and prioritised accordingly. prioritised and triaged be should patients such and threatening life is particularly shock haemorrhagic and injury blast of combination The ventilation. mechanical require or criticaldependency care environment and the will majority ahigh- in management PBLI require with Casualties Medical management CT imaging is the imaging of choice:CT Î Î Î Î Î Î Î Î Î PaO (kPa)

though this is an active area of research. research. of area this is active an though of PBLI management the for exists therapy specific No ( this typical is not although seen, be may consolidation of distribution ‘bats-wing’ Characteristic wave shock incident the of side the on denser may be which Contusions, radiography. film plain with apparent be may not which demonstratesBetter pneumatoceles and pneumothoraces haemorrhage and parenchymal haemorrhage. alveolar of extent and distribution the demonstrates Clearly Î Î Î ventilation ( CPAPambient-air mechanical of modes at optimal and early of benefit potential at the have writing) looked of time at the (unpublished studies modelling Computerised locally. made be should consideration by case acase so and circumstances such in infection HIV against prophylaxis of value the regarding guidance current is no There tissue occurred. has human with injury fragmentation when considered be must Bvaccination Hepatitis benefit. no demonstrated but studied have been VIIa factor Tranexamic recombinant Acid and hw h oeldefc natra xgnto fthe of modelled oxygenation on arterial effect the shows

2 Fig.3b PaO (kPa) benefits to the patient. patient. to the benefits ECCO (ECCO removal dioxide carbon by extracorporeal (facilitated ventilation tidal volume ultra-protective in and particular (APRV) ventilation release pressure that airway suggest also They 5cmH of application the with rate respiratory in reduction and oxygenation in improvements significant for potential the demonstrate studies These augments this effect. this effect. augments air enriched injury. oxygen Use of of hour an within air limitations in the trauma population. population. intrauma the limitations obvious has so and heparin with anticoagulation hw h oeldefc natra xgnto fthe of modelled oxygenation on arterial effect the shows 10 12 14 16 2 0 2 10 12 14 16 R requires large bore venous access and full full access and venous bore large R requires 0 Figure 3 , is an example of a CT scan in a patient with with apatient in scan aCT of , is example an 2 Time (Hours) 20 R)) may offer significant physiological ). ). b Time (Hours) 20 b 40 40 Figure 1 overleaf UPTV APRV ARDSnet 2 UPTV APRV ARDSnet O CPAP on )

Burn injury in a 33 3 t Take a good history quickly from the patient (patient may need major incident early intubation). In a MI event normal referral practices will be stopped and burns services will be closed. A Burn injured patients will remain in the

receiving hospital(s) until an appropriate Loss of airway patency can occur suddenly, especially in children. Burn injury in a major incident burns bed is found. Burn Incident Response Oedema will increase rapidly once IV Fluids given. Teams (BIRTs) can be mobilised by NHS h Always give supplemental O2 15L/min via non-rebreathe mask England to support these receiving hospitals. until COHb <5%

The BIRTs team: Consider intubation if: ` 1 Consultant Burns Surgeon Î GCS <12. Can be caused by trauma, drugs, alcohol, carbon ` 1 Consultant Burns Anaesthetist/ monoxide. Consider CT Head Specialty overview  Intensivist Î Impending upper airway obstruction ` 1 Burns Nurse Î Pharyngeal oedema INTUBATE NOW Î mobilised from burns services furthest Î Inspiratory stridor INTUBATE NOW away from the receiving hospital Î Difficulty swallowing secretions INTUBATE NOW Î Intra-oral burns including tongue Intubate BIRTs provide specialist advice, log all burns Î Intra-oral swelling. No stridor Intubate casualties, document injuries and liaise with Î Burns around mouth or nose Observe carefully the clinical cell. The clinical cell will decide on Î Soot in mouth or nostrils, singed nasal hairs Observe carefully patients’ destination. They will also assist with Î Respiratory distress continued local care and advise on fitness for Î Ventilatory inadequacy caused by circumferential burns to chest transfer, ideally within the first 72 hours. and / or abdomen Î Deep facial burns and circumferential neck burns Hospitals must: Î Increasing swelling of head and neck. May be particularly obvious Î Maintain a list of patients referred to BIRT once fluid resuscitation commenced. Î Assign a point of contact for the BIRT prior Î Other serious trauma / significant associated injuries to arrival of team t IF IN DOUBT, INTUBATE. (DO NOT cut the ET tube) For each patient: Î Copy of patient notes Î BIRT Team paperwork (when completed) Î Completed Lund and Browder chart B Î All available test results Î Details of all other injuries (after secondary ` Recheck ET tube often, as easily ‘displaced’ survey) Î Facial swelling may cause: Î Details of fluid requirements, fluid Î a cut ET tube to ‘disappear’ into the mouth administered and urine output Î a tied ET tube to pull out, as face swells Î ET tube may migrate into the right main bronchus (more likely National Burn Bed Bureau with uncut tubes) Î Consider Blast Lung Injury if lung contusions and haemo 01384 679 036 pneumothorax. see Speciality Overview 3 

t Having a burn does not exclude other C injuries! h Sit the patient up if possible. IV Fluid resuscitation may cause Î Have low threshold for trauma CT scan rapid oedema formation particularly in patients lying flat Î If there are other injuries requiring h blood product resuscitation, ignore the Place lines through unburned skin if possible (femoral site is burn formula and give blood and blood often preserved) h products according to the patient’s Regularly review anchor sutures. May ’cut out’ of burned or physiology. oedematous skin Î Expect tachycardia (HR x2 is common). Hypotension and

cardiovascular instability are late signs. If there is early v2.0 hypotension, look for another cause.  KEY POINTS Î Consider using long lines for IV access. Indwelling lines may migrate as a result of tissue oedema. Î If in doubt, intubate Î Don’t cut the ETT Î Don’t forget C-Spine Î Don’t include simple erythema in D estimation of burn wound size

Î Hypothermia kills Î Circumferential full thickness burns can cause limb ischaemia. Updated: 13/01/2020

a Is escharotomy required?  SO/4A Burn injury in a major incident

E

Î Complete the secondary survey. Î Prevent hypothermia. Burn injury in a major incident Î Hypothermia adversely affects outcomes in burns Î Keep the patient covered Î Warm the fluids and the environment if possible Î If possible, measure core and peripheral temperature Î Start fluid replacement as soon as possible to prevent ‘Burn Shock’ Specialty overview 

% REGION PTL FTL Area Head Neck Ant. trunk Post. trunk Right arm Left arm Buttocks Genitalia Right leg Left leg Total burn

Area Age 0 1 5 10 15 Adult A = ½ of head 9½ 8½ 6½ 5½ 4½ 3½ B = ½ of one thigh 2¾ 3¼ 4 4½ 4½ 4¾ C = ½ of one lower leg 2½ 2½ 2½ 3 3¼ 3½

Management of ‘Burn Shock’ Start fluid replacement as soon as possible to prevent ‘Burn Shock’. Î Crystalloid based IV Fluids (e.g. Hartmanns) is better than normal saline. Î Calculate 3-4mls/kg/%TBSA (this is the total volume for the first 24 hours). Î Calculate fluid requirements from time of injury. Î Give half of this volume in the first 8 hours, and the second half over the next 16 hours. Î After 24 hours, titrate fluids to urine output. 0.5mls/kg/hr (Adults) and 1.0mls/kg/hr (Children). Î REDUCE fluid input if urine output exceeds this amount.

v2.0 Palliation of unsurvivable burns injury Local non-burns specialists staff should not make decisions on survivability of burns injuries without discussion with the burns network, even in a MI. The decision to invoke the P4 casualty category for expectant patients will made by NHS England. This decision will be time limited, continually under review and only used at a time when NHS resources are overwhelmed.

References Concept of Operations for the Management of Mass Casualties (Burns Annex) NHS England EPRR National Burns Incident Clinical Management Guidance NHS England EPRR Further advice on Chemical Injuries NHS England EPRR IOR https://www.england.nhs.uk/ourwork/eprr/hm/#ior  PHE guidance https://assets.publishing.service.gov.uk/government/uploads/system/uploads/

 Updated: 08/01/2020 attachment_data/file/738497/ED_briefing_note_nerve_agents.pdf  SO/4A Burn injury in a major incident

Special Circumstances: t Carbon Monoxide Poisoning Suspected Hyperpyrexia Î Î

Affinity of Carbon Monoxide (CO) for Hb is 240x that of When core temperature greater than 39°C Burn injury in a major incident oxygen Î Patients with major burns are often hyperthermic. Î COHb causes a functional anaemia and displaces the Î A short period of very high temperature can cause oxygen dissociation curve to the left, worsening tissue significant morbidity hypoxia. Î Temperatures of 41.6 to 42°C can cause irreversible cell Î Signs and symptoms; damage in as little as 45 minutes Î essentially those of reduced oxygen delivery to the tissues i.e. shock. Î Management of core temperature >39°C Specialty overview  Î Pulse oximeter is unreliable in the presence of COHb. Use a Î Septic screen, check U&E, CK co-oximeter. Î Antipyretics Î Review Airway Management Î Open burn wound dressings (discuss with burn surgeon Î CO dissociates from Hb very slowly. Half-life in air > 4 hours. first if possible) Half-life in 100% oxygen 40 mins. Use 100% oxygen until Î Consider ice packs to axilla and groin COHb <5% Î Refrigerate NG/NG feed and flush t Cyanide Poisoning Î Management of core temperature >40°C for more than 6 Î Cyanide gas (HCN) is 20 x more toxic that carbon monoxide consecutive hours Î Suspect in all cases of smoke inhalation, but particularly in Î As above (>39°C) plus patients with significant lactic acidosis and raised venous Î Consider immediate active cooling e.g. CVVHDF, oxygen oesophageal cooling, coolguard. Î Review Airway Management Î Consider treatment with hydroxocobalamin Î Management of core temperature >41°C for more than 2 consecutive hours Hypermetabolism Î As above (>40°C) plus Î Burn injuries of more than 20% TBSA result in a Î Consider additional active cooling methods e.g. CVVHDF, hypermetabolic response. oesophageal cooling, coolguard. Î Cardiac output and heart rate can often increase by 150–200%. The patient will also typically have a t Stop active cooling measures when the core temperature hyperglycaemic insulin resistant state and often require reaches 38.5°C. Core temperature of up to 38.5°C can insulin supplementation. be considered normal, secondary to the massive SIRS Î Manage in a thermoneutral environment. Early excision of response to thermal injury. deep burns where possible. Î Signs and symptoms; Î hyperdynamic circulation, increased body temperature, catabolism and inefficient energy substrate cycling.

Infection Î Burns patients are vulnerable to infection in the early stages due to loss of the protective skin layer and immunosuppression secondary to major trauma Î The massive SIRS response in major burns makes diagnosis of sepsis challenging. A high index of suspicion is essential Î Isolation in a single cubicle and an ante-room is the gold standard Î Stringent infection control precautions cannot be over emphasised. All clinical staff should follow hospital standards for hand washing and wear aprons and gloves as a minimum v2.0  Updated: 08/01/2020  SO/4B Burn injury in a major incident Specialty overview  THIS PAGE HAS BEEN INTENTIONALLY LEFT BLANK v2.0  Updated: 08/01/2020  SO/4B They are not intended to act as a professional reference for forensic collection forensic for reference aprofessional as act to intended not are They apatient. treating by importance evidential potential of items disturb to forced clinicians for created been have guidelines *These Dealing with multiple casualties from asingle suspicious incident structure has been established. established. been has structure investigative aclear before outset at their to occur tend to hospital admissions and events, complex are scenes crime Major ` apatient. by treating importance evidential potential of items to disturb forced clinicians for created have been guidelines These collection. over evidence precedence takes treatment patient Critical awareness Forensic If you find a substance on a patient that you believe might be a form of drug: of form be a might believe that you patient on a a substance find you If attack. an of sequence and nature the reconstructing in assist can to clothing, damage and clothing, on evidence pattern blood and DNA Fibre, Clothing and footwear and Clothing them. between contamination cross- of risks the of aware be incident, suspicious same the from casualties multiple with dealing are you If t Ammunition components (bullets, shot or wadding) t Firearms t Edged weapons (knives etc) Weapons Drugs Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î

may be. be. may it what guess not do like but looks it what describe statements, in or labels exhibit notes, in asubstance describing When secure. somewhere bag aplastic in Store substance the hand. agloved with sparingly it Handle substance. the with contact Avoid direct front upper. the on evidence to preserve upper ashoe of part posterior the through cut example, For uppers. the through cutting when bloodstains/tears/cuts avoid obvious apatient, from footwear removing When footwear. seized clean not Do bag. plastic asingle in together them grouping before bags plastic individual in items Package bag. plastic asingle in bloodstains wet with items multiple Avoid putting fabric. the in tears and cuts existing through avoid cutting clothing removing/cutting When Î Î significance; evidential potential any of with items record one at least Make a separate team in a separate area if possible if area aseparate team in a separate by for cared be should they suspicion, is under patient If change. the document and casualties two the between equipment protective your of all change you ensure not, If casualties. of the one for care only staff that request possible, If stored collectively. be can shot Shotgun rattling. it to stop bag a plastic with lined pot plastic asmall in individually packaged be can These live. longer is no and expended have will been wound gunshot asuspected from removed shot or A bullet inform the police immediately. You live. should potentially are cartridges shotgun or propellant) containing cartridge ametal with (a bullet Rounds make it safe. and weapon the inspect to police the Call it. handle or touch not do afirearm, tobe believe you what recover you If bag. aplastic than tub, rather Place rigid into aclean (base). pommel the or hilt the of edges as the such contact, of points uncommon by handling knife Move the Handle sparingly with gloved hands. care. with and minimally weapon the handle safety; your Consider blade. the and handle the both on evidence harbour might it that mindful be apatient, on found is weapon edged an If

Avoid contamination between patients (crime scenes), or by introducing material of your own (DNA, fibres etc) fibres (DNA, own your of (crime material scenes), patients by introducing or between Avoid contamination notes/description and/or Sketch (with Clinical scale) and/orPhotograph written * in a major incident a in Injuries ` ` Î

valuable. very also are notes written clear and sketches Clinical Î Î injury; an of Take photographs scaled dressed/bandaged. or glued stitched, been has it once injury the record to likely only are Police photographers cameras/apps. photographers/DIY Usehospital in evidence. vital provide can treatment before injuries of recording The

and another detailed shot showing its extent is ideal. extent its showing shot detailed another and is, injury the where showing shot’ ‘locating wide one

SO/6  Updated: 08/01/2020  v2.0 Specialty overview  Forensic awareness in a major incident SO/6  Updated: 08/01/2020  v2.0 Specialty overview  Forensic awareness in a major incident ` ` teams. police/forensic by the it with associated types evidence to the according stored and packaged be will Exhibits ` by: as evidence value any potential to optimise precautions sensible take still should you but is it seized, before evidence of rules isn’t by covered the item An below). (see custody of chain police the into entered document or image any is item, exhibit An Exhibits ` ` person. their on had victim/suspect the items what know or priorities, clinical your understand may not hospital the at present teams Police/Forensic Communication collection forensic for reference as aprofessional to act intended not are They patient. a by treating importance evidential potential of items to disturb forced clinicians for created have been guidelines These incident major a in awareness Forensic Î

contamination by wearing two pairs of nitrile gloves and discarding the outer pair after handling each item. each handling after pair outer the discarding and gloves nitrile of pairs two by wearing contamination cross- of risk the of aware be incident, suspicious same the from exhibits multiple to handle likely are you If analysis. DNA for frozen and bag evident atamper in packaged may be bloodstaining with ashirt example, For clothing/items. discarded to collect police Allow exhibit. an becomes later that item an of origin and nature the about avoid confusion will This interest. of item an of nature and location appearance, the Recording inquiry. any in subsequent as evidence used may be as these place, and time with notes, clinical clear good Make Î Î Î by noting: police the Assist

How these removed items have been packaged and where they are currently stored currently are they where and packaged have items been removed these How victim/suspect the from removed been has footwear and clothing What injuries of description and number, position The 2 olfactory systems are not recognised and the psychological impact of facial disfigurement can be devastating. devastating. be can disfigurement facial of impact psychological the and recognised not are systems olfactory and vestibular gustatory, visual, auditory, to injuries if result can disability changing life significant However, important circulation. or airway on is impacting bleeding if survey primary the during addressed only are injuries facial and appearances, despite exsanguination in results rarely neck and face head, to the trauma Severe incident Head, face and neck injuries in amajor t a a C atastrophic haemorrhage atastrophic

trauma or cervical spine injury spine cervical or trauma potential of intracranial as indicator an regarded be should trauma facial Severe Î Î proximally pressure applying consider fails, pressure direct If bleeding. Facial arterial Î Î laceration ascalp from bleeding Excessive

Scalp above the ear (superficial temporal artery). Apply pressure to the scalp, just anterior to the crux of the pinna of the crux to the anterior just scalp, pressure to the Apply artery). temporal (superficial ear the above Scalp muscle. to masseter anterior just mandible, the of border lower to the pressure Apply artery). (facial nose lip,Chin, midface, bleeding the tamponade used be can sutures silk deep or staples haemostats, scalp, hairy the Within Manage with bleed a tight, compression bandage KEY POINTSKEY D o not blindly place haemostats due to risk of damaging the facial nerve facial the todamaging of risk due haemostats place blindly o not . 1 1 4 3 ` ` obstruct. obstruct. to injuries maxillofacial with apatient mayC-Collar: cause a a a a Nasal haemorrhage Nasal Head and neck wounds Î Î

As per standard trauma resuscitation trauma standard per As resuscitation trauma standard per As

h Î Î obstructions: airway of causes Other Î airway. obstructing tongue displaced Distally h fractures. Comminuted mandible h obstruction of the airway. causing fracture) (Le Fort maxilla loose displaced Distally additional anterior packing) ( packing nasal anterior and Posterior nasal haemorrhage may require both posterior Rhino®) Rapid ( tampons nasal or gauze ribbon with packing nasal Anterior Î Î Î

C-Collar as soon as possible C-Collar as soon C-Spine to if remove injury, consider or cleared be can spinal no and conscious if forwards up, face patient Sit Congealed and blood vomit dentures Missing teeth/fractured . tongue to secure used be can suture silk tongue Anterior oropharynx. the to clear fragments mandible the De-rotate nasopharynx. the clear and fracture the reduce palate to soft on the fingers Use two patient) (Intubated filled with saline, to tamponade the bleed the tamponade to saline, with filled and wound into the inserted be can catheter afoley then wound, neck ableeding stop not does pressure direct If out scrubbed not if tattooing at of risk are particles foreign and grit with Facial abrasions and wounds in theatre explored be should muscle platysma to the deep wounds All C B A D ie Epistat® or Foley catheter with with catheter Foley or Epistat® 2 ie

SO/7  Updated: 08/01/2020  v2.0 Specialty overview  Head, face and neck injuries in a major incident SO/7  Updated: 08/01/2020  v2.0 Specialty overview  Head, face and neck injuries in a major incident How to pack anterior and posterior nasal cavities nasal posterior and anterior pack to How neck and head the injuries in Important Î

and then fill the anterior balloon with <30mls. with <30mls. balloon anterior the fill then and resistance meets it until catheter the on Pull gently saline. <10mls with balloon posterior Fill the palate. soft the passes tip until the floor nasal the along catheter Epistat Insert Teeth Mandible Maxilla Nose/ears h Ears h Eyes incident Head, face and neck injuries in amajor Î Î Î Î Î Î Î Î Î Î Î Î

Missing teeth – are they on the floor, in the lip or lung(s)? floor, lip the on in the they –are teeth Missing airway the distally,displace obstructing and attachments anterior its may lose tongue The allow airway obstruction elderly, may the in especially fractures, Communited obstruction) (airway fractures Fort Le Mobile displaced Distally meatus auditory external or nose the from bleeding or leak CSF days few next the in test Hearing damage ear Inner rupture Tympanic membrane acuity visual Check Children’s out eye blow white detachment Retinal lens) contact (incl bodies Foreign haemorrhage Retrobulbar perforation Globe

3 Î

anterior packing such as ribbon gauze and saline/TXA. and gauze as ribbon such packing anterior (12-14G) catheter A Foley additional with used, be also can Clavicle to cricoid cartilage 1 Zone t Neck a involvement structure deep with tissue laceration Soft Face a a a mandible and skull base angle of Between 3 Zone a a a Cricoid to angle the of mandible cartilage 2 Zone a a a a a Î Î

Penetrating should not objects removed be injury avascular may that indicate haematoma expanding an or haemorrhage external for Look fatal potentially is trauma neck Penetrating Î nerve? facial or duct parotid to risk the potential Is there cranial nerves (IX-XII) nerves cranial internal jugular vein artery carotid internal of voice) hoarseness emphysema, surgical (stridor, haemoptysis, larynopharynx internal jugular vein arteries carotid plexus brachial apices lung (dysphagia, haematemesis)oesophagus trachea great vessels

Must be assessed prior to surgery/GA prior assessed be Must

4

Paediatric ‹C› ` Place infant head in neutral position (larger occiput than adults) casualties in a Î Fulcrum of C-Spine is C1-2 (high C-Spine injury more likely) major incident A Î Smaller airway and softer cartilage is more easily obstructed by This guideline has been created for non- swelling, foreign bodies or poor positioning paediatric specialists. The paediatric groups Î Infants are obligate nose breathers; tonsils are often enlarged are defined as: Î Larynx is higher and more difficult to view during intubation Baby 0–6 months, Infant 6–12 months, Toddler 1–2 years, Child >3 years. incident major a in casualties Paediatric >12 years can cautiously be managed as an adult B

History – take an AMPLE history Î Ribs are horizontal, therefore can only move up. Limited ability to A Allergies increase tidal volumes M Medications Î Difficult to localise chest sounds on auscultation P Past medical history . Î Decompress stomach early to improve breathing. The diaphragm

L Last food/liquids is an important respiratory muscle in infants and action may be Specialty overview  E Event compromised by a full stomach. Î Children fatigue earlier than adults Extras Î Normal respiratory rates vary greatly with age a Is child up to date with routine Î Infants become bradycardic when hypoxic vaccinations? a Birth History: As child becomes older, this is less significant. C a In infants, postnatal respiratory difficulties may contribute to a condition worsening Î Blood volume is relatively larger 80–90mls/kg beyond what would be expected based on (adult 65–70mls/kg) injury ` Record all blood loss (100mls in a 5kg child = 10% of total blood volume) Î Hypotension is a late sign a If there small vessels: consider IO, scalp veins and ext. jugular vein

D

Head 0–18 months have open sutures and fontanelles 1 Î Bulging fontanelle = intracranial bleeding ( ICP) Î Sunken fontanelle = significant blood loss

2 3 Chest Î The force transmitted may not fracture ribs but may still cause significant internal injuries 1 Î Mobility of mediastinum increases the likelihood of a simple pneumothorax developing into a tension pneumothorax, or a mediastinal vessel transection.

Abdomen Î Thin abdominal wall, with less muscle and sub-cutaneous fat, offers less protection to abdominal organs than in adults 2 Î Increased likelihood of bladder, liver and spleen injury

Musculoskeletal Î Fractures through growth plates may influence x-ray interpretation, however if missed can seriously affect future Normal paediatric vital signs by age group growth of the fractured bone 3 Age group Resp rate Heart rate Min sys BP v1.0 Term baby 40–60 100–170 50 3 month 30–50 100–170 50 E 6 month 30–50 100–170 60 Î Increased risk of multiple organ involvement from blunt trauma 1 year old 30–40 110 –160 70–90 ` Monitor plasma glucose. Children have a higher metabolic rate 1–2 years 25–35 100–150 80–95 and smaller glycogen stores than adults. 2–5 years 25–30 95–140 80–100 Î Heat loss: large surface area to volume ratio therefore increased 5–12 years 20–25 80–120 90 –110 risk of heat loss. Remember the patient’s exposed head >12 years 15–20 60–100 100–120  Updated: 08/01/2020  SO/8 SO/8  Updated: 08/01/2020  v1.0 Specialty overview  Paediatric casualties in a major incident INTENTIONALLY LEFT BLANK THIS PAGE HAS BEEN

‘Reverse’ WHO pain ladder Pain management Î Corresponds to UK DMS 0-3 Scale Regional analgesia Î De-escalate as pain improves Î Consider RA/EA at each stage

in a major incident Strong opiate Regional analgesia ‘Reverse’ the WHO pain ladder in complex injury and establish effective pain control early; then reduce and stop +NSAID or weak opiate NSAID or weak opiate Regional analgesia pain medications as appropriate

Î Start analgesia as soon as possible +Paracetamol +Paracetamol Paracetamol Î Use multi-nodal medication principles a Consider peri-operative nerve blocks TIME Pain management in a major incident major a in management Pain

1 – Chest injury After initial surgery a Intercostal nerve blocks a Serratus plane blocks NaCl jsjsd vdisudv dvdv dgfdf sahfg wyda gm dkf dfkvm asudh kid ojnf iawfa dkmg jsjsd vdisudv dvdv dgfdf sahfg wyda gm dkf dfkvm asudh kid ojnf iawfa dkmg jsjsd Specialty overview  vdisudv dvdv dgfdf sahfg wyda gm dkf dfkvm asudh kid ojnf iawfa dkmg jsjsd vdisudv dvdv dgfdf sahfg wyda gm dkf dfkvm asudh kid ojnf iawfa dkmg

2 – Abdominal injury

a Transverse abdominus plane (TAP) block a Epidural Analgesia or LA (Lignocaine) infusion

3 – Limb injury

a Single shot nerve block a +/- Indwelling nerve catheter for continuous infusion 1

 Regional or epidural analgesia

Consider regional analgesia at every step Î Single shot block +/- continuous nerve blockade

a If spinal and epidural analgesia  Urinary catheter may be required 2

t Beware: Î Hypovolaemia 2 Î Coagulopathy Î Distorted spinal anatomy eg crush fractures in explosive injury

1 CPNB LA  Direct or anticipated nerve injury

a Pregabalin a Tricyclic anti-depressants

KEY POINTS v2.0

Î Start analgesia as soon as possible Î Use multi-nodal medication principles Î ‘Reverse’ WHO pain ladder a Consider peri-operative nerve blocks  Updated: 08/01/2020  SO/9 Pain management in a major incident Establish pain control early and stop medications as and when appropriate.

Pharmacology Adjuncts – Co-analgesics

Multi–modal analgesia using the reverse WHO pain ladder A. Ketamine (overleaf) Î 10–20 mg intravenous aliquots can be used de novo or to supplement opiate analgesia. Particularly effective prior to

Pain management in a major incident major a in management Pain I. Opioids eg morphine patient movement or splint procedures Î Morphine is familiar to most trauma clinicians. Multiple Î Effect will persist for 10–15 minutes routes available but in acute situation is best given by Î Administrator should be resuscitation proficient as intravenous bolus: 1–5 mg as bolus and then additional anaesthesia is possible with inappropriate dosage 1–2 mg doses , every 2–5 minutes, titrated to effect. Î Relatively large doses may be required in young athletic B. Tricyclic Antidepressants casualties and analgesia is slow in onset. Î Neuropathic injury – start as soon as possible. Reassess need

Specialty overview  Î Fentanyl is a faster acting alternative. 50 micrograms i/v at two weeks as a bolus and repeat doses of 25–50 micrograms every Î Amitriptyline often assists sleep at night – a useful effect. 2–5 minutes. Î Start amitriptyline dose at 25mg and titrate to effect Î Degree of sedation more closely related to acute overdose than respiratory rate C. Gabapentinoids eg. Pregabalin Î Accidental overdose requires intravenous naloxone. Take Î Start as soon as possible – reassess need at two weeks one ampoule (0.4 mgs) and dilute to 8 mls with water for Î Initial dose = 75mg bd injection. Inject 1 ml (0.05 mgs) and repeat until sedation Î Review every day, increasing dose if necessary and reversed and respiratory rate ≥ 8 tolerated Î Effect is short acting – observe casualty closely Î Dose range is 150 to 600 mg per day PO given in either two or three divided doses II. Weak opioids eg Tramadol, Codeine D. Clonidine Tramadol Î Anxiolytic/ analgesic. Î Synthetic weak opioid with noradrenergic and Î PO 50 – 600 mcg 8 hourly (150–200 mcgs per 24hrs typical serotonergic effects. co-analgesic dose ) Î Alternative to codeine Î IV bolus – 50–150 mcg over 1–10 mins. May be repeated Î Recognised role in neuropathic pain eight hourly Î 50-100 mgs QDS po. Start at 50 mgs if patient is opiate Î Infusion in HDU/critical care: 1–2 mcg/kg/hour naive E. Lignocaine III. Non-opioids Î Can assist in difficult situations – alternative to epidural in abdominal surgery NSAIDs Î 1–2 mg/kg iv bolus over 30 mins Î Avoid with acute haemorrhage/coagulopathy or critical Î Infusion – 0.5 -2 mg/kg/hr illness. Î Side effects more likely in elderly patients. Ibuprofen (200 –400 mgs tds, po, pr) or diclofenac (50 mgs tds, Input from hospital acute po, iv, pr) commonly used. pain services Paracetamol Î 1g iv/po/pr QDS (500 mgs if body weight less than 50 kgs) Patient Controlled Analgesia (PCA) Î Few contraindications. Î Encourage use of PCA when appropriate. Î Will have some opioid sparing effect. Î PCA can be employed prospectively before surgery. v2.0  Updated: 08/01/2020  SO/9 Management of a pregnant casualty in a major incident <20 weeks Fundus below the umbilicus t Predict need for blood/fluids early ` Gynaecology input Î Maternal hypotension due to shock is a late sign of haemorrhage – associated with 80% foetal mortality. >20 weeks Î Treating the mother gives the best outcomes for Fundus above the umbilicus the child. ` Obstetric team for emergency LSCS ` Midwife input for baby

Primary survey

Standard ABC care as for any trauma patient incident major a in casualty pregnant a of Management h O2 h 2 × IV Access h Pelvic binder as usual (cut to fit if necessary)

t However, RSI may be difficult t If >20 weeks, tilt scoop to 30º to the left or manually displace uterus to avoid compression of IVC. Specialty overview 

Secondary survey

` Secondary survey as usual Plus observe for: a uterine contractions a vaginal bleeding a amniotic fluid PV Î Obstetric team should do the vaginal exam

Trauma checklist

The patient or spine board can be log rolled to Tranexamic Acid (TXA) 15-30 degrees to displace the uterus to the left, in a Î Give if strong suspicion of significant haemorrhage hypotensive, pregnant patient. Î If LSCS is planned, give after delivery of the child

Bloods Î Inform blood bank that patient is pregnant Î

Add Kleihauer test (extra FBC bottle and G&S bottle) v2.0 Î Consumptive coagulopathy can develop rapidly KEY POINTS

Î If mother is Rh D-ve, consider Rh Immunoglobulin therapy. Discuss with Haematology. If needed, should be given within 72 hours. Î Maternal bicarb is low in pregnancy Î Obstetric ward is not appropriate place for patient requiring head injury monitoring

Î Discuss with obstetrics for destination after ED  Updated: 08/01/2020  SO/10 SO/10  Updated: 08/01/2020  v2.0 Specialty overview  Management of a pregnant casualty in a major incident INTENTIONALLY LEFT BLANK THIS PAGE HAS BEEN

How can I help myself or others to overcome More information on post trauma reactions these difficulties? www.rcpsych.ac.uk/ healthadvice/problemsdisorders/ posttraumaticstressdisorder.aspx Do: www.nhs.uk/Conditions/Post-traumatic- • Take time out to get sufficient sleep (your normal stress-disorder/Pages/Treatment.aspx amount), rest and relax, and eat regularly and healthily.

• Tell people what you need. Talk to people you trust. You don’t have to tell everyone everything but telling nobody anything is often unhelpful.

• Take care at home or when driving or riding - accidents are more common after a traumatic or stressful event.

• Try to reduce outside demands on you and don’t take on extra responsibilities for the time being. Coping with

• Make time to go to a place where you feel safe and calmly go over what happened in your mind. Don’t stress following force yourself to do this if the feelings are too strong at the moment. a major incident

Don’t:

• Bottle up these feelings. Think whether it would be You may find this leaflet helpful if you helpful to talk about them with somebody you trust. have been involved in, or affected by, The memories may not disappear straight away. a traumatic incident. Where to find more help? • Get embarrassed by your feelings and thoughts, or It provides information on how you may expect those of others. They are normal reactions to a very Contact your GP or NHS111 about possible to feel in the days and months ahead, and to stressful event. symptoms of anxiety, depression, or post traumatic disorder, visit NHS Choices - www.NHS.uk help you understand and have more control over • Avoid people you trust. or call the Samaritans on 08457 90 90 90 your experience.

SO/11  Updated: 08/01/2020  v1.0 Specialty overview  Psychosocial support for anyone affected by a major incident SO/11  Updated: 08/01/2020  v1.0 Specialty overview  Psychosocial support for anyone affected by a major incident

You might need help if you have been In addition, if a child has witnessed or experienced • Try to help your child understand what has happened by giving a truthful explanation that is appropriate for their experiencing any of the following a traumatic event it is quite natural for them to be stressed. They may be very upset and/or frightened. age. This may help reduce feelings of confusion, anger, reactions for several weeks and there This should not usually last beyond four weeks. sadness and fear. It can also help correct misunderstandings is no sign of them getting better: that might, for example, lead the child to feel that they If symptoms of being very upset continue beyond four are to blame. They can also help reassure the child that weeks, this may indicate Post Traumatic Stress Disorder • You want to talk about what happened and feel you don’t although bad things can happen, they don’t need to be (PTSD) and it is important to seek help for your child. have anyone to share your feelings with. scared all the time.

• You find that you are easily startled and agitated. • In the event of a death, particularly a traumatic one, it can These are typical reactions after a traumatic event: be difficult to accept the ealityr of what has happened. It is • You experience vivid images of what you saw and have •Nightmar es. important to be patient, simple and honest in response to intense emotional reactions to them. questions about a death. Some children, for example, will •Memories or pictures of the event unexpectedly seem to accept a death but then repeatedly ask when that • You have disturbed sleep, disturbing thoughts preventing popping into their mind. person is coming back. It is important to be patient and clear you sleeping or dreams and nightmares. •Feeling as if it is actually happening again. when dealing with these questions: for example, it is better • You are experiencing overwhelming emotions that you feel to say “John has died” than “John has gone on a journey”. •Playing or drawing about the event time and time again. unable to cope with or experience changes in mood for no obvious reason. •Not wanting to think or talk about the event. What to look for:

• You experience tiredness, loss of memory, palpitations •A voiding anything that might remind them of the event. Children experiencing PTSD might show that they (rapid heartbeat), dizziness, shaking, aching muscles, •Getting angry or upset more easily. think differently either about themselves or other people. nausea (feeling sick) and diarrhoea, loss of concentration, They might: •Not being able to concentrate. breathing difficulties or a choking feeling in your throat • Blame themselves or show lowered self-esteem. and chest. •Not being able to sleep. • Describe thinking that they are a bad person or talk about • You feel emotionally numb. •Being more jumpy and being on the lookout for danger. thoughts of deserving bad things to happen to them.

• Your relationships seem to be suffering since the incident. •Becoming more clingy with parents or carers. • Show less trust in other people and be less able to •Physical complaints such as stomach aches or headaches. experience a sense of safety. • You are worried about your alcohol or drug use since the incident. •T emporarily losing abilities (e.g. feeding and toileting). • Experience overwhelming feelings in the form of shame, sadness and fear. • Your performance at work has •Pr oblems at school. suffered since the incident. • Avoid situations that they fear could increase their emotional response – i.e. might make them feel more frightened, • Someone who you How to help your child: threatened, ashamed or reminded of the event. are close to tells •T ry to keep things as normal as possible: keeping to your you they are usual routine and doing normal activities as much as you What to do: concerned can, will help your child feel safer more quickly. about you. If you have any concerns about your child, it is important •Be available to talk to your child as and when they are to seek help via your GP. There are some very effective ready. If it is difficult for you to do this, ask a trusted adult treatments including Cognitive Behavioural Therapy (CBT) for such as a family member or teacher to help. children and young people experiencing the effects of trauma. identify those who may need specialist mental health services. health mental specialist may need who those identify to and disorders to mental prevent incident, amajor in involved those all to support is advised strategy phased following The and physical environments. environments. physical and social particular of context the in people of experiences physical and social cognitive, emotional, to the refers ‘Psychosocial’ majora incident after staff for support Psychosocial Mental healthcare refers to delivering biomedical interventions from which people with disorders may benefit. disorders with people which from interventions biomedical to delivering refers healthcare Mental advice below. advice 1 Phase follow Instead, organised. tobe need not do and practice routine be not should event, particular the on focus that interventions session single brief, personal, event, atraumatic following Immediately time. right the at help right the toaccess However, important is it healthcare. mental tospecialist access may require people of proportion A small family, from separation loss isolation). of social and home possessions, (e.g. distress their maintaining factors social are there where example for incapacitating, more be and longer last may distress people’s Some disorders. health mental developing of indicative or dysfunction with associated not and transient is distress cases, most In effects. short-term tosuffer likely are incident amajor in involved people Most disorders. health mental developing of risk at are settings, hospital in care subsequent provide to worked who those and responders first as support to attended who staff incident, amajor After Specialist support support Additional intervention Early response Major incident Treatment posting sign and Monitoring advice Getting support Initial the psychosocial wellbeing of staff, and the cumulative effects may be negative and long-lasting. and negative be may effects cumulative the and staff, of wellbeing psychosocial the affect departments emergency in encountered that events shows research Recent support. peer and social effective offered and led well briefed, are well they that ensuring by staff support should Employers colleagues. and friends relatives, from is available support social if emergencies after recover and well cope respond who staff of majority The later. disorders developing people of risks the reduce can early intervening and adequate as perceive they support receive they if severity in reduces Distress distress. their despite resilient, psychosocially are incidents major by affected are who people all of 70% more or around events, of nature the on Depending

Occupational Health Occupational Peer and family family and Peer primary healthcare primary support (Trauma risk management ) or equivalent TRiM service TRiM Specialist Mental Health Services Health Mental Specialist acknowledges Organisation Organisation staff efforts staff Major Incident Care Support GP Primary Primary GP

psychological therapies) psychological (Improving accesss to accesss (Improving activities and public public and activities Community

IAPT IAPT support support Screen and Treat and Screen

External professional professional External (eg. Mind BlueLight NHS 111 NHS support support infoline)

SO/12  Updated: 08/01/2020  v2.0 Specialty overview  Psychosocial support for staff after a major incident SO/12  Updated: 08/01/2020  v2.0 Specialty overview  Psychosocial support for staff after a major incident t population: general the than disorder a mental developing of risk at higher may be following the of ahistory with People # help more Phase support/getting 4Specialist to: people referring may include This health occupational via risk at staff Monitoring support Continuing psychosocial # Phase help support/getting 3Additional # Phase advice 2Getting # Phase support 1Initial major incident a after staff for support Psychosocial Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î

Personal or significant family psychiatric history psychiatric family significant or Personal disorder amental of history previous and trauma developmental including trauma, personal post-event) or (pre- Significant event the during response Dissociative to event proximity Close trauma of to high-severity Exposure response the or during event in the injured Staff event an after weeks twelve and four between present still are symptoms When care intensive psychosocial more for service IAPT The continuing beyond support four weeks may need who people to identify services created Specially (ifavailable) equivalent or service TRiM The care Primary onwards weeks From two screening access and to of time period longer over a monitoring offers that programme to a referred be may staff some consent, their With support and advice Involves listening, connectedness and receiving people social support social maintaining on emphasis an but distress, toAim manage support Psychosocial tofour two Weeks it need who people for healthcare mental biomedical leaving support as peer such interventions level low using Intervene services) specialist and care/GP (community, primary services universal existing through as necessary support Access and to advice organisation to the external and internal services, support and self-care acknowledgement, of key messages by communicating incident to amajor response leadership employer’s the Includes (PFA)aid support first peer and Psychological event tothe reaction in Launched a specialist mental health service may be advised. may be service health mental a specialist to referral early an present, are factors risk these any of and 4 weeks after disorder amental of have or symptoms distressed are people If Traumatic bereavement misuse Substance network support social of absence Perceived Advice available from: Advice available from: Advice available from: Advice available from: Î Î Î Î Î Î Î Î Î Î

uk/stress-management-policy Ambulance Service) Traumatic Stress Guidance (London leaflet.pdf attachment_data/file/617321/nhs_trauma_ uk/government/uploads/system/uploads/ (NHS Guidance) incident Coping with Stress following a major service) 111NHS appropriate an to (to signpost news-campaigns/campaigns/bluelight Mind Blue Light Programme mind.org.uk/ with-traumatic-events MIND health/adults/iapt Services (IAPT) Improving access to Therapy Psychological IAPT) to referral (for GP care/own Primary news-campaigns/campaigns/bluelight Mind Blue Light Programme mind.org.uk/ england.nhs.uk/mental-health/adults/iapt support PTSD specialist for (IAPT) Services Improving access to Therapy Psychological IAPT) to referral (for GP Care/own Primary mind.org.uk/news-campaigns/coping-

england.nhs.uk/mental-

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For each patient transferred: patient each For 4 Step of: consisting team, into up ahyperacute Form 2 Step Î Î Î Î Î Î Î Î

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SO/13  Updated: 08/01/2020  v1.0 Specialty overview  Rehabilitation co-ordination and medical support in a major incident SO/13  Updated: 08/01/2020  v1.0 Specialty overview  Rehabilitation co-ordination and medical support in a major incident Acquired Brain Injury with; patients For Front door hyperacute rehabilitation Spasticity and dissociation disorder Functional neurological Movement disorder Seizures and seizure prevention injury Peripheral nerve Plexopathy Spinal Cord Injury Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î medical support in a major incident major a in support medical and co-ordination Rehabilitation High quality hyperacute rehab methods can support the major incident response and optimise patient outcomes patient optimise and response incident major the support can methods rehab hyperacute quality High

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V Injuries to Special Senses toSpecial Injuries Orthotics and Prosthetics:Orthotics Post acute Interventions Agitation and Delirium Communication tools Cognitive Assessments Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î Î ision

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Forensic and witness issues news bad Breaking prognosis and Classification

Royal Centre for Defence Medicine, Birmingham, UK Birmingham, Medicine, Defence for Centre Royal Birmingham Hospital, Heartlands Consultant Trauma and Colorectal Surgeon Bowley Doug Col Kingdom United Group medical Joint Medicine, CBRN Advisor Consultant Defence Medicine Consultant Emergency RN Steve Bland Cdr Surg Foundation Trust, London NHS Hospital College Kings Trauma Surgery, and for Director Clinical Surgeon Care Trauma Acute and Consultant Bew Duncan Mr Professor of Trauma of UK Birmingham, Neurosurgery, University SRMRC NIHR the of Director Birmingham NHS Foundation Trust, Birmingham Hospitals University Birmingham, Hospital Elizabeth Queen Consultant Neurosurgeon Professor Tony Belli UK Birmingham, Medicine, Defence for Centre Royal Foundation Trust, Birmingham NHS Birmingham Hospitals University Hospital, Elizabeth Queen Radiology in Adviser Consultant Army Consultant Radiologist RAMC Ballard Mark Lt Col Contributors Wood Paul Dr Veen Harald Mr Tovey,Jane Illustration, Birmingham QEH, of Head Medical Porter Keith Sir Prof. Parker Paul Col Moss Rob Dr Prof. Chris Moran Prof. Pete Mahoney Lee Justine Miss Pete Jefferson Lynn Hyatt England NHS EPRR, of Stephen Head Groves, National Doughty Heidi Col RAMC Hospital, Field (Welsh) 203 Officer Commanding Davies, Tim Col Buck Jenny Lt Cdr ToniProf. Belli Initial Working Project Groups Army British tothe Adviser Health Senior ProfessorHonorary of Medicine Emergency CBEBrigadier Timothy QHS Hodgetts England. Trauma, NHS for Director Clinical National Nottingham Hospital, University surgery, Nottingham ofProfessor Orthopaedic Nottingham Hospital, Consultant Trauma University Nottingham Surgeon, Professor Chris Mora Professor of Clinical Traumatology, of Birmingham Birmingham, University Consultant Trauma of Birmingham NHS Trust, University Surgeon, Birmingham KBE Porter Keith Sir Professor networks professional extensive to access and knowledge expert guidance, their for following the to indebted is project The Contributors , Head of Emergency Preparedness and Resilience, QEH, Birmingham QEH, Resilience, and Preparedness Emergency of , Head , Anaesthetic Consultant,, Anaesthetic Birmingham QEH, , Consultant Birmingham QEH, Anaesthetist, , EPRR Locality Lead for West Midlands West for Lead Locality , EPRR , Professor of Neurosurgery, Birmingham QEH, , Consultant Trauma and Orthopaedic Surgeon, QEH, Birmingham QEH, Surgeon, Trauma Orthopaedic and , Consultant , Consultant Trauma Surgeon, World Health Organisation, Geneva Organisation, Health World Trauma Surgeon, , Consultant , Major Trauma Specialty Doctor, QEH, Birmingham QEH, Doctor, Trauma Specialty , Major , National Clinical Director for Trauma, NHS England Trauma, NHS for Director Clinical , National , Defence Specialist Advisor in Perioperative Care, MOD Care, Perioperative in Advisor Specialist , Defence , Consultant in Transfusion Medicine for NHS Blood and Transplant and Blood NHS for Medicine Transfusion in , Consultant , Consultant Anaesthetist, RCDM and QEH, Birmingham QEH, and RCDM Anaesthetist, , Consultant , Professor of Clinical Traumatology, QEH, Birmingham QEH, Traumatology, Clinical of , Professor n

Honorary Senior Research Fellow, University of Birmingham, UK Birmingham, of Fellow, University Research Senior Honorary Birmingham Hospital Elizabeth Trauma, Queen Clinical of Department Consultant, Honorary Medicine Transfusion in Consultant Philos Dr MBA OBE Doughty Heidi Dr RAMC Hospital, Field (Welsh) 203 Officer Commanding MBE Davies Tim Col Birmingham Trust, Foundation NHS Hospitals University Hospital, Elizabeth Queen Surgeon &Neck ENT/Head Consultant Coulson Chris Mr Derriford Hospital, Plymouth, UK Consultant Radiologist Interventional RN Coates Philip Cdr Surg UK RCDM, Trauma &Orthopaedics, Professor Defence Past Trust, Frimley, UK Foundation NHS Park Frimley Surgeon Consultant Orthopaedic Clasper Jon Col UK Salisbury, Down, Porton Accelerator, Security and Defence University, Defence Academy of Shrivenham the UK, andImpact Armour Group, Centre for Defence Engineering, Cranfield FCSFS FIMMM CEng PhD Carr Debra .

Appendix/1a  Updated: 08/01/2020  v2.0

Appendices Glossary & Links Appendix/1a  Updated: 08/01/2020  v2.0 Royal Centre for Defence Medicine, Birmingham, UK Birmingham, Medicine, Defence for Centre Royal Foundation Trust, Birmingham NHS Birmingham Hospitals University Hospital, Elizabeth Queen Past Defence Professor Anaesthesia, PhD QHS TD CBE Mahoney Peter Col England NHS Response, Clinical Reference Group Preparedness, Emergency Resilience and Birmingham TraumaMajor Hospital, Elizabeth Queen Service, Trauma Major in Doctor Specialty Lee Justine Miss LtdHealthplanning Director Ms Verity Kemp UK Birmingham, Medicine, Defence for Centre Royal Foundation Trust, Birmingham NHS Birmingham Hospitals University Hospital, Elizabeth Queen Surgeon Plastics and Burns Consultant Kay Alan Col UK Birmingham, Medicine, Defence for Centre Royal Foundation Trust, Birmingham NHS Birmingham Hospitals University Hospital, Elizabeth Queen Care Critical in Consultant RAMC Johnston Andy Lt Col UK Birmingham, Medicine, Defence for Centre Royal Foundation Trust, Birmingham NHS Birmingham Hospitals University Hospital, Elizabeth Queen Surgeon Plastic and Burns Consultant Jeffery Steven Lt Col NHS England – West Midlands SolihullBirmingham, and the Black Country, for lead Locality Resilience and Response Preparedness Emergency Pete Jefferson Foundation Trust, Birmingham NHS Birmingham Hospitals University Hospital, Elizabeth Queen Surgeon &Neck ENT/Head Consultant Mr Richard Irving Derriford Hospital, Department, Emergency Plymouth UK Defence UK Medical Services, Medicine Consultant in Emergency RAMC Horne Simon Lt Col UK Trust, Northampton, NHS Hospital General Northampton Surgery Consultant and Maxillofacial in Oral RAMC Herd MKerry Lt Col Cranfield University,Defence Academy of Shrivenhamthe UK, Archaeology Forensic in Lecturer MCIfA MSc PhD DSc Harrison Karl Dr NHS England and Resilience Response Preparedness, Emergency of Head National Stephen Groves (ARMY) Microbiology Adviser Consultant Civilian Foundation Trust, Birmingham NHS Birmingham Hospitals University Hospital, Elizabeth Queen Consultant Microbiologist Medical JGill Martin Dr Medicine and Exercise Defence Consultant Advisor Rheumatotolgy, Rehabilitation and Sport Rehabilitation, Defence of Director L/RAMC Col FRCP CBE Etherington John Contributors Foundation Trust, Birmingham NHS Birmingham Hospitals University Hospital, Elizabeth Queen Consultant (Neurorehabilitation) Neurologist Professor Steve Sturman Foundation Trust, Birmingham NHS Birmingham Hospitals University Hospital, Elizabeth Queen Birmingham Hospital, Heartlands Director Medical and Deputy Surgeon Consultant Cardiothoracic Mr Richard Steyn Shrivenham UK, the of Academy Defence University, Cranfield University, Institute Forensic Cranfield PhD Student RN Tom Lt Cdr Surg Stevenson UK Birmingham, Medicine, Defence for Centre Royal Defence Professor of Medicine, Emergency Derriford Hospital, Department, Emergency Plymouth Medicine Consultant in Emergency RN Smith Jason Capt Surg NHS England (National) Preparedness,Emergency Resilience and Manager Response Portfolio Mark Sewell Care Critical and Anaesthesia Military of Department Academic Lecturer Stoke Hospital, University Stoke Royal The Medicine Care Intensive and Anaesthesia in Consultant RN EScott Tim Cdr Surg Ireland Cork, College, University Medicine, Operation Special in Lecturer Senior UK Birmingham, Medicine, Defence for Centre Royal Foundation Trust, Birmingham NHS Birmingham Hospitals University Hospital, Elizabeth Queen Consultant Trauma &Orthopaedic RAMC Parker Paul Col Foundation Trust, Birmingham NHS Birmingham Hospitals University Hospital, Elizabeth Queen and Clinical Collaboration Research - Innovation Lead hearWELL Military UK Birmingham, Medicine, Defence for Centre Royal Surgeon &Neck ENT/Head Consultant RAMC Orr Linda Lt Col Children’sBirmingham Birmingham Hospital, Trauma Major for Trust and Lead Medicine Emergency for Lead Clinical Medicine Consultant in Emergency Paediatric Newton Tina Dr Cambridge of University Neurosciences, Clinical of Department Trust Student, PhD Foundation NHS Birmingham Hospitals University Surgery, Throat and Ear, in Nose Registrar Specialist Medicine Defence for Centre Royal Trauma, and Surgery Military of Department Fellow, Academic Research Muzaffar Mr Jameel Foundation Trust, Birmingham NHS Birmingham Hospitals University Hospital, Elizabeth Queen Medicine Transfusion and Haematology in Consultant Dr Civilian Consultant Adviser Microbiology (RAF) Foundation Trust, Birmingham NHS Birmingham Hospitals University Hospital, Elizabeth Queen Consultant Microbiologist Mortiboy Dr Deborah

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Graphic Designers Graphic Lead Designer Graphic Editor-in-chief Production Team RCDM – Royal Centre for Defence Medicine, Birmingham, UK Birmingham, Medicine, Defence for Centre –Royal RCDM App the from download for Trauma’ isavailable ‘Combat www.4trauma.org.uk Trauma App Combat 4Trauma and Website Role Porter M. Keith Greaves, Ian Smith, Jason Desk ReferenceOxford Major Trauma Advanced Group Life https://www.alsg.org/home Support Hospital Major Incident Medical Management (HMIMMS) and Support (UK provider) https://www.rcseng.ac.uk/education-and-exams/courses/search/advanced-trauma-life-support-atls-provider-programme/ (USA) https://www.facs.org/quality-programs/trauma/atls/about Advance Trauma Life Support https://www.clinicalguideforops.co.uk Defence of (CGOs) Ministry (JSP999) operations for guidelines Clinical have guidelines These heavily been influenced by andsourcemany open materials: military RN Steve Cdr Bland Surg by produced were graphics MOI/5 Guideline UK Security, and Defence Cranfield at Services Learning Director, Art Pratchett, Clare by produced were graphics MOI/1 Guideline toProf. Mahoney Assistant Yau, toYvonne Personal and Birmingham QEH, at team Illustration Medical the of toall thanks Many Artist Medical Wales South of University Care and Social Health for Institute Welsh Strategy, Health Mental of Professor Emeritus Professor Richard Williams UK Birmingham, Medicine, Defence for Centre Royal Academic of Medicine, Emergency Military Department Derriford Hospital, Department, Emergency Plymouth Fellow Research Doctoral Post RN Vassallo James Lt Cdr Surg Contributors

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Appendix/1b  Updated: 08/01/2020  v2.0 Appendix/1b  Updated: 08/01/2020  v2.0 INTENTIONALLY LEFT BLANK THIS PAGE HAS BEEN

FFP FBC FAST fVIla EZIO Ex-Fix ET EPRR ENT EDH ED ECOSA ECMO ECCO ESBL EA Dr1, Dr2 DNA DAI D50 CTwb Report Hot CT CT CSF C-Spine CPE CPAP cloud on the horizon screen clotting CK CHL CCS C-Collar CBRN CABCDE approach CABC C1 o big bang BTX-A BP BOAST4 BM stix BBV AVPU AVM ATMIST ATLS ASIA ARDS AMPLE AK47 A-line ALS ATD ABx ABSCM ABO C

Glossary/list of terms of Glossary/list

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erious threat such as a significant chemical or nuclear release developing elsewhere and needing needing and elsewhere developing release or nuclear chemical as asignificant such threat erious

Antibiotics A Ar A C B C a s A E E E C D B E E C E B B A r F D C A D A F D C A E fi E A A A E C T C C A Factor VIIa CPE Carbapenemase producing Enterobacteriaceae p injuries a s b E C F C E C de C e efers to blood group types A,B and O and A,B types group to blood efers rade name for blood glucose test strip (Boehringer Mannheim, now called Roche) called now Mannheim, (Boehringer strip test glucose blood for name rade resh Frozenresh Plasma ull Blood Count Blood ull ocussed Assessment with Sonography in Trauma in Sonography with Assessment ocussed mergency Co-ordination Scientific Advice system system Advice Scientific Co-ordination mergency mergency Department mergency ndotracheal tube ndotracheal pidural Analgesia pidural mergency Preparedness, Resilience and Response and Resilience Preparedness, mergency ar, Nose and Throat surgical specialty surgical ar, Throat and Nose g. INR, PT, Fibrinogen APTT, INR, g. xtra Corporealxtra Membrane Oxygenation xternal Fixator xternal xtended Spectrum Beta-Lactamase Beta-Lactamase Spectrum xtended xtra Corporealxtra Carbon Dioxide Removal xtra Dural Haemorrhage Dural xtra rst report issued by radiologist reviewing a trauma CT scan, usually within 15mins within usually scan, CT atrauma reviewing by radiologist issued report rst ritish Orthopaedic Association Standards for Trauma Pathway 4, for patients with open lower limb limb lower Trauma for open Standards with Pathway patients 4, for Association Orthopaedic ritish lood Bornelood Virus lood Pressure lood otulinum Toxin Type A omputed Tomography imaging whole body ontinuous Positive Airway Pressure Positiveontinuous Airway onductive hearing loss omputed Tomography scan/imaging ervical Spine ervical erebroSpinal Fluid ervical Spine 1(Atlas) Spine ervical ervical spine immobilisation collar immobilisation spine ervical reatine Kinase reparatory action action reparatory hemical, Biological, Radiation, Nuclear Radiation, Biological, hemical, attery powered driver intra-osseous attery with needle asualty Clearing Station asualty atastrophic Haemorrhage, Airway, Circulation, Breathing, Disability, Environment/Exposure Haemorrhage, atastrophic atastrophic Haemorrhage, Airway, Breathing, Circulation (standard ATLS/ALS (standard Circulation Airway, routine) Breathing, assessment Haemorrhage, atastrophic utomatic Kalashnikov assault rifle assault Kalashnikov utomatic ge, Time, Mechanism of Injury, Injuries, Signs (vital signs), (vital Signs Injury, of Injuries, Treatments Mechanism given Time, ge, dult Respiratory Distress Syndrome Distress Respiratory dult dvanced Life Support Dose Therapeutic dult dvanced Trauma Life Support llergies, Medications, Past Medical History, Last eaten, Events leading up to up injury leading Events eaten, Last History, Medical Past Medications, llergies, nterior Border of the SternoCleido Mastoid muscle merican Spinal Injury Association Injury Spinal merican lert, Voice, consciousness) of (levels Unresponsive Pain, lert, rterio-Venous Malformation iffuse Axonal Injury Axonal iffuse eoxyriboNucleic Acid eoxyriboNucleic extrose 50% in water in 50% extrose octor 1, Doctor 2 1,octor Doctor terial line grees centigrade erious transport accident, explosion or series of smaller incidents smaller of series or explosion accident, transport erious

Appendix/2 a  Updated: 08/01/2020  v2.0 Appendix/2a  Updated: 08/01/2020  v2.0 NHS NGO NaCl NA MTC mls/hr mm MI MRI MTFA MTF mTBI MSK MRSA MPTT-24 M-LLSACF mmHg MIND/Mind MHP mg MDT MCS mcg MCE METHANE mass casualty LFTs LCSC LA IVC IV IPPV IPC IOR IO in IED ICU ICP ICD IAPT LEH L/hr HR hot debrief HME HIV HIBI headline news HAZMAT HALO GSW GP GCS GA (Fwd)CCP FTL FiO

Glossary/list of terms of Glossary/list

2

M S M millimetres I milligrams milligrams L m H M F I I G F M micrograms N M M Intra-Venous I M li G I H L Intra-Osseous H H I G M M N m inches p Mo ( L G I I Musculoskeletal M t H N Aureus Staphylococcus Resistant Methicillin c a m M H M L I m nfection Prevention & Control nfection nitial Operational Response Operational nitial Unit ntensive Care mprovised Explosive Device ntermittent Positive Pressure Ventilationntermittent ntraCranial Pressure ntraCranial Drain Chest ntercostal nferior Vena Cavae mproving Access to Psychological Therapies Access tomproving Psychological Forward) Casualty Collection Point Collection Casualty Forward) ypically events with casualties in the 100s, where the normal major incident response must be be must response incident major normal the 100s, where the in casualties with events ypically asualties, Emergency services on scene on services asualties, Emergency tres per hour per tres raction of Inspired Oxygen Oxygen Inspired of raction ull Thickness Loss (in burns) Thickness ull ocal Emergency Hospital Emergency ocal ocal Anaesthetic ocal ower Segment Caesarean Section Caesarean Segment ower iver Function Tests ugmented with extraordinary measures extraordinary with ugmented odium Chloride (normal Chloride saline)odium ublic or media alarm about an impending situation, reputation management issues issues management reputation situation, impending an about alarm media or ublic unShot Wound umanVirus Immunodeficiency lasgow Coma Score azardous Material, accidental incident involving hazardous material ypoxic-Ischaemic Brain Injury Brain ypoxic-Ischaemic ospital Ambulance Liaison Ambulance Officer ospital Anaesthesia eneral eart Rate eart eat and Moisture Exchanger Moisture and eat eneral Practitioner ational Health Service ational Health on Government Organisation Government on erve Agent erve ulti Disciplinary Team Disciplinary ulti arauding Terrorist,arauding Firearms Attack ajor Traumaajor Centre inimally Conscious State Conscious inimally ajor Incident, Myocardial Infarction Myocardial Incident, ajor assive Haemorrhage Pack agnetic Resonance Imaging ass Casualty Event Casualty ass ajor Incident?, Exact location, Type of incident, Hazards?, Type of incident, of Access/arrival/egress, location, Number Incident?,ajor Exact oderate Traumatic Injury oderate Brain edial to Lateral Lazy S across the Ante Cubital Fossa incision Fossa Ante Cubital the Sacross Lazy to Lateral edial edical Treatmentedical Facility illilitres per hour per illilitres illimetres of mercury, eg. unit of blood pressure measurement pressure blood of unit eg. mercury, of illimetres eeting that occurs immediately after an incident or period of duty of period or incident an after immediately occurs that eeting ental health charity, Mind, delivers the blue light programme for all first responders first all for programme light blue the delivers Mind, charity, health ental dified Physiological Triage Tool-24

STEP1-2-3PLUS NPIS NBM NHSBT TAP SVR SORT SNHL SI(J) SIEVE pack shock SAGM Rx RT1/2 RT RSI ROTEM rising tide RhD REBOA Resus RBC RA R&R QDS PV PTSD PTL PTA PRAFO PR PPI POC PO PHE PFA PEP PEEP PCA PBLI pAPRV P2S P3 P2 Hold P1 P1 OPD OGJ ODP OD O TRS TM TIC TEG TDS TBSA TBI scribe 2

Glossary/list of terms of Glossary/list

T T T P P P R N P T P P a d P P O O q Oxygen Re R ThromboElastoGraphy ThromboElastoGraphy p P P p Na pr Ra p S O E m I p o R N S R P T P T t re solution of Saline, Adenine, Glucose and Mannitol used for storing red blood cells for transfusion cells for blood red storing for used Mannitol and Glucose Adenine, Saline, of solution R P R P S S R P s R P ‘ pack’ issued by blood bank in response to massive haemorrhage to haemorrhage massive response in bank by blood issued pack’ nitial on scene triage of casualties by ambulance/pre-hospital services by ambulance/pre-hospital casualties of triage scene on nitial er die sumendus, three times per day per times three sumendus, die er afety triggers for emergency personnel in personnel CBRN triggers for events emergency afety error Related Stab (injury) Related error (used Area Burns) in Surface Body otal Injury Brain otal ympanic Membrane ympanic rauma Induced Coagulopathy ransverse Abdominis Plane Abdominis ransverse ystemic Vascularystemic Resistance econdary triage of casualties triage econdary ensorineural hearing loss hearing ensorineural acro-Iliac (Joint) acro-Iliac xpectant, serious injuries with a poor chance of survival, or needing extensive treatment, casualties casualties treatment, extensive needing or survival, of chance apoor with injuries serious xpectant, ost Traumaticost Stress Disorder oint Of Care Of oint ositive End Expiratory Pressure ositive End Expiratory ost Traumaticost Amnesia ublic Health England Health ublic radidoxime (nerve agent antidote) roton Pump Inhibitor riority 2, needing early resuscitation and/or surgery, but some delay is acceptable delay some and/or but surgery, resuscitation early 2,needing riority artial Thickness Loss Thickness artial riority 3, requires treatment but a longer delay is acceptable delay alonger but treatment 3, requires riority ressure Relief Ankle-Foot Orthoses Ankle-Foot Relief ressure atient Analgesia Controlled riority 1, needing life-saving resuscitation or intervention or resuscitation 1, life-saving needing riority sychological First Aid, Psychosocial First Aid First Psychosocial Aid, First sychological rimary Blast Lung Injury Lung Blast rimary re-Event Planning, Post-Exposure Prophylaxis Post-Exposure Planning, re-Event apid Tranfusionist 2 apid 1and Otational ThromboElastoMetry Otational apid Transfuserapid esuscitation area in department the emergency hesus D, a protein found on surface of RBCs of surface on D,hesus found aprotein esuscitative Endovascular Balloon Occlusion of the Aorta the of Occlusion Balloon Endovascular esuscitative egional Analgesia egional ed Blood Cell(s) Blood ed mni die, every day every die, mni uarter die sumendum, four times aday times four sumendum, die uarter artial Anomalous Pulmonary Venous connection Pulmonary Anomalous artial er os, by mouth, orally by mouth, os, er er rectum, rectal examination, rectal administration of medication administration rectal examination, rectal rectum, er er vaginam, vaginal examination, describes vaginal blood loss through the vagina the loss through blood vaginal describes examination, vaginal vaginam, er il byil mouth HS Blood Transfusion Service HS Blood perating Department Practitionerperating Department utpatient department esophageal Gastric Junction Gastric esophageal ceive treatment compatible with resources resources with compatible ceive treatment edic who records results and actions during a trauma alert atrauma during actions and results records who edic escription, prescribes pid Sequence Induction st and Relaxation tional Poisons Information Service eveloping infectious disease epidemic, or capacity/staffing crisis or industrial action action industrial crisis or capacity/staffing or epidemic, disease infectious eveloping

Appendix/2b  Updated: 08/01/2020  v2.0 Appendix/2b  Updated: 08/01/2020  v2.0 WHO WBCT VX VTE VS VHA VBG USS DMS UK U&Es U TXA TU TRiM Trauma ID trauma bloods TTL E D C B A C E N A H T E M P4 P3 P2 Hold P1 P1 reports incident Post debrief Multi-agency debrief Organisational Cold/Structured/ debrief Hot

Glossary/list of terms of Glossary/list

ithin 6 weeks of the close of the incident the of close the of 6weeks ithin ithin 4 weeks of the close of the incident the of close the of 4weeks ithin

D n V W P Ul V w P F Ur T p w E U T T Breathing, Breathing, A Air Hazards?, P Unit ( C Ca N T M V E E E re Disability W V i w mmediately after the incident or period of duty of period or incident the after mmediately major) Trauma Unit ype of incident, incident, of ype rauma Risk Management Risk rauma ranexamic Acid ranexamic rauma Team Leader BCs/U&Es/G&S/Clotting (PT, APTT, fibrinogen), Ca2+, lactate, A/VBG, (plus ROTEM if available) if ROTEM available) (plus (PT,Ca2+, fibrinogen), APTT, A/VBG, BCs/U&Es/G&S/Clotting lactate, mergency services on scene services mergency xpectant, serious injuries with a poor chance of survival, or needing extensive treatment, casualties casualties treatment, extensive needing or survival, of chance apoor with injuries serious xpectant, xposure (of the patient), Environment, Everything Else, Else, (of Everything patient),xposure the Environment, location, xact riority 2, needing early resuscitation and/or surgery, but some delay is acceptable delay some and/or but surgery, resuscitation early 2,needing riority riority 3, requires treatment but a longer delay is acceptable delay alonger but treatment 3, requires riority riority 1, needing life-saving resuscitation or intervention or resuscitation 1, life-saving needing riority enous Thrombo Embolic (disease) Embolic Thrombo enous enous Gas Blood egetative State egetative erve agent erve iscoelastic Haemostatic Assays atient identifier irculation ccess/arrival/egress, from the scene or from hospital from or scene the ccess/arrival/egress, from nited Kingdom Defence Medical Services Medical Defence Kingdom nited umber of casualties, of casualties, umber ead or for palliation. Use of this category can only be authorised by NHS England by NHS authorised be only can this Use of category palliation. for or ead ithin 2 weeks post incident post 2weeks ithin ajor Incident?, orld Health Organisation Health orld ceive treatment compatible with resources resources with compatible ceive treatment hole Computed Body Tomography traSound Scan traSound ea and Electrolytes and ea tastrophic Haemorrhage, also , CatHaem, bigC way,