www.atacc.net ATACC Manual 2014 Course Manual 8th Edition 2014 Volume I of III #FOAM - Free Open Access Meducation – Strictly not for commercial gain pg 1 www.atacc.net ATACC Manual 2014 Editorial Team Dr Mark Forrest BSc Hons MB ChB FRCA FICM Consultant in Anaesthetics, Critical and Prehospital Care Warrington & Halton Hospitals NHS Foundation Trust ATACC Medical Director Medical Director NW Police Firearms Collaboration Cheshire Fire & Rescue Service Medical Director UK Dr Jason van der Velde BAA, MBChB, M.Sc. (DM), MCEM Prehospital Emergency Medicine and Critical Care Retrieval Physician Clinical Lead HSE National 24 hour Emergency Telemedical Support Unit Cork University Hospital ATACC Assistant Medical Director West Cork Rapid Response Medical Director Ireland Dr Peter Lax MB ChB (Hons.), Dip RTM, Dip IMC RCSEd, FRCA, RAF Squadron Leader Anaesthetics/Intensive Care Medicine SpR, Royal Air Force Critical Care Air Support Team Baltimore Shock Trauma Anaesthesia/Intensive Care Medicine Fellow USA Contributors Dr Carin Dear Consultant Anaesthesia and Prehospital Care, Southampton MTC, UK Mr Ian Dunbar International Extrication & Rescue Specialist, Holmatro, Holland Dr Hugh Doran GP and Prehospital Emergency Medicine, East Cork, Ireland Dr John Glasheen Critical Care Retrieval Physician, Syndney HEMS, Australia Ms Jenny Grainger Surgical SpR, RCS link, Cheshire, UK Dr Peter Larcombe Consultant Anaesthetist and Neuro Intensive Care, Brighton MTC, UK Prof Mike Mcnicholas Trauma & Orthopaedic Surgeon, Aintree MTC, UK Miss Brigid Wall Advanced Paramedic, Brisbane Ambulance Service, Australia Dr Jenny Parsons Anaesthetics and Intensive Care SpR, Dundee, Scotland Dr Geoff Roberts Deputy Cheshire Coroner, UK Dr Phil Russell SpR Anaesthetics and Prehospital Emergency Medicine, UK Mr Noaman Sarfraz Consultant Surgeon, Ret. Pakistan Army Surgeon, Cheshire, UK Dr Marc Scott Senior Consultant Anaesthetist, Amsterdam Medical Centre, Holland Paul Savage OBE Clinical Operations Manager RNLI, Chairman UKSAR Medical Group Dr Craig Williams Consultant Anaesthetics and Intensive Care, Swansea, Wales Mr Lee Winterbottom Advanced Paramedic, Course Director, Frontier Medical, UK Ms Dawn Wood Senior NHS Manager, Trauma & Orthopaedics, Cheshire, UK #FOAM - Free Open Access Meducation – Strictly not for commercial gain pg 2 www.atacc.net ATACC Manual 2014 Contents Volume I 1.1 Anaesthesia Trauma and Critical Care 1.1.1 Introduction to ATACC 1.1.2 Royal College of Surgeons 1.2 Trauma Care Delivery 1.2.1 Roadside To Critical Care 1.2.2 Team Approach 1.3 Pre-hospital Care 1.3.1 The Specialty 1.3.2 Mechanism of Injury 1.3.3 Safe Approach 1.3.4 Mass Casualty Management 1.3.5 Road Traffic Collision Extrication 1.3.6 Trauma Retrieval Volume II 2.1 Initial Management 2.1.1 Massive Haemorrhage Control 2.1.2 Airway 2.1.3 Respiration 2.1.4 Circulation – Shock and Traumatic Bleeding 2.1.5 Head Injury 2.1.6 Traumatic Cardiac Arrest 2.2 On-Going Trauma Care 2.2.1 Initial Approach to Damage Control Resuscitation 2.2.2 Trauma Team Receiving Care 2.2.3 Analgesia 2.2.4 Trauma Induced Coagulopathy 2.2.5 In-hospital Damage Control Resuscitation Volume III 3.1 Specialist Care 3.1.1 Thoracic Trauma 3.1.2 Neurosurgical Intensive Care 3.1.3 Spinal Trauma 3.1.4 Musculo-Skeletal Trauma 3.1.5 Pregnancy 3.2 Environmental Trauma 3.2.1 Tactical Medicine 3.2.2 Decompression Illness 3.2.3 Immersion and Submersion 3.2.4 Thermal Injuries #FOAM - Free Open Access Meducation – Strictly not for commercial gain pg 3 www.atacc.net ATACC Manual 2014 Section 1.1 Anaesthesia Trauma and Critical Care #FOAM - Free Open Access Meducation – Strictly not for commercial gain pg 4 www.atacc.net ATACC Manual 2014 1.1.1 Introduction to ATACC Welcome to the virtual ATACC manual 8th edition: 2014 Trauma remains one of the major killers in our modern society. Improved medical care enables us to sustain life in the face of many serious conditions but until we reach 40-50 years of age, trauma is our greatest risk to life. If we total up all of the lost life years, from cancer, heart disease and stroke premature deaths, then it will still not be equivalent to the number lost as a result of trauma. It is a killer of all age groups, but especially the young. Even for survivors, without delivery of a high standard of care, at the earliest opportunity, they can be left with severe life-changing, long term, disability. As a result the impact on patients, families, the health service and us all, can be considerable with huge costs to everyone. In light of these facts there is a constant drive to improve trauma care standards, but for many years there was little real measurable improvement. In the UK, despite several reports in the past and more recently the 2007 NCEPOD ‘Trauma Who Cares’ document and the subsequent National Audit Office 2011 report, it was clear that despite increasing levels of ATLS training, improvements in paramedic skill sets, greater understanding of the complexities of trauma and recent wartime medical experience, little had actually improved in terms of outcome. What was required was a national structure for managing trauma and also training that moved rapidly with the times, which could easily be adapted, modified and enhanced as knowledge expanded. From this the UK National Trauma Network was established and modern trauma courses such as ATACC, European Trauma Course and the Emergency Trauma Medicine course became far more popular, offering a far more current and advanced level of training, including newer concepts and methods, such as effective crew resource management. Since 1997, ATACC has gone to considerable lengths to keep our course as up to date as possible and the educational content is reviewed and updated between every single course. As such, it remains academically far ahead of many rival courses and the Faculty are always keen to here of anything new that enthusiastic candidates may have also seen or read. #FOAM - Free Open Access Meducation – Strictly not for commercial gain pg 5 www.atacc.net ATACC Manual 2014 In many areas of trauma, we are still far from having all the answers and no area is a better demonstration than that of trauma induced coagulopathy. We now understand far more about coagulation in trauma, but it just seems to complicate the whole picture still further, without providing all of the necessary answers or solutions. This is typical of many aspects of trauma care and presents courses and instructors with a dilemma, as there is often no clear answer to many questions. Faced with such challenges, some courses just simplify the issue and offer an old or basic solution, whereas ATACC will do it’s utmost to present all of the current best evidence and then suggest what we consider the best current solution, often just based on the educated opinions of key players in trauma in the UK and around the world. The ATACC Faculty aim to offer the latest and most advanced trauma methods, taught in a stimulating and innovative manner, using all the modalities that we can to develop team skills, trauma skills and an appreciation of relevant human factors. History Back in 1997, Dr Mark Forrest was approached by the Head of the Mersey School of Anaesthesia to address the issue of trauma training for the local anaesthetic & critical care community. As an ATLS instructor he realised that there were many very good qualities to this course, but it was Americanised, surgically biased and it was proving difficult for it to keep up with the changes and developments that were occurring within trauma practice. To be fair ATLS aimed to do nothing more than provide a robust background of trauma skills for clinicians who may face major trauma on an infrequent basis and have to manage it in a systematic fashion as part of a trauma team. It was never designed to be the course for leading major trauma centres and as such ‘advanced’ may not be the best title, but as an initial introduction it was a good start. Sadly, as our approach to trauma has progressed, a number of the methods and principles of ATLS have proved incorrect, but these were slow to be changed, resulting in many disillusioned candidates and Faculty members. As such ATACC offered a fresh alternative, with s similar approach but an ongoing commitment to update the educational material before every course. Over the last 15 years the Faculty have achieved that and the current best practice and evidence is reflected in this course manual. In addition to the science, trauma is typically managed by a multi-disciplinary team, many of whom were excluded from the ATLS course. ATACC took a far more inclusive view, as everyone has a part to play in the Trauma Team on the patient journey from ‘Roadside to critical care’ The first course ran in late 1997, produced and written by local enthusiastic consultants in Merseyside. Since then, the Faculty has grown to several hundred and includes many of the leading trauma clinicians in UK hospitals and Major Trauma #FOAM - Free Open Access Meducation – Strictly not for commercial gain pg 6 www.atacc.net ATACC Manual 2014 Centres. Thousands of candidates from around the world have completed the course from over 20 different countries. ATACC has developed still further and we now adopt many unique and ground breaking teaching modalities. In the last 12 months alone, we have introduced Laerdal SimPad as a tool for our rolling, on going assessment process, an additional six major scenarios on day 3 for the trauma teams, a large scale, half day major incident for MERIT training and our new Virtual world Immersive simulator.